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: This study examined the effectiveness of the universal component of the Fast Track prevention model : the PATHS ( Promoting Alternative THinking Strategies ) curriculum and teacher consultation . This r and omized clinical trial involved 198 intervention and 180 comparison classrooms from neighborhoods with greater than average crime in 4 U.S. locations . In the intervention schools , Grade 1 teachers delivered a 57-lesson social competence intervention focused on  self-control , emotional awareness , peer relations , and problem solving .  Findings indicated significant effects on peer ratings of aggression and hyperactive-disruptive behavior and observer ratings of classroom atmosphere . Quality of implementation predicted variation in assessment s of classroom functioning . The results are discussed in terms of both the efficacy of universal , school-based prevention models and the need to examine comprehensive , multiyear programs This study was a r and omized clinical trial of Project Support , an intervention design ed to reduce conduct problems among children exposed to intimate partner violence . Participants were 66 families ( mothers and children ) with at least 1 child exhibiting clinical levels of conduct problems . Families were recruited from domestic violence shelters . The Project Support intervention involves ( a ) teaching mothers child management skills and ( b ) providing instrumental and emotional support to mothers . Families were r and omly assigned to the Project Support intervention condition or to an existing services comparison condition . They were assessed on 6 occasions over 20 months , following their departure from the shelter . Children in families in the Project Support condition , compared with those in the comparison condition , exhibited greater reductions in conduct problems . Mothers in the Project Support condition , compared with those in the comparison condition , displayed greater reductions in inconsistent and harsh parenting behaviors and psychiatric symptoms . Changes in mothers ' parenting and psychiatric symptoms accounted for a sizable proportion of Project Support 's effects on child conduct problems at the end of treatment . Clinical and policy implication s are discussed Objective : To determine the effectiveness of an on-site modular intervention in improving access to mental health services and outcomes for children with behavioral problems in primary care relative to enhanced usual care . The study includes boys and girls from six primary care offices in metropolitan Pittsburgh , PA . Methods : One hundred sixty-three clinical ly referred children who met a modest clinical cutoff ( 75th percentile ) on the externalizing behavior scale of the Pediatric Symptom Checklist-17 were r and omized to a protocol for on-site , nurse-administered intervention or to enhanced usual care . Protocol for on-site , nurse-administered intervention applied treatment modules from an evidence -based specialty mental health treatment for children with disruptive behavior disorders that were adapted for delivery in the primary care setting ; enhanced usual care offered diagnostic assessment , recommendations , and facilitated referral to a specialty mental health provider in the community . The main outcome measures such as st and ardized rating scales , including the Pediatric Symptom Checklist-17 , individualized target behavior ratings , treatment termination reports , and diagnostic interviews were collected . Results : Protocol for on-site , nurse-administered intervention cases were significantly more likely to receive and complete mental health services , reported fewer service barriers and more consumer satisfaction , and showed greater , albeit modest , improvements on just a few clinical outcomes that included remission for categorical behavioral disorders at 1-year follow-up . Both conditions also reported several significant improvements on several clinical outcomes over time . Conclusions : A psychosocial intervention for behavior problems that was delivered by nurses in the primary care setting is feasible , improves access to mental health services , and has some clinical efficacy . Options for enhancing clinical outcome include the use of multifaceted collaborative care interventions in the pediatric practice This study examined whether Project Support , a parenting intervention shown to reduce child conduct problems , also exerts positive effects on features of  psychopathy in children . Participants were 66 families ( mothers and children ) recruited from domestic violence shelters who participated in a r and omized controlled trial evaluating Project Support . Each family included at least one child between the ages of 4 and 9 who was exhibiting clinical levels of conduct problems . Families were r and omly assigned to the Project Support intervention condition or to an existing services comparison condition , and they were assessed on 6 occasions over 20 months , following their departure from the shelter . Children in families in the Project Support condition , compared with those in the comparison condition , exhibited greater reductions in features of psychopathy . Moreover , the changes in features of psychopathy remained after accounting for changes in conduct problems .  