Brain disorders and mental health: Assessing your child for neuropsychological difficultiesBBrain disorders and mental health: Assessing your child for neuropsychological difficultiesBrain disorders and mental health: Assessing your child for neuropsychological difficultiesEnglishPsychiatryChild (0-12 years);Teen (13-18 years)BrainBrainNon-drug treatmentCaregivers Adult (19+)NA2017-07-12T04:00:00ZKyla McDonald, MA, PhD (c);Tricia Williams, PhD, C Psych, ABPP-CN​​12.000000000000040.00000000000001051.00000000000Health (A-Z) - ProcedureHealth A-Z<p>Learn what happens during a neuropsychological assessment and how you can use the results to help your child.</p><h2>What is a neuropsychological assessment?</h2><p>A neuropsychological assessment is an assessment of how your child’s brain works. It is done by trained specialists called a neuropsychologist and a psychometrist.</p><p>The neuropsychologist focuses on how <a href="/Article?contentid=1926&language=English">changes in the health of the brain</a> may affect a child’s ability to pay attention, remember things or solve problems. </p><p>Paediatric neuropsychologists have special training in how the brain develops. They use this training to assess and help manage brain disorders in children and help parents, teachers and doctors:</p><ul><li>understand how problems with the brain may relate to problems seen at school, at home or with peers</li><li>understand how a child learns best</li><li>understand why a child may have behaviour problems</li><li> <a href="/Article?contentid=2003&language=English">help a child deal with thinking or behaviour problems</a></li><li>identify neurological or psychiatric problems</li><li>help match expectations to a child’s specific strengths and weaknesses</li><li>work with other doctors and teachers to develop the best treatment and school plan for a child.</li></ul><br><h2>Key points</h2> <ul> <li>A neuropsychological assessment measures a child’s overall mental wellbeing, their behaviour, emotions, problem-solving skills, perception, language, attention and memory.</li> <li>The neuropsychologist focuses on understanding why a child is having problems in school or at home and how these issues may relate to the health of the brain.</li> <li>Before the assessment, you will receive questionnaires for you and your child’s teacher to fill in and bring to the appointment.</li> <li>The assessment involves gathering information about your child’s functioning at home and at school through interviews, questionnaires and one-to-one tests with your child.</li> <li>When the assessment is complete, you will get a report of the results, recommendations for you and your child’s teachers and, if needed, referrals to other specialists.</li> </ul><h2>When would my child need a neuropsychological assessment?</h2> <p>A neuropsychological assessment might be recommended if a child had a brain injury, illness or medical condition that can affect their learning or mental health. Neuropsychological assessments can also be helpful to understand neurodevelopmental disorders such as <a href="/Article?contentid=1922&language=English">ADHD</a> or learning disability, especially when a previous educational assessment or intervention has not helped.</p> <h2>Why is a neuropsychological assessment important for my child’s mental health?</h2> <p>A neuropsychological assessment is important for several reasons.</p> <ul> <li>It provides important information about your child’s current mental health – addressing thinking, learning, behaviour and emotions.</li> <li>It is a reliable tool for reporting your child’s learning progress at different points in time.</li> <li>It can provide information about your child’s mental health in relation to their medical conditions with suggestions on how best to support your child.</li> <li>Depending on the results of the assessment, it may offer evidence of your child’s needs to help you get extra supports at school or in your community.</li> </ul><h2>What happens during a neuropsychological assessment?</h2> <p>Through parent and child interviews, questionnaires and one-to-one testing with your child, the neuropsychologist will gather information about your child’s development, medical history and functioning at home and at school. The following issues are commonly assessed:</p> <ul> <li>intelligence (IQ)</li> <li>problem solving</li> <li>planning and organization</li> <li>attention and memory</li> <li>processing speed</li> <li>language</li> <li>academic skills</li> <li>visual perception</li> <li>control over hand movements</li> <li>depression and anxiety</li> <li>aggression and impulsive behaviour</li> <li>social skills</li> </ul><h2>What happens after the assessment?