Eve Beasley Jerry Friemoth Tanya Froehlich Georgine Getty Joseph Kiesler Susan Louisa Montauk Marsha

1
Eve Beasley Jerry FriemothTanya
FroehlichGeorgine GettyJoseph KieslerSusan
Louisa MontaukMarsha SmithAshley Tucker
Homeless Childrens Thrive And
GrowTeamCincinnati Health care for the homeless
HOMELESS ChildrensThrive And GrowTeam
major funders Procter Gamble Cincinnati
health network
Cincinnati 2009
2
Introduction to Developmental Delays
Homeless Childrens Thrive And
GrowTeamCincinnati Health care for the homeless
major funders Procter Gamble Cincinnati
health network

• Tanya Froehlich

Cincinnati 2009
2
3
Introduction to Developmental Delays

• Delay refers to a significant lag in meeting
  milestones in one or more developmental areas

4
Introduction to Developmental Delays

• Individuals with Disabilities Education Act
  IDEA mandates services for infants, toddlers,
  and preschool children with specific delays

5
Introduction to Developmental Delays

• Delays covered under IDEA include
• Communication Development
• Cognitive Development
• Physical (Motor) Development
• Social-Emotional Development
• Adaptive Development

6
Scope of the Problem

• 12-17 of American children have delays in at
  least one developmental area
• 5 have delays in gt2 areas

Boyle CA, Decoufle P, Yeargin-Allsoop MY.
Pediatrics. 1994 93 863-865
7
Speech and Language (S/L) Delays

• Speech and language delays
• Receptive language
• Expressive language
• Articulation
• Oral-motor coordination
• Fluency
• Language pragmatics

Nelson HD, Nygren P, Walker M, Panoscha R.
Pediatrics. 2006 117 e298-e319. Law J, Boyle
J, Harris R, Harkness A, Nye C. Int J Lang
Commun Disord. 1998 33(suppl)21-23
8
Speech and Language (S/L) Delays

• Untreated speech/language delays in preschool
  children are persistent in 40-60 of kids

Nelson HD, Nygren P, Walker M, Panoscha R.
Pediatrics. 2006 117 e298-e319. Law J, Boyle
J, Harris R, Harkness A, Nye C. Int J Lang
Commun Disord. 1998 33(suppl)21-23
9
Speech and Language DelaysSo What?

• Increased risk for learning disabilities
• Difficulty with reading, written language
• Lower overall academic achievement

Bashir AS, Scavuzzo A. J Learn Disabil.
19922553-65. Catts HW et al. J Speech Lang
Hear Res. 2002451142-1157. Bishop D, Clarkson
B. Cortex. 200339215-237. Sterm LM et al. J
Paediatr Child Health. 199531207-212
10
Speech and Language DelaysSo What?

• More behavior problems
• Impaired psychosocial adjustment
• Lower-skilled jobs compared to non-language
  impaired peers

Bashir AS, Scavuzzo A. J Learn Disabil.
19922553-65. Catts HW et al. J Speech Lang
Hear Res. 2002451142-1157. Bishop D, Clarkson
B. Cortex. 200339215-237. Sterm LM et al. J
Paediatr Child Health. 199531207-212
11
Cognitive Delays

• Deficits in intellectual abilities that might
  include difficulties in
• Ability to acquire, process, retain information
• Problem-solving reasoning

Gortmaker SL, et al. Pediatrics. 199085
267-276.
12
Cognitive Delays

• Deficits in intellectual abilities that might
  include difficulties in
• Ability to generalize information
• Deficits seen in both verbal and visual-spatial
  domains

Gortmaker SL, et al. Pediatrics. 199085
267-276.
13
Cognitive DelaysSo What?

• In a 20-yr follow-up study of children identified
  with developmental delays as 3 yr olds,
  greater cognitive delay assoc w/
• More academic problems
• Less skilled employment
• Less functional independence
• More behavior problems
• Less reported life satisfaction

Keogh BK et al. Am J of Mental Retardation.
2004 3 219-230
14
Physical (Motor) DelaysFine Motor Gross Motor

• Fine motor skills
• Skills that involve use of the hands and fingers
• Calls for the interpretation of visual
  information that guides the fingers
• Gross motor skills
• Control posture and locomotion

Accadro PJ Whitman BY. Dictionary of Developal
Disabilities Terminology, 2nd Ed, 02
15
Motor Delays So What?

