human
***TASK*** the task is to summarize an input biomedical literature in six sentences 
    ***INPUT*** the input is a biomedical literature 
    ***OUTPUT*** the output is the summary of an input biomedical literature in six sentences 
    ***DOCUMENTATION*** 
    ***EXAMPLES*** 
    Input: OBJECTIVE Impairments associated with attention-deficit/hyperactivity disorder ( ADHD ) and noncompliance are prevalent in children with autism spectrum disorder ( ASD ) . However , ADHD response to stimulants is well below rates in typically developing children , with frequent side effects . Group studies of treatments for noncompliance are rare in ASD . We examined individual and combined-effectiveness of atomoxetine ( ATX ) and parent training ( PT ) for ADHD symptoms and noncompliance . METHOD In a 3-site , 10-week , double-blind , 2 × 2 trial of ATX and PT , 128 children ( ages 5 - 14 years ) with ASD and ADHD symptoms were r and omized to  ATX , ATX+PT , placebo+PT , or placebo . ATX was adjusted to optimal dose ( capped at 1.8 mg/kg/day ) over 6 weeks and maintained for 4 additional weeks . Nine PT sessions were provided . Primary outcome measures were the parent-rated DSM ADHD symptoms on the Swanson , Nolan and Pelham ( SNAP ) scale and Home Situations Question naire ( HSQ ) . RESULTS On the SNAP , ATX , ATX+PT and placebo+PT were each superior to placebo ( effect sizes 0.57 - 0.98 ; p values of .0005 , .0004 , and .025 , respectively ) . For noncompliance , ATX and ATX+PT were superior to placebo ( effect sizes 0.47 - 0.64 ; p values .03 and .0028 , respectively ) . ATX was associated with decreased appetite but was otherwise well tolerated . CONCLUSION Both ATX and PT result ed in significant improvement on ADHD symptoms , whereas ATX ( both alone and combined with PT ) was associated with significant decreases on measures of noncompliance . ATX appears to have a better side effects profile than psychostimulants in the population with ASD . CLINICAL TRIAL REGISTRATION INFORMATION Atomoxetine , Placebo and Parent Management Training in Autism ; http:// clinical trials.gov/ ; NCT00844753 Fathers , in general , have been underrepresented in studies of parent training outcome for children with attention deficit hyperactivity disorder ( ADHD ) , and the present study aim ed to investigate the efficacy of a behavioral parent training program developed expressly for fathers . The present investigation r and omly assigned 55 fathers of children ages 6 to 12 with ADHD to the Coaching Our Acting-out Children :  Heightening Essential Skills ( COACHES ) program or a waitlist control group . Outcomes for the study included objective observations of parent behaviors and parent ratings of child behavior . Results indicated that fathers in the COACHES group reduced their rates of negative talk and increased rates of praise as measured in parent – child observations , and father ratings of the intensity of problem behaviors were reduced , relative to the waitlist condition . Groups did not differ on observations of use of comm and s or father ratings of child behavior problems . Untreated mothers did not significantly improve on observational measures or behavioral ratings . This study provides preliminary evidence for the efficacy of the COACHES parenting program for fathers of children with ADHD . Results are cast in light of the larger literature on behavioral parent training for ADHD as well as how to best work with fathers of children with ADHD in treatment context This study examined the individual and combined effects of two nonpharmacological treatments for attention deficit/hyperactivity disorder ( ADHD ) :  Cogmed working memory training ( CWMT ) for adolescents and  behavioral parent training ( BPT ) for mothers . Ninety-one adolescents ( ages 11–15 ) and their mothers were r and omized to one of four CWMT and BPT treatment and active control ( placebo ) group combinations of 5-week interventions . At pre- and posttest , mothers and teachers completed rating forms , and adolescents completed neuropsychological measures of working memory ( WM ) . Individual intervention effects showed that treatment CWMT significantly improved WM spans , whereas there were no significant differences for treatment or control BPT on reports of parent-related outcomes . Combined treatment effects indicated an overall pattern of greatest improvements for the control CWMT/treatment BPT group , as compared to the other three groups , on adolescent WM deficit , behavioral regulation problems , and global executive deficit . Most significant effects for outcomes were main effects of improvements over time . A combination of CWMT and BPT did not result in increased treatment gains . However , potential effects of combined treatment may have been masked by greater perceived benefits arising from lack of struggle in the nonadaptive , CWMT active