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Delivering difficult news to parents: guidelines for school counselors.

School counselors often have to give difficult news to parents, a process that can be stressful and troubling for everyone involved. While the reaction of each parent is unique, research indicates that many parents who have been given difficult news about their children feel that the information was delivered poorly. This article provides guidelines for the delivery of difficult news to parents, including strategies for appropriate preparation and follow-through.

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School counselors are often in the position of giving difficult or troubling news to parents and other caregivers. Informing parents that their child is falling or has been involved in a behavioral incident at school or being part of a team that informs parents that their child has a disability requiring special education are tasks that are often part of the daily life of school counselors.

Communicating difficult news to parents or caregivers is an unpleasant and stressful task. Under the best of circumstances, parents come to school conferences wanting to hear good news about their children, yet often fearing they will hear something distressing (Lawrence-Lightfoot, 2003). Parents receiving difficult news about their child are likely to struggle with the competing desires to hear the truth but also resist the truth (Abrams & Goodman, 1998). Hearing difficult news about their children can result both in emotional distress (Heiman, 2002; Nissenbaum, Tollefson, & Reese, 2002) and physical distress (Heiman) for parents. The difficult nature of the interaction can lead to behaviors and reactions in both the giver and receiver of difficult news that impede productive communication and make it more difficult for parents to deal with the news in a proactive manner.

Research has indicated that recipients of difficult or troubling news often feel as if the news has been delivered poorly. For example, research consistently indicates that the majority of parents being informed that their child has a disability are dissatisfied or very dissatisfied by the way the news was presented to them (Quine & Rutter, 1994; Sloper & Turner, 1993). Parents receiving bad news from professionals have reported that some professionals appeared tense, hurried, distracted, and even took phone calls during the conversation (Ablon, 2000; Nissenbaum et al., 2002). In addition, parents often perceive that professionals do not present difficult news in a manner that provides hope for the future (Cottrell & Summers, 1990).

School counselors and other educators would benefit from greater awareness of the impact difficult news can have on parents and families. In addition, school counselors would benefit from guidelines and strategies for how best to handle the challenging task of delivering difficult news to parents or other caregivers. This article examines the impact on parents of receiving difficult news about their children, followed by a review of the existing research relevant to this area. The research literature is used to generate a set of guidelines for school counselors to follow when delivering difficult news to parents.

THE IMPACT OF BAD NEWS ON PARENTS AND FAMILIES

Receiving any type of difficult or troubling news can be very disturbing. Hearing bad news--which can be defined as news that substantially and negatively alters people's view of their future (Buckman, 1992)--can elicit profound negative reactions. Receiving difficult news about one's child can be particularly devastating. Initial reactions to this type of news can include anger, shock, grief, self-blame, tears, and disbelief (Heiman, 2002). While these types of intense negative responses to receiving bad news are commonplace, the response of each parent is unique. Some parents may hear news that seems quite disturbing, but react with apparent equanimity (Nissenbaum et al., 2002). Some parents may view the news that their child has a disability with distress; other parents may view the same news with acceptance and relief (Heiman). Many parents turn to friends or family members to help cope with the difficult news. Reactions from friends or family members are generally, but not always, supportive; one group of parents reported that 28% of the people they turned to for support upon hearing that their child had a disability reacted to the news with shock or profound sorrow (Heiman). Indeed, friends and family members may have their own grief reactions to the difficult news that add to, rather than relieve, parents' stress (Kerr & McIntosh, 2000).

RESEARCH ON THE PROCESS OF DELIVERING BAD NEWS

Two separate bodies of research have examined the process that occurs between a person giving bad news (generally a professional of some kind) and a person receiving that news. One source of research is the medical profession, where physicians and other medical professionals are often in the position of having to share profoundly difficult news with patients and patients' families. The other body of research consists of studies of professionals who must inform parents that their child has a disability.

