Brief Report: Telephone Administration of the Autism Diagnostic Interview-Revised: Reliability and Suitability for Use in Research

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DOI: 10.1007/s10803-010-0987-x · Source: PubMed
The Autism Diagnostic Interview--revised is one of the "gold standard" diagnostic tools for autism spectrum disorders. It is traditionally administered face-to-face. Cost and geographical concerns constrain the employment of the ADI-R for large-scale research projects. The telephone interview is a reasonable alternative, but has not yet been examined for reliability with face-to-face administration. In this study, participants were interviewed both face-to-face and on the telephone using the complete ADI-R interview. Results indicate that there was no significant difference between the algorithm scores or the diagnoses arrived at for face-to-face and telephone administrations. Reliability statistics across the two modalities were very good and indicate that telephone interviews using the ADI-R are a viable option for researchers.
Brief Report: Telephone Administration of the Autism Diagnostic
Interview—Revised: Reliability and Suitability for Use
in Research
Jessica Ward-King Ira L. Cohen
Henderika Penning Jeanette J. A. Holden
Published online: 2 March 2010
ÓSpringer Science+Business Media, LLC 2010
Abstract The Autism Diagnostic Interview—Revised is
one of the ‘‘gold standard’’ diagnostic tools for autism
spectrum disorders. It is traditionally administered face-
to-face. Cost and geographical concerns constrain the
employment of the ADI-R for large-scale research projects.
The telephone interview is a reasonable alternative, but has
not yet been examined for reliability with face-to-face
administration. In this study, participants were interviewed
both face-to-face and on the telephone using the complete
ADI-R interview. Results indicate that there was no sig-
nificant difference between the algorithm scores or the
diagnoses arrived at for face-to-face and telephone admin-
istrations. Reliability statistics across the two modalities
were very good and indicate that telephone interviews using
the ADI-R are a viable option for researchers.
Keywords Autism spectrum disorders Autism
diagnostic interview—revised Telephone interview
The Autism Diagnostic Interview (ADI; Le Couteur et al.
1989) was originally intended for research, as an aid to
diagnosing autism according to the ICD-10 (World Health
Organization 1993) and DSM-IV (American Psychiatric
Association 1994) definitions. This original version of the
standardized, investigator-based interview was intended
for caregivers of subjects with a chronological age of
5 years or older, and a mental age of at least 2 years. The
interview is semi-structured, contributing to both its reli-
ability and validity. It is based upon open-ended questions
that inquire about various aspects of a subject’s devel-
opment and current behaviour, allowing the informant to
describe freely the relevant traits of the affected individ-
ual. The interviewer uses clearly defined codes to classify
the traits and behaviours described in response to each
The ADI-R fills a need in research for a sensitive and
reliable tool based on accepted diagnostic criteria that can
determine whether an individual fits into the diagnostic
category of ‘‘autism’’ and has become a ‘‘gold standard’
diagnostic tool for autism research. In the absence of a
reliable tool, it is difficult for researchers to ensure con-
sistent classification of individuals as having autism or
Since its creation in 1989, the ADI (and then the ADI-R)
has been employed as a face-to-face semi-structured inter-
view. For clinical use, this makes sense; the ADI-R is often
used as part of a wider, multidisciplinary assessment in the
J. Ward-King H. Penning J. J. A. Holden
Department of Psychiatry, Queen’s University, Kingston,
ON K7M 8A6, Canada
J. J. A. Holden
Department of Physiology, Queen’s University, Kingston,
ON K7M 8A6, Canada
J. J. A. Holden (&)
Genetics and Genomics Research Laboratory, Ongwanada,
Kingston, ON K7M 8A6, Canada
I. L. Cohen
Department of Psychology, NYS Institute for Basic Research in
Developmental Disabilities, Staten Island, NY 10314, USA
J. Ward-King I. L. Cohen H. Penning J. J. A. Holden
Autism Spectrum Disorders, Canadian-American Research
Consortium (ASD-CARC),
J Autism Dev Disord (2010) 40:1285–1290
DOI 10.1007/s10803-010-0987-x
diagnosis of autism, with families being seen in a clinic. For
research purposes, the ADI-R is often used for diagnostic
confirmation to empirically assess the previous clinical
diagnosis that an individual has autism. It is not always
