ACE Test and Questionnaire: What the Questions Measure and What They Miss
Author: Ukrainian Psychological Hub · Published: September 22, 2026 · Editorial Policy
An “ACE test” is usually a questionnaire about adverse childhood experiences: categories of abuse, neglect, and household adversity that occurred before age 18. The best-known version produces a simple count of categories endorsed, often from 0 to 10. That count can be useful in public-health research and as a structured prompt for discussing childhood adversity. It is not a diagnostic test for psychological trauma, post-traumatic stress disorder (PTSD), complex PTSD, dissociation, attachment problems, depression, anxiety, or any other clinical disorder.
The word “test” can therefore be misleading. A laboratory test is designed to detect or rule out a condition with known diagnostic properties. A classic ACE questionnaire does something different: it asks whether a limited set of experiences occurred and summarizes the breadth of those reported exposures. The CDC’s current overview of adverse childhood experiences describes ACEs as potentially traumatic events and adverse conditions in childhood, while also noting that its examples are not a complete list. An adverse childhood experience is an exposure category; a trauma response is the person’s psychological and physiological response to an event or environment. Those are related concepts, but they are not interchangeable.
This distinction matters because two people can report the same ACE category and have very different histories, meanings, protective relationships, symptoms, and health trajectories. A person can also have an ACE score of 0 and still have lived through events that were frightening, dangerous, destabilizing, or traumatic but are not included in the classic questionnaire. Conversely, a high ACE count does not establish that a person has been “damaged,” does not prove a psychiatric diagnosis, and does not tell a clinician what treatment—if any—is needed.
The scientifically defensible use of an ACE questionnaire begins with a modest question: which of these specified categories of childhood adversity does this person report? Everything beyond that—severity, timing, chronicity, current symptoms, diagnosis, individual prognosis, protective factors, and treatment needs—requires additional information.
What Is an ACE Test?
“ACE test” is a popular search term rather than the name of one universal clinical instrument. In practice, it may refer to the familiar 10-category ACE questionnaire derived from the CDC–Kaiser Permanente ACE research, to a version of the Behavioral Risk Factor Surveillance System (BRFSS) ACE module, to the World Health Organization’s ACE International Questionnaire (ACE-IQ), or to an online quiz that has modified the wording, number of items, or scoring rules.
The historical foundation is the CDC–Kaiser Permanente ACE Study, conducted in the 1990s among adult health-plan members in Southern California. The landmark 1998 paper by Felitti and colleagues analyzed seven categories of exposure and found graded associations between cumulative exposure and a range of adult health-risk behaviors and health outcomes. Later CDC–Kaiser work used additional domains; a CDC Public Access copy of Ports, Ford, and Merrick (2015) reproduces the Wave II ACE items and their category assignments.
That historical detail is important. The familiar “10 ACEs” should not be imagined as a psychiatric scale that appeared fully formed in the 1998 paper. The broader CDC–Kaiser program collected additional domains across study waves; neglect was collected in Wave 2, and later summaries commonly present 10 categories. The resulting ACE score is a cumulative category count, not a latent clinical severity score in the way many symptom scales are designed.
What Does the Classic ACE Questionnaire Measure?
The classic ACE framework groups experiences into three broad areas: abuse, neglect, and household challenges. In the familiar 10-category presentation, a person typically receives one point for each category that meets the questionnaire’s threshold, regardless of how many qualifying events occurred within that category. A CDC Public Access version of the Wave II item table shows that several categories were constructed from more than one question rather than from a single yes-or-no item.
Abuse
The three abuse categories are emotional abuse, physical abuse, and sexual abuse. The historical questionnaire operationalized these categories with specific behaviors and frequency or threshold rules. Endorsing one of these categories records exposure as defined by that instrument. It does not by itself measure the person’s current distress, the subjective meaning of the experience, the duration of symptoms, or whether diagnostic criteria for a trauma-related disorder are met.
Neglect
The two neglect categories are emotional neglect and physical neglect. These domains ask about the absence of expected care, protection, emotional support, basic needs, or family closeness. Neglect illustrates why an ACE count can compress very different realities into the same number: one person may report a brief period of unmet needs, while another may describe chronic deprivation across years. A one-point category count does not preserve that difference.
