Journal of Autism and Developmental Disorders

, Volume 47, Issue 12, pp 3756–3764 | Cite as

The Stability of Self-Reported Anxiety in Youth with Autism Versus ADHD or Typical Development

  • Hillary Schiltz
  • Nancy McIntyre
  • Lindsay Swain-Lerro
  • Matthew Zajic
  • Peter Mundy
S.I. : Anxiety in Autism Spectrum Disorders


Children with autism spectrum disorder (ASD) are at risk for anxiety symptoms. Few anxiety measures are validated for individuals with ASD, and the nature of ASD raises questions about reliability of self-reported anxiety. This study examined longitudinal stability and change of self-reported anxiety in higher functioning youth with ASD (HFASD) compared to youth with symptoms of attention deficit hyperactivity disorder and typical development (TD) using the Multidimensional Anxiety Scale for Children (March, 2012; March et al. J Am Acad Child Adolesc Psychiatry 36(4):554–565, 1997). Diagnostic groups demonstrated comparable evidence of stability for most dimensions of anxiety. The HFASD group displayed higher anxiety than both comparison groups, especially physical symptoms. These findings have implications for identification and measurement of anxiety in ASD.


Anxiety Self-Report Autism spectrum disorder Reliability 

Current research suggests that there is a great deal of heterogeneity in the phenotypic expression of autism spectrum disorder (ASD), one dimension of which concerns individual differences in symptoms of anxiety (Nebel-Schwalm and Worley 2014). The presence of anxiety may contribute directly to variability in the symptom presentation of ASD and/or the adaptive behavior and quality of life of affected children. Thus, it is an important construct for measurement related to prognosis and intervention in youth with ASD (Antshel et al. 2011; Wood et al. 2009). Several recent reports have addressed aspects of anxiety in ASD, such as the etiology (e.g., Bellini 2006; White et al. 2009; Wood and Gadow 2010) and treatment (e.g., Reaven et al. 2015; White et al. 2013; Wood et al. 2009), yet a dearth of empirical research exists on the psychometric properties of measures of anxiety in youth with ASD (Grondhuis and Aman 2012; White et al. 2012). Although a growing area of focus for research, the lack of such fundamental information has implications for the identification of anxiety disorders and the measurement of anxiety treatment outcomes in ASD.

In typically developing (TD) populations, self-report is recommended for assessing and verifying the presence of internalizing symptomology such as anxiety (Hope et al. 1999). Because of the cognitive and language phenotype of ASD, however, previous research has raised concerns regarding the ability of youth with ASD to accurately report their awareness of internalizing symptoms. Parent-report is often employed as an alternative solution, but their external vantage point is subject to an inherent imprecision of measurement with respect to symptoms of anxiety. As parents must infer their child’s internally experienced symptoms, externalizing characteristics (i.e., tantrums/oppositionality, inattention, hyperactivity) may be misinterpreted as anxiety (Sterling et al. 2015) or parents may exhibit the “parent distortion” bias (Bitsika et al. 2015).

Informant discrepancies between parents and children with ASD raise the specter of unreliable self-report of anxiety in samples of youth with ASD, with concerns that children may over-report (Hurtig et al. 2009) or under-report symptoms (Lopata et al. 2010; Russell et al. 2005). Moreover, meta-analytic evidence suggests that informant discrepancies of internalizing symptomology in ASD dyads are similar to those observed in TD dyads (Stratis and Lecavalier 2015). Thus, informant discrepancies may be normative for internalizing symptoms and are not necessarily indicative of unreliable ASD child-report. Further, parent–child agreement improves with increasing IQ and social skills in those with ASD (Kaat and Lecavalier 2015), suggesting that self-report may provide meaningful information especially in higher functioning individuals.