feasible for a participating family to come to the research
centre to see the interviewer or for an interviewer to travel
to each family’s home. Further, the use of the ADI-R for
research requires that the interviewer obtain extensive
training and must become reliable in scoring the interview
with a designated research group (Le Couteur et al. 2009). It
is difficult and expensive to train sufficient interviewers to
send to each family’s home, especially for large-scale
studies that sample from a wide geographic area. In short,
while the ADI-R has long been used successfully as a
face-to-face interviewing tool, it has become necessary to
adapt this reliable and valid diagnostic tool for the needs of
large-scale research projects such as those designed to
identify genetic and environmental factors leading to ASD
One group (Vrancic et al. 2002) adapted the ADI-R for
administration over the telephone. In that study, the
authors used the algorithm items of the ADI-R to develop
an interview that consisted of 47 items and required
approximately 20–40 min to complete. The wording of
the interview was completely rephrased with necessary
inclusion of examples and explanations to obtain reliable
answers over the telephone. As it is not the complete
ADI-R, the Autism Diagnostic Interview—Telephone
Screening in Spanish (ADI-TSS) was developed as a
screening tool that enables the selection of cases of
probable autism. It was designed to compliment, and not
replace, the ADI-R; the authors suggested that patients
who are identified by the ADI-TSS should later be
assessed using the ADI-R.
The ADI-R takes approximately 2 h to complete.
Partly for this reason, the full interview has never been
tested using the telephone modality. While the ADI-R can
take several hours to complete, its authors report that
informants find it an enlightening and comfortable expe-
rience ‘‘because they are allowed to describe important
aspects of their child’s behaviour in their own words’’
(Lord et al. 1994, p. 663). It is clear that it would be an
advantage to autism spectrum disorder (ASD) research if
the ADI-R could be administered in one session over the
telephone, as it could then be used inexpensively and
efficiently with minimum disruption for both the inter-
viewers and participants. In this study we sought to
determine whether it is possible for participants to com-
plete the ADI-R with a trained ADI-R interviewer, and
whether and how the telephone interview results would
compare with face-to-face interview results in terms of
Twenty children with autism and their primary caregivers
were recruited for this study. Children’s ages at the time of
the first interview ranged from 3.42 to 19.0 years (mean:
8.92 years). There were 14 boys and six girls included in the
study, all of whom had a previous clinical diagnosis of an
ASD; 15 with a diagnosis of Autistic Disorder; four with a
diagnosis of Asperger’s Disorder; and one with a diagnosis
of PDD Not Otherwise Specified. No IQ or adaptive func-
tioning data was available for the participants. One primary
caregiver of each child (16 mothers, 4 fathers) volunteered
to act as the informant on both face-to-face and telephone
administrations of the ADI-R. All participants were
recruited by the Autism Spectrum Disorders—Canadian
and American Research Consortium (ASD-CARC) through
an on-line Research Registry (,
which invites families to complete questionnaires online
and to agree to be contacted when studies are being carried
out in their area. For this study, participants were recruited
from a circumscribed geographical area in Southeastern
Ontario. All informants identified themselves as Caucasian.
Informants were asked to participate in an interview using
the Autism Diagnostic Interview—Revised (ADI-R; Lord
et al. 1994) twice: once face-to-face with the interviewer,
and once in an interviewer-initiated telephone call at a
mutually convenient time. A single interviewer conducted
all interviews. The order in which the interviews were
conducted was counter-balanced. Interviews were com-
pleted at least 14 and not more than 122 days apart, with
a mean interval of 29.6 days (standard deviation =
30.97 days), and all were completed within a 6-month
The interview was the complete, standard ADI-R
interview (Lord et al. 1994) which includes items relating
to both verbal and non-verbal individuals. The ADI-R was
scored using the algorithm provided, but only at the con-
clusion of data collection, after all interviews had taken
place. The interviewer (H.P.) was fully trained and certified
in conducting and scoring the ADI-R for research purposes.