Research from the medical field indicates that the communication of bad news by a physician to a patient is difficult and stressful for both parties. Some patients describe the physician reporting the news as being unsympathetic, being cold, and providing inadequate information (Ellis & Tattersall, 1999). Conversely, many physicians report feeling considerable anxiety about giving difficult news to patients, due to factors such as fearing a negative reaction from the patients or the patient's family and fearing the sense of powerlessness that comes with not being able to provide a cure (Dosanjh, Barnes, & Bhandari, 2001; Fallowfield & Jenkins, 2004; Girgis & Sanson-Fisher, 1998). Furthermore, physicians report that the stress associated with the delivery of difficult news persists hours or days after the interaction (Ptacek, Ptacek, & Ellison, 2001).

Research examining the situations in which professionals must share a diagnosis of a child's disability with parents has clearly indicated that professionals feel torn between providing accurate, realistic information but yet being sensitive and avoiding saying things that will be painful for parents to hear. This has been described as a struggle between realism and hope (Bartolo, 2002). The realistic side is the urge to be honest when communicating both the diagnosis and the impact of the diagnosis, while the hopeful side is the desire to communicate the diagnosis with compassion and to focus on potential rather than limitations. Other researchers have found that conversations with parents about their children's disabilities consist of subtle and fluid negotiations between optimism and pessimism, with delicate bargaining taking place with parents over the degree of optimism with which to view the information (Abrams & Goodman, 1998).

It is clear from the existing research that what may initially seem to be a straightforward process of delivering bad news is actually saturated with strong emotions for both the deliverer and the recipient of the bad news. The process of sharing bad news, particularly sharing bad news about a child to the child's parent or primary caregiver, is far from simple; rather, it is a complex linguistic and psychological process in which realism, pessimism, hope, and optimism are all negotiated in an atmosphere of shared tension and anxiety. While not all bad-news interactions between school counselors and parents involve situations as dire as telling parents their child has a lifelong disability, all such interactions are likely to involve heightened emotions and are fraught with the potential for misunderstandings. The following section presents guidelines and strategies that can assist school counselors with the challenging task of communicating bad news to parents.

GUIDELINES AND STRATEGIES FOR DELIVERING DIFFICULT NEWS

The face-to-face meeting or conference during which the difficult news is to be shared with parents ideally consists of a two-stage process: (a) presenting the difficult information, and (b) engaging parents in a therapeutic dialogue about the information. There are also some things school counselors can do prior to this type of meeting to increase the chances that the meeting will go well, as well as follow-up tasks that can be helpful. Accordingly, presenting difficult or troubling news to parents can be thought of as consisting of four main stages: (a) preparation, (b) delivering the news, (c) engaging the parents in a therapeutic dialogue about the news, and (d) follow-up.

Preparation for Delivering Difficult News

An important part of communicating difficult news is making preparations that can pave the way to a productive conversation. A critical issue related to pre-meeting preparation is choosing how much information to share with parents prior to the meeting, as well as how that information is to be communicated. One important question is whether the bad news should be clearly mentioned when inviting the parents to the meeting. For example, if a school counselor needs to talk to parents about their son's failing grades, should the counselor invite the parents to attend a meeting to discuss their son's failing grades, or just generally invite them to discuss their son's performance in school, with no mention of the Fs? If the general approach is selected, how should the school counselor respond if the parents ask for more specific information regarding the purpose of the meeting?

While there are no cookbook answers to these questions, two guidelines can provide some assistance. First, difficult information is best shared in person. Second, school counselors should avoid giving the impression that they are withholding information, and they should respond without hesitation to direct requests for immediate information. While these guidelines appear to provide contradictory advice in cases where parents ask for specific information prior to the face-to-face meeting, a sensible way to honor both guidelines is to invite parents to a meeting with a general statement about wanting to talk about some important concerns about their child. If the parents want more specific information about the nature of the concerns, they can be encouraged to wait until the meeting where a full discussion of the information can best take place. Statements like "If it is OK with you, I think it would be better if we waited for a more complete discussion until we can meet face-to-face with everyone involved" can be used. Certainly, though, if the parents seem quite anxious about the nature of the concern, or request more details immediately, the school counselor should be prepared to go into as much detail as is necessary to satisfy the parents. Another important step in the preparation

