| Attention Deficit Hyperactivity Disorder (ADHD) - Questions and Answers

***Q.� What is Attention Deficit Hyperactivity Disorder (ADHD)?***

A.� ADHD refers to a family of related chronic neurobiological disorders that   interfere with an individual's capacity to regulate activity level (hyperactivity),   inhibit behavior (impulsivity), and attend to tasks (inattention) in developmentally   appropriate ways.� The core symptoms of ADHD include an inability to sustain   attention and concentration, developmentally inappropriate levels of activity,   distractibility, and impulsivity.� Children with ADHD have functional impairment   across multiple settings including home, school, and peer relationships.� ADHD   has also been shown to have long-term adverse effects on academic performance,   vocational success, and social-emotional development.� Children with ADHD experience   an inability to sit still and pay attention in class and the negative consequences   of such behavior.� They experience peer rejection and engage in a broad array   of disruptive behaviors.� Their academic and social difficulties have far-reaching   and long-term consequences.� These children have higher injury rates.� As they   grow older, children with untreated ADHD, in combination with conduct disorders,   experience drug abuse, antisocial behavior, and injuries of all sorts.� For   many individuals, the impact of ADHD continues into adulthood. 

***Q.� What are the symptoms of ADHD?***
- Inattention.  People who are inattentive have a hard time keeping     their mind on one thing and may get bored with a task after only a few minutes.�     Focusing conscious, deliberate attention to organizing and completing routine     tasks may be difficult.    
-  Hyperactivity.  People who are hyperactive always seem to be in motion.�     They can't sit still; they may dash around or talk incessantly.� Sitting still     through a lesson can be an impossible task.� They may roam around the room,     squirm in their seats, wiggle their feet, touch everything, or noisily tap     a pencil.� They may also feel intensely restless.    
-  Impulsivity.  People who are overly impulsive, seem unable to curb     their immediate reactions or think before they act.� As a result, they may     blurt out answers to questions or inappropriate comments, or run into the     street without looking.� Their impulsivity may make it hard for them to wait     for things they want or to take their turn in games.� They may grab a toy     from another child or hit when they are upset. 

***Q.� How is ADHD diagnosed?***

A.� The diagnosis of ADHD can be made reliably using well-tested diagnostic   interview methods.� Diagnosis is based on history and observable behaviors in the child's usual settings.� Ideally, a   health care practitioner making a diagnosis should include input from parents   and teachers.� The key elements include a thorough history covering the presenting   symptoms, differential diagnosis, possible comorbid conditions, as well as medical,   developmental, school, psychosocial, and family histories.� It is helpful to   determine what precipitated the request for evaluation and what approaches had   been used in the past.� As of yet, there is no independent test for ADHD.� This   is not unique to ADHD, but applies as well to most psychiatric disorders, including   other disabling disorders such as schizophrenia and autism. 

***Q.� How many children are diagnosed with ADHD?***

A.� ADHD is the most commonly diagnosed disorder of childhood, estimated to   affect 3 to 5 percent of school-age children, and occurring three times more   often in boys than in girls. On average, about one child in every classroom   in the United States needs help for this disorder. 

***Q.� Aren't there various types of ADHD?***

A.� According to *DSM-IV*, the fourth and most recent edition of the *DSM*,   while most individuals have symptoms of both inattention and hyperactivity-impulsivity,   there are some individuals in whom one or another pattern is predominant (for   at least the past 6 months).� 

***Q.� How are schools involved in diagnosing, assessing, and treating ADHD?***

A.� Physicians and parents should be aware that schools are federally mandated   to perform an appropriate evaluation if a child is suspected of having a disability   that impairs academic functioning.� This policy was recently strengthened by   regulations implementing the 1997 reauthorization of the Individuals with Disabilities   Act (IDEA), which guarantees appropriate services and a public education to   children with disabilities from ages 3 to 21.� For the first time, IDEA specifically   lists ADHD as a qualifying condition for special education services.� If the   assessment performed by the school is inadequate or inappropriate, parents may   request that an independent evaluation be conducted at the school's expense.�   Furthermore, some children with ADHD qualify for special education services   within the public schools, under the category of "Other Health Impaired."�   In these cases, the special education teacher, school psychologist, school administrators,   classroom teachers, along with parents, must assess the child's strengths and   weaknesses and design an Individualized Education Program.� These special education   services for children with ADHD are available though IDEA. 

***Q.� Is ADHD inherited?***

A.� Research shows that ADHD tends to run in families, so there are likely   to be genetic influences.� Children who have ADHD usually have at least one   close relative who also has ADHD.� And at least one-third of all fathers who   had ADHD in their youth have children with ADHD.� Even more convincing of a   possible genetic link is that when one twin of an identical twin pair has the   disorder, the other is likely to have it too. 