Informant concerns are not the only obstacle in measuring anxiety in youth with ASD. The lack of consensus regarding acceptable measures to use for research with this population is likely due to the paucity of anxiety measures that have been validated on youth with ASD. This issue is further convoluted by the possibility that anxiety may manifest differently in ASD (Kerns et al. 2014). Although clinician-administered measures, such as the Pediatric Anxiety Rating Scale (PARS) may be adequate for assessing anxiety in children with ASD (Storch et al. 2012), findings are mixed in the literature on parent reported anxiety measures that include child self-report versions. Evidence indicates that commonly used combined parent and self-batteries such as the Behavioral Assessment System for Children–2 (BASC-2; Reynolds and Kamphaus 2004), the Screen for Child Anxiety Related Disorders (SCARED; Birmaher et al. 1997), and the anxiety subscale of the Negative Affectivity Self-Statement Questionnaire (NASSQ; Ronan et al. 1994) display poor sensitivity and specificity for non-treatment seeking youth with ASD (Kerns et al. 2015). Other studies examining the use of the SCARED in children with ASD have found fair to strong parent–child agreement (Blakeley-Smith et al. 2012) as well as comparable psychometric properties to youth with anxiety disorders (van Steensel et al. 2013). Further, aspects of anxiety unique to those with ASD may also be important to consider (Mayes et al. 2013); interview (Kerns et al. 2017) and questionnaire based (Rodgers et al. 2016) instruments have been developed to tap into ASD-specific constructs and may be a fruitful resource for future research.

Another measure that has shown promise in the assessment of children with ASD is the Multidimensional Anxiety Scale for Children (MASC) (March, 2012; March et al. 1997). The MASC is one of few measures currently deemed appropriate, with conditions, for measuring anxiety in ASD as a treatment outcome (Lecavalier et al. 2014). White and colleagues have investigated the factor structure of both the child and parent reports on the MASC in a comparison of youth with ASD to TD peers (White et al. 2015). Parent-reported data from the ASD group did not conform to the established MASC factor structure. However, self-reported data revealed the same factors in both the ASD and TD samples, but the relations among those factors differed. Nevertheless, White and colleagues also reported evidence of discriminant validity and high internal consistency for the MASC in a sample of youth with ASD (White et al. 2012).

The foregoing indicates that some research exists on the issue of whether youth with ASD can provide valid and useful self-report data on anxiety, although many questions remain unanswered (Grondhuis and Aman 2012). One important question yet to be examined is the longitudinal stability of self-reported anxiety in youth with ASD. Related to this question is to what degree anxiety symptoms of youth with ASD change across time and if the pattern of change is specific to ASD or similar to that displayed by youth with typical development or youth with other neurodevelopmental clinical conditions.

Comparison with children with other clinical conditions may be especially important, as anxiety is not the only co-morbid condition observed in ASD. In particular, ADHD is thought to be present in a large proportion of youth with ASD with estimates suggesting that between approximately 28–55% of individuals with ASD meet criteria for ADHD or exhibit significant higher standard scores on measures of ADHD than typical controls (Leyfer et al. 2006; Simonoff et al. 2008). Anxiety is also a frequent comorbid feature of ADHD. Past estimates have suggested that nearly 25% of individuals with ADHD also experience anxiety (Schatz and Rostain 2006). Multiple theories have been put forth to elucidate the mechanism connecting anxiety and ADHD symptoms, involving the presence of sluggish cognitive tempo (Skirbekk et al. 2011), sensory overresponsivity (Reynolds and Lane 2009), and problems with emotion regulation (Steinberg and Drabick 2015). The later two processes are also common to children with ASD. This confluence of observations suggests that in studies of anxiety in youth with ASD it may be useful to include a clinical control sample of children with ADHD as well as sample with typical development. The former control could enhance the power of study to elucidate the characteristics of anxiety that are specific to ASD versus those that may differ from the typical but be shared by other clinical conditions.

The current study was designed to address the three issues highlighted in this review of the literature and advance the understanding of the measurement of anxiety in higher functioning youth with ASD by: (1) comparing the longitudinal stability of self-reported anxiety on the MASC in ASD, ADHD and TD Diagnostic Groups, (2) comparing the mean level of self-report on multiple dimensions of anxiety across the Diagnostic Groups, and (3) comparing the patterns of change over time on multiple dimensions of self-reported anxiety symptoms across the Diagnostic Groups.



This study was reviewed and approved by the institutional review board at UC Davis. Age matched participants with ASD or ADHD were recruited via the subject tracking system (STS) of the UC Davis MIND Institute. Age matched participants with typical development were recruited from community elementary and secondary schools. All participants were part of a larger longitudinal study of adolescents with HFASD and ADHD funded by the Institute of Education Sciences. All parents provided informed consent for all children in this study and all child participants provided informed assent before data collection.

