Journal of Developmental and Behavioral Pediatrics最新文献

{"title":"In Their Own Words: Qualitative Study of Parenting During the COVID-19 Pandemic.","authors":"Quinn Tucker, Robert Sege, Allison Stephens, Twinkle Suthar, Eliza Loren Purdue, Charlyn Harper Browne, Dina Burstein","doi":"10.1097/DBP.0000000000001363","DOIUrl":"10.1097/DBP.0000000000001363","url":null,"abstract":"<p><strong>Objective: </strong>The authors aimed to understand the experience of parents and caregivers during COVID-19, including the challenges they faced and what helped them cope using the Strengthening Families (SF) Approach and Protective Factors Framework's five factors: parental resilience, social connections, knowledge of parenting and child development, concrete support in times of need, and social and emotional competence of children.</p><p><strong>Methods: </strong>The Family Snapshot Survey was developed to assess the impact of COVID-19 on family life, including items for quantitative analysis and 2 open-ended responses. This national survey of 9000 parents recruited from an opt-in internet panel was conducted in 3 waves of 3000 in November 2020, February 2021, and July 2021 using the online YouGov platform. The 2 open-ended responses are analyzed here using qualitative thematic analysis based on the SF Approach and Protective Factors Framework for caregivers with children aged 0 to 5 years.</p><p><strong>Results: </strong>The SF factors were used to classify 770 responses, with many responses identified as containing multiple factors, representing their interrelated nature. A lack of concrete support was the most frequent challenge, and parental resilience was the most frequent support.</p><p><strong>Conclusion: </strong>Access or lack of access to concrete support in times of need underscored many of the strengths and challenges, respectively. Participants described interactions between individual protective factors that allowed for safety, stability, or positive experiences. In future community policy creation, policymakers may look at how programs interact and allow families to access multiple protective factors at once, with a critical need for providing these concrete supports.</p>","PeriodicalId":50215,"journal":{"name":"Journal of Developmental and Behavioral Pediatrics","volume":"46 3","pages":"e292-e299"},"PeriodicalIF":1.8,"publicationDate":"2025-06-17","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC12175968/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"144318550","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":3,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Challenging Case January 2025: An Autistic Youth With ARFID During the COVID Pandemic.","authors":"Tammy Lim, Alison Cheng, Elana Bern, Marion Aw, Marilyn Augustyn","doi":"10.1097/DBP.0000000000001386","DOIUrl":"https://doi.org/10.1097/DBP.0000000000001386","url":null,"abstract":"<p><strong>Case: </strong>Andrew is a 12-year-old boy living in Southeast Asia with autism spectrum disorder (minimally verbal), who first presented with new symptoms of low mood and anhedonia during the COVID pandemic. This was associated with loss of appetite, which culminated in him eventually refusing to eat any food or swallow any liquids (including saliva). He would hold his saliva in his mouth in the daytime and refused to swallow. He would spit out the saliva when instructed to do so. Because of his worries about swallowing his saliva involuntarily during sleep, he also experienced insomnia. If he managed to fall asleep, he would involuntarily swallow his saliva.Three months from his initial symptoms, he was relocated by his family, to another southeast Asian country for specialty care. At this time, he also refused to speak. He went from intermittently accepting some foods, to being completely averse to any food or fluid intake. He was diagnosed with avoidant restrictive food intake disorder. Because of his acute refusal to eat or drink, a nasogastric tube was inserted and subsequently a gastrostomy tube for enteral nutrition. With this intervention, he was able to maintain good weight and nutrition.Simultaneously, he began treatment in a multidisciplinary feeding and nutrition program. Genetic testing done for concerns of neurological regression yielded a variant of unknown significance. He also began an anti-depressant and sleep medication.During this period, he returned to his country of origin and was no longer able to receive direct in-person specialty feeding support, but did have a dedicated caregiver. He was seen once every few months either in-person or by telehealth by the multidisciplinary feeding and nutrition clinic in the second country. His caregiver was taught to implement behavior strategies with a goal of him resuming oral food intake eventually.What factors should be considered when evaluating a child with co-existing neurodevelopmental and psychiatric conditions, who completely stops eating or drinking in the midst of a global pandemic? What feeding approach would be helpful in managing a complex case like this? What feeding interventions can be actualized at home to reintroduce solids? How did the pandemic impact access to services?