Diagnostic Implications of Informant Disagreement
for Manic Symptoms
Gabrielle A. Carlson, M.D., and Joseph C. Blader, Ph.D.
manic symptoms and when only a parent observes them. We hypothesized that the diagnosis of mania/bipolar (BP) disorder
would occur when there is parent/teacher concordance on high mania symptom scores.
Methods: Subjects were 911 5–18-year-old psychiatrically diagnosed youths with caregiver and teacher completed Child
Mania Rating Scales (CMRSs) and Achenbach parent and teacher forms. Parent–teacher concordance on the CMRS was
definedasbothinformants ‡75percentileontheCMRS;discordanceontheCMRSwasdefinedasparent ‡75percentileand
teacher £25 percentile. Logisticregressionexaminedfactorsassociatedwith achild’sparentand teacher ratingsconcordant
for high CMRS total scores.
Results: Correlation between parent CMRS (CMRS-P) and teacher CMRS (CMRS-T) scores was r=0.27 (p<0.000).
Correlation between the CMRS-P and the Child Behavior Checklist ‘‘bipolar/dysregulation’’ phenotype was r=0.757 and
911 children were diagnosed with BP I (n=20) or II (n=3) or BP disorder not otherwise specified (BPNOS, n=43). If the
or disagreement did not add to diagnostic accuracy for students with BP I or II. BPNOS was more common in children with
who were diagnosed with externalizing disorders (attention-deficit/hyperactivity disorder, oppositional defiant disorder,
3.7 times more likely to have discordant CMRS-P/CMRS-T ratings.
Conclusion: Parent and teacher concordance on high mania rating scale scores was most associated with externalizing
disorders, and discordance was most associated with internalizing disorders.
givers, youths, and teachers when describing the mood and
behavior of children and adolescents. Meta-analyses have found
correlations in the 0.2–0.3 range (Achenbach et al. 1987) between
the various informants. However, as information provided by each
person typically meets high standards for internal consistency re-
liability and retest stability (Achenbach and Rescorla 2001), poor
reliability is not the explanation.
Reasons for poor agreement have included the fact that chil-
dren’s behavior changes with settings and contexts, that informants
interpret symptom statements in terms of behaviors that are most
relevant for their daily concerns, and that, depending on the dis-
order, one informant may simply be more knowledgeable than
another (Hartley et al. 2011; Gadow et al. 2004; De Los Reyes and
nly modest levels of agreement are found between care-
Kazdin 2005). Jensen et al. (1999) have suggested that discrepant
diagnoses (those reported by one but not the other informant) may
reflect meaningful clinical conditions and that further research is
needed to determine the diagnostic impact of informant discrep-
Several studies have examined parent–child concordance in
mania or manic symptoms (Thuppal et al. 2002; Tillman et al.
2004; Youngstrom et al. 2004; Biederman et al. 2009). As with
other disorders, rates of parent–child concordance are relatively
low. However, investigators have drawn somewhat different con-
clusions. In one case, using interviews, researchers said that qual-
itative information about mania was no different in instances in
which the child did or did not agree with the parent (Biederman
et al. 2009) and concluded that if the manic syndrome looked the
same, the child informant did not add anything. In another, manic
symptoms reported by the child were felt to substantially add to
Division of Child and Adolescent Psychiatry, Department of Psychiatry and Behavioral Science, Stony Brook University School of Medicine, Putnam
Hall-South Campus, Stony Brook, New York.
JOURNAL OF CHILD AND ADOLESCENT PSYCHOPHARMACOLOGY
Volume 21, Number 5, 2011
ª Mary Ann Liebert, Inc.