Project Support ’s effects on features of psychopathy were mediated by improvements in mothers ’ harsh and inconsistent parenting . These findings on the effects of an intervention on features of psychopathy are the first from a r and omized controlled trial . They inform the debate about whether features of psychopathy in children  are responsive to intervention , and hold important implication s for clinical practice The impact of the Fast Track intervention on  externalizing disorders across childhood was examined . Eight hundred-ninety-one early-starting children ( 69 % male ; 51 % African American ) were r and omly assigned by matched sets of schools to intervention or control conditions . The 10-year intervention addressed parent behavior-management , child social cognitive skills , reading , home visiting , mentoring , and classroom curricula . Outcomes included psychiatric diagnoses after grade s 3 , 6 , 9 , and 12 for conduct disorder , oppositional defiant disorder , attention deficit hyperactivity disorder , and any externalizing disorder . Significant interaction effects between intervention and initial risk level indicated that intervention prevented the lifetime prevalence of all diagnoses , but only among those at highest initial risk , suggesting that targeted intervention can prevent externalizing disorders to promote the raising of healthy children BACKGROUND The concept of differential susceptibility has challenged the potential meaning of personal traits such as poor ability to regulate emotions . Under the traditional model of diathesis/stress , personal characteristics such as liability to angry outbursts are seen as essentially disadvantageous , emerging under duress in a way that is maladaptive . In contrast , with differential susceptibility , there is the same poorer functioning under adverse conditions but , under favorable conditions , individuals with the trait function better than those without it . To date , there have been limited studies on response under positive environments . We used the experimental power of an intervention trial to test the differential susceptibility hypothesis that children with emotional dysregulation would show greater response to an experimentally induced improvement in their parenting environment . METHODS Data were from the SPOKES trial ( IS RCT N 77566446 ) , a r and omized controlled trial of 112 school children who were 5 - 6-years old , screened for elevated levels of oppositionality , r and omized to parenting groups or control ; 109 ( 97 % ) were followed-up a year later . Using DSM-IV oppositional-defiant symptoms , children were divided into an Emotionally-Dysregulated type ( ED , n = 68 ) and a Headstrong type ( n = 44 ) . The parenting intervention was the Incredible Years program supplemented by positive strategies to use when reading with children . Assessment of conduct problems and parenting was by semistructured interviews . RESULTS At follow-up , parents of Emotionally-Dysregulated and Headstrong children allocated to the intervention showed significant improvements in their parenting strategies to an equal extent compared to parents in the control group . However , the Emotionally-Dysregulated children showed a significantly greater decrease in conduct problems between intervention and control groups ( treatment effect-size 0.84 st and ard deviations ) than the Headstrong ( es 0.20 SD ) , p = 0.04 . CONCLUSIONS Using the power of a controlled experiment , this study showed that children who exhibited Emotionally-Dysregulated behavior pretreatment were more responsive to improvements in parental care that were experimentally induced . The findings extend prior work on differential sensitivity in suggesting that children exhibiting irascibility and emotionality may show greater susceptibility to the caregiving environment , and may identify a subset of children who respond better to existing treatments OBJECTIVE To evaluate the effectiveness and mechanisms of Hitkashrut , a " common elements " co-parent training ( PT ) program for early intervention with preschoolers ( 3 - 5 years of age ) at risk for conduct problems ( CP ) . METHOD A r and omized controlled trial with 140 participants in PT and 69 in a minimal intervention control group . The primary outcome ( presence of CP ) was assessed at pre-intervention , post-intervention , and 1-year follow-up . Callous-unemotional traits , effortful control , parental distress , negative/inconsistent parenting , and couple relationship quality were assessed at pre- and post-intervention , whereas callous-unemotional traits and effortful control were also assessed in the PT group at follow-up . Retention was 87.1 % at post-intervention and 60 % at follow-up . Hitkashrut incorporated evidence -based components of established PT programs into a culturally adapted protocol . The facilitators were trained and supervised psychologists working in Israel 's Educational Psychology Services . RESULTS Intervention effect ( Cohen 's d ) was large at