Thursday Feb 23, 2023

The Role of Occupational Therapy in Trauma Informed and Responsive Care: An OT’s Personal Story

According to the Administration for Children and Families (n.d.), nearly 500,000 children and youth are currently in the foster care system in the United States. Caregivers and professionals who work with children in the foster care system must have an understanding of and tools to provide trauma-responsive and trauma-informed care. Listen as occupational therapist and foster parent, Rachel Ashcraft, shares her personal and professional path to providing this care.

Episode Guest: Rachel Ashcraft, MS, OTR/L

The views expressed in the following presentation are those of the presenter(s) and do not necessarily reflect those of STAR Institute.

Resources Mentioned In this episode:


Episode transcript:

Carrie Schmitt
Join Today by Rachel Ashcraft, she's an occupational therapist and assistant professor at the University of Alabama, Birmingham. Thanks for being here today. Could you tell everyone a little bit about yourself? Hey, everyone,

 

Rachel Ashcraft 
I'm so excited to be here. I'm Rachel, I'm assistant professor, as she said, at the University of Alabama in Birmingham. And my main focus and work that I do is within the realm of trauma responsive and trauma informed practices, and then really looking at what that means for us in the occupational therapy world and kind of how to take that lens and put it to what we do.

 

Carrie Schmitt  
In your personal story, you were an occupational therapist practicing in pediatrics. And then you and your husband made a decision that took you down the road of getting interested in this trauma informed and trauma responsive work, do you mind sharing a little bit about.

 

Rachel Ashcraft 
I love to Yeah, so I was a fairly new practitioner, and I was working in a pediatric outpatient clinic with a sensory focus. And just doing the day to day regular work, they're learning how to be a new clinician, you know, just kind of learning the ropes of everything, when my husband and I became aware of a really big need in our community within our foster care system. So we have learned that a lot of the kids in our county, we're not even having homes to go to. So I think at one point, it was like, there was maybe over 400 kids in care and just our specific county and like less than 40 homes, for them to even potentially go to, and most of those were full. And so kids were really ending up in places that were not ideal, just because there's nowhere for them to go. And so we've really felt kind of a burden of injustice just in the sense that we did have capacity to open our home up to open our family up to to take in not just these kids, but also to partner with their families, in the hopes of them being able to be reunified, because that's really the goal of foster care is for the children and the family to be able to stay together. And so we really felt like that was something that we could do. And so each day that we weren't doing this thing that we knew that we could do just really started to feel really like we were doing an injustice in our community by not showing up for that for that group. And so that's what happened, we became foster parents. And as that was happening, we had in the span of five years, we've had 24 Kids come through our house, as infants all the way through 17. So it was just a really kind of different way to enter that experience. Just even in just like, my season of life just being where I was kind of late 20s started my career. And now I'm trying to figure out how to help these kids and these families. What I felt like I noticed was that kids were coming into my home that were unable to do things that I expected them to be able to do that. Not that they should have based on their life experiences, but my lens, I was expecting them to be able to do things that they really wasn't a fair ask for them. So things like I distinctly remember, a child that couldn't had no idea how to take a shower. And so and they're really too old for me to be in there with them. Right? So trying to figure out how do I help this child learn how to take a shower in a way that's appropriate, but also honors, whatever experiences they've had that have been harmful and traumatic surrounding that space, you know, in their life. And just, all these different occupations were happening. And I was thinking these kids just don't, aren't getting help, you know, for what they need. And I wasn't even thinking of it from a really sensory health lens, or trauma informed lens. Like I really didn't even know enough at the time to be to be thinking that way. I was just thinking. I'm in a profession that helps people learn how to do the things they want me to do. And here's a group of kids that has no opportunity to do the things they want me to do. And that is wrong. And I really just started feeling like the same sense of kind of injustice about our profession, that we weren't stepping up for this group of kids and these families in our culture. In the same way. We my husband and I were feeling you know, we're really doing an injustice. If we don't step up for these kids and bring them into our home. I started feeling that same like professional injustice of why are we as occupational therapy practitioners, not showing up for these kids and not really kind of seeing what we need to do to help them be able to participate. And so that kind of started me down this path, where as I learned more i I was able to understand what the barriers were in the foster care system and started trying to figure out how to eliminate some of those barriers that ended up in me creating a nonprofit actually, with the mission of reducing systemic injustice and access to care that kids in Alabama's foster system experience. But it also ended up in me doing things like going to the star mentorship program and learning more about sensory health, you know, and then as I did that, I was able to bring that back to the kids I was working with and think about, oh, gosh, like, I've learned all these, like subtypes and all this stuff about sensory health from starts to two. And now I'm seeing these very specific expressions of those patterns, but in ways that have to be really gently met in a trauma informed way, so that we're not harming these kids. And so that we're really valuing safe relationship and everything we do, which I know is what you know, the star model does already. So that started to be a really good fit for me. And then I started learning more about trauma informed models and got trained in trust based relational intervention, you know, and started really bringing that perspective to what I was doing. And then what happened is I started realizing like, it's not just the foster care community, but it's trauma is this whole bigger conversation that actually impacts all of us. And it impacts at these individual levels, but also all the way systemically. And it's just so broad and started really realizing that's how all our practice should be, you know, for everybody is really looking through that lens. And so I've just kind of continued to do work down that path over the last 1015 years. And that's kind of where I've ended up today, really, as an advocate for what I believe is that we should all be using trauma responsive, and trauma informed practices, and everything we do with everybody will be interact with. But it's been kind of a journey to get there.