***Q.� Is ADHD on the increase?******If so, why?***

A.� No one knows for sure whether the prevalence of ADHD per se has risen,   but it is very clear that the number of children identified with the disorder   who obtain treatment has risen over the past decade.� Some of this increased   identification and increased treatment seeking is due in part to greater media   interest, heightened consumer awareness, and the availability of effective treatments.�   A similar pattern is now being observed in other countries.� Whether the frequency   of the disorder itself has risen remains unknown, and needs to be studied. 

***Q.� Can ADHD be seen in brain scans of children with the disorder?***

A.� Neuroimaging research has shown that the brains of children with ADHD differ   fairly consistently from those of children without the disorder in that several   brain regions and structures (pre-frontal cortex, striatum, basal ganglia, and   cerebellum) tend to be smaller.� Overall brain size is generally 5% smaller   in affected children than children without ADHD.� While this average difference   is observed consistently, it is too small to be useful in making the diagnosis   of ADHD in a particular individual.� In addition, there appears to be a link   between a person's ability to pay continued attention and measures that reflect   brain activity.� In people with ADHD, the brain areas that control attention   appear to be less active, suggesting that a lower level of activity in some   parts of the brain may be related to difficulties sustaining attention. 

***Q.� Can a preschool child be diagnosed with ADHD?***

A.� The diagnosis of ADHD in the preschool child is possible, but can be difficult   and should be made cautiously by experts well trained in childhood neurobehavioral   disorders.� Developmental problems, especially language delays, and adjustment   problems can sometimes imitate ADHD.� Treatment should focus on placement in   a structured preschool with parent training and support.� Stimulants can reduce   oppositional behavior and improve mother-child interactions, but they are usually   reserved for severe cases or when a child is unresponsive to environmental or   behavioral interventions. 

***Q.� What is the impact of ADHD on children and their families?***

A.� Life can be hard for children with ADHD.� They're the ones who are so often   in trouble at school, can't finish a game, and have trouble making friends.�   They may spend agonizing hours each night struggling to keep their mind on their   homework, then forget to bring it to school.� It is not easy coping with these   frustrations day after day for children or their families. Family conflict can   increase.� In addition, problems with peers and friendships are often present   in children with ADHD.� In adolescence, these children are at increased risk   for motor vehicle accidents, tobacco use, early pregnancy, and lower educational   attainment.� When a child receives a diagnosis of ADHD, parents need to think   carefully about treatment choices.� And when they pursue treatment for their   children, families face high out-of-pocket expenses because treatment for ADHD   and other mental illnesses is often not covered by insurance policies.� School   programs to help children with problems often connected to ADHD (social skills   and behavior training) are not available in many schools.� In addition, not   all children with ADHD qualify for special education services.� All of this   leads to children who do not receive proper and adequate treatment.� To overcome   these barriers, parents may want to look for school-based programs that have   a team approach involving parents, teachers, school psychologists, other mental   health specialists, and physicians. 

***Q.� Aren't there nutritional treatments for ADHD?***

A.� Many parents have exhausted nutritional approaches, such as eliminating   sugar from the diet, before they seek medical attention.� However, there are   no well-established nutritional interventions that have been consistently demonstrated   to be efficacious for assisting the great majority of children with ADHD.� A   small body of research has suggested that some children may benefit from these   interventions, but delaying the implementation of well-established, effective   interventions while engaged in the search for unknown, generally unproven allergens,   is likely to be harmful for many children. 

***Q.� What are behavioral treatments?***

A.� There are various forms of behavioral interventions used for children with   ADHD, including psychotherapy, cognitive-behavioral therapy, social skills training,   support groups, and parent and educator skills training.� An example of very   intensive behavior therapy was used in the NIMH Multimodal Treatment Study of   Children with ADHD (MTA), which involved the child's teacher, the family, and   participation in an all-day, 8-week summer camp.� The consulting therapist worked   with teachers to develop behavior management strategies that address behavioral   problems interfering with classroom behavior and academic performance.� A trained   classroom aide worked with the child for 12 weeks in his or her classroom, to   provide support and reinforcement for appropriate, on-task behavior.� Parents   met with the therapist alone and in small groups to learn approaches for handling   problems at home and school.� The summer day camp was aimed at improving social   behavior, academic work, and sports skills. 