• Kids with fine motor delays have difficulties
  with
• Handwriting
• May lead to academic difficulties

Losse A et al. Dev Med Child Neurol. 1991
Jan33(1)55-68.
16
Motor Delays So What?

• Kids with fine motor delays have difficulties
  with
• Activities of daily living
• Tying shoes
• Clothing fasteners
• Manipulating eating utensils

Losse A et al. Dev Med Child Neurol. 1991
Jan33(1)55-68.
17
Motor Delays So What?

• Kids with fine motor delays have difficulties
  with
• Screwing and unscrewing
• Manipulating small objects such as coins
• Performing speeded movements (catching balls)

Losse A et al. Dev Med Child Neurol. 1991
Jan33(1)55-68.
18
Motor Delays So What?

• Kids with fine motor delays have difficulties
  with
• Anxiety and depression due to perceived lack of
  competence in motor activities

Losse A et al. Dev Med Child Neurol. 1991
Jan33(1)55-68.
19
Motor Delays So What?

• Isolated gross motor delays have little
  relationship to general intelligence

Henderson SE, Hall D. Dev Med Child Neurol.
1982 24448-60. Blondis TA et al. J of Child
Neurol. 1993 8 323-329. Snow JH et al. Archives
of Clin Neuropsych. 1989 3 227-238. Fox AM,
Lent B. Can Fam Physician. 1996421965-71.
Gillberg C et al. Neural Plasticity.
20031059-68. Losse A et al. Dev Med Child
Neurol. 19913355-68.
20
Motor Delays So What?

• However, clumsy children often have comorbid
  neurodevelopmental deficits and social issues

Henderson SE, Hall D. Dev Med Child Neurol.
1982 24448-60. Blondis TA et al. J of Child
Neurol. 1993 8 323-329. Snow JH et al. Archives
of Clin Neuropsych. 1989 3 227-238. Fox AM,
Lent B. Can Fam Physician. 1996421965-71.
Gillberg C et al. Neural Plasticity.
20031059-68.
21
Motor Delays So What?

• Notion that elementary school children outgrow
  early motor delays has been challenged

Henderson SE, Hall D. Dev Med Child Neurol.
1982 24448-60. Blondis TA et al. J of Child
Neurol. 1993 8 323-329. Snow JH et al. Archives
of Clin Neuropsych. 1989 3 227-238. Fox AM,
Lent B. Can Fam Physician. 1996421965-71.
Gillberg C et al. Neural Plasticity.
20031059-68. Losse A et al. Dev Med Child
Neurol. 19913355-68.
22
Motor Delays So What?

• Follow-up study by Losse et al showed that
  adolescents who were diagnosed with motor issues
  as young children (6 year olds) had continued
  motor issues, poor self-concept, and various
  learning difficulties

. Losse A et al. Dev Med Child Neurol.
19913355-68.
23
Social/Emotional/Behavioral Issues

• Broad range in infants, toddlers, and
  preschoolers
• Internalizing problems
• Externalizing problems
• Interpersonal difficulties
• Regulatory difficulties

Carter AS et al. J Child Psychol Psychtr. 2004
45 109-134. Dixon
SD Stein MT. Encounters with Children (4th
edition). 2006
24
Social/Emotional/Behavioral Issues

• Broad range in infants, toddlers, and
  preschoolers
• Internalizing problems
• Anxiety/fearfulness
• Depression
• Social withdrawal

Carter AS et al. J Child Psychol Psychtr. 2004
45 109-134. Dixon
SD Stein MT. Encounters with Children (4th
edition). 2006
25
Social/Emotional/Behavioral Issues

• Broad range in infants, toddlers, and
  preschoolers
• Externalizing issues
• Aggression
• Overactivity

Carter AS et al. J Child Psychol Psychtr. 2004
45 109-134. Dixon
SD Stein MT. Encounters with Children (4th
edition). 2006
26
Social/Emotional/Behavioral Issues

• Broad range in infants, toddlers, and
  preschoolers
• Interpersonal difficulties
• Disordered attachment to caregivers
• Difficulties with social boundaries, taking turns

Carter AS et al. J Child Psychol Psychtr. 2004
45 109-134. Dixon
SD Stein MT. Encounters with Children (4th
edition). 2006
27
Social/Emotional/Behavioral Issues

• Broad range in infants, toddlers, and
  preschoolers
• Regulatory Disorders
• May involve sleep, feeding, or emotional
  regulation

Carter AS et al. J Child Psychol Psychtr. 2004
45 109-134.
Dixon SD Stein MT. Encounters with Children
(4th edition). 2006
28
Emotional/Behavioral Issues So What?

