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1.
Although the association between adverse childhood experiences (ACEs) and adult mental health is becoming well established, less is known about the complex and multiple pathways through which ACEs exert their influence. Growing evidence suggests that adversity early in life conveys not only early impacts, but also augments risk of stress-related life course cascades that continue to undermine health. The present study aims to test pathways of stress proliferation and stress embodiment processes linking ACEs to mental health impairment in adulthood. Data are from the 2011 Behavioral Risk Factor Surveillance Survey, a representative sample of Washington State adults ages 18 and over (N = 14,001). Structural equation modeling allowed for testing of direct and indirect effects from ACEs though low income status, experiences of adversity in adulthood, and social support. The model demonstrated that adult low income, social support and adult adversity are in fact conduits through which ACEs exert their influence on mental health impairment in adulthood. Significant indirect pathways through these variables supported hypotheses that the effect of ACEs is carried through these variables. This is among the first models that demonstrates multiple stress-related life course pathways through which early life adversity compromises adult mental health. Discussion elaborates multiple service system opportunities for intervention in early and later life to interrupt direct and indirect pathways of ACE effects.  相似文献   

2.
Adverse childhood experiences (ACEs) have been linked to negative health outcomes in adulthood, but little research has been done on the effect of ACEs on the health and well-being of adults in South Carolina (SC). This study analyzed a sample of 9744 respondents who participated in the 2014 South Carolina Behavioral Risk Factor Surveillance System (BRFSS) to examine the relationship among childhood experiences of physical, sexual, and emotional abuse, as well as witnessing household violence, on mental and physical health outcomes in adulthood among SC residents. Twenty-two percent of survey respondents reported poor general health (22.1%), and a smaller proportion reported high frequent mental distress in the past month (13.1%). Each category of childhood experiences was associated with an increase in the risk of poor general health. Individuals reporting three or more types of experiences were more likely to report poor health (aOR 2.89; 95% CI 2.86–2.92) than adults without such experiences. Respondents reporting three or more types of childhood adverse experiences were more likely to report frequent mental distress (aOR 3.29; 95% CI 3.26–3.33) compared to adults who did not report three or more types of adversity. Findings from the SC BRFSS highlight a connection between ACEs and negative health outcomes later in life. Given that results of this study also demonstrated that increased exposure to ACEs was associated with greater odds of negative health in adulthood, preventing adverse events such as experiencing abuse or witnessing domestic violence in childhood will have significant effects on later adult health.  相似文献   

3.
Adverse childhood experiences (ACEs) are risk factors for interpersonal difficulties in adulthood, however the mechanism that underlies this association is unknown. The current study investigated the association of a wide range of ACEs with interpersonal difficulties in adulthood, and tested whether emotion dysregulation mediated the relationship between ACEs and interpersonal difficulties. Patients over the age of 18 were recruited from primary care clinics (N = 4006). Participants completed self-report questionnaires that assessed ACEs, emotion dysregulation, and interpersonal difficulties. Results indicated that, after controlling for a range of demographic variables, each type of ACE significantly predicted increased interpersonal difficulties and that cumulative ACEs predicted increased interpersonal difficulties, F(8, 3137) = 39.68, p < .001, R2 = 0.09. Further, emotion dysregulation mediated the association between ACEs and interpersonal difficulties, B = 0.79, SE = 0.09, 95% CI [0.64, 0.97]. These findings emphasize the role of childhood adversity on interpersonal functioning in adulthood, and highlight emotion dysregulation as a mechanism by which this association occurs. Results have the potential to inform preventative and treatment efforts to improve adaptive outcomes among individuals with a history of childhood adversity.  相似文献   