control condition . Future combined intervention research should focus on specific , theoretically driven WM deficits among individuals with ADHD , should include possible adaptations to the st and ard CWMT program , should examine effectiveness of cognitive treatments combined with context ual interventions and should utilize appropriate control groups to fully underst and the unique and combined effects of interventions BACKGROUND This is the first r and omized controlled multicenter trial to evaluate the effect of two treatments of maternal attention-deficit hyperactivity disorder ( ADHD ) on response to parent-child training targeting children 's external psychopathology . METHODS Mother-child dyads ( n = 144 ; ADHD according to DSM-IV ; children : 73.5 % males , mean age 9.4 years ) from five specialized university outpatient units in Germany were central ly r and omized to multimodal maternal ADHD treatment [ group psychotherapy plus open methylpheni date medication ; treatment group ( TG ) : n = 77 ] or to clinical management [ supportive counseling without psychotherapy or psychopharmacotherapy ; control group ( CG ) : n = 67 ] . After 12 weeks , the maternal ADHD treatment was supplemented by individual parent-child training for all dyads . The primary outcome was a change in the children 's externalizing symptom scores ( investigator blinded to the treatment assignment ) from baseline to the end of the parent-child training 6 months later . Maintenance therapy continued for another 6 months . An intention-to-treat analysis was performed within a linear regression model , controlling for baseline and center after multiple imputations of missing values . RESULTS Exactly , 206 dyads were assessed for eligibility , 144 were r and omized , and 143 were analyzed ( TG : n = 77 ; CG : n = 66 ) . After 6 months , no significant between-group differences were found in change scores for children 's externalizing symptoms ( adjusted mean TG-mean CG=1.1 , 95 % confidence interval -0.5 - 2.7 ; p = .1854 ) , although maternal psychopathology improved more in the TG . Children 's externalizing symptom scores improved from a mean of 14.8 at baseline to 11.4 ( TG ) and 10.3 ( CG ) after 6 months and to 10.8 ( TG ) and 10.1 ( CG ) after 1 year . No severe harms related to study treatments were found , but adverse events were more frequent in TG mothers than in CG mothers . CONCLUSIONS The response in children 's externalizing psychopathology did not differ between maternal treatment groups . However , multimodal treatment was associated with more improvement in maternal ADHD . Child and maternal treatment gains were stable ( CCT-IS RCT N73911400 ) We investigated whether parenting and child behavior improve following psychosocial treatment for Attention-Deficit/Hyperactivity Disorder , Predominantly Inattentive Presentation ( ADHD-I ) and whether parenting improvements mediate child outcomes . We analyzed data from a r and omized clinical trial investigating the efficacy of a multicomponent psychosocial intervention ( Child Life and Attention Skills , CLAS , n = 74 ) in comparison to Parent-Focused Treatment ( PFT , n = 74 ) and treatment as usual ( TAU , n = 51 ) for youth with ADHD-I ( average child age = 8.6 years , range 7–11 years , 58 % boys ) . Child and parent/family functioning were assessed prior to treatment , immediately following treatment , and at follow-up into the subsequent school year using parent and teacher reports of inattention , organization , social skills , academic competency ( teachers only ) , parenting daily hassles , and positive and negative parenting behaviors ( parents only ) . Both treatment groups improved on negative parenting and home impairment , but only CLAS families also improved on positive parenting as well as academic impairment . Improvements in positive and negative parenting mediated treatment effects on child impairment independent of improvements in child inattention , implicating parenting as an important mechanism of change in psychosocial treatment for ADHD-I. Further , whereas parent-focused training produces improvements in negative parenting and impairment at home for children with ADHD-I , a multicomponent approach ( incorporating child skills training and teacher consultation ) more consistently produces improvements at school and in positive parenting , which may contribute to improvements in social skills into the next school year OBJECTIVE In the intent-to-treat analysis of the Multimodal Treatment Study of Children With ADHD ( MTA ) , the effects of medication management ( MedMgt ) , behavior therapy ( Beh ) , their combination ( Comb ) , and usual community care ( CC ) differed at 14 and 24 months due to superiority of treatments that used the MTA medication algorithm ( Comb+MedMgt ) over those that did not ( Beh+CC ) . This report examines 36-month outcomes , 2 years