 

Carrie Schmitt 
I love the almost organic way your journey happened. Going back to kind of this the origin story of your involvement in the foster system and your recognition of injustice that you felt called to remedy. You had training in development, training in occupation, and then you received into your home, children who were at an age where you would have thought someone had already taught them some of the life skills, daily occupations. And it sounds like your very first realization was that you are uniquely trained to recognize, you know, developmental differences or skills that haven't been learned, and then teach them. And yet, suddenly, you realized what the root of the impact of some of their histories was having and how their histories might have contributed to, and are still contributing to barriers to learning those skills. Does that sound right?

 

Rachel Ashcraft 
Well, that's exactly right. And, I mean, again, I have to emphasize I was such a new practitioner, when I first kind of came to this. So I really didn't know if I was way out of line and saying like, occupational therapy has a role in foster care, occupational therapy has a role on trauma. I, I didn't know that other people were even considering this topic. And at the time, there, there weren't that many people who were. And I remember one day, I just, it would have been the occupational therapy third framework, Third Edition, I just printed our framework, which is, you know, our document that kind of outlines from the videotape perspective, this is what our scope is right? And I just went through and I wish I had kept that document because I highlighted every part of it that I felt like applied to foster care specifically, and was like, Is this our scope? Right? Like, do we have a place in this field of practice? And the whole thing was marked up and I was like, No, I think we did. You know, I think we do have have a space in that and then the only way that I really ended up getting connected with other people who also believed that who were doing work on it but just in different parts of the country is our State Association Conference, and they had advertised this like pediatric track they were gonna have and somebody backed out, you know that happen? It's like they've advertised, we're gonna have this pediatric session, and the person didn't, you know, for whatever reason they couldn't come. And so they called me a little bit in, you know, in a panic, and they're like, We know you work in a kid's clinic, can you come up with something, you know, to present? And I was like, well, it's gonna be different. I said, because here's the deal, like, all I'm thinking about right now is foster care and OT, and this idea of trauma, keep reading about, and I'm just really thinking about that. And it's basically going to be about how we need to do better as a profession. So like, if you want to lecture, that's what I'm gonna talk about, because that's what's on my mind. They're like, sure, whatever. Thank you for coming, you know. And so that's the presentation I did. And I really just talked about how we have a responsibility to step up specifically for the foster care community, and that our profession wasn't doing enough. Well, it just so happened that at that conference, it was actually it was Debbie Heiner filled, she was on the Volunteer Leadership Development Committee at AOTA. And she heard that presentation, and connected me with a group of people at AOTA that were on a community of practice, and doing like, pediatric mental health. And so they connected me with them. And then it just so happened that I met Dr. Amy Lynch through that, who was really passionate also about trauma work, and had been doing it for many more years than me, and I just didn't know her. And so we were able to connect, and we've been doing work collaboratively together ever since. So I always say like, sometimes it's just showing up and putting yourself out there you know, to was like part of how I even was able to learn more, because I was able to meet these other people with a similar passion that that we're doing this work, but in someone in Miami, someone in California, someone in Pennsylvania, you know, and we were able to kind of come together and push the profession a little bit forward, that in ways that I couldn't have done by myself.