One hundred twenty-five 8- to 16-year-old youth completed the questionnaire data used in this study. Participants either had a community diagnosis of ASD without evidence of intellectual disability (HFASD n = 57), attention deficit hyperactivity disorder (ADHD n = 28), or no diagnosis of a neurodevelopmental disability or childhood psychopathology (TD n = 40). ASD symptoms were confirmed using the ADOS-2 modules 3 and 4 (Lord et al. 2012), as well as parent reports on the Autism Spectrum Screening Questionnaire (ASSQ) (Ehlers et al. 1999), Social Communication Questionnaire (SCQ) (Eaves et al. 2006), and the Social Responsiveness Scale (SRS) (Constantino and Gruber 2005). Symptom confirmation for the ADHD group was provided with the Conners-3 Parent Report scale (Conners 2008), and participants in this group did not display significant levels of symptoms on the battery of parent report ASD measures (see Table 1). Participants in the TD group were screened for ASD and ADHD using the same questionnaires as those administered to the HFASD and ADHD; TD participants were included if they did not meet criteria on these measures (see Table 1). Parents also reported no other developmental, learning or mental health disorder among the children in the TD group. Participants with a full scale IQ (FIQ) less than 75 were excluded. The groups were comparable in terms of gender ratio and age (Table 1). However, the full scale IQ (FIQ) of the TD group was significantly higher than that of the HFASD and ADHD groups F(2, 122) = 14.25, p > 0.01. Therefore, IQ was used as a covariate in analyses where appropriate.

Table 1

Demographic variables


HFASD (N = 57)

ADHD (N = 28)

TD Controls (N = 40)










Gender (% male)







χ 2 = 4.78


Age at T1









Full IQac









Conners Global Index Totalac




































Significant group differences: aHFASD versus TD

bHFASD versus ADHD

cADHD versus TD


Participants provided two sets of self-report on the Multidimensional Anxiety Scale for Children (MASC; March 1997, 2013) across a 15 month interval. Participants read and responded to the questionnaire independently, with some participants in the clinical samples requiring prompts to complete the task. Parents completed the questionnaires independently. All questionnaires were completed during a laboratory visit.


The first and second editions of the Multidimensional Anxiety Scale for Children (MASC-SR, 39 items; MASC 2-SR, 50-items) were used to assess symptoms related to anxiety disorders in youth from ages 8 to 19 (March 1997, 2013). Subscales on the self-report MASC used in this report include Separation Anxiety, Social Anxiety, Physical Symptoms, Harm Avoidance, and the Generalized Anxiety Disorder Index. The MASC has been standardized on 2698 children (March et al. 1997), and the 2nd edition has been normed on a sample of 1800 children (March 2013), with both editions having high internal consistency and test–retest reliability. Further, the MASC has been shown to have excellent internal consistency in youth with ASD (α = 0.92) (White et al. 2012). The T-scores for each subscale were used in this study.

The Wechsler Abbreviated Scale of Intelligence (WASI; Wechsler 1999) was used to obtain IQ estimates. The WASI Full Scale IQ has well-established internal consistency (α = 0.98) and test–retest reliability (α= 0.92).

Data Analyses

The first step in the planned analyses was to compare the longitudinal stability and test–retest reliability of the MASC subscale and Global Index scores for the Diagnostic Groups over a 15-month interval. Test–retest reliability was examined utilizing partial correlations. FIQ was used as a covariate in all groups. To account for a potential overlap of symptoms between the HFASD and ADHD groups, the Conners-3 Global Index Total was used as a covariate in the HFASD group, and the SRS Total Score was used as a covariate in the ADHD group. Scatterplots for the bivariate Pearson’s test–retest reliability coefficients in the HFASD sample, rather than partial correlation coefficients, were generated to visually present the details of the the stability of their self-report of anxiety.

Repeated measures ANCOVAs, controlling for IQ, were then computed to test for Diagnostic Group differences on the MASC self-report of anxiety. Post-hoc Bonferroni corrected tests were computed for pairwise Diagnostic Group comparisons. These analyses also were used to determine if the Diagnostic Groups displayed similar or different patterns of change on the MASC subscales or global index of anxiety over the 15-month test–retest interval.