diagnosis (Tillman et al. 2004). In a third, youth-contributed
symptoms concurred less often with clinician ratings than parent
reports did (Youngstrom et al. 2004) and were thus felt to be less
relevant. Finally, when parent, teacher, and child agreement on
a greater likelihood for serious and possibly manic disorders to be
diagnosed if at least two of three informants agreed about the
presence of manic symptoms (Thuppal et al. 2002). Unfortunately,
there is some degree of tautology to these conclusions as the cli-
nician making the diagnosis puts more weight on parent informa-
tion if a structured interview is the diagnosis gold standard or on
information if there is concordance between at least two infor-
Four studies have focused on the significance of teacher infor-
mation related to a diagnosis of mania (Geller et al. 1998a; Carlson
and Youngstrom 2003; Youngstrom et al. 2004, 2008). Geller and
colleagues (1998a) used old subscales from the Teacher Report
Form (TRF) (Achenbach and Edelbrock 1983) and found higher
aggression subscale scores in children diagnosed with mania
compared with those with attention-deficit/hyperactivity disorder
(ADHD). In psychiatrically hospitalized children with a variety of
disorders, the correlation between parent and outpatient teacher
mania ratings on the Child Symptom Inventory (Gadow and
Sprafkin 1994) was r=0.3 (Carlson and Youngstrom 2003). Fur-
ther, parent/teacher agreement about manic symptoms prior to
hospitalization predicted a greater likelihood of manic symptoms
being observed by hospital staff than in children for whom only
parents but not teachers reported manic symptoms. This was one of
the few studies in which the second set of observations, namely
those made by the nurses and psychologist rater during hospitali-
zation, was completely independent of the first.
In outpatients, Youngstrom et al. (2004) found a correlation of
(Young et al. 1978) and the externalizing T scores from the TRF
(Achenbach and Rescorla 2001). In that study, however, the goal
was to select the most appropriate informant for mania. Relatively
poor agreement was found between four different parent and tea-
cher rating scales (Youngstrom et al. 2008) and different factors
youth self-report. The authors concluded that although teachers are
was not useful for diagnostic purposes and that low scores should
not automatically invalidate concerns reported by others.
The present study uses the long form of the Child Mania Rating
Scale (CMRS) (Pavuluri et al. 2006), obtained from parents and
teachers, to examine rates of best-estimate diagnosis when both
informants agree about the presence of manic symptoms versus
instances in which symptoms are reported only by parents.
The hypothesis of this study was that the diagnosis of mania
would be made more often in situations in which there was con-
cordance between parents and teachers on the high scores on the
CMRS. This is because in an episode of mania/hypomania one
expects that if a parent describes manic symptoms, these symptoms
should be evident to other observers. Given how much time a child
spends in school, teachers should be aware of at least some manic
symptoms or some disruptive behavior if manic symptoms are
having to do with sleep and sex may be avoided in teacher re-
sponses, but the irritability and aggression/rages that are so im-
pairing at home should be apparent in school. On the other hand,
there are some who suggest that manic symptoms occurring only at
home constitute an ultradian cycle in which moods switch in a day
the child gets home. The point is that reasons for information
variance have not been explored.
The study, then, not only asks what disorders most often occur
with parent/teacher agreement for significant symptoms, but also
examines what diagnoses are likely to be made in situations in
which there is a significant disparity in parent and teacher obser-
vations of manic symptoms, that is, if the parent observes manic
symptoms but the teacher does not.
Participants included 911 consecutively referred school-aged
children and adolescents (between ages 5 and 18 inclusive) re-
ferred to a child psychiatry outpatient clinic during the aca-
demic years between 2005 and 2008 (and who therefore had both
parent- and teacher-completed rating scales) received a thorough
psychiatric evaluation. The study was approved by the Stony
Brook Institutional Review Board.
As part of the evaluation of their child, parents and the child’s
teacher completed the Child Behavior Checklist (CBCL) and TRF
(Achenbach 1991a), respectively, and the parent and teacher ver-
sions of the Child and Adolescent Symptom Inventory (Sprafkin
et al. 2002). Parents and teachers also completed the CMRS
(Pavuluri et al. 2006), a questionnaire that solicits symptoms of
mania using a 4-point Likert scale format. The CMRS score of >20
has been found to distinguish mania from ADHD with a sensitivity
of 0.81 and specificity of 0.94 in the site that developed the instru-
ment. Children were not evaluated unless rating scale information
was received from both parents and teacher.
Four child and adolescent psychiatry faculty members were re-
sponsible for making best-estimate diagnoses based on 3-hour in-
terviews with parent and child and using the Child and Adolescent
Inventory as a guide to obtain a systematic symptom review
(Carlson et al. 2009). The assessments included reviews of school
and other past information as was available. An extensive report
that provides diagnostic justification is generated for the children,
which is the basis on which reliability of diagnosis was obtained.