 

Carrie Schmitt 
I think it's so important for younger practitioners to hear that message. Oftentimes, the change comes from following an interest, a passion and a curiosity. And then connecting with other people who share that interest, that passion, that curiosity. One of the terms that keeps coming to mind when you're speaking because it was like, first I had my occupational therapy lens on then I had my foster care lens on, then I realized there was a sensory basis. Right. And so I put my sensory lens on, you know, and then I realized, oh, trauma is, you know, trauma traumatic experiences, AB underlying, and interrupting a lot of developmental milestones a trajectory in the brain and things. So you put your trauma informed, or trauma responsive care, that the humility that it takes to keep pivoting, I think is something that also keeps jumping out at me, just keep going, just keep learning the next thing, just keep accepting an invitation to speak at that conference, to meet this community of practice, to connect with Dr. Amy Lynch, to take it, you know, just taking.

 

Rachel Ashcraft 
Take that next step, and also to be okay with the not knowing right, and to really embrace for me and even still so much as about how much I still have to learn and being excited about that. And being open to that and staying curious about things. You know, I think about to kind of this idea of being curious about things, and then if I can backtrack and kind of apply it within trauma. You know, a lot of the literature in trauma informed care has come out of, you know, historically based work in psychology, and in neurobiology, and going back several decades, which means it was a lot done by primarily white men, right? If we go back and look at kind of what the research is, historically, right, so when they first were looking at aces, this idea of adverse childhood experiences, the first study was in this fairly predominantly white homogenous group done by you know, researchers without using a lens, it's looking more at holistic perspectives, considering systemic and justices things like that, right. So the first the first data that came out of that was all about those just like individual traumas that people experienced as a child. So whether it was child abuse or you know, physical abuse or how household dysfunction or something like that it was these very like individual things that over time as more and more justice occurred within academic spaces within research spaces, and that's not at all to say that that's been achieved. But as more and more voices were at least allowed in, more and more research was able to be done that expanded that concept to understand not just what this looks like in majority Western white spaces, but what does this look like in all spaces and in global spaces, and when we look at the global majority, racially, when we start looking at systemic and justices that occur, and there are some things that were wrong, you know, there are some things as a group that have really expanded and come to understand a lot of interventions that we need to be doing have to look at systemic injustice. Before we even get to some of the more individual things, and how are we also participants in that system? And are we doing the work we need to do to make sure we're not re traumatizing individuals. But I guess I say all that to say like staying curious, because so much of that has come out of pushes for more justice and more equity in the way we even consider even in the way we ask questions, you know, and who's invited to the table for those questions? And who's doing that research. And I've learned so much now from, you know, the people who are doing trauma and trauma work in spaces where they're looking at intersectionality, right, between different identities and how those things impact people and how systems of oppression impact people and not just these individual experiences to tell.

 

Carrie Schmitt 
Tell us for people who are listening and interested in curious about taking their curiosity on this topic or the little maybe that they already know, and integrating some of this intersectionality some of the bigger justice issues, who are a couple of voices that you are listening to in this space that we could be exposed to that we could go look at their work.

 

Rachel Ashcraft 
The three four, I would say in occupational therapy that have pretty accessible online platforms are Dr. Kalia Johnson, and Dr. Ryan Lavalle. They have a podcast called Doctor thoughts. But I listened to them a lot and they have a lot of really great conversations surrounding just justice and accountability for our profession to which is has just been really helpful to have a lot of fun conversations too. So I like to listen to their voices. Dr. Alaa Abu Arif also is someone who has a online presence. He's an occupational therapy therapist in California, he wrote a chapter in the trauma textbook on racism and has brings a really I find a really helpful perspective has research has been on bias within the within the occupational therapy profession. So looking at explicit and implicit bias, specifically within OT, which is is an enlightening and hard work. That is important work that he's been doing. And then Sheila with disruptive T is out in the California area as well. And that's she has a social media presence, disruptive T and then also a website. And they do like training events and free events that you can go where she has different speakers of different identities speak and talk. And so those are some of the OT voices I'm really listening to. I'm really inspired by the work of Reza and then I come he does a lot of work within like somatic experiences of trauma specifically related to racial trauma. He wrote the book, my grandmother's hands. And so if anyone's familiar with that book, I find it I found it really helpful. One thing that, that I noticed is that in this conversation surrounding trauma, is SAMSA has put together six principles of trauma-informed care. And I think of those almost in my mind as like a gatekeeper of, if you're not doing those six principles, then you're not really doing it. Right. So like people will say I'm doing trauma-informed care different people mean different things when they say that right? And there's actually been a movement kind of away from that term. Some because people mean different things when they say that and some people are not doing this the work to make sure they're not re-traumatize Seeing people in this kind of systemic consideration. But the sixth principle of trauma-informed care, according to SAMSA is consideration of gender cultural, historical trauma. So the idea being if you're not including that, it doesn't matter if you're doing the other five, you know, and so what I find is a lot of the models that have come out over the years, they might have the first five, but they don't really address like, How are you holding those practitioners accountable to not engaging in other systems of bias? Your presenters in season two talked about when they did the anti black black experiences that autistic children have? I don't remember the name of that