process is determining who should be at the meeting (Fallowfield, 1993). While some meetings, such as meetings in which special education eligibility decisions are made, have mandated categories of participants, in other cases it is up to the school counselor to determine who should be at the meeting. Unless compelling reasons exist for not doing so, both parents should be encouraged to attend. School counselors should be sure to reject the unspoken societal message that mothers, but not fathers, are expected to attend school meetings (Klein & Schive, 1996). Because hearing bad news alone can be particularly difficult, single parents or parents whose spouses or partners are unable to attend should be encouraged to bring other supportive adults with them if they believe that would be helpful. When deciding which professionals to invite to the meeting, school counselors may consider factors such as who has unique information or perspectives that would be helpful for parents to hear, who may have a particularly strong relationship with the student or the parent, and who tends to be particularly sensitive (or insensitive) to parents' feelings in these kinds of meetings. The number of professionals attending the meeting also should be considered. Entering an important meeting with a large number of teachers and administrators can be intimidating to parents and can be counterproductive (Klein & Shive).

In addition to carefully considering which professionals should be invited to the meeting, it is also important for school counselors to consider who is the best person to actually deliver the difficult news. It is generally best to have one person who is responsible for breaking the difficult news (Girgus & Sanson-Fisher, 1998). Often this will be the school counselor, but in some situations it may be an administrator, teacher, or other school staff member. All of the professionals at the meeting should know prior to the meeting who will deliver the difficult news, so there is no confusion during the meeting. If multiple people need to provide different parts of the information, they should all be aware of their colleagues' information and conclusions (Fallowfield & Jenkins, 2004).

School counselors should attend to the physical environment in which the meeting will take place. The physical environment should provide both comfort and privacy (Fallowfield, 1993). Tissues should be discreetly available. If the meeting will take place around a rectangular table, it is desirable to avoid a seating arrangement where parents are on one side of the table and a number of professionals are on the other side. This arrangement can feel isolating to some parents, and it tends to make it more difficult for parents to feel as if they are partners with the school professionals. The school counselor can modify this standard arrangement by choosing to sit across a corner of the table from the parents. In addition to attending to the physical arrangements, it is also important to schedule sufficient time for the meeting (Fallowfield). Parents receiving difficult news report higher satisfaction if they have adequate time to ask questions (Sloper & Turner, 1993), which cannot happen if sufficient time is not allocated for the meeting.

Once all participants have arrived, it is critical to make sure that all parties are introduced. The parents or caregivers and anyone they bring with them should be acknowledged and welcomed. All professionals at the meeting should be introduced and their roles explained. If professionals are not able to attend until mid-meeting, when they arrive they should be introduced; it can be disconcerting for a parent to have an unknown adult enter an important discussion with no introduction.

Delivering Difficult News

In order to present difficult news in a manner that is most helpful to parents, it is desirable to begin by finding out both what the parents know about the situation and the manner in which they want the information communicated to them. Because bad news is defined as news that significantly and negatively alters people's view of their future or their children's future (Buckman, 1992), it is clear that school counselors cannot judge the degree of distress generated by the news they present to parents unless they know how parents view their child and the current situation. One parent may be well aware that her child struggles academically and, when hearing that her child scored poorly on a college entrance examination, may take a "well, at least we tried" attitude. Another parent may have had lifelong dreams of seeing his child attend an Ivy League school, and he may be devastated by the same news. Questions such as "What do you know about your son's progress in school this term?" and "Do you have some concerns about what you will hear in this meeting?" will give the school counselor a sense of what the parents know and how to proceed. If it is apparent that the news to be delivered presents a very different picture of the child than the parents currently believe, the school counselor is wise to proceed slowly and gently.

In addition to determining how discrepant the news will be for parents, it is also helpful to determine the level of detail they would like included when hearing the news. For example, if the news is based on test scores, some parents will prefer to hear a detailed review of each specific score area and sub-score, while other parents will simply want to hear the conclusions and recommendations. School counselors can ask questions such as "Would you prefer to hear about these results in detail, or should I just focus on the big picture?" in order to determine how specific to be when delivering the news.

Once the school counselor has a sense of what the parents know about the child's situation, a good way to proceed is to reinforce the parts of the parents' understanding that are correct, a process Buckman (1992) has described as aligning. This provides parents with the sense that the school counselor has listened to their description of the situation and is respecting their view of the child. After aligning with the parents, school counselors can slowly and gently address the parts of the parents' understanding that is not correct. If the information to be presented seems to be very new to the parents, consider giving a "warning shot" to alert the parents that they will be hearing news that may be disturbing (Buckman). Warning shots are statements such as "Some of what I need to tell you will be new information, and it may be disturbing."