The ADI-R is scored using an algorithm that examines
the main diagnostic criteria emphasized by the DSM-IV
and ICD-10. There are four domains examined by the ADI-
R. Domain A assesses qualitative abnormalities in reci-
procal social interaction (QARSI), specifically examining
use of eye-gaze and facial expression, development of peer
relationships and emotional reciprocity, and seeking to
1286 J Autism Dev Disord (2010) 40:1285–1290
share one’s own enjoyment. Domain B assesses qualitative
abnormalities in communication (QAC), and arrives at
different scores for participants who are verbal (BV), and
those who are non-verbal (BNV). For the present study, BV
and BNV scores were analyzed together as one commu-
nication score since there were only four non-verbal par-
ticipants and our concern was with repeat test reliability.
Domain C assesses restricted, repetitive and stereotyped
patterns of behaviour (RRSPB), including compulsions and
unusual preoccupations as well as stereotyped mannerisms.
Domain D deals with the requirement that abnormalities in
the three diagnostic behavioural criteria be apparent before
age 36 months.
Data Analyses
Domain means for the first three content domains were
compared using repeated measures multivariate analysis of
variance (MANOVA). Both domain and method of inter-
view served as within-subjects factors. Order of the inter-
view format (face to face or telephone) served as a
between-subjects factor. Domain D scores at both inter-
views were negatively skewed (-1.5 and -1.2) and so
these domain scores were compared across time with the
Wilcoxon matched pairs test, and across group with the
Mann–Whitney U, both non-parametric tests. Domain
scores across interview conditions did not significantly
vary with prior diagnosis (all pvalues [0.17) and groups
did not significantly differ in mean age (F(1,18) =0.7, ns).
Figure 1shows the mean (±SEM) domain scores across
interview conditions for the two groups. While those who
received the telephone interview first had marginally lower
group means on the first and second interviews, these dif-
ferences were not statistically significant. Overall, there
were no significant main effects for group (F(1,18) =1.07,
ns), method of interview (F(1,18) =0.07, ns), or their
interaction (F(1,18) =0.002, ns). Multivariate tests also
revealed no significant effects due to interaction of domain
with group, domain by interview type, or their three-way
interaction (all pvalues [0.6). Likewise, Domain D scores
did not significantly vary across time or group (all pvalues
[0.6). Table 1shows the ADI-R means and standard
deviations across interview conditions for the two groups.
Telephone interview domain scores were correlated
(Pearson R) with face-to-face interview scores as the ref-
erence in order to examine repeat reliability. Correlations
across domains A, B, C, and D were, respectively, 0.84,
0.73, 0.90, and 0.89; all pvalues \0.001. Mean (SD) ADI-
R difference scores across subjects within conditions and
interview conditions are shown in Table 2. As shown,
MEANS (+/- 95% CI)
Fig. 1 ADI-R domain means (±95% confidence interval) across interview type and order. QARSI qualitative abnormalities in reciprocal social
interaction, QAC qualitative abnormalities in communication, RRSPB restricted, repetitive and stereotyped patterns of behaviour
J Autism Dev Disord (2010) 40:1285–1290 1287
difference scores did not significantly vary across groups
and were close to zero (F(2,36) =0.5, ns).
In terms of diagnostic agreement, 18 of the 20 cases met
ADI-R criteria for autism based on the face-to-face inter-
view. The other two cases met two of the three content
domain criteria suggesting they could be classified as
PDDNOS (Rutter et al. 2003). Of the 18 autism cases, 15
(83%) met criteria for autism using the telephone interview
and the other 3 would have been classified as PDDNOS. Of
the two cases classified as PDDNOS based on the face-to-
face interview, one met criteria for autism and the other for
PDDNOS using the telephone interview. Thus, irrespective
of method, all cases remained in the autism spectrum. We
did not compute Kappa for a measure of agreement
because we did not have a non-spectrum comparison
group; autism and PDDNOS groups are typically difficult
to distinguish (Mahoney et al. 1998), and the number of
PDDNOS cases was too small to provide a meaningful
Our results indicate that the ADI-R remains a reliable
diagnostic interview when it is administered over the
telephone. There were no differences in the results, either
on the diagnostic algorithm, or in terms of diagnosis
reached depending on interview administration method.
The telephone has many advantages as an interview
modality in research settings. For one, it is cost-effective
(Bauman 1993; Burnard 1994; Corey and Freeman
1990; Marcus and Crane 1986; Musselwhite et al. 2007;
Siemiatycki 1979; Tausig and Freeman 1988; Wilson et al.