• Child behavior problems associated with
  parental distress

Duchovic CA. J child Adol Psych Nursing. 2009
22 40-48. Lavigne JV et al. J Am Acad Child
Adol Psych. 2001 40 1393-1400. Rubin KH et
al. Child Devel. 2002 73 483-495. Caspi A et
al. Archives Gen Psych. 1996 53 1033-1039.
Robins LN. J Child Psychol Psych. 1991 32
193-212
29
Social/Emotional/Behavioral Issues So What?

• Children do not automatically outgrow early
  behavioral difficulties
• Persistence of difficulties from early to later
  childhood observed for both disruptive behavior
  problems and inhibited behaviors

Duchovic CA. J child Adol Psych Nursing. 2009
22 40-48. Lavigne JV et al. J Am Acad Child
Adol Psych. 2001 40 1393-1400. Rubin KH et
al. Child Devel. 2002 73 483-495. Caspi A et
al. Archives Gen Psych. 1996 53 1033-1039.
Robins LN. J Child Psychol Psych. 1991 32
193-212
30
Social/Emotional/Behavioral Issues So What?

• Behavioral difficulties at 3 years of age shown
  to be predictive of later psychopathology and
  antisocial behavior

Duchovic CA. J child Adol Psych Nursing. 2009
22 40-48. Lavigne JV et al. J Am Acad Child
Adol Psych. 2001 40 1393-1400. Rubin KH et
al. Child Devel. 2002 73 483-495. Caspi A et
al. Archives Gen Psych. 1996 53 1033-1039.
Robins LN. J Child Psychol Psych. 1991 32
193-212
31
Adaptive Skills

• Skills that allow coping with the natural and
  social demands of the environment
• Feeding
• Dressing
• Toileting
• Higher level social interaction

Accadro PJ Whitman BY. Dictionary of
Developmental Disabilities Terminology, 2nd Ed,
2002
32
Risk Factors for Developmental Delays in Homeless
Children

• Low birth weight
• Poor nutrition
• Increased lead levels
• Recurrent otitis media

Bryant D and Maxwell K in The Effectiveness of
Early Intervention (Guralnick MJ, ed.). 1997.
23-47.
33
Risk Factors for Developmental Delays in Homeless
Children

• Poverty
• Single parenthood
• Increased family stress
• Fewer resources and less access to support and
  services

Bryant D and Maxwell K in The Effectiveness of
Early Intervention (Guralnick MJ, ed.). 1997.
23-47.
34
Evidence forIntervention

• Tanya Froehlich

Cincinnati 2009
34
35
Early Intervention Does It Matter?

• Abecedarian Project
• Enrolled socioeconomically high risk kids
• Center-based program beginning in infancy
• Nutritional support, pediatric care, social work
  services, full-day preschool
• Children randomized to intervention and control
  groups at birth

Farran DC in Handbook of Early Childhood
Intervention, 2nd ed (ed. Shonkoff JP Meisels
SJ), 2000, pp.510-548. Campbell F Ramey C. Am
Ed Research J. 1995 32 743-72.
36
Early Intervention Does It Matter?

• Abecedarian Project
• IQs in 12-15 yos showed no significant
  differences between intervention and control
  groups

Farran DC in Handbook of Early Childhood
Intervention, 2nd ed (ed. Shonkoff JP Meisels
SJ), 2000, pp.510-548. Campbell F Ramey C. Am
Ed Research J. 1995 32 743-72.
37
Early Intervention Does It Matter?

• Abecedarian Project
• At age 15, the intervention group
• Scored significantly higher on Woodcock Johnson
  Reading and Math achievement tests
• Had lower grade retention rates (39 vs 59)
• Had lower special education rates (24 vs 48)

Farran DC in Handbook of Early Childhood
Intervention, 2nd ed (ed. Shonkoff JP Meisels
SJ), 2000, pp.510-548. Campbell F Ramey C. Am
Ed Research J. 1995 32 743-72.
38
Early Intervention Does It Matter?