</h2> <p>Once the assessment is complete, the neuropsychologist will review the results and provide a written report for you and for your child’s school and the school board as needed. The report will:</p> <ul> <li>indicate your child’s current functioning, thinking skills and mental health status</li> <li>describe how these issues relate to each other and to your child’s medical condition</li> <li>offer personalized recommendations for your child’s schooling and for <a href="/Article?contentid=2004&language=English">boosting your child’s mental health at home</a>.</li> </ul> <h2>Working with your child’s school</h2> <p>With your permission, before and after the assessment, neuropsychologists often work with your child’s school to identify the services or special help your child needs. The neuropsychologist may contact your child’s educators (again with your permission) to learn more about their everyday classroom experiences and learning environment. In some cases, a meeting will take place where a team (including the neuropsychologist) discusses the school goals and accommodations for your child.</p><h2>How should I prepare for the assessment?</h2> <p>Before the assessment, the neuropsychologist will usually mail you a package with questionnaires for you and your child’s teacher to fill in. As well as filling in your own questionnaire, give the teacher their questionnaire and collect it from them when it is completed.</p> <p>To prepare your child for the assessment, tell them that this is a different kind of doctor’s appointment. For example, you might explain that the doctor will be doing different activities with your child, some that are like school activities and others like games. Many children enjoy the experience once they understand that there is no pressure to give the "right" answer. </p> <h2>Do I need to bring anything to the assessment?</h2> <p>It is always helpful to bring a copy of your child’s recent report cards and/or their individual education plan (IEP), if they have one. Remember also to bring the questionnaires that you and your child's teacher have completed.</p>​<h2>Further information</h2> <p>For more information on brain disorders and related mental health challenges, please see the following pages:</p> <p><a href="/Article?contentid=1926&language=English">Brain disorders and mental health: Overview</a></p> <p><a href="/Article?contentid=2003&language=English">Brain disorders and mental health: How to help your child cope</a></p> <p><a href="/Article?contentid=2004&language=English">Brain disorders and mental health: Common treatments</a></p> <h2>Resources</h2> <p>The following books offer useful information about brain disorders and related mental health issues.​</p> <p>Dawson, P. & Guare, R. (2009). <em>Smart but Scattered.</em> New York, NY: The Guildford Press.</p> <p>Dawson, P. & Guare, R. (2010). <em>Executive Skills in Children and Adolescents</em>. New York, NY: The Guildford Press.</p> <p>Greene, R. W. (2014). <em>The Explosive Child.</em> New York, NY: HarperCollins.</p> <p>Guare, R. & Dawson, P. (2013). <em>Smart but Scattered TEENS. </em>New York, NY: The Guildford Press.</p> <p>Huebner, D. (2005). <em>What to Do When You Worry Too Much: A Kid's Guide to Overcoming Anxiety</em>. Magination Press.</p> <p>Siegel, D. J. (2013). <em>Brainstorm.</em> New York, NY: Penguin Group.</p> <p>Siegal, D. J. & Bryson, T. P. (2011). <em>The Whole Brain Child</em>. New York, NY: Random House.​​</p> ​
Les troubles du cerveau et la santé mentale : évaluer la présence de problèmes neuropsychologiques chez votre enfantLLes troubles du cerveau et la santé mentale : évaluer la présence de problèmes neuropsychologiques chez votre enfantBrain disorders and mental health: Assessing your child for neuropsychological difficultiesFrenchPsychiatryChild (0-12 years);Teen (13-18 years)BrainBrainNon-drug treatmentCaregivers Adult (19+)NA2017-07-12T04:00:00ZKyla McDonald, MA, PhD (c);Tricia Williams, PhD, C Psych, ABPP-CN​​12.000000000000040.00000000000001051.00000000000Health (A-Z) - ProcedureHealth A-Z<p> Découvrez ce qui se passe lors d’une évaluation neuropsychologique et comment vous pouvez en utiliser les résultats pour aider votre enfant.</p><h2>Qu’est-ce qu’une évaluation neuropsychologique?</h2><p>Une évaluation neuropsychologique est une évaluation du fonctionnement du cerveau de votre enfant. Elle est effectuée par des spécialistes formés à cet effet : le neuropsychologue et le psychométricien.