after treatment by the study ended . METHOD For primary outcome measures ( attention-deficit/hyperactivity disorder [ ADHD ] and oppositional defiant disorder [ ODD ] symptoms , social skills , reading scores , impairment , and diagnostic status ) , mixed-effects regression models and orthogonal contrasts examined 36-month outcomes . RESULTS At 3 years , 485 of the original 579 subjects ( 83.8 % ) participated in the follow-up , now at ages 10 to 13 years , ( mean 11.9 years ) . In contrast to the significant advantage of MedMgt+Comb over Beh+CC for ADHD symptoms at 14 and 24 months , treatment groups did not differ significantly on any measure at 36 months . The percentage of children taking medication > 50 % of the time changed between 14 and 36 months across the initial treatment groups : Beh significantly increased ( 14 % to 45 % ) , MedMed+Comb significantly decreased ( 91 % to 71 % ) , and CC remained constant ( 60%-62 % ) . Regardless of their treatment use changes , all of the groups showed symptom improvement over baseline . Notably , initial symptom severity , sex ( male ) , comorbidity , public assistance , and parental psychopathology ( ADHD ) did not moderate children 's 36-month treatment responses , but these factors predicted worse outcomes over 36 months , regardless of original treatment assignment . CONCLUSIONS By 36 months , the earlier advantage of having had 14 months of the medication algorithm was no longer apparent , possibly due to age-related decline in ADHD symptoms , changes in medication management intensity , starting or stopping medications altogether , or other factors not yet evaluated Behavioral parent training is an efficacious treatment for attention-deficit/hyperactivity disorder ( ADHD ) . However , single-mother households are at high risk for poor outcomes during and following behavioral parent training . This study r and omly assigned cohorts of 120 single mothers of children ( ages 5–12 years ) with ADHD to a waitlist control group , a traditional behavioral parent training program , or an enhanced behavioral parent training program — the Strategies to Enhance Positive Parenting (  STEPP )  program . Intent-to-treat analysis demonstrated benefits of participating in behavioral parent training , in general , and the STEPP program more specifically at immediate posttreatment on child and parental functioning . Moreover , the STEPP program result ed in increased engagement to treatment . However , results indicated that behavioral parent training does not normalize behavior for most children and treatment gains are not maintained OBJECTIVES To determine any long-term effects , 6 and 8 years after childhood enrollment , of the r and omly assigned 14-month treatments in the NIMH Collaborative Multisite Multimodal Treatment Study of Children With Attention-Deficit/Hyperactivity Disorder ( MTA ; N = 436 ) ; to test whether attention-deficit/hyperactivity disorder ( ADHD ) symptom trajectory through 3 years predicts outcome in subsequent years ; and to examine functioning level of the MTA adolescents relative to their non-ADHD peers ( local normative comparison group ; N = 261 ) . METHOD Mixed-effects regression models with planned contrasts at 6 and 8 years tested a wide range of symptom and impairment variables assessed by  parent , teacher , and youth report . RESULTS In nearly every analysis , the originally r and omized treatment groups did not differ significantly on repeated measures or newly analyzed variables ( e.g. , grade s earned in school , arrests , psychiatric hospitalizations , other clinical ly relevant outcomes ) . Medication use decreased by 62 % after the 14-month controlled trial , but adjusting for this did not change the results . ADHD symptom trajectory in the first 3 years predicted 55 % of the outcomes . The MTA participants fared worse than the local normative comparison group on 91 % of the variables tested . CONCLUSIONS Type or intensity of 14 months of treatment for ADHD in childhood ( at age 7.0 - 9.9 years ) does not predict functioning 6 to 8 years later . Rather , early ADHD symptom trajectory regardless of treatment type is prognostic . This finding implies that children with behavioral and sociodemographic advantage , with the best response to any treatment , will have the best long-term prognosis . As a group , however , despite initial symptom improvement during treatment that is largely maintained after treatment , children with combined-type ADHD exhibit significant impairment in adolescence . Innovative treatment approaches targeting specific areas of adolescent impairment are needed Abstract During a 3-month intervention program , 43 
    Output:
    
agent
The results revealed that findings are becoming increasingly nuanced with variations in levels of evidence related to ages of the children and characteristics of the specific treatment .