Household challenges
The five household-challenge categories commonly included in the classic 10 are parental separation or divorce; household substance-use problems; household mental illness or suicidality; an incarcerated household member; and violence toward the mother or stepmother in the historical wording. The last item reflects the language and family assumptions of the original instrument. Contemporary research and clinical practice may use broader, gender-inclusive formulations for exposure to intimate-partner violence or caregiver violence.
These household categories also need careful interpretation. Having a parent with a mental disorder or substance use disorder is not, by itself, a statement that the parent was harmful, uncaring, or abusive. The epidemiological category is intended to capture a feature of the childhood environment that may correlate with stress, instability, caregiving disruption, or other exposures. The pathway from a household condition to a child’s outcome varies widely and is shaped by treatment access, caregiving quality, family resources, other adults, community support, socioeconomic conditions, and many other factors.
How Is an ACE Score Calculated?
In the common 10-category approach, each category is coded as exposed or not exposed and the categories are summed. The resulting number describes how many of the measured categories were endorsed. It does not add up the number of individual incidents, and it generally does not weight categories by severity, age of onset, chronicity, frequency, relationship to the person involved, or current impact.
That means two people with an ACE score of 3 can have entirely different histories. One might report parental separation, household substance problems, and incarceration of a household member. Another might report emotional abuse, physical abuse, and sexual abuse. Even within one category, exposure can vary greatly in duration and severity. The score treats these histories as the same cumulative count because the research question is breadth of category exposure, not individualized clinical formulation.
Research has repeatedly found dose-response patterns in which groups reporting more ACE categories, on average, have higher rates of some later health and behavioral outcomes. A dose-response association at the group level does not turn the ACE score into a personal forecast. It means that outcome prevalence differs across groups defined by exposure counts, not that a person with a particular score will develop a particular disorder or disease.
What an ACE Score Does Not Mean
An ACE score is not a diagnosis. There is no DSM or ICD diagnosis called “high ACE score,” and a number such as 4 does not mean that a person has PTSD, complex PTSD, depression, anxiety, a dissociative disorder, an attachment disorder, or a personality disorder. Diagnosis requires the relevant symptom pattern, duration, impairment, exclusions, clinical context, and diagnostic criteria for the disorder being considered.
The score is also not a linear damage scale. A score of 6 is not “twice as traumatized” as a score of 3. The units are categories, not standardized units of injury or symptom severity. Likewise, 4+ is not a biological threshold at which a person crosses from healthy to damaged. Researchers sometimes group scores as 0, 1, 2–3, and 4+ for statistical analysis, but a research cut point does not become a diagnostic boundary simply because it is convenient for a table or regression model.
The American Academy of Pediatrics states this explicitly: ACE scores are associated with poor health at the population level but do not predict individual health. The AAP notes that the score omits many forms of trauma, does not capture severity, chronicity, or frequency, and does not include protective factors that may buffer risk.
ACE Test vs. Childhood Trauma Test
An ACE questionnaire and a “childhood trauma test” are not the same thing. ACE is an epidemiological framework for specified forms of childhood adversity. Trauma is a broader concept involving exposure and response. Some ACEs are potentially traumatic, but an ACE does not automatically produce psychological trauma, and an event can be traumatic even if it is absent from the classic ACE list.
An exposure questionnaire therefore cannot tell whether someone has a trauma-related disorder. PTSD and complex PTSD require disorder-specific diagnostic criteria, clinically significant symptom patterns, and appropriate clinical assessment; neither can be inferred from the number of ACE categories a person endorses. The ACE count is an exposure summary, not a trauma-disorder assessment.
The same caution applies to attachment and dissociation. An ACE questionnaire does not measure adult attachment dimensions, diagnose an attachment disorder, or establish that an adult relationship pattern was caused by childhood adversity. It also does not diagnose dissociation or prove that memory gaps reflect hidden trauma. Exposure history, current symptoms, developmental context, and alternative explanations have to be assessed separately.
What Does the Classic ACE Test Miss?
The strongest reason not to treat the classic ACE-10 as a complete inventory of childhood trauma is simple: its content is deliberately limited. The CDC’s 2026 ACE overview explicitly says that its examples are not a complete list. The original framework was historically influential because it made cumulative childhood adversity visible in population research, not because its 10 categories exhaust everything that can threaten safety, stability, development, or well-being.