</p><p>La neuropsychologue s’intéresse à la façon dont <a href="/Article?contentid=1926&language=French">les changements dans la santé du cerveau </a> peuvent affecter la capacité d’un enfant à prêter attention, à mémoriser ou à résoudre des problèmes.</p><p>Les neuropsychologues pédiatriques ont une formation particulière dans le développement du cerveau. Cette formation leur permet d’évaluer les troubles du cerveau chez l’enfant, de participer à leur prise en charge et d’aider les parents, les enseignants et les médecins à:</p><ul><li>mieux comprendre comment les problèmes du cerveau peuvent être reliés aux problèmes rencontrés à l’école, à la maison ou avec les pairs;</li><li>mieux comprendre la meilleure façon dont l’enfant apprend;</li><li>mieux comprendre pourquoi l’enfant peut avoir des problèmes de comportement;</li><li> <a href="/Article?contentid=2003&language=French">aider un enfant à composer avec des problèmes de comportement ou des troubles de la pensée;</a></li><li>détecter des problèmes psychiatriques ou neurologiques;</li><li>contribuer à harmoniser les attentes avec les forces et les faiblesses particulières d’un enfant;</li><li>collaborer avec d’autres médecins et enseignants pour élaborer le plan de traitement et d’intervention scolaire le plus approprié pour l’enfant.</li></ul><br><h2>À retenir</h2> <ul> <li>L’évaluation neuropsychologique permet de mesurer l’état de bien-être mental général d’un enfant, son comportement, ses émotions, ses compétences en matière de résolution de problèmes, sa perception, son langage, son attention et sa mémoire.</li> <li>Le neuropsychologue cherche à comprendre pourquoi un enfant éprouve des difficultés à l’école ou à la maison et comment ces problèmes peuvent être liés à la santé du cerveau.</li> <li>Avant l’évaluation, vous recevrez des questionnaires à remplir par l’enseignant de votre enfant et vous que vous apporterez lors du rendez-vous.</li> <li>L’évaluation consiste à recueillir des renseignements sur le fonctionnement de votre enfant à la maison et à l’école par l’intermédiaire d’entrevues, de questionnaires et d’évaluations individuelles avec votre enfant.</li> <li>Quand l’évaluation est terminée, vous obtenez un rapport sur les résultats, des recommandations pour les enseignants de votre enfant et pour vous et, si nécessaire, un aiguillage vers d’autres spécialistes.</li> </ul><h2>Quand mon enfant a-t-il besoin d’une évaluation neuropsychologique?</h2> <p>Une évaluation neuropsychologique peut être recommandée si un enfant a une lésion au cerveau, une maladie ou un problème médical connexe qui peut compromettre son apprentissage ou sa santé mentale. Une évaluation neuropsychologique peut aussi être souhaitable pour mieux comprendre les troubles neurodéveloppementaux comme le <a href="/Article?contentid=1922&language=French">TDAH </a> ou le trouble d’apprentissage, en particulier quand une évaluation ou une intervention pédagogique antérieure n’a pas aidé à améliorer la situation.</p> <h2>Pourquoi une évaluation neuropsychologique est-elle importante pour la santé mentale de mon enfant?</h2> <p>Une évaluation neuropsychologique est importante pour plusieurs raisons.</p> <ul> <li>Elle permet d’obtenir des informations importantes sur la santé mentale de votre enfant sur les plans du raisonnement, de l’apprentissage, du comportement et des émotions.</li> <li>Il s’agit d’un outil fiable pour noter, à différents moments, les progrès de votre enfant en matière d’apprentissage.</li> <li>Elle peut renseigner sur la santé mentale de votre enfant et son lien avec des problèmes médicaux, et fournir des pistes quant à la meilleure façon de soutenir votre enfant.</li> <li>Selon les résultats de l’évaluation, elle peut fournir la preuve documentée des besoins de votre enfant. Ceci vous aidera ainsi à obtenir du soutien supplémentaire à l’école ou dans votre collectivité.</li> </ul><h2>Qu’arrive-t-il lors d’une évaluation neuropsychologique?</h2> <p>À l’aide d’entrevues, de questionnaires et d’évaluations individuelles réalisés avec l’enfant et ses parents, le neuropsychologue recueille des renseignements sur le développement de l’enfant, ses antécédents médicaux et son fonctionnement à la maison et à l’école. Les aspects suivants sont couramment évalués:</p> <ul> <li>l’intelligence (QI);</li> <li>la résolution de problèmes;</li> <li>la planification et l’organisation;</li> <li>l’attention et la mémoire;</li> <li>la rapidité du traitement;</li> <li>le langage;</li> <li>les aptitudes aux études;</li> <li>la perception visuelle;</li> <li>le contrôle des mouvements de la main;</li> <li>la dépression et l’anxiété;</li> <li>l’agression et les comportements impulsifs;</li> <li>les aptitudes sociales.