Full Text PA-96-013
 
DRUG ABUSE PREVENTION THROUGH FAMILY INTERVENTION
 
NIH GUIDE, Volume 25, Number 1, January 26, 1996
 
PA NUMBER:  PA-96-013
 
P.T. 34

Keywords: 
  Drugs/Drug Abuse 
  Disease Prevention+ 
  Family Health/Planning/Safety 

 
National Institute on Drug Abuse
 
PURPOSE
 
The purpose of this program announcement (PA) is to test, under
controlled conditions, the efficacy and effectiveness of theory-based
drug abuse prevention intervention for families at risk for abusing
drugs.  For the purpose of this PA, the term family can have a broad
definition to include: family of origin; family of procreation;
biological kin; nonrelated persons who consider themselves part of
the family through mutual commitment or a combination of these.  The
family may live in one household, or members may live in different
households.  Research has demonstrated that there are a number of
precursors to the initiation of substance abuse, many of which relate
to risk or protective factors in the family.  One of the primary
responsibilities of the family is a protective function.  The family
is seen as a first line of defense in imparting pyschological
infrastructures such as self esteem to prevent  vulnerability to drug
abuse.  In many situations, however, the family is not able to assume
the function of nurturance and protection and may be considered a
risk factor contributing to vulnerability.  Therefore, it is
important that family prevention interventions reduce family risk
factors and foster protective factors to negate the initiation of
drug abuse.
 
HEALTHY PEOPLE 2000
 
The Public Health Service (PHS) is committed to achieving the health
promotion and disease prevention objectives of "Healthy People 2000,"
a PHS-led national activity for setting priority areas.  This PA,
Drug Abuse Prevention through Family Intervention, is related to the
priority area of health promotion/alcohol and other drugs.  Potential
applicants may obtain a copy of "Healthy People 2000" (Full Report:
Stock No. 017-001-00474-0) or "Healthy People 2000" (Summary Report:
Stock No. 017-001-00473-1) through the Superintendent of Documents,
Government Printing Office, Washington, DC 20402-9325 (telephone 202-
512-1800).
 
ELIGIBILITY REQUIREMENTS
 
Applications may be submitted by foreign and domestic, for-profit and
non-profit, public and private organizations such as universities,
colleges, hospitals, laboratories, units of State and local
governments, and eligible agencies of the Federal Government.
Foreign institutions are not eligible for First Independent Research
Support and Transition (FIRST) (R29) awards.  Racial/ethnic minority
individuals, women, and persons with disabilities are encouraged to
apply as principal investigators.
 
MECHANISM OF SUPPORT
 
This PA will use the National Institutes of Health (NIH) research
project grant (R01), small grant (R03) and the FIRST (R29) award.
Because the type and scope of proposed research responsive to this
Program Announcement may vary, it is anticipated that the size and
period of the award will also vary.
 
Awards made under the R29, R03 or R21 mechanism may not be renewed,
but it is expected that projects supported by these mechanisms will
provide sufficient data to apply for support of a research project
grant (R01).  There are special requirements and criteria for the
program project (P01), FIRST (R29), small grant (R03), and
exploratory/developmental (R21) grant applications.  The FIRST award
is intended for investigators at the beginning of their careers who
have not been previously designated as a principal investigator on
any PHS research project (except R03).  The small grant award (R03)
is intended for new or established investigators beginning in a new
area. The exploratory/ developmental grant (R21) is intended for
investigators to apply experience and sound methodology from other
scientific areas to drug addiction research.  If any applicant
intends to apply utilizing any of these mechanisms, he or she should
contact the program person listed in INQUIRIES for further
information.
 
RESEARCH OBJECTIVES
 
Background
 
The dynamics of social, psychological and familial factors in
combination play a predominant role in the initiation and
continuation of substance abuse (Botvin, Schinke, Orlandi, 1989).
Correlational research has demonstrated that there are a number of
precursors to the initiation of substance abuse, many of which relate
to the family.  Some of these precursors include:  relationships with
peers who use drugs, psychosocial development (e.g. conduct
disorders), low academic performance, parental use of drugs and
alcohol, inadequate mother-infant bonding and nuturance, sexual or
physical abuse in childhood, economic instability, poor family
management, (e.g. ineffective monitoring by the parents), antisocial
behavior, high levels of stress and conflict, juvenile delinquency,
genetic propensity toward substance abuse; low self-esteem, and high
sensation-seeking.
 