4.
Suicide is among the main causes of death of people aged between 15 and 44 years old. Childhood trauma is an important risk factor for suicide. Hence, the objective of this study was to verify the relationship between childhood trauma and current suicide risk (suicidal behavior and ideation) in individuals aged 14–35 years, in the city of Pelotas, Brazil. This is a cross-sectional, population-based study. Sample selection was performed by clusters. Suicide risk was evaluated using the Mini International Neuropsychiatric Interview (MINI) and Childhood trauma was assessed with the Childhood Trauma Questionnaire (CTQ). Moreover, the participants responded to a questionnaire concerning socioeconomic status, work, and substance use. The sample was composed of 1,380 individuals. The prevalence of suicide risk was 11.5%. The prevalence figures of childhood trauma were 15.2% (emotional neglect), 13.5% (physical neglect), 7.6% (sexual abuse), 10.1% (physical abuse), and 13.8% (emotional abuse). Suicide risk was associated (p < .001) with gender, work, alcohol abuse, tobacco use, and all types of childhood trauma. The odds of suicide risk were higher in women (OR = 1.8), people who were not currently working (OR = 2.3), individuals who presented alcohol abuse (OR = 2.6), and among tobacco smokers (OR = 3.4). Moreover, suicide risk was increased in all types of trauma: emotional neglect (OR = 3.7), physical neglect (OR = 2.8), sexual abuse (OR = 3.4), physical abuse (OR = 3.1), and emotional abuse (OR = 6.6). Thus, preventing early trauma may reduce suicide risk in young individuals.  相似文献   

5.
Adverse childhood experiences (ACEs) are important public health concerns, with links to higher prevalence rates of both health-risk behaviors and physical health difficulties in adulthood. Research has demonstrated an association between early adversity and long-term health-risk behavior development. The current study assessed the role of emotion dysregulation and facets of impulsivity as potential mediators in the relation between ACEs and general health-risk behaviors, including alcohol-related consequences and risky sexual behavior. College students (N = 668) completed online questionnaires that assessed history of ACEs, emotion regulation difficulties, impulsivity under extreme affect, and current engagement in health-risk behaviors. Emotion dysregulation and impulsivity under extreme positive emotion, but not negative emotion, demonstrated a significant serial mediation between ACEs and alcohol-related consequences. Results also suggest that emotion dysregulation mediates the relation between early adversity and all three outcomes (i.e., overall engagement in maladaptive behavior, alcohol-related consequences, and risky sexual behavior). Impulsivity under positive or negative affect did not demonstrate a mediation effect on the three outcomes. Results of this study highlight the importance of assessing for emotion regulation skills when working with young adults with histories of adversity.  相似文献   

6.
The goal was to identify factors that might affect likelihood of seeking health-related interventions for young adults with adverse childhood experiences (ACEs). We tested whether ACEs were associated with (1) regulatory focus (tendency toward promoting good outcomes versus preventing bad outcomes), and (2) patient activation (the intention to take active charge of one’s health). We further tested whether promotion and prevention and patient activation were associated with each other and with health. Students at a public university (N = 321) completed online questionnaires assessing ACEs, regulatory focus, patient activation, and health. Greater childhood adversity showed small but significant associations with being a less activated patient and being less focused on promoting good outcomes. In contrast, greater childhood adversity had a much stronger association with focusing on preventing negative outcomes. Students with a more significant mental health history were more likely to have been exposed to childhood adversity, to be less activated patients, and to focus more on prevention. Results suggest that using a prevention focus may be effective in health messages aimed to reach individuals with high levels of ACEs. Furthermore, individuals with high levels of ACEs may benefit from interventions aimed at increasing patient activation.  相似文献   

7.
BackgroundAdverse childhood experiences (ACEs) are a potent risk factor. Despite these findings, studies have also recognized the importance of considering additional sources of genetic and environmental influence that cluster within families.ObjectiveTo properly control for latent sources of genetic and within-family environmental influences and isolate the association between ACEs and the following outcomes in adulthood: physical health, depressive symptoms, educational attainment, income attainment, alcohol problems, and antisocial behavior.Participants and SettingTwo independent samples of twins and siblings from the United States: the Midlife Development in the United States (MIDUS) study (N = 862) and the National Longitudinal Study of Adolescent to Adult Health (Add Health; N = 3112).MethodsSibling comparison models, which control for latent sources of genetic and within-family environmental influences, were estimated to examine whether differential exposure to ACEs was associated with the examined outcomes.ResultsFamilies that experienced more adversity also experienced more deleterious outcomes. However, siblings that experienced more adversity were no more likely to experience deleterious outcomes than their co-siblings. However, greater exposure to ACEs was associated with increases in depressive symptoms (Add Health). Additional models revealed that the similarity between siblings from the same family stemmed from latent sources of within-family environmental influences not captured by traditional ACEs measures.ConclusionsConsidering genetic influences and additional latent sources of within-family influences is crucial in isolating the effects of ACEs. Currently employed ACEs measures may not adequately capture the full range of impactful sources of family-level environmental influence.  相似文献   