Although the other rating scales were available as part of the
evaluation, clinicians were blind to the CMRS ratings. Based on 50
evaluations, kappa agreement between two child psychiatrists for
major diagnostic categories (ADHD, any anxiety disorder, any
depressive disorder, bipolar [BP] disorder, any pervasive devel-
opmental disorder) based on the diagnostic evaluations ranged
from k=0.78 (depression) to 1.0 (ADHD, BP disorder).
The top quartile (25%) of scores on the parent and teacher ver-
on the presence of significantly elevated manic symptoms. The
lowest quartile of the teacher CMRS (CMRS-T) was selected to
define very low teacher endorsement of manic symptoms. Dis-
cordant ratings consisted of the highest quartile of parent ratings
and lowest quartile of teacher ratings. [The cutoff score of 20, used
by Pavuluri et al. (2006), represented about one standard deviation
for both parent and teacher scores. There was insufficient power
with the resulting sample sizes to examine the diagnostic signifi-
cance of concordant and discordant teacher ratings.]
Besides BP disorder, specific diagnoses examined for their as-
sociation with parent/teacher agreement patterns were those that
have been most associated with BP disorder in children. These
included ADHD, oppositional defiant disorder (ODD)/conduct
disorder (CD), their combination (defined as externalizing disor-
CARLSON AND BLADER
In addition to Diagnostic and Statistical Manual of Mental Dis-
orders 4th ed., Text Revision (DSM-IV-TR) (American Psychiatric
Association) diagnoses, subscale scores on the CBCL (Achenbach
1991b) and TRF (Achenbach 1991a) were also compared with the
CMRS as were T scores ‡67 on the CBCL called the ‘‘Bipolar’’
(Biederman et al. 1995) or ‘‘dysregulation’’ (Ayer et al. 2009)
phenotype and the three subscales that comprise it, namely the
anxiety/depression, attention (hyperactivity), and aggression prob-
correlations between CMRS-T and TRF ratings and examined tea-
cher reports of homework completion and test performance. Treat-
ment data described in the study included lifetime treatments
children had prior to their evaluation.
Logistic regression examined factors associated with a child’s
parent and teacher ratings concordant for high CMRS total scores.
The covariates considered were demographic variables, best-
estimate DSM diagnosis, school type (elementary, secondary), and
full-scale intelligence quotient (IQ) from evaluations conducted by
the child’s school psychologist within the preceding 3 years. Of the
911 subjects, 698 (75%) had IQ testing. School type was included,
because the students’ secondary school teacher informant has spent
much less time with the student than an elementary school teacher
and therefore might provide less accurate information.
In this sample, iternal consistency was high for both parent-
completed and teacher versions of the CMRS (parent: Chronbach’s
coefficient a=0.858; teacher: a=0.862).
The top quartile for the parent CMRS (CMRS-P) score was
demarcated by a total score of 15, and for the CMRS-T the value
was 13. The bottom teacher quartile score was 2. Forty-two chil-
dren and adolescents (4.6%) met our criteria for the most variant on
the CMRS-P and CMRS-T, and 105 (11.5%) were the most con-
cordant. (Sample sizes using a score of ‡20 would have been 17
and 39, respectively.) Of children whose parents gave them high
scores on CMRS-P and thus were endorsing significant explosive
and moody behavior, about a quarter (28.6%) had teachers who
observed almost no symptoms on the CMRS (i.e., parent high/
teacher low). (Only 25 children had high teacher and low parent
mania scores and are not the subject of this study.)
Academic competence was reported in 95% of the sample.
Youths with high CMRS-P and low CMRS-T scores, compared
with high CMRS-P and CMRS-T endorsements, were significantly
more likely to have good homework completion (63.2% vs. 34.0%;
odds ratio [OR]: 0.30; 95% confidence interval [CI]: 0.14–0.66;
p=0.002) and test performance (59.0% vs. 38.6%; OR: 0.44; 95%
CI: 0.14–0.66; p=0.034). Teachers, in other words, were internally
consistent with their symptom rating scores.
The rates of ‘‘often/very often’’ for CMRS symptoms and their
rank order were similar between parents and teachers and the most
commonly reported symptoms were distractibility, irritability,
any rage attacks (54% from parents; 29% from teachers).