Adversities outside the classic 10 categories
Important experiences that may fall outside the classic 10 include bullying and peer victimization; community violence; war and forced displacement; racism and other forms of discrimination; homelessness and housing instability; food insecurity; severe poverty and material deprivation; bereavement and caregiver death; foster-care disruption; serious accidents, disasters, or medical experiences; exposure to terrorism; chronic neighborhood danger; and other losses or threats. Whether a particular experience is best described as adversity, a potentially traumatic event, trauma exposure, or another construct depends on the event, the measurement framework, and the research or clinical question.
Newer instruments often broaden the content domain. The World Health Organization’s Adverse Childhood Experiences International Questionnaire (ACE-IQ) is designed for adults aged 18 and older and includes family dysfunction, abuse and neglect, peer violence, community violence, and collective violence. It is therefore not simply the classic ACE-10 translated into another language; it measures a broader set of exposures for international survey use.
Severity, frequency, timing, and chronicity
A cumulative category count usually loses information about how intense an event was, how often it occurred, how long it lasted, when in development it occurred, whether several experiences overlapped, and whether the child had any route to safety. These dimensions can matter for developmental and clinical interpretation. A binary category can be valuable for large epidemiological datasets while remaining too coarse for an individualized history.
Context and meaning
The same nominal event can occur in very different contexts. Parental separation, for example, can follow prolonged conflict and violence, or it can reduce a child’s exposure to conflict and create a safer household. Household mental illness may range from a well-treated condition with stable caregiving to severe, untreated symptoms that repeatedly disrupt care. The category label alone cannot recover these distinctions.
Protective and positive experiences
The classic ACE score counts specified adversity and does not subtract points for stable caregiving, supportive teachers, friendships, community belonging, safe housing, access to health care, family strengths, or other positive childhood experiences. Protective factors do not erase an adverse experience from history, but they can change developmental pathways and later outcomes. A score that records exposure without protection should not be interpreted as a complete model of a person’s childhood.
Trauma response, symptoms, and functioning
Most importantly, the ACE score does not ask the central clinical questions: What symptoms are present now? How severe are they? How long have they lasted? How do they affect sleep, concentration, mood, relationships, work, school, physical health, or daily functioning? Is there current danger? What supports are available? Exposure measures and symptom measures answer different questions.
There Is No Single Universal ACE Questionnaire
Online search results often make “the ACE test” look like one standardized object. Scientific practice is more complicated. A 2025 systematic review by Mosler and colleagues identified 31 validated self-report questionnaires used to assess childhood adversity in adults. Nine met one set of criteria for “well-established” assessments and two were “approaching well-established,” yet none was rated sufficient across all evaluated COSMIN measurement properties. The ACE Study questionnaire and ACE-IQ were among the measures with the largest number of positively rated properties.
A 2026 COSMIN-based review by Carreres Sanchis and colleagues likewise found heterogeneous psychometric evidence across ACE instruments. The review judged the ACE-IQ to have particularly strong support across contexts, while also noting under-studied properties such as measurement error and responsiveness and limitations in the populations used for validation. The two reviews use somewhat different inclusion and rating approaches, but both reinforce the same practical conclusion: the phrase “ACE test” covers a heterogeneous measurement landscape.
The 2026 Annual Review of Public Health synthesis by Trejos and Kirby goes further, arguing that lack of consensus in how adverse and positive childhood experiences are operationalized and measured limits interpretation across studies. Context and sociocultural factors matter when instruments are developed, adapted, and compared.
Classic ACE-10, BRFSS ACE Module, and WHO ACE-IQ Are Not Interchangeable
The classic ACE-10 is the version most often reproduced in public-facing quizzes, but population surveillance can use different item structures. The CDC BRFSS questionnaire portal documents year-specific core questions and optional modules, and Swedo and colleagues (2023) describe the ACE questions used in their 2011–2020 BRFSS analysis as 11 questions identifying eight types of ACEs. A BRFSS-derived score therefore needs to be interpreted against the exact survey year, jurisdiction, item set, and scoring rule rather than assumed to be identical to every classic ACE-10 quiz.
WHO’s ACE-IQ is broader and was built for international use. It includes peer, community, and collective violence in addition to family and caregiver domains. A score from ACE-IQ therefore should not be assumed to mean the same thing as a score from a 10-category online quiz. Before interpreting any result, identify the actual instrument, its population, its time frame, its scoring rule, and its intended use.