8.
Research has demonstrated the negative impact of Adverse Childhood Experiences (ACEs) on long-term trajectories of mental and physical health. Yet existing literature on this topic is limited in its understanding of outcomes among youth samples, optimal measurement items and methods, and differences in adverse experiences across race/ethnicity. The current study used a person-centered approach to measure ACEs and their impact on youth health outcomes across three different racial/ethnic groups from a large national database. Patterns of exposure to adverse experiences among Black, Latinx, and White youth (N = 30,668, ages 12–17) were determined empirically using latent class analysis (LCA). Significant differences in class membership by demographic indicators (age, household income, sex) and concurrent health outcomes were identified. Different models emerged for Black (2 classes), Latinx (3 classes), and White youth (3 classes). Older and lower-income youth were more likely to have experienced adversities, but there were no differences in adversity likelihood by sex. Additionally, racial/ethnic minority youth were at greater risk of experiencing higher levels of adversity, poverty, and poor health when compared to their White counterparts. Rather than occuring in meaningful clusters, adverse experiences among youth reflected a cumulative risk model such that classes were defined by the overall intensity of adverse experiences (i.e., low, moderate, high). Findings provide greater knowledge regarding the relationship between ACEs and health and future research directions to inform more targeted and culturally-appropriate screening, prevention, and intervention programs.  相似文献   

9.
Although Adverse Childhood Experiences (ACEs) are linked to increased health problems and risk behaviors in adulthood, there are no studies on the association between ACEs and adults’ states of mind regarding their early childhood attachments, loss, and trauma experiences. To validate the ACEs questions, we analyzed the association between ACEs and emotional support indicators and Adult Attachment Interview (AAI) classifications in terms of unresolved mourning regarding past loss or trauma and discordant states of mind in cannot classify (U/CC) interviews. Seventy-five urban women (41 clinical and 34 community) completed a questionnaire on ACEs, which included 10 categories of abuse, neglect, and household dysfunction, in addition to emotional support. Internal psychological processes or states of mind concerning attachment were assessed using the AAI. ACE responses were internally consistent (Cronbach's α = .88). In the clinical sample, 84% reported ≥ 4 ACEs compared to 27% among the community sample. AAIs judged U/CC occurred in 76% of the clinical sample compared to 9% in the community sample. When ACEs were ≥ 4, 65% of AAIs were classified U/CC. Absence of emotional support in the ACEs questionnaire was associated with 72% of AAIs being classified U/CC. As the number of ACEs and the lack of emotional support increases so too does the probability of AAIs being classified as U/CC. Findings provide rationale for including ACEs questions in pediatric screening protocols to identify and offer treatment reducing the intergenerational transmission of risk associated with problematic parenting.  相似文献   

10.

Objective

The goal of this study was to investigate the adverse childhood experiences (ACEs) in youth in a low-income, urban community.

Study design

Data from a retrospective chart review of 701 subjects from the Bayview Child Health Center in San Francisco are presented. Medical chart documentation of ACEs as defined in previous studies were coded and each ACE criterion endorsed by a traumatic event received a score of 1 (range = 0-9). This study reports on the prevalence of various ACE categories in this population, as well as the association between ACE score and two pediatric problems: learning/behavior problems and body mass index (BMI) ≥ 85% (i.e., overweight or obese).

Results

The majority of subjects (67.2%, N = 471) had experienced 1 or more categories of adverse childhood experiences (ACE ≥ 1) and 12.0% (N = 84) had experienced 4 or more ACEs (ACE ≥ 4). Increased ACE scores correlated with increased risk of learning/behavior problems and obesity.

Conclusions

There was a significant prevalence of endorsed ACE categories in this urban population. Exposure to 4 or greater ACE categories was associated with increased risk for learning/behavior problems, as well as obesity.