Dishion, Patterson, and Reid (1988) found significant correlations
between the child's early drug use and composite scores reflecting
maladjustment, including antisocial behavior, coercive behavior with
family members, self-esteem and depression.  Attitudes, beliefs, and
personality traits showing a lack of social bond between the
individual and society are involved in delinquency and drug abuse.
Research findings suggest a link between certain personality traits,
specifically antisocial and neurotic traits and the risk for
substance abuse; however adverse outcomes also depend on a variety of
developmental and environmental factors (Tarter, 1988).   Brook and
colleagues proposed a family interactional theory for explaining
psychosocial aspects of adolescent drug use including developmental
perspectives, family influences and vulnerability factors.  They
found that peer drug use risks were offset by protective factors such
as adolescent and parent conventionality, maternal adjustment, and
strong parent-child attachment.  (Brook, Brook, Gordon, Whiteman, et
al. 1990).  Research has suggested that when families become involved
positively, precursors can be reduced and early signs of problems can
be turned around (Bry, 1983).
 
Most prevention intervention studies have been conducted on children
from middle school through high school with a few intervening in 4th
and 5th grades.  The literature, however, is beginning to suggest
that children at risk can be identified as early as preschool for
prevention interventions.
 
Dishion, Reid and Patterson's (1988) studies show that an effective
family intervention should target parent monitoring, peer associates,
parents' drug use, social skills and antisocial behavior; and that
parent and peer training interventions are viable methods of
preventing premature drug use.
 
Most family oriented prevention-interventions involve the parent or
family and focus on strengthening the family's role in positive
socialization of the child in hopes of preventing future alcohol or
drug abuse in a child who is currently not an abuser (DeMarsh and
Kumpfer, 1985).  Family prevention interventions represent a variety
of approaches and techniques including parent-child interactions,
communication and affective skill building, child management
principles and parenting styles.  Teaching and strengthening parental
skills may be of particular importance since parents may be
contributing to the vulnerability of their children.  The focus of
family prevention interventions may be predominantly behavioral,
affective or cognitive.
 
There are few family oriented prevention programs with adequate
efficacy studies.  Some programs have been developed in other areas,
but have not been tested in the area of substance abuse.  Others have
focused on substance abuse and outcome evaluations, but are not
controlled studies.  Some interventions have been tested in  highly
functional and motivated parents but not with families at risk for
drug abuse.  Many studies do not have longitudinal follow-up to
enable the determination of long term program effects.  Complicating
matters is the fact that many of the family studies have small
numbers of subjects and are under powered from a statistical
perspective.  In addition, families can play a risk and/or protective
role in terms of the initiation of substance abuse by offspring and
it is necessary to understand both of these roles.  Family predictors
of drug use may also differ by race or ethnic group.  Hawkins and
colleagues (1992) found significant differences between black, white
and Asian American families on measures of family predictors and the
initiation of drug use for preadolescents.
 
Some controlled studies for family prevention/intervention models
that have had positive results are the Focus on Families Project
(Catalano and colleagues, 1992); Preparing for the Drug Free Years
(Hawkins and colleagues, 1988); Family Effectiveness Training
(Szapocznik and colleagues, 1989); and the Strengthening Families
Program (Kumpfer and associates, 1993).  The targeted children for
these models range in age from three through fourteen.
 
An additional issue which needs to be addressed in family prevention
intervention studies is attrition of parents or dropouts from the
study design.  In addition, the issue of low participation needs to
be addressed.  Forehand, Middlebrook, Rogers and Steffe (1983)
examine parent-training studies to determine the dropout rate of
parents who were being taught to modify their children's problem
behavior.  The overall rate was 28% in those studies that reported
the drop-out rate.  They noted that certain types of assessment and
treatment may be differentially associated with drop-out rates.  For
example, although skill practice is important in teaching parenting
skills, parents may feel uncomfortable engaging in this component and
may drop out.
 