 

Carrie Schmitt 
Anti black racism in some pathway?

 

Rachel Ashcraft 
Yes, So.

 

Carrie Schmitt 
You were just missing all the barriers to particularly they're looking at the population of black children and their caregivers who are seeking acknowledgment of symptoms that might end up in the diagnostic pathway. And the barriers they encountered was what their research was around.

 

Rachel Ashcraft 
Yes. So when I was listening to that, I was thinking of how that applies to the kids I see. Even if the autistic diagnosis isn't the conversation on the table, but definitely for that as well. But with kids who've experienced trauma, those kids are more likely to be labeled as a behavior, you know, a behavior problem than a child who's experienced harm, and you see, like racism and things like that start to scaffold within that community as well. I was just thinking, that's the perfect example. How are you holding professionals accountable to not engaging in that bias? That actually is a trauma to people as well, you know, so that conversation goes so deep.

 

Carrie Schmitt 
Thank you for referencing that. Because one of the things I loved about their research was that they really helped to point us in the direction of taking action, meaningful action, to make change. And I hear that and your drive to that you have recognized some injustices you use experience, you know, had an experience where you were trying to seek services for the foster children in your care and encountering barriers, and started asking questions and came up against some systematic issues, right. And then your strong sense of justice brought you forward into and called you to action. So I do love kind of the intersection of those two conversations, I keep going back to some curiosity around people who don't understand even the basic issues surrounding trauma. So we started this conversation talking about foster children, children in foster care who entered your home. For some people, it might be obvious that those children might have encountered trauma in their lives that were impacting then impacted in their brain or developmentally impacted them. I also heard you say that as occupational therapists, we have a place both in caring for people in foster care, but that we're often encountering individuals with trauma histories that might not be advertised or might not be obvious to us. So in your case, a child was temporarily removed from their care system caregivers, placed, hopefully temporarily in your home until circumstances would allow reunification. And so there was a relationship that was temporarily hopefully impacted. But we recognize in that, that when relationships are interrupted and a child needs to leave an environment that they were previously in that that might be experienced, as traumatic to their little systems. Absolutely. But let's dive into that a little bit. Like what like maybe defining trauma, okay. What is it about maybe children and foster care that make them a little bit more vulnerable but also So how do we take that to every client who walks through the door, who might not have a history of needing foster care? So we don't, you know, taking it outside of the context of fostering, but may have also experienced, you know, trauma in their young lives.

 