In addition , we focused our critique on generalization of treatment effects across setting s and time and on sample diversity ( with regard to ethnicity and levels of parent education ) in relation to the population .
Children of parents with higher levels of education than average appear to be overrepresented in the literature .
***TASK*** the task is to summarize an input biomedical literature in six sentences 
    ***INPUT*** the input is a biomedical literature 
    ***OUTPUT*** the output is the summary of an input biomedical literature in six sentences 
    ***DOCUMENTATION*** 
    ***EXAMPLES*** 
    Input: OBJECTIVE Impairments associated with attention-deficit/hyperactivity disorder ( ADHD ) and noncompliance are prevalent in children with autism spectrum disorder ( ASD ) . However , ADHD response to stimulants is well below rates in typically developing children , with frequent side effects . Group studies of treatments for noncompliance are rare in ASD . We examined individual and combined-effectiveness of atomoxetine ( ATX ) and parent training ( PT ) for ADHD symptoms and noncompliance . METHOD In a 3-site , 10-week , double-blind , 2 × 2 trial of ATX and PT , 128 children ( ages 5 - 14 years ) with ASD and ADHD symptoms were r and omized to  ATX , ATX+PT , placebo+PT , or placebo . ATX was adjusted to optimal dose ( capped at 1.8 mg/kg/day ) over 6 weeks and maintained for 4 additional weeks . Nine PT sessions were provided . Primary outcome measures were the parent-rated DSM ADHD symptoms on the Swanson , Nolan and Pelham ( SNAP ) scale and Home Situations Question naire ( HSQ ) . RESULTS On the SNAP , ATX , ATX+PT and placebo+PT were each superior to placebo ( effect sizes 0.57 - 0.98 ; p values of .0005 , .0004 , and .025 , respectively ) . For noncompliance , ATX and ATX+PT were superior to placebo ( effect sizes 0.47 - 0.64 ; p values .03 and .0028 , respectively ) . ATX was associated with decreased appetite but was otherwise well tolerated . CONCLUSION Both ATX and PT result ed in significant improvement on ADHD symptoms , whereas ATX ( both alone and combined with PT ) was associated with significant decreases on measures of noncompliance . ATX appears to have a better side effects profile than psychostimulants in the population with ASD . CLINICAL TRIAL REGISTRATION INFORMATION Atomoxetine , Placebo and Parent Management Training in Autism ; http:// clinical trials.gov/ ; NCT00844753 Fathers , in general , have been underrepresented in studies of parent training outcome for children with attention deficit hyperactivity disorder ( ADHD ) , and the present study aim ed to investigate the efficacy of a behavioral parent training program developed expressly for fathers . The present investigation r and omly assigned 55 fathers of children ages 6 to 12 with ADHD to the Coaching Our Acting-out Children :  Heightening Essential Skills ( COACHES ) program or a waitlist control group . Outcomes for the study included objective observations of parent behaviors and parent ratings of child behavior . Results indicated that fathers in the COACHES group reduced their rates of negative talk and increased rates of praise as measured in parent – child observations , and father ratings of the intensity of problem behaviors were reduced , relative to the waitlist condition . Groups did not differ on observations of use of comm and s or father ratings of child behavior problems . Untreated mothers did not significantly improve on observational measures or behavioral ratings . This study provides preliminary evidence for the efficacy of the COACHES parenting program for fathers of children with ADHD . Results are cast in light of the larger literature on behavioral parent training for ADHD as well as how to best work with fathers of children with ADHD in treatment context This study examined the individual and combined effects of two nonpharmacological treatments for attention deficit/hyperactivity disorder ( ADHD ) :  Cogmed working memory training ( CWMT ) for adolescents and  behavioral parent training ( BPT ) for mothers . Ninety-one adolescents ( ages 11–15 ) and their mothers were r and omized to one of four CWMT and BPT treatment and active control ( placebo ) group combinations of 5-week interventions . At pre- and posttest , mothers and teachers completed rating forms , and adolescents completed neuropsychological measures of working memory ( WM ) . Individual intervention effects showed that treatment CWMT significantly improved WM spans , whereas there were no significant differences for treatment or control BPT on reports of parent-related outcomes . Combined treatment effects indicated an overall pattern of greatest improvements for the control CWMT/treatment BPT group , as compared to the other three groups , on adolescent WM deficit , behavioral regulation problems , and global executive deficit . Most significant effects for outcomes were