Areas of Interest
 
The focus of this PA is to develop and test, under controlled
conditions, theory-based drug abuse prevention interventions models
for the family to lower risk factors, enhance protective factors, and
prevent drug abuse behaviors.  Prevention intervention strategies for
families should entail a comprehensive approach to their needs at the
Universal, Selective and Indicated levels.  Specifically Universal
prevention interventions are targeted to the general population group
which share a general risk to drug abuse.  Selective prevention
interventions are targeted to individuals or a subgroup of the
population with well defined risk factors within their life profiles
and whose risk to resilience status to developing substance abuse
disorders is significantly higher than average.  Indicated preventive
interventions are targeted to individuals or subgroups who are
identified as having minimal but detectable signs or symptoms
foreshadowing drug abuse, dependence, and addiction, or with
biological markers indicating predisposition for substance use
disorders AND who have not met diagnostic levels for drug abuse or
dependence according to DSM-IIIR or DSM-IV.
 
These models may be:  (1) theory-based models which have been tested
for efficacy in controlled studies in other fields such as juvenile
delinquency, but have not been tested specifically for the prevention
of drug abuse; (2) theory-based family-focused intervention models in
the drug abuse field which have been developed, but have not
undergone rigorous controlled study; and, (3) highly novel and
innovative theory-based models for family intervention.
 
Studies should be theory driven.  The application should discuss the
theoretical background of the issue(s) and the theory underlying the
proposed intervention.  Studies should assess an intervention(s)
against an appropriate control group(s) into which families are
randomized.  If appropriate all of the children in the family should
participate in the intervention.  Applicants are encouraged to use a
combination of quantitative and qualitative methods for data
collection and analysis.  State-of-the-art techniques in study
design, sampling procedures, power analysis, implementation,
instrumentation and measurement, data collection, quality control,
client tracking, follow-up, and mediational and outcome data analysis
should be addressed in the application.   Applicants should focus on
families who live in communities that have multiple risk factors such
as high rates of unemployment, crime, violence, drug trafficking,
drug abuse, school dropouts, high teen pregnancy, etc.  Applicants
should give an adequate description of the community and target
families in order to demonstrate level of risk.  Applicants are
encouraged to develop collaborative arrangements with community
groups and institutions.
 
Since retention and attrition have been of concern in previous
research studies of family interventions, applicants should propose
procedures to attract and retain families in the study and should
specify efforts to follow-up study drop-outs.  Applicants should make
a thorough analyses of attrition, retention and follow-up issues.
Included in this assessment should be an analysis of the reasons for
attrition or non-compliance of study participants and measures for
estimating the effects of differential attrition.  Applicants should
be prepared to identify at what points in the study subjects do not
show up or drop out, the demographics and previous drug using
backgrounds of these subjects, reasons for dropping out and then
describe efforts to follow-up subjects.  Studies should be able to
identify and assess the role played by risk and protective factors
within the family that either aid or hinder family participation in
proposed experimental studies of drug abuse prevention.  Multi-year
follow-ups of study cohorts should be conducted in order to ascertain
long term effects of the intervention.
 
In considering future issues of knowledge transfer to the clinical
field, it is important to address the issue of cost/benefits by
identifying the costs and benefits associated with exposure to the
program interventions.  Appropriate cost-benefit and cost
effectiveness methods for describing and estimating effects should be
employed.
 
The following themes are of interest and should be considered in the
development of a grant application:
 
o  Ethnic and cultural considerations
 
Research is needed to test family interventions which are ethnically,
culturally, religiously and/or racially relevant to family members.
This means more than hiring staff of the same ethnic and/or racial
background as the target population.  Applicants must demonstrate
that the development and testing of specific intervention(s) proposed
are theory-based models which are derived from the understanding of
ethnic, cultural, racial and/or religious norms and influences on the
family.
 
o  Interventions with nuclear and extended families
 
Many interventions focus on strengthening family skills and focus
specifically on the parent(s).  However, intervention research is
also needed which may include extended family -- those persons who
are also influential in the life of the child such as grandparents,
aunts, uncles, siblings, virtual parents, etc.  These people may live
in the same household or they may live in separate households.
 
o  Interventions relevant to functional level of the family
 
Interventions need to be tested with families at different levels of
functioning.  Determination needs to be made regarding what kinds of
interventions will work based on the level of functioning of the
family.  For example, parents who take drugs themselves, and/or are
physically or emotionally abusive towards their children, and/or may
have a DSM IV diagnosis of depression, psychosis, etc. may not be
able to utilize "established" family interventions.  Research is
needed to develop and test family prevention interventions which
focus on the most at-risk dysfunctional families and what works for
them in helping to prevent drug abuse in their children.
 
