Intervention for multicultural and international clients with communication disorders

Chapter 13 Intervention for multicultural and international clients with communication disorders



With the increasing diversity of the U.S. population, speech-language pathologists (SLPs) have skills in cultural competence to ensure that they are able to meet the needs of children and adults with communication and swallowing disorders from diverse cultural and linguistic backgrounds. Professionals providing services need to be prepared to work with people from a variety of ethnic, racial, and cultural groups (American Speech-Language-Hearing Association [ASHA], 2008; 1985). The intervention chapter in previous editions of this book focused on cultural and linguistic diversity in the United States and included considerations for clinical practice, information for avoiding cultural conflicts in the clinic, the use of ethnographic interviews to learn about cultures, and guidelines for culturally relevant intervention procedures. Because of the increase in diversity in the United States and the need for information about clinical practice for communication disorders around the world, a more global perspective is addressed in this edition. Laws affecting persons with disabilities, best practices for intervention, and information about various cultures and religions are provided.


The increase in diversity resulting from immigration to industrialized countries all over the world has resulted in the need for changes in assessment and intervention for communication disorders. Many countries that did not provide clinical services for communication disorders as recently as 30 years ago are now seeking information, services, and training. Persons who immigrated to the United States and to other parts of the world are now seeking services for disorders. Issues for clinical intervention must recognize the increase in consumers who speak languages other than English and those who are learning English as a second language. The SLPs and audiologists must find ways to deliver services to persons from various cultures and those who speak various languages in order for assessment and intervention to be culturally and linguistically appropriate and for information to be disseminated around the world to people who need these services.



Legal aspects of intervention in the united states


The No Child Left Behind (NCLB) Act (2002) seeks to correct achievement gaps that are most prevalent among students in specific subgroups, including those with disabilities, those with linguistic and cultural diversity, and those with economic disadvantage. The reauthorization of federal special education legislation through the Individuals with Disabilities Education Improvement Act (IDEIA, 2004) moved to align the accountability for learners with disabilities with the guiding principles of NCLB, which was signed into law in January 2002. This federal mandate was a major revision to the Elementary and Secondary Education Act (ESEA) of 1965. The law significantly challenged the status quo of public schools and established the U.S. Department of Education as a responsible party for increasing student achievement in public schools. Turnbull (2005) identified six primary principles of NCLB: accountability, highly qualified teachers, scientifically based instruction, local flexibility, safe schools, and parent participation and choice. IDEIA was reauthorized in 2004 with the intent of improving the existing legislation with a primary purpose of aligning the provisions of IDEIA with NCLB. Although the individual provisions of IDEIA are different from NCLB, the overall goals of the two are similar. The partnership of NCLB and IDEIA provides the opportunity for successful academic achievement for students with disabilities by implementing the systemic changes mandated by NCLB through the Individual Education Plans (IEPs) as regulated by IDEIA. In addition, IDEIA mandated the use of evidenced-based strategies to address concerns associated with the overidentification of culturally and linguistically diverse students, students from low-income families, and students in certain disability categories.


Overidentification and disproportionality of culturally and linguistically diverse children occur in special education, especially those identified with learning disability, mild mental retardation, and emotional behavior disorders. The disproportionality involves African American, Latino, and American Indian/Native American children, those from low-income families, and those learning English as a second language. Their identification as children in need of special education is often unrelated to a disability and is often related to poor instructional programs, language difficulty, and stress related to situations at school, in the family, or in the community. A new provision under IDEIA 2004 requires states to develop policies and procedures to decrease inappropriate identification of students with disabilities and to avoid and examine disproportionate representation by race and ethnicity. Schools are required to collect data to show the number of students in special education programs by race and ethnicity for each of the disability categories. Furthermore, if states identify a disproportionate number of students of color receiving special education services, they must follow through with procedures for analyzing and reporting the findings. This provision is linked to the 2004 IDEA Special Rule for eligibility determination: that a disability cannot be identified if the determining factor is a lack of instruction in reading or math or limited English proficiency (Wright & Wright, 2006). While ensuring access to high-quality instruction, the provision also ensures that students with limited English proficiency have sufficient time and instruction to acquire adequate English language skills. By providing both high-quality instruction and time to learn English, it will decrease incidents of misdiagnosis and overrepresentation of minority students, particularly students with limited English proficiency, in special education (Bowen, 2006).