Practice implications

Results from this study demonstrate the need both for screening of ACEs among youth in urban areas and for developing effective primary prevention and intervention models.  相似文献   

11.
BackgroundExtensive research has documented the association between adverse childhood experiences (ACEs) and poor outcomes later in life, as well as the high prevalence of ACEs in the American population. Studies consistently find that over half of American adults have experienced at least one ACE. Despite this, research on the long-term impacts of ACEs is challenging due to the complex nature of adversity.ObjectiveOur study aimed to define underlying constructs of adversity, and explore how they changed throughout childhood, in a low-income population.Participants and SettingWe fielded a survey to Medicaid-enrolled adults in the Portland, OR metropolitan area.MethodsOur survey captured different experiences in childhood, including relationships and support, educational challenges, housing and employment stability, neighborhood environment, discrimination, abuse, neglect, and household dysfunction; questions were asked for 6–12 and 13–18 years of age. We then used factor analysis to identify underlying constructs of adversity in the two age ranges.ResultsWe identified two factors - Inadequate Emotional Support and Instability – in each age range. Inadequate Emotional Support remained consistent in both time periods while the Instability factor changed, expanding from household-centric experiences in childhood to a wider variety of experiences in adolescence. Additionally, a number of variables did not load on either factor in either age range.ConclusionsThese results underscore the importance of expanding how we think about instability specifically, and childhood adversity in general.  相似文献   

12.
Although adolescents with delinquency are known to have higher-than-average rates of depression or substance use disorder (SUD), research on the topic is inconsistent. It remains unclear weather depression or SUD leads to delinquency, whether delinquency leads to depression or SUD, or whether there is bi-directionality. Utilizing the National Survey of Child and Adolescent Well-Being (Wave I: 2008–2009; Wave II: 18 months later: N = 5872), we used logistic regression to predict depression from delinquency (and vice versa), and SUD from delinquency (and vice versa). After inclusion of control variables, we found that females with minor theft in Wave I were more than 4 times as likely (adjusted odds ratio [aOR] = 4.34; 95% CI: 1.10–17.16) as females without minor theft to be depressed in Wave II, and those with public disorder in Wave I were almost 3 times as likely (aOR = 2.74; 95% CI: 1.03–7.30) as those without public disorder to have SUD in Wave II. Overall delinquency also predicted depression or SUD, and SUD predicted delinquency. Practitioners could address risk for depression or SUD among child welfare-involved adolescent females by focusing on overall delinquency or on specific types of delinquency (minor theft for depression and public disorder for SUD) and by offering interventions (e.g., cognitive-behavioral psychotherapy) that have been shown to be effective in preventing depression or SUD. In addition, with respect to our finding that SUD predicts delinquency among adolescent females, practitioners can help prevent delinquency by offering interventions (e.g., intensive outpatient treatments) that have well documented effectiveness in addressing SUD.  相似文献   

13.
The current study examined the association between child maltreatment and trauma-related symptoms in emerging adulthood – over and above the incidence of such symptoms and conduct problems during adolescence – among a sample of female adolescents in residential care. This study used data from a longitudinal study. The sample was composed of 89 adolescent females who were first interviewed at time of admission in a residential center (Mage = 15.33 years, SD = 1.31) and later in young adulthood (Mage = 19.27, SD = 1.55). At time 1, trauma-related symptoms were assessed with the Trauma Symptom Checklist for Children and conduct problems with a composite measure. At time 2, child maltreatment was assessed retrospectively with the Childhood Trauma Questionnaire, and trauma-related symptoms were reassessed with the Trauma Symptom Inventory-2. Results indicated that child maltreatment, especially emotional abuse and neglect, was related to anxious arousal, depression, and anger in emerging adulthood. This study showed that females from our sample often reported different types of maltreatment during childhood and that these traumatic experiences were significantly associated with poor adult psychological functioning.  相似文献   

14.
Adverse childhood experiences (ACE) tend to be interrelated rather than independently occurring. There is a graded effect associated with ACE exposure and pathology, with an increase when ACE exposure is four or more. This study examined a sample of active individuals (n = 129) to determine distribution patterns and relationships between ACEs, attachment classification, unresolved mourning (U), and disclosure difficulty. The results of this study demonstrated a strong relationship between increased ACEs and greater unresolved mourning. Specifically, the group differences for individuals who experienced no ACE (n = 42, 33%), those with 1–3 ACEs (n = 48, 37.8%), and those with ≥4 ACEs (n = 37, 29.1%) revealed a pattern in which increased group ACE exposure was associated with greater lack of resolution for past trauma/loss experiences, more adult traumatic events, and more difficulty disclosing past trauma. Despite ≥4 ACEs, 51.4% of highly exposed individuals were classified as secure in the Adult Attachment Interview. Resilience in this group may be related to a combination of attachment security, college education, and engagement in meaningful activities. Likewise, adversity may actually encourage the cultivation of more social support, goal efficacy, and planning behaviors; factors that augment resilience to adversity.  相似文献   