post-intervention ( ES = .76 , p < .001 ) , and an additional medium effect was found at follow-up ( ES = 0.63 , p < .001 ) . Parallel post-intervention and follow-up intervention effects were also found in the degree of clinical ly significant improvements . Effects of the intervention on callous-unemotional traits ( ES = 0.85 , p < .001 ) and effortful control ( ES = 0.47 , p < .001 ) were maintained at follow-up . Follow-up improvement in CP was mediated by improvements in parental practice s and distress . CONCLUSIONS Hitkashrut 's implementation and subsequent dissemination in real-world setting s demonstrates the potential effectiveness of common elements programs to promote innovations within service-delivery systems . Improvements in dispositional variables and the mediated follow-up effect support theoretical cascade models that emphasize early developmental malleability and the growing preventive effects of PT 's facilitated parental changes on disruptive developmental trajectories . Clinical trial registration information - The effect of a " common elements " co-parent training program ( called ' Hitkashrut ' ) on conduct in preschoolers at risk for conduct problems ; http://www.anzctr.org.au ; ACTRN12612000148875 IMPORTANCE Disruptive behavior disorders , such as attention-deficient/hyperactivity disorder and oppositional defiant disorder , are common and stable throughout childhood . These disorders cause long-term morbidity but benefit from early intervention . While symptoms are often evident before preschool , few children receive appropriate treatment during this period . Group parent training , such as the Incredible Years program , has been shown to be effective in improving parenting strategies and reducing children 's disruptive behaviors . Because they already monitor young children 's behavior and development , primary care pediatricians are in a good position to intervene early when indicated . OBJECTIVE To investigate the feasibility and effectiveness of parent-training groups delivered to parents of toddlers in pediatric primary care setting s. DESIGN , SETTING , AND PARTICIPANTS This r and omized clinical trial was conducted at 11 diverse pediatric practice s in the Greater Boston area . A total of 273 parents of children between 2 and 4 years old who acknowledged disruptive behaviors on a 20-item checklist were included . INTERVENTION A 10-week Incredible Years parent-training group co-led by a research clinician and a pediatric staff member . MAIN OUTCOMES AND MEASURES Self-reports and structured videotaped observations of parent and child behaviors conducted prior to , immediately after , and 12 months after the intervention . RESULTS A total of 150 parents were r and omly assigned to the intervention or the waiting-list group . An additional 123 parents were assigned to receive intervention without a r and omly selected comparison group . Compared with the waiting-list group , greater improvement was observed in both intervention groups ( P < .05 ) . No differences were observed between the r and omized and the nonr and omized intervention groups . CONCLUSIONS AND RELEVANCE Self-reports and structured observations provided evidence of improvements in parenting practice s and child disruptive behaviors that were attributable to participation in the Incredible Years groups . This study demonstrated the feasibility and effectiveness of parent-training groups conducted in pediatric office setting s to reduce disruptive behavior in toddlers . TRIAL REGISTRATION clinical trials.gov Identifier : NCT00402857 OBJECTIVE Multifamily psychoeducational psychotherapy ( MF-PEP ) is an efficacious treatment for children with mood disorders . Given the comorbidity between disruptive behaviors and mood disorders , this study examined associations between disruptive behaviors and impairment , impact of MF-PEP on disruptive behaviors , and whether disruptive behaviors affected treatment response of mood symptoms . METHOD Secondary analyses examined a r and omized controlled trial of MF-PEP versus waitlist control  ( N = 165 children 8 - 11 years old with mood disorders and their parents ) . Comorbid behavioral diagnoses occurred in 97 % of children . All participants continued treatment as usual . RESULTS Greater degree of disruptive behaviors was associated with worse mood symptoms and impairment . Between-group analyses examining outcome of disruptive behaviors were nonsignificant . Within-group analyses and between-group effect sizes suggested that MF-PEP was associated with decreases in attention-deficit/hyperactivity disorder ( d = 0.39 ) , oppositional defiant disorder ( d = 0.30 ) , and overall disruptive behavior symptoms ( d = 0.30 ) , but not conduct disorder symptoms . Baseline severity of disruptive behaviors did not affect treatment response of mood symptoms to MF-PEP . CONCLUSIONS MF-PEP is an effective intervention for children with mood disorders and provides some benefit for disruptive behaviors . Given that dis 
    Output:
    
agent
Comorbidity , gender , age , number of sessions , duration , intervention type , setting , medication use or dropout percentage did not influence the effect of treatment .