Test–retest Reliability

There was evidence of significant stability of self-report across the 15-month interval for the MASC Total Anxiety, Physical Symptoms, and Separation Anxiety scores in all Diagnostic Groups (Table 2), as indicated by positive partial-correlations from Time 1 to Time 2. Evidence of stability was only observed for the Harm Avoidance scale scores in the HFASD and ADHD group, and the MASC Anxiety Disorder Index displayed evidence of stability in the HFASD and TD groups.

Table 2

Partial correlation for stability from Time 1 to Time 2 by Diagnostic Group




TD Controls

MASC Total Anxiety




MASC Physical Symptoms




MASC Harm Avoidance




MASC Social Anxiety




MASC Separation Anxiety




MASC Anxiety Disorder Index




Full IQ was controlled in all groups, SRS Total in the ADHD group, and Conners-3 Global Index in the HFASD group

*p ≤ 0.05, ** p≤ 0.01

More details about the evidence of stability in self-report of anxiety on the MASC for HFASD sample are illustrated in Fig. 1. As can be seen in panels A and B of Fig. 1, clinically elevated scores were stable per subtest as follows: 14% of youth (n = 8) on Total Anxiety, 16% of youth (n = 9) on Separation Anxiety, 14% of youth (n = 8) on Physical Symptoms, and 10% of youth (n = 6) on the Anxiety Disorder Index.

Fig. 1

Scatter plots of the longitudinal stability of HFASD self-reports on the MASC. a Illustrates the stability of the Total Anxiety symptom scale score. b Illustrates the stability of the Physical Symptoms anxiety subscale score. c Illustrates the stability of the Harm Avoidance anxiety symptom subscale score. d Illustrates the stability of the Social Anxiety symptom subscale score. e Illustrates the stability of Separation Anxiety symptom subscale score. f Illustrates the stability of the Anxiety Disorder Index score

Additionally, 23% of youth (n = 13) with lower scores on the Total Anxiety Scale at time 1 (T ≤ 64) had more elevated scores (T ≥ 65) at time 2. Thus 37% of youth (n = 21) youth had elevated Total Anxiety scores at time 2. An additional 28% of youth (n = 16) in this sample had more elevated Time 2 than Time 1 scores on the Physical Symptoms subscale, for a total of 42% of youth (n = 24) in this sample with elevations of these symptoms at Time 2. Additionally, 23% of youth (n = 13) had more elevated Time 2 than Time 1 scores on the Anxiety Disorder Index, for a total of 33% of youth (n = 19) displaying elevated scores on the Anxiety Disorder Index at Time 2. Harm Avoidance and Social Anxiety subscales displayed slightly different patterns than the other subscales, such that only 17% of youth (n = 10) displayed elevations of Social Anxiety symptoms and only 12% of youth (n = 7) displayed elevations of Harm Avoidance either consistently across Time 1 and Time 2, or ultimately at Time 2 (T ≥ 65).

Relatively few youth with HFASD in this sample displayed a decrease on either Total Anxiety or Physical symptom measures (Fig. 1). However, 14% of youth (n = 8) displayed elevation on the Anxiety Disorder Index at Time 1, but not at Time 2. Additionally, this pattern of remission was also observed in 17% of youth (n = 10) for the Social Anxiety subscale and 23% of youth (n = 13) for the Separation Anxiety subscale.

Diagnostic Group Differences and Developmental Change

A repeated measures ANCOVA revealed a significant main effect of Diagnostic Group for self-report on MASC Total Anxiety score, F(2, 121) = 4.95, p = 0.01. Post hoc comparisons revealed that the HFASD group was significantly higher on Total Anxiety than the TD group (p = 0.02; Table 3). The difference between the HFASD and ADHD group approached significance (p = 0.08), with the HFASD group higher than the ADHD group (Table 3).