1998); Marcus and Crane (1986) argue that telephone
interviewing techniques could reduce costs 50–75% when
compared to face-to-face interviews. Use of the telephone
to conduct interviews allows an interviewer to cover a
larger geographical area (Burnard 1994; Musselwhite et al.
2007). Telephone interviews can be scheduled and com-
pleted more quickly than can face-to-face interviews
(Worth and Tierney 1993).
There is scientific support for the telephone interview as
a legitimate method of data collection (Oppenheim 1992;
Barriball et al. 1996; Law 1997). Like face-to-face inter-
views, telephone interviews have a high response rate
(Polit and Hungler 1991) and incorporate the possibility for
the interviewer to clear up misunderstandings (Robson
1993). Robson (1993) also argues that they have smaller
interviewer effects and a lower tendency for the respondent
to give socially desirable responses. Quality control, which
can be ensured with fewer, centrally-located interviewers
who have the opportunity to self-correct, is a feature of
telephone interviewing (Lavrakas 1987). The interviewers
are also able to take interview notes more discreetly over
the telephone, minimizing the discomfort that participants
may have during the interview (Musselwhite et al. 2007).
Telephone interviews are not without disadvantages.
Establishing rapport can be a problem in telephone inter-
views (Robson 1993). It is important to establish an
appropriate relationship in order for the telephone interview
to be successful, and for authentic responses to be provided.
Furthermore, it has been argued that telephone interviews
produce shorter responses than face-to-face interviews
(Marcus and Crane 1986), possibly because they are more
focused than face-to-face interviews (Carr and Worth
2001). The possible length of an interview changes with the
modality, however. Many researchers advise a shorter
telephone interview as compared to face-to-face interviews,
with Lavrakas (1987) suggesting 20–30 min as a maximum.
However, Waterman et al. (1999) found that telephone
interviews of up to 60 min were ‘‘efficient in time and
conducive to free-flowing conversation’’. There is nothing
preventing a telephone call from lasting for even longer
than this, though fatigue may set in. It is important to note
that for this study all interviews were conducted comfort-
ably in one session, regardless of modality. Participants
reported that they preferred the telephone interview due to
its convenience and the length of the interview did not cause
significant concern. Thus telephone interviews have dif-
ferent characteristics compared to face-to-face interviews,
Table 1 Mean (SD) domain scores across group and method of interview for each ADI-R domain
Group NFace Telephone
Overall 20 21.75 (4.78) 16.80 (4.72) 5.85 (3.00) 21.70 (4.86) 16.85 (5.15) 5.50 (3.36)
Face first 10 22.20 (4.37) 17.90 (3.11) 6.60 (3.37) 22.60 (3.66) 17.60 (5.04) 6.10 (4.46)
Phone first 10 21.30 (5.36) 15.70 (5.89) 5.10 (2.51) 20.80 (5.88) 16.10 (5.43) 4.90 (1.80)
Table 2 Mean (SD) difference scores across subjects within groups
and method of interview for each ADI-R domain
Overall 20 0.05 (2.72) -0.05 (3.66) 0.35 (1.50)
Face to face 10 -0.40 (3.03) 0.30 (4.16) 0.50 (1.58)
Telephone 10 0.50 (2.46) -0.40 (3.27) 0.20 (1.48)
1288 J Autism Dev Disord (2010) 40:1285–1290
but are largely proven to yield comparable results
(Siemiatycki 1979). These results are consistent with the
findings of this study.
As with any interview or rating scale that is applied
twice within a reasonably tight timeline by the same
interviewer, the issue of order effect is a significant one;
however, in this study we found none. This may be because
a single interviewer performed all of the face-to-face and
telephone interviews. This method was chosen to reduce
inter-rater biases that may obscure the data. However, this
resulted in a lack of blindness of the interviewer to the
participant’s diagnosis. The first interview was always
performed blind, but while the second interview was per-
formed on average a month later, the interviewer was
potentially able to recall the diagnosis reached as a result of
the first interview. While the interviewer could be expected
to forget many of the details of each case over the month or
more between interviews, overall impressions and biases
are difficult to erase in that time. For example it is possible
that the interview that is done second might benefit from
the knowledge gained in the first interview. In an effort to
reduce these order effects, the interviewer did not compute
the algorithm scores for any of the interviews until all
interviews had been completed. This minimized the
amount of information the interviewer had about the indi-
vidual’s diagnosis prior to any one interview. Furthermore,
the interviewer had a full schedule of other ADI-R inter-
views to complete during that time period and reports that
it was difficult to recall and predict responses to items on
the ADI-R. While these exigencies may have contributed to
better data collection, it is still possible that some bias may
have clouded the second interviews. This is why it is sig-
nificant that counterbalancing of interview modality was
practiced, and that no order effects were found in the data.