o  Multiple phase interventions vs. single phase intervention
 
Studies regarding the "dosage" of interventions need to be conducted.
For example, what are the enduring effects of a single phase family
intervention (e.g. a series of 10 sessions) compared to a multi-phase
intervention (multiple series on a yearly basis; booster sessions,
etc.)?  Studies also need to be conducted on the interaction of
"dosage" and level of family functioning.  For example, the more
dysfunctional families may need a higher "dosage" of family
intervention.
 
o  Comparisons of influences of peer social networks and family
 
Peer social networks may function as either positive or negative
influences in terms of drug abuse prevention.  Families often feel
that they are in competition with peers and feel powerless in the
face of negative peer influences.  Studies need to be conducted to
test how strengthening families through theory-based preventive
interventions can counteract negative peer influences.
 
o  Comprehensive "systems" approaches
 
Studies need to be conducted using a "systems" approach with multiple
levels of interventions which can have a synergistic affect.  This
includes research of various combinations of interventions such as
family and school; family, school and community and other
combinations of components.  Particular emphasis is placed on the
"macro" contexts of community interventions such as how boys and
girls clubs and other supportive community family services which can
be incorporated into prevention efforts.
 
o  Ages and developmental stage of children
 
Research has indicated that school-based prevention intervention may
be effective during late elementary or during the middle school
years.  However, we know little about the relationship between
appropriate ages and stages of child development and the type of
family prevention interventions selected.  At what age and/or stage
of the child's development are prevention interventions most
effective?  Can family prevention interventions be effective for
children entering elementary school as well as adolescents entering
high school?  Applicants are encouraged to study different and
distinctive family interventions and their cumulative effects based
on the level of family functioning and the age and developmental
stage of the children.
 
o  Gender issues
 
Most school-based and family prevention interventions have not been
gender specific.  It is also not known whether some of the risk and
protective factors are gender related and if the nature of prevention
intervention needs to reflect this.  Some major risk factors for
girls (more so than boys) are childhood sexual abuse, eating
disorders, and anxiety and depression.  This prompts the question:
Do boys and girls require different interventions and at what age or
stage of development should gender specific interventions within the
family be targeted?  There is also little known about family
prevention interventions based on the gender of the parents and the
effectiveness of these interventions.  It is not known what kinds of
family interventions would be most effective based on the gender of
the child and/or parents.
 
o  Longitudinal and Cross Sectional Studies
 
Longitudinal and cross sectional studies with tests of the effects of
booster sessions or differing levels of intermittent intervention are
important to examine in order to assess long-term effects of drug
abuse prevention interventions focused upon families.
 
o  Methodological and Measurement Studies
 
Applicants may need to develop methodologies and measures that are
sensitive to family interventions.  These include innovative research
designs, sampling and tracking plans to identify, access, recruit,
engage, intervene with, retain, and follow-up families and
children/adolescents at highest risk; and innovative applications of
state-of-the-art data analytic procedures.   Applicants may also
develop new instruments and scales appropriate for family prevention
intervention research.  Scales and measurements that have been
"proven" with other types of families may be tested for validity and
reliability for families with drug abuse as a risk factor or scales
and measurements may be tested for families with different
racial/ethnic backgrounds.  Applicants may also test new techniques
and/or technologies for accruing family data more efficiently and
economically (e.g. Audio-CASI - audio-enhanced Computer Assisted Self
Interview technology which allows subjects to listen to questions on
earphones, view questions on a personal computer screen or list and
view at the same time and record their answers via labelled keys on
the computer.)
 
o  Technologies of Intervention
 
Studies need to be made of family prevention interventions using new
technologies of intervention delivery compared to traditional talking
or educational family prevention interventions and/or compared to
various combinations of new technologies and traditional methods.
The use of these technologies such as video tapes, television,
computers, interactive disks, etc. needs to be theory-based.  New
technologies of delivery may be developed or technologies that have
proven effective in other areas may be modified and applied to family
prevention interventions.
 