This is especially important with commercial or informal quizzes. Some websites add items on bullying, emotional unavailability, poverty, discrimination, illness, or other experiences while still presenting a number called an “ACE score.” Broader content may be useful for reflection, but once the item set changes, the score is no longer directly comparable with the classic 10-category count unless the instrument has a defined scoring and validation framework.
How Good Are ACE Questionnaires as Measurement Tools?
The evidence is mixed in a specific, methodological sense. ACE questionnaires have clear value in epidemiology: they can efficiently summarize reported exposure domains and have generated a large body of research on childhood adversity and later health. At the same time, broad use has outrun careful attention to measurement properties in some settings. McLennan, MacMillan, and Afifi (2020) criticized ACE-10 applications for limited content coverage, collapsing multiple items or response options into binary categories, simplistic cumulative scoring, and insufficient psychometric scrutiny.
That critique should not be read as saying that ACE research is meaningless. It identifies a mismatch between what a simple exposure count can validly do and what people sometimes ask it to do. A measure can be useful for estimating population prevalence or studying statistical associations while being poorly suited to diagnosing an individual, forecasting that individual’s future illness, or deciding who should receive treatment.
For researchers, measurement choice should follow the research question. A study of household adversity may need different domains from a study of child maltreatment. A cross-cultural survey may require validated translation and cultural adaptation. A study of timing and chronicity needs more detailed exposure assessment than a binary cumulative score. For clinicians, the relevant question may be less “What is the ACE count?” and more “What happened, what is happening now, what symptoms or risks are present, what is the person’s current environment, and what support is needed?”
How Reliable Is Retrospective Recall?
Many adult ACE questionnaires are retrospective: adults are asked to report experiences that occurred years or decades earlier. Retrospective reporting is a legitimate research method, but it is not identical to prospective documentation gathered during childhood. A major systematic review and meta-analysis by Baldwin, Reuben, Newbury, and Danese (2019) examined 16 studies with 25,471 participants and found poor agreement between prospective and retrospective measures of childhood maltreatment (Cohen’s kappa 0.19). The two methods often identified different groups of people.
A longitudinal analysis from the Dunedin cohort by Reuben and colleagues (2016) found moderate agreement between prospectively recorded and retrospectively recalled adversity and showed that both kinds of measure were associated with adult outcomes, but the pattern of associations differed depending on whether outcomes were subjectively or objectively assessed. These findings show that method matters; they do not justify treating every disagreement between records and later recall as proof that one source is “false.”
Memory is reconstructive, records can be incomplete, childhood events may never have been documented, respondents may interpret questions differently over time, and willingness to disclose can change. For self-reflection, uncertainty should remain uncertainty. An ACE questionnaire should not be used to fill memory gaps, infer hidden abuse, or persuade someone that dreams, body sensations, emotions, or unexplained symptoms prove an unremembered childhood event.
Can an ACE Test Predict Your Future Health?
Not with the precision implied by many online interpretations. ACE research supports population-level associations: groups reporting more measured adversity often have higher average rates of some mental-health, behavioral, and physical-health outcomes. Population association is not individual prediction.
This distinction was tested directly by Baldwin and colleagues (2021) in two population-based birth cohorts. ACE scores were associated with mean group differences in later mental and physical health, but they had poor accuracy for identifying which specific individuals would later have health problems. Many people with high scores did not develop the outcomes studied, and many people with poor health outcomes had low scores.
The correct interpretation of a dose-response pattern is therefore probabilistic and population-based: as cumulative measured adversity increases, the average prevalence or risk of some outcomes may increase across groups. It does not mean “an ACE score of 4 means you will develop depression,” “a score of 6 means your nervous system is damaged,” or “a score of 0 means your childhood could not have affected you.” Those statements convert epidemiological associations into deterministic personal claims that the evidence does not support.
Does an ACE Test Measure Toxic Stress?
No. ACE exposure and toxic stress are different constructs. The American Academy of Pediatrics’ trauma-informed care guidance describes toxic stress in developmental terms involving prolonged or excessive stress-response activation without sufficient protective buffering. An ACE questionnaire asks about specified experiences; it does not directly measure stress hormones, autonomic function, immune activity, allostatic processes, or a child’s actual stress-response trajectory.