</li> </ul><h2>Que se passe-t-il après l’évaluation?</h2> <p>Une fois l’évaluation terminée, le neuropsychologue examinera les résultats et vous fournira un rapport écrit, une copie pour vous et une autre pour l’école de votre enfant et pour le conseil scolaire, au besoin. Le rapport:</p> <ul> <li>précisera le fonctionnement présent de votre enfant, sa capacité de raisonnement et son état de santé mentale;</li> <li>décrira comment ces difficultés et les problèmes médicaux de votre enfant sont interreliés;</li> <li>fournira des recommandations personnalisées pour améliorer la scolarisation de votre enfant et pour <a href="/Article?contentid=2004&language=French">stimuler sa santé mentale à la maison</a>.</li></ul> <h2>Travailler de concert avec l’école de votre enfant</h2> <p>Avec votre permission, avant et après l’évaluation, le neuropsychologue travaillera régulièrement de concert avec l’école de votre enfant pour déterminer les services offerts ou les besoins d’aide particuliers de votre enfant. Le neuropsychologue pourra communiquer avec les enseignants de votre enfant (avec votre permission) pour en savoir plus sur son quotidien en classe et sur son milieu d’apprentissage. Dans certains cas, une réunion sera organisée lors de laquelle une équipe (y compris le neuropsychologue) discutera des objectifs de l’école et des mesures d’adaptation pour votre enfant.</p><h2>Comment dois-je me préparer pour l’évaluation?</h2> <p>Avant l’évaluation, le neuropsychologue vous enverra habituellement une trousse par la poste renfermant des questionnaires à remplir par l’enseignant de votre enfant et vous. En plus de remplir votre propre questionnaire, vous fournirez à l’enseignant son questionnaire et le récupérerez une fois qu’il l’aura rempli.</p> <p>Pour préparer votre enfant à l’évaluation, dites-lui qu’il s’agit d’un autre type de rendez-vous chez le médecin. Par exemple, vous pouvez lui expliquer que le médecin fera différentes activités avec lui, certaines ressemblant à des activités qu’on fait à l’école et d’autres à des jeux. Beaucoup d’enfants apprécient l’expérience une fois qu’ils ont compris qu’ils n’ont pas à donner la « bonne » réponse.</p> <h2>Ai-je besoin d’apporter quoi que ce soit à l’évaluation?</h2> <p>Il est toujours utile d’apporter une copie des derniers bulletins scolaires de votre enfant ou son plan d’enseignement individualisé, s’il en a un. Pensez aussi d’apporter les questionnaires que l’enseignant de votre enfant et vous avez remplis.</p><h2>Pour de plus amples renseignements</h2><p>Pour de plus amples renseignements sur les troubles du cerveau et les problèmes de santé mentale, veuillez consulter les pages suivantes:</p><p><a href="/Article?contentid=1926&language=French">Les troubles du cerveau et la santé mentale: presentation generale</a></p><p><a href="/Article?contentid=2003&language=French">Les troubles du cerveau et la santé mentale: comment aider votre enfant à s’adapter</a></p><p><a href="/Article?contentid=2004&language=French">Les troubles du cerveau et la santé mentale: les traitements actuels​</a></p> ​<h2>Sources de renseignements</h2><p>Les ouvrages suivants (uniquement en anglais) fournissent des renseignements utiles sur les troubles du cerveau et les problèmes de santé mentale qui en découlent.</p><p>Dawson, P. & Guare, R. (2009). <em>Smart but Scattered</em>. New York, NY: The Guildford Press.</p><p>Dawson, P. & Guare, R. (2010). <em>Executive Skills in Children and Adolescents</em>. New York, NY: The Guildford Press.</p><p>Greene, R. W. (2014).<em>The Explosive Child</em>. New York, NY: HarperCollins.</p><p>Guare, R. & Dawson, P. (2013). <em>Smart but Scattered TEENS</em>. New York, NY: The Guildford Press.</p><p>Huebner, D. (2005). <em>What to Do When You Worry Too Much: A Kid's Guide to Overcoming Anxiety</em>. Magination Press.</p><p>Siegel, D. J. (2013). <em>Brainstorm</em>. New York, NY: Penguin Group.</p><p>Siegal, D. J. & Bryson, T. P. (2011). <em>The Whole Brain Child</em>. New York, NY: Random House.​​</p>

 

 