Difficult news, particularly if it involves considerable information, should be presented in chunks. This allows parents time to digest the news and maximizes the chances that they will accurately hear and recall the information. Research in the field of medicine indicates that receivers of difficult news fail to remember up to half of what they are told (Buckman, 1992), and professionals who deliver difficult news should assume that parents do not fully hear and remember information they only hear once. Key information should be repeated and highlighted (DeMarle & LeRoux, 2001). Furthermore, the person sharing the difficult news should frequently check with the parents to make sure they have understood what has been said. Phrases such as "Am I going too fast?" and "Was that last part clear?" should be liberally sprinkled throughout the conversation. It is important to remember that parents generally desire more, as opposed to less, information about their child, even if they are unable to articulate relevant questions (Pain, 1999; Quine & Pahl, 1986; Quine & Rutter, 1994). The difficult news should be presented with sensitivity,, but presented clearly and directly. Parents tend to feel angry and frustrated when they sense that school personnel are withholding information and using polite but evasive language (Lawrence-Lightfoot, 2003).

One way to ensure that parents are accurately hearing the message is to ask them to share their understanding of the information they have just heard. Questions such as "Just so I know that I have been clear in communicating all this information, would you be willing to share your understanding of what we have talked about today?" can be helpful in determining whether parts of the difficult news need to be repeated or clarified. While this technique can be valuable, school counselors must be careful when using it, so as not to appear patronizing to parents.

Professionals delivering difficult news also should strive to avoid using jargon. If there is any doubt as to whether parents may understand a term, the term should be avoided. Terms, initials, abbreviations, and acronyms such as self-contained, ADHD, NCLB, reeds, and D.A.R.E. should be avoided. Because it is easy for professionals in any field to lose track of which parts of the language that they use every day in their work life are understood by the general population and which parts are profession-specific jargon, it is helpful for school counselors to invite parents to ask questions about any words that are unclear.

While it is important to ensure that information is presented clearly, it is even more crucial to deliver the message with warmth and empathy. Parents receiving difficult news report higher levels of satisfaction when the professional giving the news is compassionate, is empathetic, listens well, and does not appear tense or anxious (Nissenbaum et al., 2002). Parents also are particularly aware of whether the professional genuinely is interested in them and their child (Nissenbaum et al.), and they are more apt to accept difficult messages from professionals if they believe at a basic level that the professionals like their child (Lawrence-Lightfoot, 2003).

Parents' Responses to Difficult News

The range of reactions that parents may have when receiving difficult news is very broad (Buckman, 1992). School counselors delivering difficult news to parents should neither assume that parents will have a certain type of reaction to hearing bad news nor judge the correctness or appropriateness of the responses that difficult news elicits from parents. Professionals are best advised to have few expectations about how parents "should" respond to difficult news. Some parents may actually have a positive reaction to hearing news that the professional presumed would be difficult, such as in cases where the parents know that their child has been having trouble at school and the news helps provide them with a better understanding of what has been happening and what to do to help. More typically, however, after receiving difficult news, parents are distressed, dispirited, and confused (Heiman, 2002).

Regardless of the nature of their response, parents should be encouraged to express their feelings about the news they have just heard, after which the school counselor can respond to those feelings with empathy. A question such as "What is your main concern about this news?" can elicit important fears and worries from parents (Kranss-Mars & Lachman, 1994). While school counselors should display empathy in these situations, they should be cautious not to offer premature reassurance. Statements that are designed to help parents feel better, but that do not acknowledge the reality of the situation and do not respond to parents' real fears and concerns, do not reassure. "I'm sure this is not as bad as you think--we just have to think positively about this" is premature reassurance. A statement that truly acknowledges the parents' fears and concerns is much more effective, such as "From the looks on your faces, I can tell it feels scary and distressing to think about what this means for your son."

While there are no clearly prescribed responses to various types of parental reactions to hearing difficult news, there are some general guidelines to assist professionals is deciding how best to respond to those reactions. These guidelines follow.