It is therefore inaccurate to say that a particular ACE score proves that a person’s body was “stuck in fight-or-flight,” that the nervous system was permanently damaged, or that the brain was rewired in a specific way. Studies of childhood adversity can find group-level differences in biological measures, but an exposure count cannot reveal an individual person’s neural, endocrine, immune, or autonomic state.
Should Doctors and Therapists Screen Everyone With an ACE Questionnaire?
Routine ACE screening is an active clinical and ethical debate, and the current evidence does not support treating a cumulative ACE score as a universal clinical decision tool. A systematic review by Cibralic and colleagues (2022) identified 36 studies of ACE screening in clinical and health-care settings serving children and young people. Screening was often feasible and acceptable, but evidence about downstream benefits, risks, referrals, and outcomes was limited; the authors concluded that widespread routine ACE screening was not supported by the evidence available.
A 2024 state-of-the-art review in Pediatrics by Austin and colleagues similarly concluded that evidence remains insufficient regarding the benefits, challenges, and harms of ACE screening in health care and other settings. The American Academy of Pediatrics now states that it does not support using ACE screening for clinical decision-making and instead recommends universal trauma-informed, relational care.
This does not mean clinicians should ignore childhood adversity. Trauma-informed care can include asking sensitively about experiences that are relevant to current health, safety, symptoms, and treatment; assessing current traumatic stress when indicated; responding to disclosed abuse or danger; and recognizing strengths and protective relationships. The key distinction is between clinically meaningful assessment and treating a cumulative ACE number as a diagnostic or prognostic test.
How to Interpret an Online ACE Test Safely
If you choose to complete an ACE questionnaire for self-reflection, start by identifying which version you are taking. Is it the classic 10-category questionnaire, the WHO ACE-IQ, a BRFSS-derived module, a validated research instrument, or a website’s own adaptation? A number without an instrument name is difficult to interpret because different tools cover different experiences and may use different scoring rules.
Read each answer as information about a reported exposure, not as proof of a diagnosis. A “yes” can mean that the questionnaire’s definition of that category was met. It does not tell you how severely you were affected, how much of your current life it explains, or whether you have a mental-health disorder. A “no” means only that the category was not endorsed under that wording; it does not certify that childhood was safe or free of adversity.
Avoid converting the total into a personal risk percentage unless a validated model for your population and outcome actually exists. Population statistics from ACE research cannot simply be pasted onto one person. Age, sex, socioeconomic conditions, genetics, current health, other childhood and adult experiences, protective relationships, health behaviors, access to care, and many unmeasured factors contribute to outcomes.
If the questionnaire brings up distressing material, the useful next question is not “What does my number say I am?” but “Is there something in my current life that I want help with?” That might be nightmares, avoidance, panic, depressed mood, substance use, relationship difficulties, chronic pain, sleep problems, current abuse, parenting stress, or simply a wish to understand a history more clearly. Help can be based on present needs and a fuller assessment rather than on the ACE count itself.
What If You Are Unsure How to Answer an ACE Question?
Retrospective questionnaires can force complex histories into yes-or-no categories. If you are genuinely unsure whether something happened, whether it met a frequency threshold, or how to classify an experience, uncertainty is an appropriate response. Do not use the quiz to manufacture certainty. Some formal instruments provide explicit coding rules; informal online quizzes may not.
If an answer matters for research, clinical care, legal proceedings, or safeguarding, use the procedures appropriate to that context rather than relying on an online score. Clinicians can ask for context and assess current symptoms and safety. Researchers can use standardized instructions and missing-data rules. Legal and safeguarding determinations require evidence and procedures far beyond a self-report ACE count.
Can Your ACE Score Change?
The childhood events themselves do not change, but a reported score can differ across time or instruments. One questionnaire may cover 10 categories while another covers peer or community violence; wording and thresholds may differ; a respondent may remember, understand, or disclose an experience differently at different times. Retrospective and prospective measurements are not interchangeable, and a change in reported score should not automatically be interpreted as evidence that a memory is true, false, repressed, or recovered.