***Q.� What medications are currently being used to treat ADHD?***

A.� Psychostimulant medications, including methylphenidate (Ritalin®) and amphetamines   (Dexedrine®, Dextrostat®, and Adderall®), are by far the most widely researched   and commonly prescribed treatments for ADHD.� Numerous short-term studies have  established the safety and efficacy of stimulants and psychosocial treatments   for alleviating the symptoms of ADHD.� NIMH research has indicated that the   two most effective treatment modalities for elementary school children with   ADHD are a closely monitored medication treatment and a treatment that combines   medication with intensive behavioral interventions.� In the NIMH Multimodal   Treatment Study for Children with ADHD (MTA), which included nearly 600 elementary   school children across multiple sites, nine out of ten children improved substantially   on one of these treatments.� Additionally, antidepressant medications may also   be used as a second line of treatments for children who show poor response to   stimulants, who have unacceptable side effects, or who have comorbid conditions   (such as tics, anxiety, or mood disorders).� Tricyclic antidepressants have   shown clinical efficacy in 60-70% of children with ADHD.� While the medications   were extremely beneficial to most children, MTA findings indicated that medications   alone may not necessarily be the best strategy for many children.� For example,   children who had accompanying problems (e.g., anxiety, stressful home circumstances,   social skills deficits, etc.), over and above the ADHD symptoms, appeared to   obtain maximal benefit from the combined treatment. 

***Q.� Are there standard doses for these medications?***

A.� Careful medication management is important in treating a child with ADHD.�   For methylphenidate (Ritalin®), the usual dosage range is 5 to 20 mg given two   to three times a day.� The dose for amphetamines (Dexedrine® and Dextrostat®   and Adderall®) is one-half the methylphenidate dose.� Dosage requirements do   not always correlate with weight, age or severity of symptoms in an individual   patient.� Dosages may need to be increased during childhood with increased lean   body weight and decreases may be necessary after puberty.� Different doctors   use these medications in slightly different ways. 

***Q.� How long are children on these medications?***

A.� The expected duration of treatment has lengthened during this past decade   as evidence has accumulated that benefits extend into adolescence and adulthood.�   However, many factors work against continued treatment during adolescence including   the partial resolution of the most obvious symptoms, the short-lasting effects   of medications that require multiple doses per day, and the need for regular   physician written prescriptions. Additionally, parents often discontinue medication   even when benefit has been demonstrated or because they see the child improve   and don't think the medication is necessary any longer. 

***Q.� How often are stimulant prescriptions used?***

A.� Data from 1995 show that physicians treating children and adolescents wrote   six million prescriptions for stimulant medications—methylphenidate (Ritalin®)   and dextroamphetamine (Dexedrine®).� Of all the drugs used to treat psychiatric   disorders in children, stimulant medications are the most thoroughly studied. 

***Q.� Isn't stimulant use on the increase?***

A.� Stimulant use in the United States has increased substantially over the   last 25 years.� A recent study saw a 2.5-fold increase in methylphenidate between   1990 and 1995.� This increase appears to be largely related to an increased   duration of treatment, and more girls, adolescents, adults, and inattentive   individuals (in addition to those individuals with both hyperactivity and inattentiveness/attention deficit) receiving treatment.� 

***Q.� Are there differences in stimulant use across racial and ethnic groups?***

A.� There are significant differences in access to mental health services between   children of different racial groups; and, consequently, there are differences   in medication use.� In particular, African American children are much less likely   than Caucasian children to receive psychotropic medications, including stimulants,   for treatment of mental disorders.� 

***Q.� Why are stimulants used when the problem is overactivity?***

A.� The answer to this question is not well established, but one theory suggests   that ADHD is related to difficulties in inhibiting responses to internal and   external stimuli.� Evidence to date suggests that those areas of the brain thought   to be involved in planning, foresight, weighing of alternative responses, and   inhibiting actions when alternative solutions might be considered, are underaroused   in persons with ADHD.� Stimulant medication may work on these same areas of   the brain, increasing neural activity to more normal levels.� More research   is needed, however, to firmly establish the mechanisms of action of the stimulants. 

***Q.� What are the risks of the use of stimulant medication and other treatments?***

A.� Stimulant drugs, when used with medical supervision, are usually considered   quite safe.� Although they can be addictive when abused by teenagers and adults,   when taken as prescribed for ADHD these medications have not been shown to be   addictive nor to lead to substance abuse problems.� They seldom make children   "high" or jittery, nor do they sedate the child.� Although little   information exists concerning the long-term effects of psychostimulants, there   is no evidence that careful therapeutic use is harmful.� When adverse drug reactions   do occur, they are usually related to dosage and are always reversible.� Effects   associated with moderate doses are decreased appetite and insomnia. �These effects   occur early in treatment and may decrease with time.� There may be negative   effects on growth rate, but ultimate height appears not to be affected. 