The correlation, however, between CMRS-P and CMRS-Tscores
was r=0.27 (p<0.000). Similar correlations were found for parent
bipolar/dysregulation’’ phenotype (r=0.227; p<0.000). Within in-
formants, however, the correlations were high. Correlation between
the CMRS-Pand the CBCL ‘‘bipolar/dysregulation’’ phenotype was
r=0.757. Correlations of the CMRS-P with each component of the
‘‘bipolar/dysregulation’’ phenotype were r=0.519 for anxiety/
depression, r=0.611 for attention, and r=0.727 for aggression.
Similarly, correlation between the CMRS-T and TRF ‘‘bipolar/
dysregulation’’ phenotype was r=0.786; correlations between the
CMRS-T and anxiety/depression were r=0.413, attention r=0.542,
and aggression r=0.780. All were significant at the p<0.000 level.
A total of 66 (7.3%) of the 911 children were diagnosed with BP
I or II (n=23, 2.5%) or BP disorder not otherwise specified
(BPNOS) (n=43, 4.7%). If the CMRS-P score was ‡15, 14.7%
(vs. 4.4%) had any BP (OR: 3.6; 95% CI: 2.1–6.2) (not shown). A
CMRS-P score of ‡20 revealed virtually identical findings (17.3%
any BP vs. 5.4%; OR: 3.6; 95% CI: 2.1–6.2). Teacher agreement or
disagreement did not add to diagnostic accuracy for students with
BP I or II. BPNOS was more common in children with concordant
high CMRS-P and CMRS-T ratings (10.5% vs. 4.8%) but the dif-
ference was not statistically significant (Table 1).
Concordant and discordant CMRS-P/CMRS-T ratings were
more strongly related to diagnoses other than BP disorder. In un-
6.4-fold greater odds of both parents and teachers providing high
CMRS ratings among children who were diagnosed with exter-
nalizing disorders (ADHD, ODD, CD, or any combination of
these). Children who were nonwhite or in lower grades were also
more apt to have concordantly high CMRS-P and CMRS-T ratings.
Children with internalizing disorders (anxiety and depressive dis-
orders) were significantly less likely (OR=0.20; 95% CI: 0.09–
0.45) to have high CMRS-P-CMRS-T agreement than to have
CMRS-P-high and -low patterns of CMRS-T ratings or, said an-
other way, they were five times more likely to have discordant
CMRS-P/CMRS-T ratings. Many of these children had a history of
receiving antidepressant treatment.
To better explain parent–teacher concordance on high CMRS
ratings, a combined variable (adjusted) model was developed that
included predictors whose bivariate association with high CMRS
concordance had p-values of 0.20 or less (right-hand section of
Table 1). Among variables that one expected a priori to have high
intercorrelations (e.g., ADHD and any expternalizing disorder), the
model included the one variable with the largest bivariate v2value.
Variables meeting these criteria were included in the combined-
variable model as a single block with no sequential variable se-
lection of deletion methods. In this adjusted model, externalizing
disorders continued to maintain a strong association with parent/
teacher high CMRS score concordance. A history of mood stabi-
lizer treatment also emerged as a predictor of concordance. An
internalizing disorder continued to predict a greater likelihood of
CMRS-P-high and -low T-CMRS ratings. Ethnicity’s bivariate
association with parent–teacher concordance was diminished in the
adjusted multivariable model, because nonwhite ethnicity was
confounded with a lower likelihood of an internalizing disorder
diagnosis (OR=0.19; 95% CI: 0.07–0.57; v2=9.52; p=0.02), and
internalizing diagnoses, in turn, had a stronger relationship than
ethnicity with parent–teacher concordance for high manic symp-
tom ratings (see Table 1). Similarly, elementary school placement
was confounded with a lower likelihood of antidepressant treat-
ment (OR=0.26; 95% CI: 0.13–0.93; v2=0.57; p<0.001), which
eclipsed its predictive value in the adjusted model.