Family-centered and culturally responsive services


An aim of all early intervention services and supports is responsivity to family concerns for each child’s strengths, needs, and learning styles (Paul, 2007; Roth & Worthington, 2005). An important component of individualizing services includes the ability to align services with each family’s culture and unique situation, preferences, resources, and priorities. The term family centered refers to a set of beliefs, values, principles, and practices that support and strengthen the family’s capacity to enhance the child’s development and learning (Boone & Crais, 2001; Dunst, 2001, 2004; IDEIA, 2004; Polmanteer & Turbiville, 2000). These practices are predicated on the belief that families provide a lifelong context for a child’s development and growth (Beatson, 2006; Bronfenbrenner, 1992). The family, rather than the individual child, is the primary recipient of service delivery to the extent desired by the family. Some families may choose for services to be focused on the family, whereas others may prefer a more child-centered approach. Family-centered services support the family’s right to choose who the recipient of the services is. Early identification and intervention efforts are designed and carried out in collaboration with the family, fostering their independence and competence and acknowledging their right and responsibility to decide what is in the best interest of their child (Dunst et al., 1993). Family-centered services emphasize shared decision making about referral, need for assessment and intervention, types of assessment and intervention approaches, methods for monitoring and sharing information with others important to the child and family, development of functional outcomes, and implementation of intervention. There is no single set of practices that is appropriate to meet the needs of all families. Family-centered early intervention practices respect family choices and decisions (Summers et al., 2005). Components of family-centered practices include offering more active roles for families in the planning, implementing, interpreting, and decision making in service delivery. Family-centered practices can maximize time and other resources, create closer alignment between family and professional decisions and plans, and increase decision making by families (Dunst, 2002; Summers et al., 2005).


All early intervention services and supports are directly influenced by the cultural and linguistic backgrounds of the family, child, and professionals. Every clinician has a culture, just as every child and family has a culture (ASHA, 2004). SLPs need to recognize their own as well as the family’s cultural beliefs, values, behaviors, and influences, and how these factors might affect their perceptions of and interactions with others. Like all clinical activities, early intervention services are inherently culture bound because they reflect the beliefs, values, and interaction styles of a social group (Battle, 2002; Johnston & Rogers, 2001). Factors such as beliefs about child rearing, discipline, authority roles, and styles of communication, as well as views on disability and past experiences with health care or other professionals, can influence the family’s interactions and decision-making process. In some cultures, for example, emphasis is placed on what a child can learn independently, whereas other cultures focus on what a learner can accomplish in collaboration with others. Therefore, different learning styles and values regarding means of teaching and learning necessitate different assessment and instructional approaches and strategies (Terrell & Hale, 1992; van Kleeck, 1994).


With the changing demographics in the United States and the differences that may occur between service providers and families in sociocultural characteristics (e.g., age, language, culture, race, gender, ethnicity, background, lifestyle, geography), it is important to gather information from families about the ways in which these factors may influence family-provider relationships and communication. For these reasons, some programs use cultural guides or cultural-linguistic mediators to facilitate communication and understanding between professionals and families (Barrera, 2000; Lynch & Hanson, 2004; Moore & Mendez, 2006). Moreover, from the perspective of “recommended practices” as well as policy (ASHA, 2004; IDEIA, 2004), all materials and procedures used in the provision of early identification and intervention services and supports should be culturally and linguistically appropriate for the individual child and family (ASHA, 2008a; National Association for the Education of Young Children [NAEYC], 2009).



Parental involvement in intervention


IDEIA (2004) (P.L. 108-446) ensures educational services for eligible infants, toddlers, children, and youth with disabilities. Under IDEIA, children with certain disabilities qualify for special education and related services designed to meet their unique needs and prepare them for further education, employment, and independent living. The law has specific provisions for ensuring that assessment and intervention are provided in a culturally and linguistically appropriate manner. Part B provides for children aged preschool through 21 years, including preparations for transition from school to community after age 21 years. Part C provides for infants and toddlers from birth through age 3 years. The law includes provisions to ensure parental participation in the decisions that are made regarding their child if they choose. If the native language of the parent is not English, the parents have the right to an interpreter for any and all sessions during which decisions are made regarding their child’s educational program. They have the right to participate in meetings related to the provision of clinical special education and related services for their child; to be members of any group that decides whether their child is a “child with a disability” and meets eligibility criteria for special education and related services; to be members of the team that develops, reviews, and revises the IEP for their child; and to be members of any group that makes placement decisions for their child. As reauthorized in 2004, IDEIA gives parents the right to refuse special education and related services or simply to not respond to a request by the school district to develop an IEP for the child.