Table 3

Time 1 and 2 MASC Data


HFASD (N = 57)

ADHD (N = 28)

TD controls (N = 40)

Time 1

Time 2

Time 1

Time 2

Time 1

Time 2

Total Anxietya

57.74 (10.17)

61.02 (12.24)

54.50 (11.53)

54.54 (12.36)

51.80 (8.37)

55.35 (9.14)

Physical Symptomsab

54.27 (9.67)

61.98 (9.63)

49.54 (9.51)

54.39 (11.23)

46.92 (7.49)

57.45 (9.21)

Harm Avoidance

53.54 (10.08)

53.44 (8.65)

52.86 (11.75)

50.61 (7.79)

53.93 (9.05)

52.27 (5.45)

Social Anxiety

55.65 (12.03)

54.28 (11.24)

56.46 (11.63)

53.43 (11.94)

51.35 (8.28)

51.85 (8.18)

Separation Anxietyb

61.54 (12.67)

57.95 (11.69)

55.00 (12.01)

51.79 (12.47)

54.67 (10.65)

54.32 (8.46)

Anxiety Disorder Index

55.05 (11.53)

59.95 (11.48)

54.43 (10.07)

53.25 (10.31)

54.02 (9.46)

56.52 (8.41)

Significant group differences: aHFASD versus TD

bHFASD versus ADHD

cADHD versus TD

Analyses conducted to examine of effects of Diagnostic Group and Time on each MASC subscale indicated that there were no effects of Diagnostic Group or time observed for Harm Avoidance and Social Anxiety subscales of the MASC. However, significant effects were observed for the both the Physical Symptoms and Separation Anxiety subscales.

For Physical Symptoms, there was a significant effect of Diagnostic Group, F(2, 121) = 8.60, p < 0.01. Bonferroni post hoc comparisons revealed that the HFASD group was significantly higher on Physical Symptoms than both the TD group (p < 0.01) and the ADHD group (p = 0.01). The interaction between Time and Diagnostic Group was also significant, F(2, 121) = 3.78, p = 0.03, such that the TD group exhibited a greater increase in self-report of physical symptoms than did than the ADHD or HFASD groups (Table 3).

For Separation Anxiety, the effect of Diagnostic Group was significant, F(2, 121) = 3.90, p = 0.02. Bonferroni post hoc comparisons revealed that the HFASD group was significantly higher on Separation Anxiety than the ADHD group (p = 0.03). With respect to the Anxiety Disorder Index, the interaction between Diagnostic Group and Time was approaching significance, F(2, 121) = 2.50, p = 0.09. The HFASD group increased to a marginally greater degree than the TD group, while the ADHD group decreased (Table 3).


The results of this study support the hypothesis that self-report in this subgroup of youth with HFASD provides meaningful (reliable) information about trait-like individual differences in anxiety. The findings were consistent with previous evidence that youth with HFASD display elevated levels of specific dimensions of anxiety compared to youth with ADHD and TD youth.

The longitudinal data in this study provides some of the first evidence of longer term stability of individual differences in anxiety among youth with HFASD. Their self-reports on the MASC total anxiety subscale and Anxiety Disorder Index were characterized by moderate to strong correlations across a 15-month time span. This was comparable to the correlations observed for the typical and clinical control sample, with the exception for a lack of stability on the Anxiety Disorder Index for the ADHD group. In terms of their specific focus of anxiety, self-report on the Physical Symptoms, Harm Avoidance, Separation Anxiety, and Social Anxiety subscales of the MASC were correlated over time in the HFASD sample, similar to the control samples. The stability correlation coefficient for physical symptoms was especially strong for the HFASD sample.

Since all the means of the MASC Scores were within two standard deviations of the normative scale means, these data do not indicate that all youth with HFASD in this study exhibited clinical elevations of anxiety. This observation is supported by the illustration of data from four of the MASC measures in Fig. 1, such that some youth increased in their reports of anxiety and subsets of youth remitted in their reports of anxiety. Hence, clinicians and researchers alike should resist the tendency to think of anxiety as a comorbid characteristic of all youth with HFASD. Rather, as illustrated by the data for the HFASD group, research should be refocused to understand why there are likely four subgroups of HFASD youth with respect to self-reported anxiety: (a) a large subgroup of youth who do not report heightened symptoms of anxiety in childhood, (b) a subgroup who consistently report anxiety, (c) a subgroup who increase in their reports of anxiety, and (d) a subgroup for whom self-reports of anxiety remit over time.