Responding to parental anger or agitation. The initial step in managing a difficult situation is to first manage oneself (Ramsey, 2002). School counselors faced with parental anger or agitation should strive to remain calm and focus on the emotions of the parents, rather than on their own emotions. It may be helpful to view angry reactions as being a mask for fear and distress (Jonson, 1999). A wise immediate response to parental anger is to simply listen. This has two benefits. First, it allows the parents to ventilate some of their feelings. Second, by hearing the parents out, the school counselor can discern whether some of the anger is due to misconceptions or distortions regarding the information, allowing the counselor to clarify the information. When school counselors do respond, they should do so with a calm voice and with empathy. Statements like "It is very upsetting to hear that your son's performance in school is much different than you had believed" can help parents feel as if their feelings have been acknowledged and accepted. If the parents disagree with all or part of the information they have just heard, the initial empathic responses can be followed by attempts to seek a mutual definition of exactly what aspects of the information the parents disagree with (noting, of course, the aspects they do agree with). Once the areas of disagreement have been clarified, the parents and professionals can jointly decide on additional actions such as gathering more information or meeting again at a later time.

Responding to disbelief. At times parents will respond to difficult news by simply stating that they do not believe it. If this happens, school counselors should avoid feeling defensive or attacked and realize that disbelief generally reflects difficulty taking in news that is unexpected and disturbing (Buckman, 1992). Empathetic statements such as "It must be hard to imagine that your daughter has a disability when she seems to be developing normally to you" are appropriate.

Responding to shock. Shock is not an emotion but rather an absence of emotion, reflecting parents' inability to make sense of dissonant news and difficult emotions (Buckman, 1992). Persons receiving difficult news frequently experience what has been described as mental dulling (Buckman), which is the experience of not being able to think clearly or easily recall information. This experience should be normalized for parents, with clear statements that it is common for parents to have trouble processing and remembering emotionally difficult information. Empathetic responses such as "This must be overwhelming for you--I'll just let you process this for a minute or two, then go over the main findings once more to make sure you are clear about them" can be enormously helpful to parents.

Responding to parental tears and distress. Parents will frequently respond to difficult news about their child with tears, particularly if the professionals have created an atmosphere that feels warm, accepting, and safe. School counselors can respond to parents' tears in several ways, depending on their judgment of what would be most helpful to the parents. These responses include offering a tissue, moving closer to the distressed parent, and possibly gently touching the parent on the arm. It is also helpful to try to identify the thoughts and beliefs that have led to the tears, as it is possible that the parents have misunderstood part of the information and are reacting based on a distorted picture of the situation. If the parents are very distressed, the school counselor should be sure to remain present until the parents are calmer, even if the formal meeting has concluded.

Follow-Up Strategies

The job of the school counselor is not finished when the information is delivered and the parents have had a chance to respond to the information. Parents consistently report the need for hope when presented with difficult or troubling news about their child (Bartolo, 2002; Cottrell & Summers, 1990). School counselors can assist parents in finding a reason to feel at least a moderate level of hopefulness by offering positive, hopeful plans for the future. Certainly, school counselors should avoid the notion that nothing can be done to improve the situation. It can be helpful to give parents information about services and resources appropriate to the situation. It also can help parents feel less isolated and more hopeful to use unifying language like we, together, and partnership (Ramsey, 2002).

In addition to expressing a need for hope, parents receiving bad news also consistently indicate that they value the opportunity to ask questions (Pain, 1999). School counselors should encourage parents to ask questions throughout the meeting, but especially toward the end of the meeting after the difficult information has been shared. School counselors may consider staying with the parents at the conclusion of the meeting to help them process the experience in a more relaxed and intimate setting. It is also helpful to offer to arrange a follow-up meeting to assist the parents in further coming to terms with the information and asking questions that did not occur to them at the initial meeting. If a follow-up meeting is not practical or agreed upon by the parents, an alternate strategy is for the school counselor to make a follow-up phone call to the parents the day after the meeting to see how the parents are doing with the news and to offer to answer any questions that have arisen.