Rachel Ashcraft 
Yeah. Okay. I love this question. So the idea of trauma is really that trauma has occurred, whenever there's an event, or a series of events in someone's life, that makes them feel unsafe, or where they actually are unsafe, and in an extreme way, in a way that's going to carry lasting effects for their physical, mental, social, cognitive, spiritual well being. So it's not just oh, I had something stressful happen, I'm okay, it's this, this thing happened, or this series of things happens. And I am not the same anymore, because that happened. So what we know that's very interesting is that actually, the impact of trauma of an event like that that can happen starts as early as in utero, and then can permeate. Of course, you can experience an event like that at any point in your life. But an experience of in utero could even be if the mother is in our personal violence situation, or in a situation where there's extreme stress where the there's even physical harm, the stress and trauma of that mother will actually be passed hormonally on to the infant and the infant's brain as it's developing will wire for harm, the brain will wire to protect itself from harm. And so the way that can even look when we're talking about sensory health is an infant in development in a like fetal development stage in utero. Who mother is at physical harm risk, that infant May, and we see patterns of this, it doesn't mean it will always happen. But we do see patterns that infant's brain and sensory system may wire where they dissociate from pain from depression, that might turn out to be an individual who seeks a lot of proprioceptive input or is under responsive to proprioceptive input, who does not register pain, right? Who then engages in the sensory experiences that they're seeking out to meet their sensory needs, in ways that may not make sense to others. But when you understand how their brain wired, it makes a lot of sense. Not just one example. But then at any point in life, you can have these experiences for which are forever altered. But if those experiences happen from in utero, till 25, the brain is still developing, right? So anytime there's experiences during that period of someone's life, it just means that the impact has the potential to be that more significant, because the wiring of the brain will shape to adapt for that. And so what we'll see is we'll see differences in people's sensory needs, we'll see differences in what situations they do or don't feel safe around though, you'll see differences in how they engage socially what relationships feel like to them. Because the brain has wired to adapt for survival. And so if if someone's brain is wired to adapt for survival, then that's going to be the response they go to first, even in situations that may not seem like it makes sense for that.

 

Carrie Schmitt 
When you're speaking. I love that you're highlighting that we are all sensory beings, that experiences with a negative valance in which we lose our agency and our safety, hmm. are traumatic experiences. Yes. And so we recognize in sensory work. When a system experiences a sensation, as threatening, and it activates their sympathetic nervous system, and they experience that over and over and over, that that can be a traumatic experience. I think trauma thankfully, is in our vernacular and is in the collective consciousness now, but it does seem like something that can be overplayed and can be misunderstood, or only understood. As one thing, which is incredibly traumatic events, like a war experience for a soldier. And so understanding trauma on a continuum, I think is super helpful for practitioners, that when we encounter people to your point, who may have stored implicit memory in their body as and negative sensory experience in which they lost agency in which they lost their sense of safety or trust, in which they didn't have adequate resources to respond in the moment, that reconnecting with their body can feel.

 

Rachel Ashcraft 
To them, yeah, into them.

 

Carrie Schmitt 
And so you had mentioned that we might see that people detach a little bit from their body as a protective mechanism, because of their history. And when we detach from our body, when we detach from our agency, when we detach from the ways that we can act in the world, sometimes that shows up in not accomplishing developmental tasks that you might otherwise expect that child to do. And so we should always question if there seems to be some some interruption or some task that is on there unable to accomplish. What underlies that? And, you know, is there potentially a sensorimotor experience that underlies it? Even if it's not labeled a trauma, right? Was there something that they experienced in their bodies, that was a threat that disrupted their agency that disrupted their their sense of trusting themselves or trusting other people?

 

Rachel Ashcraft 
Yeah, I think that's such a good point. And this, I love that idea of you're saying that we're all sensory beings. And really, whenever your safety is violated, that is experienced as a trauma by our bodies, and by our brains. Bruce Perry, who has done a ton of work, although I would recommend if to any readers that haven't already read what happened to you, by Bruce Perry. Also, the audiobook is very good, because it's an interview between him and Oprah. And they read it. So it's very, it's an engaging, listen. But he has the model in an t that some people may have heard of before, but he talks about the brain in the way of, of it processing where you have to be regulated within your brain, and then you can have relationship, and then then you can reason, right, so you have to regulate be regulated, you have to feel safe in your body, before you can really access that higher level reasoning. And so what we know is that, like you were just saying these kind of like, classic traumas, I guess you would say, of these things that we would all recognize, like if a child's abused a certain way, we're all going to agree that that's a trauma, right? So there's these things that are so big, so egregious things that if they happen multiple times, or you have these kinds of scaffolding of experiences, that no one's neurology is really going to come out regulated, right? Like, in the literature, we see four aces as kind of a tip point where you start to see kind of a snowball effect of poor outcomes. Basically, it's almost like once you get to that point, very few people have the capacity to come out kind of without some kind of impact. But what we can't say is the flip of that, is that, oh, well, if this one thing happened, it shouldn't have been as traumatic as so and so's XYZ experience because the response is entirely about how the body and the brain regulates with that. And then we can take that approach and consider this idea of sensory health, and how some people's bodies themselves are traumatized by environments that do are experienced as unsafe, you know, or people experience being in their body as unsafe, you know, and so then that's where I think this meshing of a trauma informed approach with a really like affirming sensory health approach really makes sense. Because it's not really about labeling levels of trauma. It's not really about saying, you even have to know every detail of what happened in somebody's story, but it's about affirming that until you're regulated, you don't get to be to your fullest self, and that everybody deserves to be regulated, and everybody deserves to be their fullest self. And so if you can bring that lens to it, then we start being able to have compassion for our clients, but also for ourselves also, for our co workers. Also for, you know, everyone involved in a system, if we're able to come with that lens of, we all have a past, that might impact our regulation. And when our regulation doesn't feel when our isn't there, and we're not feeling safe. We don't we don't have the opportunities to be who we fully want to be, and that we all deserve that.