Nevertheless, the data did indicate that substantial numbers of youth with HFASD in this sample self-reported clinically significant symptoms of anxiety. This appeared to be especially the case for physical symptoms. In this regard, it is interesting to note that self-report on the physical symptoms subscale has previously been observed to be related to self-report of mood disturbance in youth with HFASD and that their self-report on this scale is consistent with parent reports of their physical symptoms (White et al. 2012). Bellini (2006) has also provided data to indicate that self-report on the MASC physical symptoms scale is a valid measure of individual differences in physiological arousal that, in combination with measures of social difficulties, explain individual differences in social anxiety among these youth. Hence, evidence of stability in this study adds to a literature on the potential importance of this measure in research on youth with HFASD.

The observation that relatively few youth displayed elevations of social anxiety on the MASC in this study was at odds with at least one previous report (Bellini 2004). This may reflect a sample specific effect, although others have also failed to observed a diagnostic group effect on the social anxiety measure of the MASC in a study of youth with HFASD (Jarrold et al. 2013). More focused, narrow-banded measures may be more sensitive for research on social anxiety in youth with HFASD (e.g., Bellini 2006).

The inclusion of the ADHD sample allowed this study to provide some data on the specificity of anxiety to youth with HFASD. Here the results revealed that the HFASD group was higher on levels of physical symptoms than both comparison groups and higher on separation anxiety than the ADHD group, but the HFASD group did not differ from the ADHD group in their reports of social anxiety, harm avoidance, or symptoms indicative of an anxiety disorder. This pattern of data again points to the importance of the dimension of physical symptoms in the study of anxiety in HFASD. Whatever process that contributed to the heightened physical symptoms in this sample of youth with HFASD, could not be explained in terms of the general levels of stress experienced by youth with significant neurodevelopmental problems. The observation of a specific difference on separation anxiety may also be revealing. These scale items tap into youth’s developing capacity for a sense of security in novel situations that demand autonomy. Clinical group differences in this arena for school-aged youth with HFASD may not only be surprising but also may not be as well recognized as other components of anxiety among these youth.

The observations in this study provide psychometric, group comparison data that support the reliability of the use of self-reported anxiety, such as the MASC-SR, in research with youth with HFASD. Further, these findings bolster the need for additional research on proactive monitoring and treatment of anxiety disorders in youth with HFASD. Thus, self-report of anxiety may be a valid component of prognostic and outcome assessment in research with children with HFASD.

Of course, this study is not without its limitations. In particular, there was no parent-reported measure of anxiety to compare to the self-report of anxiety. It is unknown whether the self-reported symptoms of anxiety align with parental perceptions of these symptoms in this sample, and whether stability would also be observed in parent-report. Future work may benefit from comparing the stability in both parent and child report of anxious symptoms among youth with ASD. Additionally, the measure of anxiety was not ASD specific, and thus, potential atypical anxiety was not addressed. It is possible that higher levels of anxiety may emerge if these other ASD-specific components of anxiety were included, although it is less clear whether self-report of atypical anxiety would remain stable over time.


Author Contributions

HS drafted the manuscript, performed statistical analyses and interpretation, and collected data for the study; NM collaborated on the design of the study and collected data for the study; LS-L collaborated on the design of the study and coordinated data collection for the study; MZ collaborated on the design of the study and drafting the manuscript, and collected data for the study; PM designed and coordinated the study, and collaborated on statistical analyses and drafting the manuscript.


This study was supported by the Institute of Educational Sciences Grant IES R324A120168 (P. Mundy) and the UC Davis Department of Psychiatry Lisa Capps Endowment for Research on Neurodevelopmental Disorders and Education.

Compliance with Ethical Standards

Conflict of interest

The authors declared that thery have no conflict of interest.

Ethical Approval

All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.

Informed Consent

Informed consent was obtained from all individual participants included in the study.


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Copyright information

© Springer Science+Business Media New York 2017

Authors and Affiliations

  • Hillary Schiltz
    • 1
    • 4
  • Nancy McIntyre
    • 2
  • Lindsay Swain-Lerro
    • 2
  • Matthew Zajic
    • 2
  • Peter Mundy
    • 2
    • 3
  1. 1.Department of Human EcologyUniversity of California, DavisDavisUSA
  2. 2.School of EducationUniversity of California, DavisDavisUSA
  3. 3.MIND InstituteUniversity of CaliforniaSacramentoUSA
  4. 4.Department of PsychologyMarquette UniversityMilwaukeeUSA

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