This study reports a parent/teacher correlation for manic
symptoms of r=0.27, almost identical to the r=0.23 correlation
INFORMANT DISAGREEMENT FOR MANIC SYMPTOMS 401
Table 1. Demographic, Diagnostic, and Treatment Factors for Parent-Teacher Child Mania Rating Scale Concordance Groups
Means and frequencies of predictors within CMRS
parent–teacher concordance groups
Predictor effects on parent–teacher CMRS concordance
(parent-high/teacher-low vs. parent-high/teacher high)
Bivariate association with CMRS
model (adjusted effects)
n (% of total sample)
Mean age (SD)
Mean grade (SD)
Full scale IQ (SD) (n=698)
n (%) nonwhite
n (%) elementary
n (%) male
n (%) bipolar I
n (%) BPNOS
n (%) ADHD
n (%) any externalizingdisorder
n (%) any depressive disorder
n (%) any anxiety disorder
n (%) any internalizingdisorder
n (%) any treatment
n (%) ADHD meds
n (%) antidepressant treatment
n (%) mood stabilizer treatment
n (%) antipsychotic treatment
ADHD=attention-deficit/hyperactivity disorder; BPNOS=bipolar disorder not otherwise specified; CI=confidence interval; CMRS=Child Mania Rating Scale; OR=odds ratio; SD=standard deviation;
found by Youngstrom et al. (2008) for the CMRS-P and -T in their
study. Kappa for high scores on the CMRS was significant but low.
Althoff et al. (2010) reported parent/teacher kappa agreement for
the ‘‘bipolar/dysregulation’’ profile on the CBCL/TRF between
0.139 for males and 0.236 for females, although they used a latent
0.215 in the current sample is similar. These data suggest that the
instruments in the current sample are performing in ways similar to
what others have found.
We contend that the utility of various informants is to inform the
clinician about the child’s function and diagnosis. The operative
question herein is what conditions likely explain concordant or
discordant reports. We selected the highest and lowest quartiles of
parent and teacher symptom reports to generate a sample large
enough to study and to provide a large enough contrast to ensure
truly discordant reports between parents and teachers. The majority
of the sample clearly falls between the 25 percentiles and 75 per-
centiles but, to reiterate, we were interested specifically in children
who were very symptomatic at home and not at all symptomatic in
school to examine the question of whether these youths present
with a particular kind of rapid-cycling BP disorder.
Rates of BP disorder were low in this sample especially com-
pared with how often parents reported relatively high scores on a
scale of manic symptoms. We selected the highest 25% of scores to
define the sample of parent-reported manic symptoms (n=147).
Only 15.6% of those with parent-reported manic symptoms (23/
of mania with parent-reported manic symptoms is consistent with
the recently published Longitudinal Assessment of Manic Symp-
toms study (Findling et al. 2010; Horwitz et al. 2010). In that study,
which has reported rates of ‘‘elevated symptoms of mania’’ in 6–
12-year-old clinic patients to be 42.9%, only 25% had a BP spec-
trum disorder, and half of those had BPNOS.
when parents reported manic symptoms at or above this sample’s
75 percentile than when scores were lower. [Using the ‡20 score
described by Pavuluri et al. (2006) the prediction of mania was no
higher.] In addition, as Youngstrom et al. (2008) found, low scores
on the teacher report reduced the likelihood of BP disorder mod-
erately, although in both the Youngstrom and current samples, the
low base rate of BP disorder in a large outpatient sample compared
with other diagnoses did not render the scores very useful clini-
cally. Interestingly, both parents and teachers identified similar
issues of concern on the CMRS, that is, distractibility, irritability,
mood swings, and rages. However, the modest correlation suggests
that they were often identifying these items in different children
and the items endorsed rarely indicated classic symptoms of mania.
More importantly, however, when there was parent and teacher
corroboration on high CMRS symptom ratings, externalizing dis-
orders (either or both ADHD and ODD/CD) had 10 times higher
odds to be diagnosed in the adjusted-covariates model, and when
there was complete disagreement (parent high and teacher low),
depression and/or anxiety disorders were far more likely to be part
of the diagnostic picture. Prior use of mood stabilizers or antide-
pressants inthe concordantanddiscordant groupslikelyreflects the
diagnostic thinking of clinicians who were treating these young
people prior to our assessment.
The high rate of externalizing disorders in children with parent
and teacher agreement on manic symptoms is not a surprise. Al-
though selected to identify symptoms of mania, mania rating scales
identify attention, behavior, and mood symptoms that co-occur.
The ‘‘dysregulation/bipolar phenotype’’ of the CBCL illustrates
that most clearly. It is the history of episodes (that is, symptoms
with an onset and offset compared with baseline behavior) that
identify actual mania and hypomania.