</p>","PeriodicalId":50215,"journal":{"name":"Journal of Developmental and Behavioral Pediatrics","volume":" ","pages":""},"PeriodicalIF":1.8,"publicationDate":"2025-06-17","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"144318549","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":3,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"In-home Tele-assessment for Autism in Toddlers: Validity, Reliability, and Caregiver Satisfaction with the TELE-ASD-PEDS.","authors":"Devon N Gangi, Laura Corona, Liliana Wagner, Amy Weitlauf, Zachary Warren, Sally Ozonoff","doi":"10.1097/DBP.0000000000001358","DOIUrl":"10.1097/DBP.0000000000001358","url":null,"abstract":"<p><strong>Objective: </strong>This study focused on in-home use of a tele-assessment tool for autism diagnosis in young children, the TELE-ASD-PEDS (TAP). Psychometric properties, caregiver experiences, and perceptions of feasibility were examined among families likely to experience barriers to in-person evaluation.</p><p><strong>Methods: </strong>One hundred eighty-two children between 18 and 42 months of age were recruited because of positive screening, primary care concerns, or early intervention referral. All participants completed initial tele-assessment including the TAP. Approximately 2 weeks later, a second visit was conducted: 92 were randomized to a repeat TAP administration by telehealth and 90 were randomized to an in-person evaluation. Caregivers completed surveys regarding challenges with technology and satisfaction with telehealth assessment.</p><p><strong>Results: </strong>Overall, 77% of the sample was diagnosed with autism spectrum disorder (n = 140). There were few diagnostic disagreements (n = 10, 6%) between initial and second evaluations, with disagreements equally distributed between second visit type. Diagnostic outcomes (autism vs no autism) agreed between telehealth and in-person evaluation for 94% of cases, kappa = 0.82. Outcomes agreed between 2 telehealth visits for 94% of cases, kappa = 0.84. Test-retest reliability of total TAP scores across 2 administrations was strong, intraclass correlation coefficient = 0.85. Very few caregivers reported challenges with technology during telehealth appointments (<6%); 92% reported that there was nothing they would change about the telehealth visit. Examiners also reported high satisfaction with telehealth assessments.</p><p><strong>Conclusion: </strong>In-home use of the TAP is valid, reliable, feasible, and acceptable to caregivers. Findings support the continued use of telehealth assessment for autism in toddlers, which can reduce disparities in access to timely diagnostic services.</p>","PeriodicalId":50215,"journal":{"name":"Journal of Developmental and Behavioral Pediatrics","volume":"46 3","pages":"e261-e268"},"PeriodicalIF":1.8,"publicationDate":"2025-06-17","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC12169857/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"144318551","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":3,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Infant Distress from the Still-Face and its Association With Increased Problem Solving: Implications for Early Resilience.","authors":"Fabiola Silletti, Qingyu Jiang, Amanda Koire, Pasquale Musso, Gabrielle Coppola, Rosalinda Cassibba, Leena Mittal, Carmina Erdei, Joshua L Roffman, Cindy H Liu","doi":"10.1097/DBP.0000000000001378","DOIUrl":"https://doi.org/10.1097/DBP.0000000000001378","url":null,"abstract":"<p><strong>Objective: </strong>This study aimed to investigate the relationship between infants' negative affect and problem-solving skills, along with the moderating role of mothers' perceived social support.</p><p><strong>Methods: </strong>The sample consisted of 110 infants (49% females) and their mothers, who participated in the Perinatal Experiences and COVID-19 Effects (PEACE) Study at 2 time points: T1 (peripartum period, from late second trimester to 6 months postpartum) and T2 (when the infants were 8-10 months old). We used the Face-to-Face Still-Face (FFSF) procedure as an observational task to assess infant negative affect (T2) and maternal reports of their perceived social support (T1 and T2) and infants' problem-solving skills (T2). Spearman correlations and moderation analysis with PROCESS macro were performed in SPSS, controlling for maternal education, maternal age, maternal mental health (depression and anxiety at T1 and T2), and child sex.