 

Carrie Schmitt 
Thank you. Because I think that is a message that any practitioner can take, any person can take into relationship, any parent can take into their home foster parent or their parent. When we prioritize regulation, nervous system regulation, our own and those that were charged with their care, build upon that with a tuned relationship, established sense of safety in their environment, and within the context of that relationship, then so much more as possible, right in embodied cognitive experiences. But those embodied cognitive experiences rely on information that helps us prioritize regulation and relationship. And so thank you for bringing that kind of full circle. I feel like we could talk on and on and on. And we might have to do like a part two, because I know there's so many people out there, both occupational therapy practitioners, but also people involved in the foster system that could really benefit from what you're learning. So maybe we'll have to see about having further conversation. I do want to ask, though, like, we've been talking a lot about how you and your life have followed passions, how you have followed curiosity, how you have sought to stay humble intellectually, so that you could learn from what the literature is teaching you what other practitioners are learning. So what is one thing that you can think of that you used to believe that now your either your thinking has really evolved on? Or you've kind of changed your mind about?

 

Rachel Ashcraft 
Yeah. So I think the first thing would be really this idea of understanding, understanding systemic harm, and my role in it, you know, and really being open to questioning where have I participated in that? Where have I been hurt people and didn't realize it, you know, whether it was from, you know, ableist, thinking, you know, or just not understanding the full picture of racism within our profession, right, and what my responsibility is for that. But I think one thing that I've really used to believe that was wrong, is I graduated school. And the time when we really talked about what we really didn't talk about neurodiversity. In that paradigm, we talked about disability in ways that were that kind of like, not affirming, I guess, I would say, you know, not neuro neurologically affirming of everyone's experience, right. And so I was taught really, under this whole idea of, of, I mean, what I would really consider ableist around, like the Autistic community, specifically, and really just had some wrong thinking about that, and kind of what my role was in that, and this idea of that being something to be sad about, or something that needed to be fixed, instead of understanding that like, really, I needed to be fixed, right. And the approach I brought to the table is what was sad, and understanding that like, really, where have I caused trauma by not understanding a neuro, you know, a really neuro affirming way of being and embracing sensory health as a spectrum that we all have, right, and understanding that and so I think, really, the work that's come out of the star center, and specifically, Virginia Spielmann, a lot of her work that she's done has been so helpful and instructive to me and you know, I think I hope that that my language around that and that my practice around that sounds really different than it did when I first graduated school and had learned some things that I just don't agree with anymore, and I hope that I keep learning and keep doing better, you know.

 

Carrie Schmitt 
Thank you. It's really inspirational. And I think it is a call to action for all of us practitioners to try to examine where we hold knowledge or biases in our own practice, that are not serving us or the people that we are encountering. So thank you for modeling, learning and unlearning. The hardest work of all learning, right? No, thank you for being willing to go first, to show you know to do some of that work and then to turn around and share it with your students at UAB, which I think is, you know, going to change the way that we educate occupational therapy practitioners for the better, which is super important. Well, thank you so much for being here today. If people want to connect with you or with your work, where would they find you?

 

Rachel Ashcraft 
You can find me on Instagram at Rachel underscore Ashcraft underscore OT, or on Twitter at Rach underscore Ashcraft. Nine or you're welcome to email me as well. If you want to look me up on the UAB website, my email is there as well. So

 

Carrie Schmitt 
Great. Well, thank you so much. I really appreciate your being here today.

Rachel Ashcraft 
Yeah, I appreciate you having me.

 

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