The finding of high rates of internalizing disorders in children
with discordant parent/teacher mania ratings is clinically signifi-
cant for two reasons. The first is that parents are not identifying
trivial problems. The child has a significant psychiatric disorder.
The second is that although the irritability, rages, and other dys-
regulatory features clearly develop in the context of a mood dis-
order, the mood is probably not mania and is not ultradian cycling.
Interestingly, in the three youths with BP disorder with discordant
parent/teacher reports, all were in their depressed phase. From a
psychopharmacologic standpoint, this is very important. If one
thinks the child is having rapid cycles, one is not going to precisely
use the kinds of medication that is indicated in anxiety and de-
Circumstances in which parents report manic symptoms about
their child not corroborated by other informants raise questions
about why the disparity is occurring.
We have not systematically studied reasons why anxious and
depressed children are identified as manic-like by their parents and
not their teachers. It is possible that youth with social phobia di-
agnoses(mostoften diagnosed inthe anxietysample) may notwant
to make a spectacle of themselves outside of home. Depressed
youth may not have the energy to be disruptive or may find school
rewarding (as they are, by and large, successful there) and thus feel
less irritable. The point is that although teacher information had
little to add to the positive diagnosis of BP disorder, teacher in-
formation had a great deal to add in keeping the diagnosis of BP
disorder from being erroneously made.
Several limitations need to be considered in understanding these
results. First, we have insisted on obtaining both parent and teacher
information prior to interviewing parents and children for evalua-
tion. This may limit comparability with clinics, which are less se-
lective about patients they treat and who do not obtain teacher
information directly from teachers.
Second, although our interviews and diagnostic procedures are
thorough and based on more information than traditionally going
into a structured/semistructured interview assessment, we did not
use structured interviews to make diagnoses. Children with sus-
pected BP disorder referred for clinical trials were routinely re-
interviewed with such instruments, however. Nevertheless, some
children with hypomania or BPNOS may have been overlooked.
Third, the diagnosis of BPNOS was the equivalent of ‘‘proba-
ble’’ BP disorder. It was diagnosed when the clinical history and
or lifetime mania or hypomania. It has been our experience that
some informants simply cannot provide the kind of information
necessary on which to make a definitive diagnosis. This is a less-
precise definition than that used in the Course and Outcome of
Bipolar Youth study (Birmaher et al. 2009), in which interviewers
can elicit lifetime episodes of 1–3 days of mania or hypomania
from their informants.
of cases in which parent’s scores were elevated and the teacher
score was neither high nor low. However, the goal of the study was
not to inform about sensitivities and specificities of different in-
formantbutspecificallytoaddress thediagnostic questionofparent
mania endorsements in the face of asymptomatic school presenta-
Finally, the sample described is a clinically acquired sample.
Information gathered was part of a routine outpatient assessment
INFORMANT DISAGREEMENT FOR MANIC SYMPTOMS 403
and not collected with the goal of specifically examining informant
variance and its diagnostic implications. As such these are sec-
the range of agreement found for other psychiatric disorders, rates
of concordance and discordance between raters proffers important
clinical information. High rates of manic symptoms reported by
both parents and teachers most likely occur in children with ex-
ternalizing disorders. BP mania may certainly occur, but the rates
are considerably lower than for attention-deficit/hyperactivity dis-
order and its behavior disorder comorbidities. If the child is de-
scribed by a parent as having manic symptoms and direct and
systematic information from the teacher (vs. asking parents what
the teacher has told them) reveals no behavior problems at all, an
internalizing disorder needs to be specifically ruled out.
Dr. Blader has been a consultant to Shire Plc. and Supernus
Pharmaceuticals. He has also received research support from Ab-
bott Laboratories and the National Institute of Mental Health
(K23MH0069875 and R01MH080050).
Dr. Carlson has research support from NIMH, Bristol Myers
Squibb, Glaxo-Smith Kline and served on a DSMB for Eli Lilly.
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Address correspondence to:
Gabrielle A. Carlson, M.D.
Division of Child and Adolescent Psychiatry
Department of Psychiatry and Behavioral Science
Stony Brook University School of Medicine
Putnam Hall-South Campus
Stony Brook, NY 11794-8790
INFORMANT DISAGREEMENT FOR MANIC SYMPTOMS 405
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