main effects of improvements over time . A combination of CWMT and BPT did not result in increased treatment gains . However , potential effects of combined treatment may have been masked by greater perceived benefits arising from lack of struggle in the nonadaptive , CWMT active control condition . Future combined intervention research should focus on specific , theoretically driven WM deficits among individuals with ADHD , should include possible adaptations to the st and ard CWMT program , should examine effectiveness of cognitive treatments combined with context ual interventions and should utilize appropriate control groups to fully underst and the unique and combined effects of interventions BACKGROUND This is the first r and omized controlled multicenter trial to evaluate the effect of two treatments of maternal attention-deficit hyperactivity disorder ( ADHD ) on response to parent-child training targeting children 's external psychopathology . METHODS Mother-child dyads ( n = 144 ; ADHD according to DSM-IV ; children : 73.5 % males , mean age 9.4 years ) from five specialized university outpatient units in Germany were central ly r and omized to multimodal maternal ADHD treatment [ group psychotherapy plus open methylpheni date medication ; treatment group ( TG ) : n = 77 ] or to clinical management [ supportive counseling without psychotherapy or psychopharmacotherapy ; control group ( CG ) : n = 67 ] . After 12 weeks , the maternal ADHD treatment was supplemented by individual parent-child training for all dyads . The primary outcome was a change in the children 's externalizing symptom scores ( investigator blinded to the treatment assignment ) from baseline to the end of the parent-child training 6 months later . Maintenance therapy continued for another 6 months . An intention-to-treat analysis was performed within a linear regression model , controlling for baseline and center after multiple imputations of missing values . RESULTS Exactly , 206 dyads were assessed for eligibility , 144 were r and omized , and 143 were analyzed ( TG : n = 77 ; CG : n = 66 ) . After 6 months , no significant between-group differences were found in change scores for children 's externalizing symptoms ( adjusted mean TG-mean CG=1.1 , 95 % confidence interval -0.5 - 2.7 ; p = .1854 ) , although maternal psychopathology improved more in the TG . Children 's externalizing symptom scores improved from a mean of 14.8 at baseline to 11.4 ( TG ) and 10.3 ( CG ) after 6 months and to 10.8 ( TG ) and 10.1 ( CG ) after 1 year . No severe harms related to study treatments were found , but adverse events were more frequent in TG mothers than in CG mothers . CONCLUSIONS The response in children 's externalizing psychopathology did not differ between maternal treatment groups . However , multimodal treatment was associated with more improvement in maternal ADHD . Child and maternal treatment gains were stable ( CCT-IS RCT N73911400 ) We investigated whether parenting and child behavior improve following psychosocial treatment for Attention-Deficit/Hyperactivity Disorder , Predominantly Inattentive Presentation ( ADHD-I ) and whether parenting improvements mediate child outcomes . We analyzed data from a r and omized clinical trial investigating the efficacy of a multicomponent psychosocial intervention ( Child Life and Attention Skills , CLAS , n = 74 ) in comparison to Parent-Focused Treatment ( PFT , n = 74 ) and treatment as usual ( TAU , n = 51 ) for youth with ADHD-I ( average child age = 8.6 years , range 7–11 years , 58 % boys ) . Child and parent/family functioning were assessed prior to treatment , immediately following treatment , and at follow-up into the subsequent school year using parent and teacher reports of inattention , organization , social skills , academic competency ( teachers only ) , parenting daily hassles , and positive and negative parenting behaviors ( parents only ) . Both treatment groups improved on negative parenting and home impairment , but only CLAS families also improved on positive parenting as well as academic impairment . Improvements in positive and negative parenting mediated treatment effects on child impairment independent of improvements in child inattention , implicating parenting as an important mechanism of change in psychosocial treatment for ADHD-I. Further , whereas parent-focused training produces improvements in negative parenting and impairment at home for children with ADHD-I , a multicomponent approach ( incorporating child skills training and teacher consultation ) more consistently produces improvements at school and in positive parenting , which may contribute to improvements in social skills into the next school year OBJECTIVE In the intent-to-treat analysis of the Multimodal Treatment Study of Children With ADHD ( MTA ) , the effects of medication management ( MedMgt ) , behavior therapy ( Beh ) , their combination ( Comb ) , and usual community care ( CC ) differed at 14 and 24 months due to superiority of treatments that used the MTA medication algorithm ( Comb+MedMgt ) over those that did not ( Beh+CC ) . This report examines 36-month outcomes , 2 years after treatment by the study ended . METHOD For primary outcome measures ( attention-deficit/hyperactivity disorder [ ADHD ] and oppositional defiant disorder [ ODD ] symptoms , social skills , reading scores , impairment , and diagnostic status ) , mixed-effects regression models and orthogonal contrasts examined 36-month outcomes . RESULTS At 3 years , 485 of the original 579 subjects ( 83.8 % ) participated in the follow-up , now at ages 10 to 13 years , ( mean 11.9 years ) . In contrast to the significant advantage of MedMgt+Comb over Beh+CC for ADHD symptoms at 14 and 24 months , treatment groups did not differ significantly on any measure at 36 months . The percentage of children taking medication > 50 % of the time changed between 14 and 36 months across the initial treatment groups : Beh significantly increased ( 14 % to 45 % ) , MedMed+Comb significantly decreased ( 91 % to 71 % ) , and CC remained constant ( 60%-62 % ) . Regardless of their treatment use changes , all of the groups showed symptom improvement over baseline . Notably , initial symptom severity , sex ( male ) , comorbidity , public assistance , and parental psychopathology ( ADHD ) did not moderate children 's 36-month treatment responses , but these factors predicted worse outcomes over 36 months , regardless of original treatment assignment . CONCLUSIONS By 36 months , the earlier advantage of having had 14 months of the medication algorithm was no longer apparent , possibly due to age-related decline in ADHD symptoms , changes in medication management intensity , starting or stopping medications altogether , or other factors not yet evaluated Behavioral parent training is an efficacious treatment for attention-deficit/hyperactivity disorder ( ADHD ) . However , single-mother households are at high risk for poor outcomes during and following behavioral parent training . This study r and omly assigned cohorts of 120 single mothers of children ( ages 5–12 years ) with ADHD to a waitlist control group , a traditional behavioral parent training program , or an enhanced behavioral parent training program — the Strategies to Enhance Positive Parenting (  STEPP )  program . Intent-to-treat analysis demonstrated benefits of participating in behavioral parent training , in general , and the STEPP program more specifically at immediate posttreatment on child and parental functioning . Moreover , the STEPP program result ed in increased engagement to treatment . However , results indicated that behavioral parent training does not normalize behavior for most children and treatment gains are not maintained OBJECTIVES To determine any long-term effects , 6 and 8 years after childhood enrollment , of the r and omly assigned 14-month treatments in the NIMH Collaborative Multisite Multimodal Treatment Study of Children With Attention-Deficit/Hyperactivity Disorder ( MTA ; N = 436 ) ; to test whether attention-deficit/hyperactivity disorder ( ADHD ) symptom trajectory through 3 years predicts outcome in subsequent years ; and to examine functioning level of the MTA adolescents relative to their non-ADHD peers ( local normative comparison group ; N = 261 ) . METHOD Mixed-effects regression models with planned contrasts at 6 and 8 years tested a wide range of symptom and impairment variables assessed by  parent , teacher , and youth report . RESULTS In nearly every analysis , the originally r and omized treatment groups did not differ significantly on repeated measures or newly analyzed variables ( e.g. , grade s earned in school , arrests , psychiatric hospitalizations , other clinical ly relevant outcomes ) . Medication use decreased by 62 % after the 14-month controlled trial , but adjusting for this did not change the results . ADHD symptom trajectory in the first 3 years predicted 55 % of the outcomes . The MTA participants fared worse than the local normative comparison group on 91 % of the variables tested . CONCLUSIONS Type or intensity of 14 months of treatment for ADHD in childhood ( at age 7.0 - 9.9 years ) does not predict functioning 6 to 8 years later . Rather , early ADHD symptom trajectory regardless of treatment type is prognostic . This finding implies that children with behavioral and sociodemographic advantage , with the best response to any treatment , will have the best long-term prognosis . As a group , however , despite initial symptom improvement during treatment that is largely maintained after treatment , children with combined-type ADHD exhibit significant impairment in adolescence . Innovative treatment approaches targeting specific areas of adolescent impairment are needed Abstract During a 3-month intervention program , 43 
    Output:
    