15.
Adverse childhood experiences (ACEs) have lifetime consequences for health and development. Identification of ACEs early in childhood provides the potential to intervene before health and development are impaired. This study examined the timing and duration of exposure to ACEs experienced by children from low-income families from ages one to three years to identify whether there were patterns of exposure when infants and toddlers were most vulnerable. We were able to confirm the early negative consequences on cognitive, health, and behavior outcomes previously reported in young children using a national, longitudinal data set of parents and children from low-income households (N = 2250). Using Finite Mixture Models, five classes of exposure were identified for children, Consistently Low (63.8%), Decreasing (10.3%), High at Age 2 (11.4%), Increasing (10.4%), and Consistently High (4%). The Consistently Low and Consistently High classes had the most and least optimal development across all domains, respectively. When examining child development outcomes among children with variable exposures to adversities, we found that for cognitive, language, and physical development, the most proximal ACEs were more robust for predicting child outcomes. For socioemotional health, exposure at any time from one to three to ACEs had negative consequences. As a whole, findings from this study highlight the need to consider ACEs screening tools that are both time-sensitive and permit a lifetime report.  相似文献   

16.
BackgroundNumerous studies over the past two decades have found a link between adverse childhood experiences (ACEs) and worse adult health outcomes. Less well understood is how advantageous childhood experiences (counter-ACEs) may lead to better adult health, especially in the presence of adversity.ObjectiveTo examine how counter-ACEs and ACEs affect adult physical and mental health using Resiliency Theory as the theoretical framework.Participants and settingParticipants were Amazon mTurk users ages 19–57 years (N = 246; 42% female) who completed an online survey.MethodsWe conducted a series of regression analyses to examine how counter-ACEs and ACEs predicted adult health.ResultsCorresponding to the Compensatory Model of Resiliency Theory, higher counter-ACEs scores were associated with improved adult health and that counter-ACEs neutralized the negative impact of ACEs on adult health. Contrary to the Protective Factors Model, there was a stronger relationship between ACEs and worse adult health among those with above average counter-ACEs scores compared to those with below average counter-ACEs scores. Consistent with the Challenge Model, counter-ACEs had a reduced positive effect on adult health among those with four or more ACEs compared to those with fewer than four ACEs.ConclusionsOverall, the findings suggest that counter-ACEs protect against poor adult health and lead to better adult wellness. When ACEs scores are moderate, counter-ACEs largely neutralize the negative effects of ACEs on adult health. Ultimately, the results demonstrate that a public health approach to promoting positive childhood experiences may promote better lifelong health.  相似文献   

17.

Objectives

This study replicates and extends the research literature on poly-victimization with a vulnerable and under-served population, juvenile justice-involved youths.

Methods

N = 1959, 10–16 year old youths (76% male; 74% youth of color) consecutively newly admitted to juvenile detention facilities completed psychometric measures of trauma history, posttraumatic stress, affect regulation, alcohol/drug use, suicide risk, and somatic complaints.

Results

Using latent class analysis derived from 19 types of adversity, three unique classes best fit the data. A poly-victim class (49% female, 51% youth of color) accounted for 5% of the sample and reported a mean of 11.4 (SD = 1.1) types. A relatively moderate adversity class (31% female, 70% youth of color) accounted for 36% of the sample and reported a mean of 8.9 (SD = 0.3) types of adversity and 2.65 (SD = 1.1) types of traumatic adversity. A low adversity class (59% of the sample; 17% female, 78% youth of color) reported a mean of 7.4 (SD = 0.4) adversity types but only 0.3 (SD = 0.45) types of traumatic adversity. The relatively moderate adversity class was comparable to poly-victims in endorsing extensive non-victimization traumatic adversity (e.g., accidental and loss trauma), but poly-victims were distinct from both moderate and low adversity class members in the likelihood of reporting all but one type of traumatic victimization, multiple types of traumatic victimization, and severe emotional and behavioral problems. Girls were at particularly high risk of poly-victimization, and African American and White youths also were at risk for poly-victimization.