The culture and beliefs of the parents can play a part in the willingness of the parent to participate in intervention decision regarding their child. They may have come from a culture where special educational service for children with disabilities does not exist or is delivered in ways quite different from in the United States. Cultural differences in attitudes toward disabilities may lead to parental decision to refuse special education and related services as allowed for under the law (Middleton, 2009). Given that the status of having a disability gives rise to a child’s right to special education and related services, a nexus is created between the connotations of “disability” and “special education.” Caruso (2005) argues that newcomers and persons from certain racial and ethnic groups “are likely to be hostile to the idea of special education, which they often deem stigmatizing.” Cultural beliefs can reduce the use of disability services by some families. Some families prefer family care to care involving strangers. Some mistrust Western systems because of an inability to relate to or understand the system. Others hold perceptions that disabilities are ascribed and therefore cannot be treated with intervention (Dunnett & Schlossar, 2004). In addition, some families attach social stigmas to disabilities—this is a fourth factor that has been identified as having a possible effect on whether culturally and linguistically diverse families use disability services (Caruso, 2005).



Response to intervention


The alignment of NCLB and IDEIA puts strong emphasis on achievement for all students. Specifically, NCLB and IDEIA focus on the improved achievement for students from low-income families, those from culturally diverse backgrounds, and English language learners (ELLs). Included in IDEIA is the suggested use of Response to Intervention (RTI) to increase the likelihood that all students will receive high-quality instruction and consequent progress monitoring before being referred for special education services. RTI is a comprehensive, multitiered strategy to enable early identification and intervention for students at academic or behavioral risk. It is an alternative to the discrepancy model for the identification of students with learning disabilities. It is an approach to providing services, interventions, and supports to struggling learners at increasing levels of intensity rather than waiting for a child to fail before offering help. It involves universal screening, high-quality instruction, and interventions matched to student need, frequent progress monitoring, and the use of child response data to make educational decisions. The approach uses early supports in three tiers before determining the need for special education and clinical intervention. The usual tiers are as follows: tier 1 includes intervention in the regular education classroom; tier 2 includes direct noncategorical, non–special education interventions such as after-school math and reading programs; and tier 3 includes special education with IEP. The RTI model presumes that if a child does not make adequate progress with intensive research-based instruction delivered in tiers 1 and 2, the child may require more individualized educational support and therefore will require special education or related services. It also presumes that if the child is able to make adequate progress with tier 1 or tier 2 supports, the child may not require special education or related services.


RTI has the potential to affect clinical intervention for culturally and linguistically diverse (CLD) children and ELLs by requiring the use of research-based practices based on individual children’s specific needs. Instruction and interventions must consider a student’s cultural background and experiences as well as linguistic proficiency (in both English and the native language) in order for instruction to be appropriate before determining that the child requires special education and related services as a child with a disability. RTI requires that clinicians consider students’ life experiences, including their language proficiencies in their first and second languages, as well as the contexts in which they are taught in developing early intervention programs.



Culturally and linguistically different students and response to intervention


When deciding whether a practice is appropriate for implementation as part of an RTI model, the practice must have been validated with students with whom the interventions will be used. The RTI model is a promising practice when used with CLD students because of the implementation of universally appropriate strategies for all students, and it must include evidenced-based strategies and pedagogy. Before determining whether a strategy is evidence based for students identified as CLD, the research must clearly disaggregate CLD variables as well as additional contextual variables (Klinger & Bianco, 2006). However, children identified as ELLs are often not included in research samples because of their limited English proficiency, and this results in limited external validity. Therefore, a prescribed strategy may not be appropriate for CLD students (Klinger & Edwards, 2006).