CONCLUSIONS Psychological treatments have a small effect in reducing parent- , teacher- and observer-rated CD problems  in children and adolescents with clinical CD problems/diagnosis .
There is not enough evidence to support one specific psychological treatment over another .
Many reports failed to provide detailed information to allow optimization of psychological treatment strategies
***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: This study examined the effectiveness of the universal component of the Fast Track prevention model : the PATHS ( Promoting Alternative THinking Strategies ) curriculum and teacher consultation . This r and omized clinical trial involved 198 intervention and 180 comparison classrooms from neighborhoods with greater than average crime in 4 U.S. locations . In the intervention schools , Grade 1 teachers delivered a 57-lesson social competence intervention focused on  self-control , emotional awareness , peer relations , and problem solving .  Findings indicated significant effects on peer ratings of aggression and hyperactive-disruptive behavior and observer ratings of classroom atmosphere . Quality of implementation predicted variation in assessment s of classroom functioning . The results are discussed in terms of both the efficacy of universal , school-based prevention models and the need to examine comprehensive , multiyear programs This study was a r and omized clinical trial of Project Support , an intervention design ed to reduce conduct problems among children exposed to intimate partner violence . Participants were 66 families ( mothers and children ) with at least 1 child exhibiting clinical levels of conduct problems . Families were recruited from domestic violence shelters . The Project Support intervention involves ( a ) teaching mothers child management skills and ( b ) providing instrumental and emotional support to mothers . Families were r and omly assigned to the Project Support intervention condition or to an existing services comparison condition . They were assessed on 6 occasions over 20 months , following their departure from the shelter . Children in families in the Project Support condition , compared with those in the comparison condition , exhibited greater reductions in conduct problems . Mothers in the Project Support condition , compared with those in the comparison condition , displayed greater reductions in inconsistent and harsh parenting behaviors and psychiatric symptoms . Changes in mothers ' parenting and psychiatric symptoms accounted for a sizable proportion of Project Support 's effects on child conduct problems at the end of treatment . Clinical and policy implication s are discussed Objective : To determine the effectiveness of an on-site modular intervention in improving access to mental health services and outcomes for children with behavioral problems in primary care relative to enhanced usual care . The study includes boys and girls from six primary care offices in metropolitan Pittsburgh , PA . Methods : One hundred sixty-three clinical ly referred children who met a modest clinical cutoff ( 75th percentile ) on the externalizing behavior scale of the Pediatric Symptom Checklist-17 were r and omized to a protocol for on-site , nurse-administered intervention or to enhanced usual care . Protocol for on-site , nurse-administered intervention applied treatment modules from an evidence -based specialty mental health treatment for children with disruptive behavior disorders that were adapted for delivery in the primary care setting ; enhanced usual care offered diagnostic assessment , recommendations , and facilitated referral to a specialty mental health provider in the community . The main outcome measures such as st and ardized rating scales , including the Pediatric Symptom Checklist-17 , individualized target behavior ratings , treatment termination reports , and diagnostic interviews were collected . Results : Protocol for on-site , nurse-administered intervention cases were significantly more likely to receive and complete mental health services , reported fewer service barriers and more consumer satisfaction , and showed greater , albeit modest , improvements on just a few clinical outcomes that included remission for categorical behavioral disorders at 1-year follow-up . Both conditions also reported several significant improvements on several clinical outcomes over time . Conclusions : A psychosocial intervention for behavior problems that was delivered by nurses in the primary care setting is feasible , improves access to mental health services , and has some clinical efficacy . Options for enhancing clinical outcome include the use of multifaceted collaborative care interventions in the pediatric practice This study examined whether Project Support , a parenting intervention shown to reduce child conduct problems , also exerts positive effects on features of  psychopathy in children . Participants were 66 families ( mothers and children ) recruited from domestic violence shelters who participated in a r and omized controlled trial evaluating Project Support . Each family included at least one child between the ages of 4 and 9 who was exhibiting clinical levels of conduct problems . Families were r and omly assigned to the Project Support intervention condition or to an existing services comparison condition , and they were assessed on 6 occasions over 20 months , following their departure from the shelter . Children in families in the Project Support condition , compared with those in the comparison condition , exhibited greater reductions in features of psychopathy . Moreover , the changes in features of psychopathy remained after accounting for changes in conduct problems .  