Brain disorders and mental health: Assessing your child for neuropsychological difficulties2002.00000000000Brain disorders and mental health: Assessing your child for neuropsychological difficultiesBrain disorders and mental health: Assessing your child for neuropsychological difficultiesBEnglishPsychiatryChild (0-12 years);Teen (13-18 years)BrainBrainNon-drug treatmentCaregivers Adult (19+)NA2017-07-12T04:00:00ZKyla McDonald, MA, PhD (c);Tricia Williams, PhD, C Psych, ABPP-CN​​12.000000000000040.00000000000001051.00000000000Health (A-Z) - ProcedureHealth A-Z<p>Learn what happens during a neuropsychological assessment and how you can use the results to help your child.</p><h2>What is a neuropsychological assessment?</h2><p>A neuropsychological assessment is an assessment of how your child’s brain works. It is done by trained specialists called a neuropsychologist and a psychometrist.</p><p>The neuropsychologist focuses on how <a href="/Article?contentid=1926&language=English">changes in the health of the brain</a> may affect a child’s ability to pay attention, remember things or solve problems. </p><p>Paediatric neuropsychologists have special training in how the brain develops. They use this training to assess and help manage brain disorders in children and help parents, teachers and doctors:</p><ul><li>understand how problems with the brain may relate to problems seen at school, at home or with peers</li><li>understand how a child learns best</li><li>understand why a child may have behaviour problems</li><li> <a href="/Article?contentid=2003&language=English">help a child deal with thinking or behaviour problems</a></li><li>identify neurological or psychiatric problems</li><li>help match expectations to a child’s specific strengths and weaknesses</li><li>work with other doctors and teachers to develop the best treatment and school plan for a child.</li></ul><br><h2>How is a neuropsychological assessment different from a psychoeducational assessment? </h2> <p>Paediatric neuropsychologists and school psychologists often use some of the same tests, but they have different goals.</p> <ul> <li>School evaluations focus on <em>deciding if</em> a child has a problem with academic skills such as reading, spelling or math.</li> <li>Paediatric neuropsychologists focus on <em>understanding why</em> a child is having problems in school or at home and how it relates to the child’s medical history.</li> </ul> <p>Understanding a child’s specific thinking strengths and weaknesses helps to better focus school plans and medical treatment and helps educators and caregivers understand potential areas of future difficulty. Because neuropsychologists have training in clinical psychology and neuropsychology, they are also able to consider how learning, emotions and behaviour relate to each other and the child’s brain.</p><h2>Key points</h2> <ul> <li>A neuropsychological assessment measures a child’s overall mental wellbeing, their behaviour, emotions, problem-solving skills, perception, language, attention and memory.</li> <li>The neuropsychologist focuses on understanding why a child is having problems in school or at home and how these issues may relate to the health of the brain.</li> <li>Before the assessment, you will receive questionnaires for you and your child’s teacher to fill in and bring to the appointment.</li> <li>The assessment involves gathering information about your child’s functioning at home and at school through interviews, questionnaires and one-to-one tests with your child.</li> <li>When the assessment is complete, you will get a report of the results, recommendations for you and your child’s teachers and, if needed, referrals to other specialists.</li> </ul><h2>When would my child need a neuropsychological assessment?</h2> <p>A neuropsychological assessment might be recommended if a child had a brain injury, illness or medical condition that can affect their learning or mental health. Neuropsychological assessments can also be helpful to understand neurodevelopmental disorders such as <a href="/Article?contentid=1922&language=English">ADHD</a> or learning disability, especially when a previous educational assessment or intervention has not helped.</p> <h2>Why is a neuropsychological assessment important for my child’s mental health?</h2> <p>A neuropsychological assessment is important for several reasons.</p> <ul> <li>It provides important information about your child’s current mental health – addressing thinking, learning, behaviour and emotions.</li> <li>It is a reliable tool for reporting your child’s learning progress at different points in time.</li> <li>It can provide information about your child’s mental health in relation to their medical conditions with suggestions on how best to support your child.</li> <li>Depending on the results of the assessment, it may offer evidence of your child’s needs to help you get extra supports at school or in your community.</li> </ul><h2>What happens during a neuropsychological assessment?