This study focused on establishing the reliability of the
ADI-R by telephone interview for use in research. Future
studies should consider inclusion of a control sample of
individuals without autism in order to examine the diag-
nostic specificity of the telephone ADI-R. For research
purposes, the ADI-R is often used as a confirmatory diag-
nostic tool with individuals who have already received, or
are strongly suspected of having, an ASD diagnosis. It will
be useful to examine whether the ADI-R telephone inter-
view can be reliably and validly used to exclude the ASD
diagnosis in research participants for control purposes.
The results presented here indicate that when the ADI-R
is used to confirm an existing diagnosis for the purpose of
research, the telephone modality is as good as the tradi-
tional face to face administration. However, it should be
noted that when used for individual scores or when pre-
vious diagnoses are not clear, the administration of the
ADI-R over the telephone is not indicated. Telephone ADI-
R administration is not a substitute for face to face clinical
judgment and these data do not indicate its use for indi-
vidual assessment or diagnosis on a clinical basis.
This study indicates that, for research purposes, adminis-
tration of the ADI-R as a confirmatory diagnostic tool can
be carried out by trained interviewers over the telephone in
place of the traditional face-to-face interview. Given the
substantial advantages of the use of telephone over face-to-
face interviews, this finding is significant and overdue.
Acknowledgments We extend our sincere appreciation to our
research subjects and their extended family members for their
enthusiastic support of this study. This work was supported by an
OMHF grant (JJAH, principal investigator) and a CIHR Interdisci-
plinary Health Research Team grant (RT-43820) to the Autism
Spectrum Disorders Canadian-American Research Consortium (ASD-
CARC: (JJAH, principal investigator).
JW-K is a postdoctoral trainee with the CIHR/Autism Speaks Autism
SPectrum Interdisciplinary REsearch (ASPIRE) Strategic Training in
Health Research Program (PI: JJAH) (
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    • "In addition, Vineland II offers a Motor Skills Domain and an optional Maladaptive Behavior Index to provide more in-depth information. Both the ADI-R and Vineland II have good reliability and validity when administered over the phone [22, 23]. For the 14 patients for whom DNA samples were available at the Greenwood Genetics Center from a previous study, we were able to amplify by PCR and screen by Sanger sequencing the coding regions (including intron/exon boundaries) of the following genes: SHANK3 (22 exons), MAPK8IP2/IB2 (13 exons), RABL2B (8 exons), hsa-miR-1249 (1 exon). "
    [Show abstract] [Hide abstract] ABSTRACT: Phelan-McDermid syndrome (PMS) is a neurodevelopmental disorder associated with a terminal deletion affecting chromosome 22 (22q13) that results in the loss of function of the SHANK3 gene. SHANK3 has also been identified in gene-linkage studies to be associated with autism spectrum disorder (ASD). Diagnosis of ASD in individuals with PMS is complicated by the presence of moderate to profound global developmental delay/intellectual disability as well as other co-morbid systemic and neurological symptoms. The current study aimed to characterize the symptoms of ASD in patients with PMS and to do a preliminary exploration of genotype-ASD phenotype correlations. We conducted a standardized interview with 40 parents/guardians of children with PMS. Further, we conducted analyses on the relationship between disruption of SHANK3 and adjacent genes on specific characteristic symptoms of ASD in PMS in small subset of the sample. The majority of PMS participants in our sample displayed persistent deficits in Social communication, but only half met diagnostic criteria under the restricted, repetitive patterns of behavior, interests, or activities domain. Furthermore, logistic regressions indicated that general developmental delay significantly contributed to the ASD diagnosis. The analyses relating the PMS genotype to the behavioral phenotype revealed additional complex relationships with contributions of genes in both deleted and preserved SHANK3 regions to the ASD phenotype and other neurobehavioral impairments. There appears to be a unique behavioral phenotype associated with ASD in individuals with PMS. There also appears to be contributions of genes in both deleted and preserved SHANK3 regions to the ASD phenotype and other neurobehavioral impairments. Better characterization of the behavioral phenotype using additional standardized assessments and further analyses exploring the relationship between the PMS genotype and behavioral phenotype in a larger sample are warranted.