• Perry Preschool Project
• Piaget-focused preschool program stressing active
  learning
• 2.5 hr/day program
• Children had set daily routine
• Planning-gtWork-gtClean Up-gt Recall-gt Snack-gtSmall
  Group-gt Outdoor-gtCircle

Farran DC in Handbook of Early Childhood
Intervention, 2nd ed (ed. Shonkoff JP Meisels
SJ), 2000, pp.510-548. Schweinhart L et al.
Monographs of the High/Scope Education Research
Foundation, no. 10. (1993) Ypsilanti, MI The
High/Scope Press.
39
Early Intervention Does It Matter?

• Perry Preschool Project
• Teachers made daily 1.5 hr home visit
• Family involvement in education
• Help with problem-solving
• Parent group meetings also held

Farran DC in Handbook of Early Childhood
Intervention, 2nd ed (ed. Shonkoff JP Meisels
SJ), 2000, pp.510-548. Schweinhart L et al.
Monographs of the High/Scope Education Research
Foundation, no. 10. (1993) Ypsilanti, MI The
High/Scope Press.
40
Early Intervention Does It Matter?

• Perry Preschool Project
• Participants randomly assigned to the Perry
  program or no program condition
• Initial program effects included increased IQ,
  but IQ differences disappeared by age 8

Farran DC in Handbook of Early Childhood
Intervention, 2nd ed (ed. Shonkoff JP Meisels
SJ), 2000, pp.510-548. Schweinhart L et al.
Monographs of the High/Scope Education Research
Foundation, no. 10. (1993) Ypsilanti, MI The
High/Scope Press.
41
Early Intervention Does It Matter?

• Perry Preschool Project
• Follow-up study at age 27 published by Perrys
  Education Research Foundation
• Not peer-reviewed

Farran DC in Handbook of Early Childhood
Intervention, 2nd ed (ed. Shonkoff JP Meisels
SJ), 2000, pp.510-548. Schweinhart L et al.
Monographs of the High/Scope Education Research
Foundation, no. 10. (1993) Ypsilanti, MI The
High/Scope Press.
42
Early Intervention Does It Matter?

• Perry Preschool Project
• At age 27, compared to the controls, Perry grads
• Had higher HS grad rate (71 vs. 54)
• Had higher rates of average or better literacy
  (61 vs. 38)
• Higher reading, math, language California
  Achievement Test scores

Farran DC in Handbook of Early Childhood
Intervention, 2nd ed (ed. Shonkoff JP Meisels
SJ), 2000, pp.510-548. Schweinhart L et al.
Monographs of the High/Scope Education Research
Foundation, no. 10. (1993) Ypsilanti, MI The
High/Scope Press.
43
Early Intervention Does It Matter?

• Perry Preschool Project
• At follow-up at age 27, compared to controls,
  Perry grads
• Had lower rates of arrest
• Rates of gt 5 arrests (7 vs. 35)

Farran DC in Handbook of Early Childhood
Intervention, 2nd ed (ed. Shonkoff JP Meisels
SJ), 2000, pp.510-548. Schweinhart L et al.
Monographs of the High/Scope Education Research
Foundation, no. 10. (1993) Ypsilanti, MI The
High/Scope Press.
44
Early Intervention Does It Matter?

• Perry Preschool Project
• At age 27, cf. controls, Perry grads
• Had higher monthly incomes
• gt 2000/mo (29 vs. 7)
• But no difference in currently employed or
  employed in past 5 yrs

Farran DC in Handbook of Early Childhood
Intervention, 2nd ed (ed. Shonkoff JP Meisels
SJ), 2000, pp.510-548. Schweinhart L et al.
Monographs of the High/Scope Education Research
Foundation, no. 10. (1993) Ypsilanti, MI The
High/Scope Press.
45
Early Intervention Does It Matter?

• Head Start
• 1994 study of HS classrooms only 3/32 rated
  developmentally appropriate using the Early
  Childhood Environment Rating Scale
• Children in higher quality classrooms scored
  better on achievement and academic outcomes
  regardless of their home environment quality

Farran DC in Handbook of Early Childhood
Intervention, 2nd ed (ed. Shonkoff JP Meisels
SJ), 2000, pp.510-548. Bryant D et al. Early
Childhood Research Quarterly. 1994 9 289-304.
46
Early Intervention Does It Matter?