To promote cultural sensitivity in the implementation of RTI, Klinger and Edwards (2006) discussed the importance of the role of the teacher and teacher assistance teams in providing early intervention for CLD children. The researchers offered several concerns regarding culturally responsive environments in the classroom, including (1) the knowledge of the teacher about second language acquisition; (2) the knowledge of the teacher about bilingual education and English as second language teaching methods; (3) the teacher’s skill in effective intervention and assessment procedures for culturally and linguistically diverse students; and (4) the teacher’s culturally responsive attributes.


Under the traditional model of RTI, teacher assistance teams are put in place to facilitate the referral process when students are unresponsive to evidence-based instruction. Klinger and Edwards (2006) stated that the makeup of the team should be diverse and include members with expertise in culturally responsive instruction and, if appropriate, expertise in English language acquisition and bilingual education. There should be a team member who can offer guidance with culturally sensitive ongoing assessment. Teams should have a wide range of meaningful intervention strategies available to them. Using a problem-solving approach, they should determine how to alter the support a student has been receiving and develop specific instructional objectives based on student performance data. An SLP should be a member of the team because of the SLP’s expertise in language development and cultural and linguistic diversity.



Intervention with english language learners


Research has shown that instruction should be in the language used in the home in order to develop a firm foundation in the first language before the introduction of a second language. (See Chapter 7 for a further explanation of bilingual development and intervention for ELL children). Two approaches are recommended for intervention with ELLs: (1) provide intervention in the language of the child, and (2) provide intervention using the child’s home language and the language of the school if the clinician knows both languages. For example, when introducing concepts such as colors, shapes, and body parts to preschool children, the clinician should use both the child’s first language and English as a second language. Familiar preschool interactive activities can be used to increase receptive and expressive language skills, such as planting a seed. For example, goals should target words such as dirt, seed, water, cup, pour, window, and sun. The clinician can explain the activity in the child’s language and then provide the English word. The child will be instructed to point to the item in the first language and then to another item in English. The child should be required to explain the concept in both languages. If the child is hesitant to speak, the clinician can allow more response time. The child may be going through the silent period, which may last from a month to a year. During this time, the child may be increasing receptive language skills.


Values of the child’s culture should be taken into consideration. Information obtained in the ethnographic interview should help professionals provide services that will not cause cultural conflicts. Some cultures do not value competition, individualism, or self-fulfillment. Games that are competitive or require a winner may not be received well. Traditional reinforcers such as collecting tokens may not be effective for therapy. Parents should be consulted before selecting treatment plans and reinforcers, especially if food will be used as a reinforcer.



Language survival skills for older english language learners


Language survival skills should be an immediate intervention goal for new older ELLs and CLD students. Survival skills should be taught immediately at the preschool, grade school, and high school ages. Suggestions for topics at each age level are provided.


Prevocational skills or survival skills for young children are similar to prerequisites often required for (1) kindergarten entry, such as being able to provide personal information (full name, address, phone, and names of parents); (2) grade school, such as time concepts, money, and survival safety; (3) middle and high school (grades 7 to 12), such as vocational skills and goals. Professionals should incorporate into therapy goals information about job advertisements, applications, interviews, and expected performance. Lessons targeting pragmatic skills are a necessity for classroom and vocational success. Children from diverse cultures often have language and nonverbal styles that are different from those of mainstream cultural groups. Topics that should be covered are eye contact, gestures and facial expressions, polite terms, and conversational discourse rules. Because idioms and slang are culture bound, special therapy sessions and classroom activities should be provided to teach idioms and slang common to the culture or geographical area. Examples of idiomatic expressions common to people in the United States and some Western cultures are “catch a plane,” “hop a train,” “butterflies in your stomach,” “raining cats and dogs,” “piece of cake,” “costs an arm and a leg,” “break a leg,” “bite your tongue,” “cry wolf,” “dry run,” “funny farm,” “ride the short bus,” “not playing with full deck,” “high five,” “kicking it,” “bounce back,” and “kick the bucket.” These idioms may not be common to people outside the culture. Each geographic region may have different idiomatic expressions. Other suggestions about slang and business jargon may be sought from the students and members of the community (Roseberry-McKibbin, 2008a).