INCLUSION OF WOMEN AND MINORITIES IN RESEARCH INVOLVING HUMAN
SUBJECTS
 
It is the policy of the NIH that women and members of minority groups
and their subpopulations must be included in all NIH supported
biomedical and behavioral research projects involving human subjects,
unless a clear and compelling rationale and justification is provided
that inclusion is inappropriate with respect to the health of the
subjects or the purpose of the research.  This new policy results
from the NIH Revitalization Act of 1993 (Section 492B of Public Law
103-43) and supersedes and strengthens the previous policies
(Concerning the Inclusion of Women in Study Populations, and
Concerning the Inclusion of Minorities in Study Populations), which
have been in effect since 1990. The new policy contains some
provisions that are substantially different from the 1990 policies.
 
All investigators proposing research involving human subjects should
read the "NIH Guidelines For Inclusion of Women and Minorities as
Subjects in Clinical Research," which have been published in the
Federal Register of March 28, 1994 (FR 59 14508-14513) and reprinted
in the NIH Guide for Grants and Contracts, Volume 23, Number 11,
March 18, 1994.
 
Investigators also may obtain copies of the policy from the program
staff listed under INQUIRIES.  Program staff may also provide
additional relevant information concerning the policy.
 
APPLICATION PROCEDURES
 
The research grant application form PHS 398 (rev. 5/95) is to be used
in applying for these grants.  These forms are available at most
institutional offices of sponsored research and may be obtained from
the Office of Grants Information, Division of Research Grants,
National Institutes of Health, 6701 Rockledge Drive, Room 1040 - MSC
7710, Bethesda, MD 20892-7710, Bethesda, MD 20817 (for
express/courier service) telephone 301/435-0714, email:
girg@drgpo.drg.nih.gov.
 
Applications for the FIRST award (R29) must include at least three
sealed letters of reference attached to the face page of the original
application.  FIRST award applications submitted without the required
number of reference letters will be considered incomplete and will be
returned without review.
 
The completed original application and five legible copies must be
sent or delivered to:
 
DIVISION OF RESEARCH GRANTS
NATIONAL INSTITUTES OF HEALTH
6701 ROCKLEDGE DRIVE, ROOM 1040 - MSC 7710
BETHESDA, MD  20892-7710
BETHESDA, MD  20817 (for courier/overnight mail service)
 
REVIEW CONSIDERATIONS
 
Applications that are complete and responsive to the PA will be
evaluated for scientific and technical merit by an appropriate peer
review group convened in accordance with NIH peer review procedures.
As part of the initial merit review, all applications will receive a
written critique and undergo a process in which only those
applications deemed to have the highest scientific merit, generally
the top half of applications under review, will be discussed,
assigned a priority score, and receive a second level review by the
appropriate national advisory council or board.
 
Review Criteria
 
Criteria for scientific/technical merit review of applications will
include the following:
 
o  scientific or technical significance and originality of proposed
research;
 
o  appropriateness and adequacy of the experimental approach and
methodology proposed to carry out the research, including cultural
relevance to the target populations and evidence of familiarity with
relevant research literature;
 
o  qualifications and research experience of the Principal
Investigator and staff, particularly, but not exclusively, in the
area of the proposed research including but not limited to prevention
research, family research, statistics, and cultural relevancy
 
o  availability of the resources necessary to perform the research;
 
o  appropriateness of the proposed budget, staffing plan and time
frame to complete the project;
 
o  adequacy of plans to include both genders and minorities and their
subgroups as appropriate for the scientific goals of the research;
 
o   methods for the recruitment and retention of subjects;  efforts
to determine factors that influence refusal rate; strategies to
follow-up subjects
 
o   adequacy of the data analysis plan
 
The initial review group will also examine the provisions for the
protection of human and animal subjects and the safety of the
research environment.
 
AWARD CRITERIA
 
The following criteria will be considered in making funding decision:
scientific merit as determined by peer review;  availability of
funds; and programmatic priorities.
 
INQUIRIES
 
Inquiries are encouraged.  The opportunity to clarify any issues or
questions from potential applicants is welcome.
 