</h2> <p>Through parent and child interviews, questionnaires and one-to-one testing with your child, the neuropsychologist will gather information about your child’s development, medical history and functioning at home and at school. The following issues are commonly assessed:</p> <ul> <li>intelligence (IQ)</li> <li>problem solving</li> <li>planning and organization</li> <li>attention and memory</li> <li>processing speed</li> <li>language</li> <li>academic skills</li> <li>visual perception</li> <li>control over hand movements</li> <li>depression and anxiety</li> <li>aggression and impulsive behaviour</li> <li>social skills</li> </ul><h2>How long does the assessment take?</h2> <p>The assessment usually takes half a day for pre-schoolers and a full day for school-aged children. There are different assessments for children of different age groups and abilities.</p> <p>As a parent or main caregiver, you will actively take part in the assessment by being interviewed and completing questionnaires about your child.</p><h2>What happens after the assessment?</h2> <p>Once the assessment is complete, the neuropsychologist will review the results and provide a written report for you and for your child’s school and the school board as needed. The report will:</p> <ul> <li>indicate your child’s current functioning, thinking skills and mental health status</li> <li>describe how these issues relate to each other and to your child’s medical condition</li> <li>offer personalized recommendations for your child’s schooling and for <a href="/Article?contentid=2004&language=English">boosting your child’s mental health at home</a>.</li> </ul> <h2>Working with your child’s school</h2> <p>With your permission, before and after the assessment, neuropsychologists often work with your child’s school to identify the services or special help your child needs. The neuropsychologist may contact your child’s educators (again with your permission) to learn more about their everyday classroom experiences and learning environment. In some cases, a meeting will take place where a team (including the neuropsychologist) discusses the school goals and accommodations for your child.</p><h2>How should I prepare for the assessment?</h2> <p>Before the assessment, the neuropsychologist will usually mail you a package with questionnaires for you and your child’s teacher to fill in. As well as filling in your own questionnaire, give the teacher their questionnaire and collect it from them when it is completed.</p> <p>To prepare your child for the assessment, tell them that this is a different kind of doctor’s appointment. For example, you might explain that the doctor will be doing different activities with your child, some that are like school activities and others like games. Many children enjoy the experience once they understand that there is no pressure to give the "right" answer. </p> <h2>Do I need to bring anything to the assessment?</h2> <p>It is always helpful to bring a copy of your child’s recent report cards and/or their individual education plan (IEP), if they have one. Remember also to bring the questionnaires that you and your child's teacher have completed.</p>​<h2>Further information</h2> <p>For more information on brain disorders and related mental health challenges, please see the following pages:</p> <p><a href="/Article?contentid=1926&language=English">Brain disorders and mental health: Overview</a></p> <p><a href="/Article?contentid=2003&language=English">Brain disorders and mental health: How to help your child cope</a></p> <p><a href="/Article?contentid=2004&language=English">Brain disorders and mental health: Common treatments</a></p> <h2>Resources</h2> <p>The following books offer useful information about brain disorders and related mental health issues.​</p> <p>Dawson, P. & Guare, R. (2009). <em>Smart but Scattered.</em> New York, NY: The Guildford Press.</p> <p>Dawson, P. & Guare, R. (2010). <em>Executive Skills in Children and Adolescents</em>. New York, NY: The Guildford Press.</p> <p>Greene, R. W. (2014). <em>The Explosive Child.</em> New York, NY: HarperCollins.</p> <p>Guare, R. & Dawson, P. (2013). <em>Smart but Scattered TEENS. </em>New York, NY: The Guildford Press.</p> <p>Huebner, D. (2005). <em>What to Do When You Worry Too Much: A Kid's Guide to Overcoming Anxiety</em>. Magination Press.</p> <p>Siegel, D. J. (2013). <em>Brainstorm.</em> New York, NY: Penguin Group.</p> <p>Siegal, D. J. & Bryson, T. P. (2011). <em>The Whole Brain Child</em>. New York, NY: Random House.​​</p> ​https://assets.aboutkidshealth.ca/AKHAssets/brain_disorders_and_mental_health_assessing.jpgBrain disorders and mental health: Assessing your child for neuropsychological difficulties

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