The following suggestions can be used by SLPs, classroom teachers, special education teachers, English as a second language teachers, and other professionals when providing intervention services to CLD children:




Culturally diverse families in early intervention


Part C of the IDEIA provides for early intervention (EI) for children from birth to the age of 3 years who are diagnosed as having a physical or mental condition (with a high probability of resulting in a developmental delay), have an existing delay, are at risk for developing a delay, or have a special need that may affect their development or impede their education. The purpose of early intervention is to lessen the effects of the disability or delay. Services are designed to identify and meet a child’s needs in five developmental areas: physical development, cognitive development, communication, social or emotional development, and adaptive development. A major goal of EI is to ensure that families who have children ages birth to 3 years with a diagnosed disability, developmental delay, or substantial risk for significant delay receive resources and supports that assist them in maximizing their child’s development while respecting the diversity of families and communities.


The past two decades have seen a shift from direct services to the child toward services involving the families and caregivers as collaborators (Madding, 2000). This shift brings the primary focus of intervention to the level of the family system (Hanson & Lynch, 1995; Mahoney et al., 1999). The family system model relies on the education and empowerment of parents and caregivers to use strategies to improve their children’s communication. The model is potentially culturally problematic if parents and EI providers do not share the same assumptions and understandings about their roles in the collaboration (Lowenthal, 1996; Lynch & Hanson, 2004; Madding 1996; Rivers, 2000; van Kleek, 1994). Differences in such assumptions can be influenced further by socioeconomic status of the families served by EI providers in early intervention settings. Specifically, issues such as parent education and literacy, availability of materials such as books and toys, and context such as the physical space accessible for child-focused activities also influence the focus of such services.


According to Peña and Fiestas (2009), families from diverse cultural backgrounds and lower socioeconomic levels are less pleased with early intervention services than their white families and families of higher socioeconomic levels. They cited the problem areas as differences in (1) parent education and training, (2) expectations or outcomes of intervention, (3) parent literacy, and (4) availability of space and material. Many of the Latina mothers in their study appeared uncomfortable using the techniques suggested in training. According to Madding (1999), Hispanic mothers in a center-based intervention program appeared uncomfortable playing on the floor with their children or using reciprocal interactions to improve their children’s communication. The mothers appeared unconvinced of the value of using reciprocal interactions, a common strategy taught to parents to improve their children’s communication. Likely, they did not see their role as that of an equal conversational partner with their children (Zayas & Solari, 1994). The parents reported they did not perceive their role to be playmate and teacher for their children, but rather they saw themselves as caretaker. The studies show that the use of common elicitation techniques suggested by SLPs for children with language delay may be contrary to child-rearing practices and communication styles in various cultures. Conflict may occur when practices for early intervention, such as teaching parents strategies for modeling communication development, are not congruent with those of the parents. The clinician should explain the purpose of the activity and its expected outcome.


Parents from some cultures view parental involvement in intervention differently from what some professionals expect. They may not feel comfortable participating in planning IEPs or in engaging in practice at home. Expecting parents to view themselves as service providers and parent-teachers may present a problem for those who do not see themselves in this role because of their cultural values. Some cultures do not feel that parents should “play” with children.


Parents from some groups, such as Asian and Pacific Islanders and Hispanics/Latinos, see the clinician as the utmost authority over the child’s education or intervention program. They believe that parents are not supposed to interfere with this process and may regard clinicians who seek parental involvement as incompetent (Peña & Fiestas, 2009). It is important to explain that parental involvement is part of the intervention program. However, because the level of parental involvement varies with cultures, parents and caretakers should be involved in the clinical process according to their cultural values.


Developmental milestones, such as walking, drinking from a cup, eating solid foods, toilet training, and sleeping alone, are influenced by culture. Some cultures do not expect children to engage in equal conversational turn-taking with adults. Other cultures expect young children to have proto-conversations and real conversational dyads very early (Peña & Fiestas, 2009).


Access to materials and space may be challenging for low-income or culturally and linguistically diverse families. Toys, books, computers, electronic toys, and play materials are often used to stimulate development. If the parents cannot read aloud to their children because of their literacy level or because suitable books are not readily available in their home language, they may not be able to use the home language stimulation techniques suggested by the clinician. Using books without words or picture books may also not be appropriate if the story or events in the books are culturally unfamiliar or inappropriate to the family (Evans, 2004).