Project Support ’s effects on features of psychopathy were mediated by improvements in mothers ’ harsh and inconsistent parenting . These findings on the effects of an intervention on features of psychopathy are the first from a r and omized controlled trial . They inform the debate about whether features of psychopathy in children  are responsive to intervention , and hold important implication s for clinical practice The impact of the Fast Track intervention on  externalizing disorders across childhood was examined . Eight hundred-ninety-one early-starting children ( 69 % male ; 51 % African American ) were r and omly assigned by matched sets of schools to intervention or control conditions . The 10-year intervention addressed parent behavior-management , child social cognitive skills , reading , home visiting , mentoring , and classroom curricula . Outcomes included psychiatric diagnoses after grade s 3 , 6 , 9 , and 12 for conduct disorder , oppositional defiant disorder , attention deficit hyperactivity disorder , and any externalizing disorder . Significant interaction effects between intervention and initial risk level indicated that intervention prevented the lifetime prevalence of all diagnoses , but only among those at highest initial risk , suggesting that targeted intervention can prevent externalizing disorders to promote the raising of healthy children BACKGROUND The concept of differential susceptibility has challenged the potential meaning of personal traits such as poor ability to regulate emotions . Under the traditional model of diathesis/stress , personal characteristics such as liability to angry outbursts are seen as essentially disadvantageous , emerging under duress in a way that is maladaptive . In contrast , with differential susceptibility , there is the same poorer functioning under adverse conditions but , under favorable conditions , individuals with the trait function better than those without it . To date , there have been limited studies on response under positive environments . We used the experimental power of an intervention trial to test the differential susceptibility hypothesis that children with emotional dysregulation would show greater response to an experimentally induced improvement in their parenting environment . METHODS Data were from the SPOKES trial ( IS RCT N 77566446 ) , a r and omized controlled trial of 112 school children who were 5 - 6-years old , screened for elevated levels of oppositionality , r and omized to parenting groups or control ; 109 ( 97 % ) were followed-up a year later . Using DSM-IV oppositional-defiant symptoms , children were divided into an Emotionally-Dysregulated type ( ED , n = 68 ) and a Headstrong type ( n = 44 ) . The parenting intervention was the Incredible Years program supplemented by positive strategies to use when reading with children . Assessment of conduct problems and parenting was by semistructured interviews . RESULTS At follow-up , parents of Emotionally-Dysregulated and Headstrong children allocated to the intervention showed significant improvements in their parenting strategies to an equal extent compared to parents in the control group . However , the Emotionally-Dysregulated children showed a significantly greater decrease in conduct problems between intervention and control groups ( treatment effect-size 0.84 st and ard deviations ) than the Headstrong ( es 0.20 SD ) , p = 0.04 . CONCLUSIONS Using the power of a controlled experiment , this study showed that children who exhibited Emotionally-Dysregulated behavior pretreatment were more responsive to improvements in parental care that were experimentally induced . The findings extend prior work on differential sensitivity in suggesting that children exhibiting irascibility and emotionality may show greater susceptibility to the caregiving environment , and may identify a subset of children who respond better to existing treatments OBJECTIVE To evaluate the effectiveness and mechanisms of Hitkashrut , a " common elements " co-parent training ( PT ) program for early intervention with preschoolers ( 3 - 5 years of age ) at risk for conduct problems ( CP ) . METHOD A r and omized controlled trial with 140 participants in PT and 69 in a minimal intervention control group . The primary outcome ( presence of CP ) was assessed at pre-intervention , post-intervention , and 1-year follow-up . Callous-unemotional traits , effortful control , parental distress , negative/inconsistent parenting , and couple relationship quality were assessed at pre- and post-intervention , whereas callous-unemotional traits and effortful control were also assessed in the PT group at follow-up . Retention was 87.1 % at post-intervention and 60 % at follow-up . Hitkashrut incorporated evidence -based