</p><p><strong>Results: </strong>We found that infant negative affect was positively (b = 1.88, p = 0.045) associated with problem-solving after controlling for other variables, whereas there was no evidence for a relationship with mothers' perceived social support (b = 0.73, p = ns). Notably, in testing the interaction between negative affect during FFSF and social support (b = 1.13, p = 0.001), the findings reveal more optimal problem-solving skills in infants whose mothers reported at T1 moderate (b = 2.98, p = 0.003) or high (b = 4.11, p = 0.001) social support. There was no evidence of a moderating role of mothers' perceived social support at T2 (b = 0.32, p = ns).</p><p><strong>Conclusion: </strong>Results show that infant negative affect may reflect their capacity for problem-solving and that bolstering social support for perinatal women may enhance their infants' problem-solving abilities. Findings highlight that children's negative affect in stressful situations, such as the FFSF context, may serve as a coping mechanism and offer new insights into the intergenerational transmission of resilience.</p>","PeriodicalId":50215,"journal":{"name":"Journal of Developmental and Behavioral Pediatrics","volume":" ","pages":""},"PeriodicalIF":1.8,"publicationDate":"2025-06-17","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"144499048","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":3,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Journal Article Reviews.","authors":"Ramkumar Aishworiya, Oana deVinck-Baroody, Michele Ledesma, Carol C Weitzman","doi":"10.1097/DBP.0000000000001387","DOIUrl":"https://doi.org/10.1097/DBP.0000000000001387","url":null,"abstract":"","PeriodicalId":50215,"journal":{"name":"Journal of Developmental and Behavioral Pediatrics","volume":" ","pages":""},"PeriodicalIF":1.8,"publicationDate":"2025-06-05","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"144289739","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":3,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Complex ADHD in a Child With Tic Disorder.","authors":"Tyler Lackey, Demvihin Ihyembe, Zachary Riemenschneider, Tamar Caceres, Johanna M Lewis-Esquerre, Jason Fogler, Elizabeth A Diekroger","doi":"10.1097/DBP.0000000000001389","DOIUrl":"10.1097/DBP.0000000000001389","url":null,"abstract":"<p><strong>Case: </strong>Jaxon is a healthy 12-year-old boy who is referred to your clinic for medication management. He was diagnosed with ADHD using a validated questionnaire at age 9 years. He is currently prescribed OROS methylphenidate 54 mg capsules once daily in the morning, which he has taken for 3 years. This has generally worked well to improve his attention, focus, task persistence, and task completion. However, his parents now report increasing disruptive behaviors over the past 18 months, both at home and at school. There have been no major stressors over this period nor significant life changes or trauma in Jaxon's history.Jaxon's teachers report that although he remains in his seat, he constantly \"squirms\" and moves about. He also makes quick, jerky movements with his hands several times each class period. They report no specific trigger or activity for when this movement occurs, but report it being more intense when Jaxon is working hard to concentrate and stay focused. His mother also reports noticing the frequency increase if Jaxon thinks he is in trouble or when he is very excited (e.g., when he is playing video games). His parents share home videos to support these concerns.His teachers report problems with attention, fidgeting, and talking out of turn. They also report that his movements distract and disrupt the class. These reports are most often from his afternoon classes. Academically, he is doing well. He turns in most of his work, but his grades have dropped this semester. His teacher reports that he seems to lack the focus to complete his assignments and he rushes through them to go to the next activity.When you talk to Jaxon, he reports that he likes school, but he does not like how often he gets into trouble. He admits he gets embarrassed during quiet time when his hands randomly \"move without me moving them.