Successful evidence-based practices should be consistent with the family’s culture, values, socioeconomic status, language, religion, and educational level. Cultural sensitivity and acceptance are also important. The professional should use direct and indirect intervention techniques. When visiting the homes, indirect approaches are recommended and should be based on routines. Routine-based approaches can highlight aspects of communication development that are important to the family. Use of the routine-based approach gives the family the opportunity to determine the appropriate outcome for the child. Examples of a routine-based approach include naming colors of clothing when getting dressed, naming the types of clothing, and addressing body parts by discussing where each article of clothing will be placed.


When visiting the home, the clinician should find out the rules of the household. Many cultures expect a visitor to remove shoes before entering the home. For persons from some cultures, it is unacceptable to consider providing intervention in the home.


The NAEYC (2009) has developed quality benchmarks for cultural competence for working with the families of young children. The initial concepts that define cultural competence for working with young children are especially important when providing intervention in the home of the family and include the following (pp. 3-4):




Literacy


Alphabet knowledge and phonologic awareness are strong predictors of successful literacy development in children. It is particularly important to recognize the role that phonologic awareness plays in ELLs who must learn to read both in their native language (L1) and in their second language (L2). Recent research reported by Ford (2009) has shown that, for ELLs, phonologic awareness in the L1 predicts successful literacy acquisition in both L1 and L2. In other words, phonologic awareness skills developed in L1 transfer to L2 and facilitate L2 literacy development. Phonologic awareness skills developed in one language can transfer to another language, even while those skills are still in the process of being developed (Cisero & Royer, 1995). Although this is often an advantage, ELLs may inappropriately generalize their first language’s rules of syntax, spelling, phonology, or pragmatics to their second language, resulting in an adverse effect on L2 literacy acquisition (Bialystok, 2002; Brice & Roseberry-McKibbin, 2001). Based on a study of the connection between L1 language phonologic skills and L2 reading with 92 Spanish-speaking first-graders, Gottardo (2002) found that the strongest predictors of English word reading ability were L1 and L2 phonologic processing, L1 reading, and L2 vocabulary.


The closer the phonologies of L1 and L2 are to each other the greater the likelihood that transfer of skills will be positive rather than negative because children are more adept at manipulating the sounds and patterns that exist in their native language (Bialystok, 2002). For example, if both L1 and L2 are alphabetic languages, transfer will be facilitated, although positive transfer has also been documented between languages with very different orthographies, such as Cantonese and English (Gottardo et al., 2001). An important factor here may be the type of phonologic skill in question. As Durgunoglu (2002) notes, “there are certain literacy concepts and strategies that can be universal and operate across languages. These insights and skills need to be acquired only once and apply in all languages of LLs. However, there are also language-specific concepts and knowledge; for example, orthographic patterns that are specific to a language” (p. 192).


The goal of literacy training is to increase phonologic awareness, reading, writing, and spelling abilities. Phonologic awareness is a necessary foundation for a variety of skills including reading, writing, and spelling. The best strategies for improving phonologic awareness incorporate direct phonologic instruction. Direct phonologic instruction has been proved effective with monolingual and bilingual children. Roseberry-McKibbin (2008b) concluded that junior high school and high school students, regardless of their first language, who received specific phonologic awareness intervention showed improvement in their reading ability. Roseberry-McKibbin (2007) reported that ELL students of all ages who were poor readers and spoke English as their second language and who received direct, specific phonologic awareness intervention showed improvement in their ability to analyze the phonologic construct of words. Phonologic awareness strategies have also been effective in accent reduction.


Children who are CLD and ELLs have several major challenges to succeeding in school. They are often learning a second or third language while they are attempting to master academic skills appropriate for their grade level. An additional challenge will be placed on the child who has a language or learning disability. Children who are CLD and ELLs and are learning another language need extra support in preliteracy skills such as phonologic awareness. Measurable gains were achieved in one semester by children receiving this support.


Professionals are also encouraged to help CLD and ELL students focus on reading comprehension, create a culturally diverse environment, and develop reading strategies. These students may benefit from interactive book reading with discussions about what was been read, small group tutoring, and participation in reading groups. Younger children may enjoy read-aloud programs at the library and interactive computer programs. Numerous free read-along and read-aloud programs are available online. One program has famous people reading aloud with captions below (www.storylineonline.net/).

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Nov 8, 2016 | Posted by in NEUROLOGY | Comments Off on Intervention for multicultural and international clients with communication disorders

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