components of established PT programs into a culturally adapted protocol . The facilitators were trained and supervised psychologists working in Israel 's Educational Psychology Services . RESULTS Intervention effect ( Cohen 's d ) was large at post-intervention ( ES = .76 , p < .001 ) , and an additional medium effect was found at follow-up ( ES = 0.63 , p < .001 ) . Parallel post-intervention and follow-up intervention effects were also found in the degree of clinical ly significant improvements . Effects of the intervention on callous-unemotional traits ( ES = 0.85 , p < .001 ) and effortful control ( ES = 0.47 , p < .001 ) were maintained at follow-up . Follow-up improvement in CP was mediated by improvements in parental practice s and distress . CONCLUSIONS Hitkashrut 's implementation and subsequent dissemination in real-world setting s demonstrates the potential effectiveness of common elements programs to promote innovations within service-delivery systems . Improvements in dispositional variables and the mediated follow-up effect support theoretical cascade models that emphasize early developmental malleability and the growing preventive effects of PT 's facilitated parental changes on disruptive developmental trajectories . Clinical trial registration information - The effect of a " common elements " co-parent training program ( called ' Hitkashrut ' ) on conduct in preschoolers at risk for conduct problems ; http://www.anzctr.org.au ; ACTRN12612000148875 IMPORTANCE Disruptive behavior disorders , such as attention-deficient/hyperactivity disorder and oppositional defiant disorder , are common and stable throughout childhood . These disorders cause long-term morbidity but benefit from early intervention . While symptoms are often evident before preschool , few children receive appropriate treatment during this period . Group parent training , such as the Incredible Years program , has been shown to be effective in improving parenting strategies and reducing children 's disruptive behaviors . Because they already monitor young children 's behavior and development , primary care pediatricians are in a good position to intervene early when indicated . OBJECTIVE To investigate the feasibility and effectiveness of parent-training groups delivered to parents of toddlers in pediatric primary care setting s. DESIGN , SETTING , AND PARTICIPANTS This r and omized clinical trial was conducted at 11 diverse pediatric practice s in the Greater Boston area . A total of 273 parents of children between 2 and 4 years old who acknowledged disruptive behaviors on a 20-item checklist were included . INTERVENTION A 10-week Incredible Years parent-training group co-led by a research clinician and a pediatric staff member . MAIN OUTCOMES AND MEASURES Self-reports and structured videotaped observations of parent and child behaviors conducted prior to , immediately after , and 12 months after the intervention . RESULTS A total of 150 parents were r and omly assigned to the intervention or the waiting-list group . An additional 123 parents were assigned to receive intervention without a r and omly selected comparison group . Compared with the waiting-list group , greater improvement was observed in both intervention groups ( P < .05 ) . No differences were observed between the r and omized and the nonr and omized intervention groups . CONCLUSIONS AND RELEVANCE Self-reports and structured observations provided evidence of improvements in parenting practice s and child disruptive behaviors that were attributable to participation in the Incredible Years groups . This study demonstrated the feasibility and effectiveness of parent-training groups conducted in pediatric office setting s to reduce disruptive behavior in toddlers . TRIAL REGISTRATION clinical trials.gov Identifier : NCT00402857 OBJECTIVE Multifamily psychoeducational psychotherapy ( MF-PEP ) is an efficacious treatment for children with mood disorders . Given the comorbidity between disruptive behaviors and mood disorders , this study examined associations between disruptive behaviors and impairment , impact of MF-PEP on disruptive behaviors , and whether disruptive behaviors affected treatment response of mood symptoms . METHOD Secondary analyses examined a r and omized controlled trial of MF-PEP versus waitlist control  ( N = 165 children 8 - 11 years old with mood disorders and their parents ) . Comorbid behavioral diagnoses occurred in 97 % of children . All participants continued treatment as usual . RESULTS Greater degree of disruptive behaviors was associated with worse mood symptoms and impairment . Between-group analyses examining outcome of disruptive behaviors were nonsignificant . Within-group analyses and between-group effect sizes suggested that MF-PEP was associated with decreases in attention-deficit/hyperactivity disorder ( d = 0.39 ) , oppositional defiant disorder ( d = 0.30 ) , and overall disruptive behavior symptoms ( d = 0.30 ) , but not conduct disorder symptoms . Baseline severity of disruptive behaviors did not affect treatment response of mood symptoms to MF-PEP . CONCLUSIONS MF-PEP is an effective intervention for children with mood disorders and provides some benefit for disruptive behaviors . Given that dis 
    Output:
    