Finally, school counselors should recognize that giving bad news to parents is difficult, emotionally draining work. After such a meeting, school counselors are wise to check their own reactions to make sure they are ready for the next student or parent (Fallowfield, 1993). Often it is necessary to take a short break to regain composure prior to continuing the day.

CONCLUSION

The way in which school counselors and other school professionals share difficult news with parents affects the way parents feel about both the information and the school. Difficult news is best delivered in a private, comfortable setting after carefully selecting who should be at the meeting and having made efforts to determine what the parents already know about the situation and how they prefer to have the information presented to them. The information should be shared gently, in chunks, with ample opportunities for parents to ask questions and receive clarifications. The delivery of the information is best followed by a therapeutic discussion of the parents' reactions to the news, realizing that a wide range of reactions to difficult news can be expected.

Improving the delivery of bad news does not ensure success. An expert in giving bad news is not someone who gets it right every time, but merely one who gets it wrong less often and who is less apt to be flustered when it goes wrong (Buckman, 1992). Giving difficult news is hard, and it takes an emotional toll. School counselors are wise to talk to supportive colleagues, friends, or family members about the experience (while of course upholding the confidentiality of the students and parents) in order to manage their own stress level. School counselors can be invaluable in assisting parents and students in the very difficult situations where hard, troubling news about the student must be shared. Professional school counselors should treat parents in these situations with empathy and care--just as they should treat themselves with care afterward.

References

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Abrams, E. Z., & Goodman, J. F. (1998). Diagnosing developmental problems in children: Parents and professionals negotiate bad news. Journal of Pediatric Psychology, 23, 87-98.

Bartolo, P.A. (2002). Communicating a diagnosis of developmental disability to parents: Multiprofessional negotiations frameworks. Child: Care, Health and Development, 28, 65-71.

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Cottrell, D. J., & Summers, K. (1990). Communicating an evolutionary diagnosis of disability to parents. Child: Care, Health and Development, 16, 211-218

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Dosanjh, S., Barnes, J., & Bhandari, M. (2001). Barriers to breaking bad news among medical and surgical residents. Medical Education, 35, 197-205.

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Heiman, T. (2002). Parents of children with disabilities: Resilience, coping, and future expectations. Journal of Developmental and Physical Disabilities, 14, 159-171.

Jonson, K. F. (1999). Parents as partners: Building positive home-school relationships [Electronic version]. The Educational Forum, 63, 121-126.

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Klein, S. D., & Schive, K. (1996). Delivering difficult news. The Exceptional Parent, 26, 44-48.

Krauss-Mars, A. H., & Lachman, R (1994). Breaking bad news to parents with disabled children: A cross-cultural study. Child: Care, Health and Development, 20, 101-113.

Lawrence-Lightfoot, S. (2003). The essential conversation: What parents and teachers can learn from each other. New York: Bailantine Books.

Nissenbaum, M. S., Tollefson, N., & Reese, R. M. (2002). The interpretive conference: Sharing a diagnosis of autism with families. Focus on Autism and Other Developmental Disabilities, 17, 30-43.

Pain, H. (1999). Coping with a child with disabilities from the parents' perspective: The function of information. Child: Care, Health and Development, 25, 299-312.

Ptacek, J.T., Ptacek, J. J., & Ellison, N. M. (2001). "I'm sorry to tell you ..." Physicians' reports of breaking bad news. Journal of Behavioral Medicine, 24, 205-217.

Quine, L., & Pahl, J. (1986). First diagnosis of severe mental handicap: Characteristics of unsatisfactory encounters between doctors and parents. Social Science & Medicine, 22, 53-62.

Quine, L., & Rutter, D. R. (1994). First diagnosis of severe mental and physical disability: A study of doctor-parent communication. Journal of Child Psychology & Psychiatry, 35, 1273-1287.

Ramsey, R. D. (2002). How to say the right thing every time: Communicating well with students, staff, parents, and the public. Thousand Oaks, CA: Corwin Press, inc.

Sloper, P., & Turner, S. (1993). Determinants of parental satisfaction with disclosure of disability. Developmental Medicine and Child Neurology, 35, 816-825.

Richard W. Auger is an associate professor with the Department of Counseling & Student Personnel, Minnesota State University, Mankato. E-mail: richard.auger@ mnsu.edu
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