\"When observing Jaxon, you notice that he fidgets in his seat, often moving his hands over anything that is holding his attention (toys, papers). He is also verbally impulsive, interrupting the discussion with his mother multiple times during the visit. Twice, you witness a brisk single jerk of his right hand. It originates at the wrist and rotates away from his body with his hand closed. There was no accompanying vocalization with this movement.His parents are requesting a medication adjustment or change. What would you do?</p>","PeriodicalId":50215,"journal":{"name":"Journal of Developmental and Behavioral Pediatrics","volume":" ","pages":"e332-e334"},"PeriodicalIF":1.8,"publicationDate":"2025-06-03","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC12169855/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"144267782","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":3,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Co-occurring Anxiety in a Child With Autism and ADHD.","authors":"Molly Daffner-Deming, Devina Savant, Aqila Blakey-Armstrong, Robyn P Thom, Yamini Jagannath Howe, Jason Fogler, Elizabeth A Diekroger","doi":"10.1097/DBP.0000000000001388","DOIUrl":"10.1097/DBP.0000000000001388","url":null,"abstract":"&lt;p&gt;&lt;strong&gt;Case: &lt;/strong&gt;KM is an 11-year-old autistic boy followed by a developmental-behavioral pediatrician (DBP) practicing within a multidisciplinary autism center. He had been prescribed various attention-deficit hyperactivity disorder (ADHD) medications over the years, most recently dextroamphetamine-amphetamine extended-release capsule 10 mg daily.KM initially presented to the DBP for diagnostic confirmation of autism and ADHD at the age of 7 years. His school had conducted a detailed evaluation the year prior, indicating skills in the borderline range for cognitive, adaptive, and language functioning. Based on his developmental history, physical examination, review of school-based testing, and parent- and school-completed standardized questionnaires, he met Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) criteria for autism spectrum disorder and ADHD with combined presentation.When KM was between the ages of 8 and 10 years, he trialed several medications, including methylphenidate (which led to emotional lability), dextroamphetamine sulfate oral solution (which caused irritability), and clonidine (which led to destructive behavior). Notably, KM's parents were divorced and had differing opinions and experiences surrounding the efficacy and tolerability of his medications, which made medication trials more complex. He eventually was stabilized on extended-release dextroamphetamine-amphetamine at the age of 9 years, which both parents agreed was helpful for improving attention, despite the medication triggering a new self-injurious behavior of punching himself.At the age of 10 years, after 1 year of stability on dextroamphetamine-amphetamine extended-release capsule 10 mg daily, his parents chose not to refill the medication, to see whether it was still helpful for him. They observed that he seemed much \"happier\" with improved mood and decreased anxiety when dextroamphetamine-amphetamine was withheld; however, they did note worsened hyperactivity. A few weeks later, he began demonstrating increased symptoms of anxiety such as somatization and externalizing behaviors. This included frustration, aggression, and oppositionality, especially in anticipation of and/or when confronting anxious stimuli.His neuropsychologist and DBP collaborated to create a behavior monitoring plan to help his parents clarify and track his symptoms across households, with the goal of monitoring symptom severity and differentiating ADHD from anxiety-related symptoms. Because of this, his parents identified hyperactivity and impulsivity as KM's most problematic symptoms; therefore, dextroamphetamine-amphetamine extended-release 10 mg daily was restarted. Although this was effective for his hyperactivity, ongoing monitoring suggested that his anxiety symptoms continued to be clinically significant. The DBP consulted a psychiatrist who advised a trial of escitalopram in conjunction with dextroamphetamine-amphetamine. Several weeks after sta","PeriodicalId":50215,"journal":{"name":"Journal of Developmental and Behavioral Pediatrics","volume":" ","pages":"e329-e331"},"PeriodicalIF":1.8,"publicationDate":"2025-06-03","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC12169862/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"144267783","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":3,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Triple Nudge for Improving ADHD Assessment: A QI Initiative Using Reminders, Workflow Changes, and EMR Integration.","authors":"Pattra Charleowsak, Therdpong Thongseiratch, Pathrada Tripidok","doi":"10.1097/DBP.0000000000001385","DOIUrl":"https://doi.org/10.1097/DBP.0000000000001385","url":null,"abstract":"","PeriodicalId":50215,"journal":{"name":"Journal