When an ACE Questionnaire Is Useful
ACE questionnaires are most defensible when the purpose is explicit. In population research, they can estimate prevalence of defined adversity categories and test associations with later outcomes. In public health, they can help reveal how preventable childhood conditions are distributed across communities and how social and economic environments shape exposure. In some clinical conversations, a questionnaire may provide a structured way to ask about history, provided the result is not treated as a diagnosis or stand-alone treatment algorithm.
The tool becomes less defensible when it is asked to answer questions it was not built to answer: “Do I have childhood trauma?”, “Which disorder do I have?”, “Did my childhood cause my autoimmune disease?”, “Is my attachment style proof of abuse?”, “Will I develop depression?”, or “How damaged is my nervous system?” These questions require different evidence and often different forms of assessment.
Frequently Asked Questions
What are the 10 ACE categories?
The familiar 10-category model includes emotional, physical, and sexual abuse; emotional and physical neglect; parental separation or divorce; household substance-use problems; household mental illness or suicidality; an incarcerated household member; and exposure to violence toward the mother or stepmother in the historical wording. Modern instruments may use different wording or broader domains.
Is the ACE test a diagnostic test?
No. It is an adversity-exposure questionnaire or research/screening measure, depending on the instrument and context. It does not diagnose trauma, PTSD, complex PTSD, depression, anxiety, dissociation, attachment disorders, personality disorders, or physical disease.
Does an ACE score of 4 mean you have childhood trauma?
No. Four means four measured categories were endorsed under that scoring system. “4+” is often used as a research grouping because some studies observe higher average rates of outcomes in groups with greater cumulative exposure. It is not a diagnostic cutoff and does not establish a trauma response.
Can an ACE score predict disease?
ACE counts are associated with group-level differences in many outcomes, but individual predictive accuracy is poor. They should not be used to tell a person that a particular mental or physical illness will occur or that an existing illness was caused by childhood adversity.
Does an ACE score of 0 mean no childhood trauma?
No. The classic questionnaire omits many potentially traumatic or adverse experiences. A score of 0 means none of that questionnaire’s categories were endorsed, not that every aspect of childhood was safe or that a trauma-related disorder is impossible.
Are all online ACE tests the same?
No. Some reproduce the classic 10-category framework, some adapt BRFSS items, some use the WHO ACE-IQ or other validated measures, and some add or remove domains. Results are not automatically comparable. Check the source, item set, scoring rules, target population, and validation evidence.
Is the WHO ACE-IQ the same as the classic ACE-10?
No. The WHO ACE-IQ is designed for international adult surveys and includes a broader set of domains, including peer, community, and collective violence. It is a different instrument with a different measurement scope.
Can an ACE test uncover repressed or hidden trauma?
No. A questionnaire cannot establish that an unremembered event occurred. Uncertainty, memory gaps, emotional reactions, dreams, images, or bodily sensations are not proof of hidden childhood trauma. Memory concerns require careful assessment that considers ordinary forgetting, childhood amnesia, dissociative phenomena, mental-health factors, sleep, substances, medication, neurological conditions, and other explanations when relevant.
Should I seek therapy because my ACE score is high?
A high ACE score alone does not mean that therapy is required. Therapy may be useful if you have current distress, symptoms, relationship or functioning problems, unresolved experiences you want to work on, or a diagnosed condition for which psychotherapy is indicated. Treatment decisions should be based on present needs and a full assessment rather than a cumulative adversity number.
What should I do if the questionnaire brings up current safety concerns?
If the questions reveal that a child may currently be unsafe, or that violence, abuse, coercion, or neglect is ongoing, the priority is present safety and appropriate safeguarding—not calculating a historical score. Contact relevant local child-protection, health-care, domestic-violence, or emergency services according to the situation and jurisdiction.
The Bottom Line
The ACE questionnaire changed public-health research by making cumulative childhood adversity measurable at scale. Its influence is justified by an extensive literature showing that adverse childhood conditions matter across the life course. Its limits are equally important. An ACE test measures selected reported exposures. It does not measure a person’s total childhood, does not directly measure trauma response, does not diagnose a disorder, does not quantify “damage,” and does not reliably predict an individual future.
The most accurate interpretation is therefore both useful and restrained: an ACE score can summarize how many defined adversity categories were reported on a particular instrument. The number can inform research and conversation. Understanding a person requires the history behind the categories, what the instrument omitted, the social and developmental context, current symptoms and functioning, protective relationships and resources, and the person’s own goals.
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References
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