• Head Start
• Difficult to evaluate program overall due to
  variable quality and variety of curricular
  approaches

Farran DC in Handbook of Early Childhood
Intervention, 2nd ed (ed. Shonkoff JP Meisels
SJ), 2000, pp.510-548. Bryant D et al. Early
Childhood Research Quarterly. 1994 9 289-304.
47
Early Intervention Does It Matter?

• Head Start (HS)
• After 1 yr of Head Start, compared to controls
  (no preschool or non-HS preschool)
• Head Start led to gains on measures of
• Impulsivity
• Socio-cognitive development

Farran DC in Handbook of Early Childhood
Intervention, 2nd ed (ed. Shonkoff JP Meisels
SJ), 2000, pp.510-548. Lee V et al. Devel Psych.
1988 24 210-22. Lee V et al. Annual Progress
in Child Psych and Child Devel. 1990 600-18.
48
Early Intervention Does It Matter?

• Head Start (HS)
• Gains observed after 1 yr of HS more likely for
  African American children those more
  cognitively delayed at baseline

Farran DC in Handbook of Early Childhood
Intervention, 2nd ed (ed. Shonkoff JP Meisels
SJ), 2000, pp.510-548. Lee V et al. Devel Psych.
1988 24 210-22. Lee V et al. Annual Progress
in Child Psych and Child Devel. 1990 600-18.
49
Early Intervention Does It Matter?

• Head Start (HS)
• Later follow-up results less impressive
• HS attendees scored higher on a social competency
  test at end of kindergarten
• Measured effects still present but not as large
  by end of 1st grade

Farran DC in Handbook of Early Childhood
Intervention, 2nd ed (ed. Shonkoff JP Meisels
SJ), 2000, pp.510-548. Lee V et al. Devel Psych.
1988 24 210-22. Lee V et al. Annual Progress
in Child Psych and Child Devel. 1990 600-18.
50
Early Intervention Does It Matter?

• Head Start (HS)
• Publication by the Head Start Evaluation,
  Synthesis, Utilization Project states that HS
  grads
• Less likely to repeat a grade
• Less likely to be in special education
• Higher rates of high school graduation
• But not peer-reviewed!

Lee V et al. Annual Progress in Child Psych and
Child Devel. 1990 600-18. McKey RH et al.
Final Report of the Head Start Evaluation,
Synthesis, and Utilization Project.
1985Washington, DC CSR.
51
Early Intervention Does It Matter?

• Infant Health and Development Program (IHDP)
• Program for low birth weight kids (lt2500 g),
  sample disproportionately from poor families
• Enrolled at birth
• 1/3 randomly assigned to intervention

Farran DC in Handbook of Early Childhood
Intervention, 2nd ed (ed. Shonkoff JP Meisels
SJ), 2000, pp.510-548. Brooks-Gunn J. J Peds.
1992 120 350-9.
52
Early Intervention Does It Matter?

• Infant Health and Development
• Program (IHDP) Intervention
• Home visits qwk x 12 mo, then bimonthly
• From 12 mo-36 mo, children attended Child
  Development Center (Partners for Learning
  Curriculum)
• Parent group q2mo while child attending the Child
  Development Center
• Cost 15,146 per child per year

Farran DC in Handbook of Early Childhood
Intervention, 2nd ed (ed. Shonkoff JP Meisels
SJ), 2000, pp.510-548. Brooks-Gunn J. J Peds.
1992 120 350-9.
53
Early Intervention Does It Matter?

• Infant Health and Development
• Program (IHDP)
• Intervention group IQ 9.4 pts higher at age 3 !
• But by age 8, differences attenuated, with no
  significant differences between the groups in
• IQ
• Receptive vocabulary (PPVT)
• Woodcock Johnson Psycho-Educational Battery
• Grade retention
• Special education referrals
• ? Lack of difference due to stopping intervention
  at age 3 ?

Farran DC in Handbook of Early Childhood
Intervention, 2nd ed (ed. Shonkoff JP Meisels
SJ), 2000, pp.510-548. McCarton C et al. JAMA.
1997 277, 126-32.
54
Early Intervention Does It Matter?