    Full-text · Article · Dec 2015
    • "The studies in high-risk samples generally reported high percentages of agreement and high kappa values. Six of these studies, however, reported on \40 participants [27, 30, 34, 36, 38, 39]. Paing assessed 12 parents of children for assessing 21 psychiatric disorders. "
    [Show abstract] [Hide abstract] ABSTRACT: For reasons of feasibility, diagnostic telephone interviews are frequently used in research of psychiatric morbidity. However, it is unknown whether diagnostic telephone interviews are as valid as diagnostic face-to-face interviews. Are diagnostic telephone interviews for psychiatric disorders as valid as diagnostic face-to-face interviews? A systematic review of original studies in PubMed, PsychINFO and Embase was carried out. We included studies considering (1) the sensitivity and specificity of diagnostic telephone interviews using face-to-face interviews as a golden standard and (2) the agreement between diagnostic telephone and diagnostic face-to-face interviews. Eligible were studies in the general population, in patients at risk for psychiatric disorders and in psychiatric outpatients. We assessed risk of bias with the quality assessment of diagnostic accuracy studies (QUADAS) instrument. We included sixteen studies. The included studies were generally small with thirteen studies reporting about <100 participants. Specificity was generally high in populations with low or intermediate prevalence of psychiatric morbidity. Sensitivity was low in these populations, but slightly higher in samples with more psychiatric disorders. Studies with a higher risk of psychiatric disorders generally reported higher percentages of agreement and higher kappa values. Considering the QUADAS-2 criteria, most studies had a medium or high risk of bias, especially concerning patient selection and unbiased judgement of the test. Of the six studies with a medium or low risk of bias, the three studies assessing current anxiety and depressive disorders yielded kappa values between 0.69 and 0.84, indicating good agreement. There is insufficient evidence that diagnostic telephone interviews for the diagnosis of psychiatric disorders are valid, although results for depression and anxiety disorders seem promising.
    Full-text · Article · Mar 2014
    • "For the majority of participants (recruited from across Canada), the ADI-R was administered over the phone. Although the ADI-R is traditionally administered face to face, telephone interviews are a valid and reliable alternative when cost and geographic challenges limit the feasibility of an in-person administration [Ward-King, Cohen, Penning, & Holden, 2010] . Following the interview, a link to the online survey web page was emailed to the caregivers. "
    [Show abstract] [Hide abstract] ABSTRACT: Autism and its related disorders are commonly described as lying along a continuum that ranges in severity and are collectively referred to as autism spectrum disorders (ASDs). Although all individuals with ASD meet the social impairment diagnostic criteria outlined in the DSM-IV-TR, they do not present with the same social difficulties. The variability in the expression and severity of social competence is particularly evident among the group of individuals with "high-functioning" ASD who appear to have difficulty applying their average to above average intelligence in a social context. There is a striking paucity of empirical research investigating individual differences in social functioning among individuals with high-functioning ASD. It is possible that more detailed investigations of social competence have been impeded by the lack of standardized measures available to assess the nature and severity of social impairment. The aim of the current study was to develop and evaluate a parent rating scale capable of assessing individual differences in social competence (i.e. strengths and challenges) among adolescents with ASD: the Multidimensional Social Competence Scale (MSCS). Results from confirmatory factor analyses supported the hypothesized multidimensional factor structure of the MSCS. Seven relatively distinct domains of social competence were identified including social motivation, social inferencing, demonstrating empathic concern, social knowledge, verbal conversation skills, nonverbal sending skills, and emotion regulation. Psychometric evidence provided preliminary support for the reliability and validity of the scale. Possible applications of this promising new parent rating scale in both research and clinical settings are discussed. Autism Res 2013, ●●: ●●-●●. © 2013 International Society for Autism Research, Wiley Periodicals, Inc.
    Full-text · Article · Dec 2013
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