***Q.� Will children taking these medications for ADHD become drug addicts?***

A.� Actually, it appears to be just the opposite.� Although an increased risk   of drug abuse and cigarette smoking is associated with childhood ADHD, this   risk appears mostly due to the ADHD condition itself, rather than its treatment.�   In a study jointly funded by the NIMH and the National Institute on Drug Abuse,   boys with ADHD who were treated with stimulants were significantly less likely   to abuse drugs and alcohol when they got older.� Caution is warranted, nonetheless,   as the overall evidence suggests that persons with ADHD (particularly untreated   ADHD) are indeed at greater risk for later alcohol or substance abuse.� Because   some studies have come to conflicting conclusions, more research is needed to   understand these phenomena.� Regardless, in view of the substantial, well-established   findings of the harmful effects of inadequate or no treatment for a child with   ADHD, parents should not be dissuaded from seeking effective treatments because   of misconstrued or exaggerated claims about substance abuse risks. 

***Q.� Wasn't there a large conference held at NIH on ADHD recently?***

A.� In 1998, the NIH held a two-day Consensus Conference on ADHD, bringing   together national and international experts, as well as representatives from   the public.� The Consensus statement is now available at  http://odp.od.nih.gov/consensus/cons/110/110_statement.htm  .

***Q.� What is the relationship between ADHD and other disorders, such as   learning disabilities, anxiety disorders, bipolar disorder, or depression?***

A.� Comorbidity occurs in most children clinically treated for ADHD.� ADHD   can co-occur with learning disabilities (15-25%), language disorders (30-35%),   conduct disorder (15-20%), oppositional defiant disorder (up to 40%), mood disorders   (15-20%), and anxiety disorders (20-25%).� Up to 60 percent of children with   tic disorders also have ADHD.� Impairments in memory, cognitive processing,   sequencing, motor skills, social skills, modulation of emotional response, and   response to discipline are common.� Sleep disorders are also more prevalent. 

***Q.� What is the history of ADHD? How is it related to ADD?***

A.� ADHD has assumed many aliases over time from hyperkinesis (the Latin derivative   for "superactive") to hyperactivity in the early 1970s.� In the 1980s,   *DSM-III* dubbed the syndrome Attention Deficit Disorder, or ADD, which   could be diagnosed with or without hyperactivity.� This definition was created   to underline the importance of the inattentiveness or attention deficit that   is often but not always accompanied by hyperactivity.� The revised edition of   *DSM-III*, the *DSM-III-R*, published in 1987, returned the emphasis   back to the inclusion of hyperactivity within the diagnosis, with the official   name of ADHD.� With the publication of *DSM-IV*, the name ADHD still stands,   but there are varying types within this classification, to include symptoms   of both inattention and hyperactivity-impulsivity, signifying that there are   some individuals in whom one or another pattern is predominant (for at least   the past 6 months).� In the *International Classification of Diseases*   (used predominantly in other Western countries), the term "Hyperkinetic   Disorder" is used, but the criteria are the same as for ADHD/combined type. 

***Q.� What are the future research directions for ADHD?***

A.� Continued research on ADHD is needed from many perspectives.� The societal   impact of ADHD needs to be determined. Studies in this regard include (1) strategies   for implementing effective medication management or combination therapies in   different schools and pediatric healthcare systems; (2) the nature and severity   of the impact on adults with ADHD beyond the age of 20, as well as their families;   and (3) determination of the use of mental health services related to diagnosis   and care of persons with ADHD.� Additional studies are needed to improve communication   across educational and health care settings to ensure more systematized treatment   strategies.� Basic research is also needed to better define the behavioral and   cognitive components that underpin ADHD, not just in children with ADHD, but   also in unaffected individuals.� This research should include (1) studies on   cognitive development, cognitive and attentional processing, impulse control,   and attention/inattention; (2) studies of prevention/early intervention strategies   that target known risk factors that may lead to later ADHD; and (3) brain imaging   studies before the initiation of medication and following the individual through   young adulthood and middle age.� Finally, further research should be conducted   on the comorbid (coexisting) conditions present in both childhood and adult   ADHD, and treatment implications. 

For More Information on Mental Disorders in Children, Contact:

Office of Communications and Public Liaison, NIMH  Information Resources and Inquiries Branch  6001 Executive Blvd., Room 8184, MSC 9663  Bethesda, MD 20892-9663  Phone: 301-443-4513  TTY: 301-443-8431  FAX: 301-443-4279  Mental Health FAX 4U: 301-443-5158  E-mail: [email protected]NIMH home page address:http://www.nimh.nih.gov
March 2000                                                                                                                                                                                                                                                                                                                                   |
|---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------|