of Developmental and Behavioral Pediatrics","volume":" ","pages":""},"PeriodicalIF":1.8,"publicationDate":"2025-05-28","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"144210091","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":3,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"The Case for Structured Data in Developmental-Behavioral Pediatrics: Project STANDARD (Structured Approach to Neurodevelopmental Care and Clinical Research Data).","authors":"William Barbaresi, Yair Bannett, Nathan J Blum, Shang Chee Chong, Justice Clark, Magdalena Dall, Jeffery N Epstein, Johannes Fellinger, Tanya E Froehlich, Johannes Hofer, Daniel Holzinger, Patty Huang, YingQi Kang, Ramkumar Aishworiya, Marie Reilly, Ann M Reynolds, Gehan Roberts, George Sideridis, Deanna Swain, Carol Weitzman","doi":"10.1097/DBP.0000000000001376","DOIUrl":"https://doi.org/10.1097/DBP.0000000000001376","url":null,"abstract":"<p><strong>Abstract: </strong>Neurodevelopmental and behavioral problems (NBPs) such as attention-deficit hyperactivity disorder and autism spectrum disorder are highly prevalent in children and adolescents. Clinical care for NBPs is characterized by unwarranted variation, a limited number of systematic approaches to measuring outcomes and evidence-based treatments, and significant challenges to conducting large, longitudinal clinical research studies. Clinical documentation of care provided to children with NBPs can be lengthy and time-consuming, lacks standardization, and often does not include precise details about clinically and scientifically important information (e.g., diagnostic criteria, services provided, response to treatment). The lack of standardization and missing data limit the utility of clinical documentation to support clinical research and quality improvement.</p>","PeriodicalId":50215,"journal":{"name":"Journal of Developmental and Behavioral Pediatrics","volume":" ","pages":""},"PeriodicalIF":1.8,"publicationDate":"2025-05-27","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"144175535","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":3,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Developmental Behavioral Clinicians' Perspectives on Education Transitions for Young Children with Developmental Disorders.","authors":"Sally S Cohen, Jennie Olson, Timothy C Guetterman","doi":"10.1097/DBP.0000000000001381","DOIUrl":"https://doi.org/10.1097/DBP.0000000000001381","url":null,"abstract":"<p><strong>Objective: </strong>The purpose of this study was to explore developmental behavioral clinicians' (DBP) perspectives on transitions between education programs for children age 8 and younger with developmental disabilities.</p><p><strong>Method: </strong>We used a qualitative descriptive design to systematically gather and analyze DBP clinicians' perspectives. Most of the 25 participants were members of the Society for Developmental and Behavioral Pediatrics (SDBP). Interviews were conducted between June and October, 2022. Audio recordings of the interviews were transcribed. We used MAXQDA software for thematic analysis.</p><p><strong>Results: </strong>We organized categories regarding barriers and facilitators of educational transitions according to the child and family and broader community levels and identified four major themes: (1) acknowledging that families play critical roles in education transitions; (2) communicating effectively at the intersections of the families and education and health care systems; (3) helping families navigate health and education systems and make education transitions; and (4) overcoming systems-level issue.</p><p><strong>Conclusion: </strong>Organizational and systemic barriers often impede DBP clinicians' ability to be involved with education transition activities. Education transitions often exacerbate underlying inequities in access to assessment, care, and outcomes among children with developmental disabilities from historically minoritized populations. Our data prompted us to propose a new framework that features the intersections among child and family, health care, and education teams. We found innovative ways for coordinating education transitions by cultivating relationships among children and families and professionals in health care and education systems.</p>","PeriodicalId":50215,"journal":{"name":"Journal of Developmental and Behavioral Pediatrics","volume":" ","pages":""},"PeriodicalIF":1.8,"publicationDate":"2025-05-27","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"144210090","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":3,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}