• Infant Health and Development
• Program (IHDP)
• Follow-up at 18 yrs old
• For the higher low birth weight group
  (2001-2499g), intervention assoc w/
• Higher math achievement test scores
• Better receptive vocabulary
• Fewer high risk behaviors

McCorkmick MC et al. Pediatrics. 2006 117
771-780.
55
Early Intervention Does It Matter?

• Child Parent Centers (CPC)
• Federally funded Title 1 preschool program and
  later school based intervention conducted by
  Chicago public schools
• ½ day preschool age 3-4
• ½ or full-day kindergarten
• Extra svcs linked to school at 6-9
• Parents had to attend school ½ day/wk
• Families received health and nutrition svcs, help
  accessing resources

Reynolds AJ. JAMA. 2001 285, 23392346.
56
Early Intervention Does It Matter?

• Child Parent Centers
• Intervention group compared to non-randomized,
  matched group at age 20
• Comparison group similarly impoverished
• Participated in alternative early childhood
  programs (full-day kindergarten, some Head Start)

Reynolds AJ. JAMA. 2001 285, 23392346.
57
Early Intervention Does It Matter?

• Child Parent Centers
• Cost in 1996 for 1 yr of participation
• Preschool 4350
• School-age 15

Reynolds AJ. JAMA. 2001 285, 23392346.
58
Early Intervention Does It Matter?

• Child Parent Centers
• Attendance for 1-2 yrs of preschool intervention
• Higher rates of H.S. completion (50 vs. 39)
• Lower rates of juvenile arrest (17 vs. 25)
• Lower rates of violent arrest (9 vs. 15)

Reynolds AJ. JAMA. 2001 285, 23392346.
59
Early Intervention Does It Matter?

• Child Parent Centers
• Compared to less extensive participation,
  intervention from preschool to 2nd or 3rd grade
  assoc with
• Lower grade retention rates (22 vs. 32)
• Lower special education rates (14 vs. 21)

Reynolds AJ. JAMA. 2001 285, 23392346.
60
Early Intervention Does It Matter?

• Psychosocial benefits
• Strengthens parent/child relationship
• Improves parent confidence in ability to care of
  child outside of therapy
• Helps parents feel they are doing everything they
  can for their child

Berlin LJ, et al. Prev Med. 1998 27238-245.
Blann LE. MCN
Am J Matern Child Nurs. 2005 30263-7.
61
Early Intervention Does It Matter?

• National survey of Early Intervention (EI)
  participants found that 82 of parents believed
  their family was better off as a result of EI

Bailey DB et al. Pediatrics. 2005 116
1346-1352.
62
Early Intervention Does It Matter?

• Short-term effects are heartening for
  disadvantaged children
• Experience with preschool and school-like tasks
  raises test scores, including IQ, immediately

Farran DC in Handbook of Early Childhood
Intervention, 2nd ed (ed. Shonkoff JP Meisels
SJ), 2000, pp.510-548. Berlin LJ, et al. Prev
Med. 1998 27238-245. Blann LE. MCN Am J
Matern Child Nurs. 2005 30263-7.
63
Early Intervention Does It Matter?

• Short-term effects are heartening for
  disadvantaged children
• Participation in programs improves parent/child
  relationship and raises parents sense of
  competency

Farran DC in Handbook of Early Childhood
Intervention, 2nd ed (ed. Shonkoff JP Meisels
SJ), 2000, pp.510-548. Berlin LJ, et al. Prev
Med. 1998 27238-245. Blann LE. MCN Am J
Matern Child Nurs. 2005 30263-7.
64
Early Intervention Does It Matter?

• Longer-term effects are more discouraging
• IQ gains not sustained
• But. . .

Farran DC in Handbook of Early Childhood
Intervention, 2nd ed (ed. Shonkoff JP Meisels
SJ), 2000, pp.510-548. Reynolds AJ. JAMA. 2001
285, 23392346.
65
Early Intervention Does It Matter?

• Some notable programs have since demonstrated
• Improved achievement test scores
• Lower rates of special education placement
• Lower rates of grade retention
• Higher rates of high school graduation
• Lower rates of juvenile arrest and arrest for
  violent offenses

Farran DC in Handbook of Early Childhood
Intervention, 2nd ed (ed. Shonkoff JP Meisels
SJ), 2000, pp.510-548. Reynolds AJ. JAMA. 2001
285, 23392346.