Direct inquiries regarding programmatic issues to:
 
Rebecca Ashery D.S.W.
Division of Epidemiology and Prevention Research
National Institute on Drug Abuse
5600 Fishers Lane, Room 9A-53
Rockville, Maryland 20857
Telephone:  (301) 443-1514
FAX:  (301) 443-2636
Internet Address:  RAshery@AOADA.SSW.DHHS.GOV
 
Direct inquiries regarding fiscal matters to:
 
Gary Fleming, J.D., M.A.
Chief, Grants Management Branch
National Institute on Drug Abuse
5600 Fishers Lane, Room 8A-54
Rockville, Maryland 20857
Telephone: (301) 443-6710
Internet:  gfleming@aoada2.ssw.dhhs.gov
 
AUTHORITY AND REGULATIONS
 
This program is described in the Catalog of Federal Domestic
Assistance No. 93.279.  Awards are made under authorization of the
Public Health Service Act, Title IV, Part A (Public Law 78-410, as
amended by Public Law 99-158, 42 USC 241 and 285) and administered
under PHS grants policies and Federal Regulations 42 CFR 52 and 45
CFR Part 74.  This program is not subject to the intergovernmental
review requirements of Executive Order 12372 or Health Systems Agency
review.
 
The Public Health Service (PHS) strongly encourages all grant
recipients to provide a smoke-free workplace and promote the non-use
of all tobacco products.  In addition, Public Law 103-227, the Pro-
Children Act of 1994, prohibits smoking in certain facilities (or in
some cases, any portion of a facility) in which regular or routine
education, library, day care, health care or early childhood
development services are provided to children.  This is consistent
with the PHS mission to protect and advance the physical and mental
health of the American people.
 
REFERENCES
 
Botvin, G.J., Schinke, S.P., and Orlandi, M.A. (1989) Psychosocial
approaches to substance abuse prevention:  Theoretical foundations
and empirical findings, Crisis (10)1, 62-77.
 
Brook, J.S., Brook, D.W., Gordon, A.S., Whiteman, M., et al. (1990).
The psychological etiology of adolescent drug use:  A family
interactional approach, Genetic, Social & General Psychology
Monographs. 116(2), 111-267.
 
Bry, B.H. (1983) Substance abuse in women:  Etiology and prevention,
Issues in Mental Health Nursing, 5(1-4), 253-272.
 
Catalano, R.F., Morrison, D.M., Wells, E.A., Gillmore, M.R., Iritani,
B., and Hawkins, J.D. (1992) Ethnic differences in family factors
related to early drug initiation, Journal of Studies on Alcohol,
53(3), 208-217.
 
DeMarsh, J., and Kumpfer, K. (1985) Family-oriented interventions for
the prevention of chemical dependency in children and adolescents,
Journal of Children in Contemporary Society, 18(1-2), 117-151.
 
Dishion, T.J., Patterson, G.R., and Reid, J.R. (1988) Parent and peer
factors associated with drug sampling and early adolescence:
Implications for treatment, National Institute on Drug Abuse:
Research Monograph Series. 77, 69-93.
 
Dishion, T.J., Reid, J.B., and Patterson, G.R. (1988) Empirical
guidelines for a family intervention for adolescent drug use, Journal
of Chemical Dependency Treatment, 1(2), 189-224.
 
Forehand, R., Middlebrook, J., Rogers, T., Steffe, M. (1983) Dropping
out of parent training. Behaviour Research & Therapy. 21(6), 663-668.
 
Hawkins, J.D., Catalano, R.F., Brown, E.O., Vadasy, P.F., Roberts,
C., Fitzmahan, D., Starkman, N., Ransdell, M. (1988) Preparing for
the drug (free) years:  A family activity book.  Seattle, WA:
Comprehensive Health Education Foundation.
Kumpfer, K.L. (1993) Strengthening America's Families:  Promising
Parenting Strategies For Delinquency Prevention:  User's Guide,
Office of Juvenile Justice and Delinquency Prevention, Office of
Justice Programs, U.S. Department of Justice, September 1993,
NCJ140781.
 
Szapocznik, J., Santisteban, D., Rio, Arturo, Perez-Vidal, A.,
Santisteban, D., Kurtines, W.M. (1989)  Family Effectiveness
Training:  An Intervention to Prevent Drug Abuse and Problem
Behaviors in Hispanic Adolescents, Hispanic Journal of Behavioral
Sciences, 11(1), 4-27.
 
Tarter, R. (1988) Are There Inherited Behavioral Traits that
Predispose to Substance Abuse? Journal of Consulting and Clinical
Psychology, 56(2), 189-196.
 
.

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