Conclusions

Although youth involved in the juvenile justice system typically have experienced substantial victimization, a poly-victimized sub-group, especially (but not exclusively) girls, warrants particular scientific, clinical, and rehabilitative attention in order to address the most severe behavioral and mental health problems and risks faced by this vulnerable population.  相似文献   

18.
This study contributed to the school readiness literature by taking an intrachild perspective that examined the relations between Latino/a children's school readiness profiles and later academic achievement. Teachers rated the school readiness of 781 Latino/a kindergartners during the first month of school using the Kindergarten Student Entrance Profile (KSEP). Latent class analysis (LCA) examined KSEP profiles across social-emotional, physical, and cognitive domains and identified five distinct school readiness classes that described students’ strengths and weaknesses at kindergarten entry. Among the predictors examined, gender was the only significant difference among the top two readiness classes, with girls less likely to be in the lower of these two classes (OR = 0.38). In addition, children in the bottom three readiness classes were significantly less likely than students in the top readiness class to have preschool experience (ORs = 0.02–0.19) and had significantly lower levels of English proficiency (ORs = 0.51–0.72). Class membership was significantly associated with scores on the Grade 2 California Standards Tests and only the top two readiness classes had reading fluency rates near or above a national benchmark at the end of Grade 2. The variation of early achievement found across readiness classes also showed that considering the pattern of a child's social-emotional and cognitive readiness might enhance school readiness assessment. Implications for integrating universal school readiness screeners within a comprehensive multigating assessment model are also discussed.  相似文献   

19.
Brain development in the early years is especially susceptible to toxic stress caused by adverse childhood experiences (ACEs). According to epigenetics research, toxic stress has the capacity to physically change a child’s brain and be hardwired into the child’s biology via genes in the DNA. The compelling nature of the impact of early adversity on later health and development has generated interest in protection against the impact of early adversity. Research highlights three interrelated “core protective systems” associated with positive adaptation. Early childhood educators are in a unique position to play a role in early identification of ACEs and to contribute to the development of protective skills. Adults within the early childhood education community can assist in increasing physical health and mental well-being for children who have encountered ACEs. Safe and healthy environments that allow the child to play, explore, and maximize his/her capacities are examples of how individual protective factors can be enhanced. Early childhood educators can support the child’s protective system by building the child’s personal attributes associated with resiliency, such as self-efficacy and self-regulation. Early childhood educators can provide a secure relationship, which is especially critical for children who have experienced trauma because it can provide extra support in times of stress. Additionally, by working collaboratively with parents, early childhood educators provide an additional layer of protection for children who experience adversity. Lastly, at the community level, early childhood educators can bring awareness to the public and private sectors by informing others of ACEs effect on early brain development and the link to later outcomes on individuals and society. Society is positively impacted when ACEs are reduced and individuals are raised in thriving families and communities.  相似文献   

20.
BackgroundAdverse childhood experiences (ACEs) are an identified risk factor for the social and emotional development of children. What is less known is the long-term effects of ACEs when poverty and ACEs coincide.ObjectiveUsing longitudinal cohort-panel data, we examined whether exposure to ACEs by the age of three among poor children would longitudinally result in behavioral problems at ages three, five, nine, and 15, after controlling for mothers’ socioeconomic status and their children’s characteristics.Participants and settingWe used a subsample of 2750 children and their parents living in urban poverty from the Fragile Families and Child Wellbeing study.MethodsLogistic regression modeling was used to obtain adjusted odds ratios of ACE categories predicting behavioral problems after accounting for family socioeconomic position.ResultsOur findings indicate that experiencing ACEs in early childhood was significantly associated with later behavioral outcomes from childhood to adolescence. Exposure to multiple ACEs before the age of three was significantly associated with the top-risk behavior group at age five; the odd ratios were 2.0 (CI = 1.3–3.1) and 2.9 (CI = 1.8–4.6) for two ACEs and three or more ACEs, respectively. At both ages nine and 15, children experiencing two or more ACEs had 1.9 to 3.2 times higher odds to demonstrate more the top 10th percentile of behavioral problems. Among covariates, mothers’ race and education, and children’s gender and temperament were identified as significant factors to determine behavior problems.ConclusionsThe findings support policies and programs for families with children who have experienced economic disadvantages and early childhood adversity.  相似文献   

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