James Case 2: Maria

Home , Child PTSD Symptom Scale, Psychosurgery

WORKINGWITHCHILDRENWITHA DISCLOSURES HISTORYOFTRAUMA

ƒ Nofinancialdisclosuresorconflictsofinterest

KarenBos,MD,MPH AssistantProfessor,Child&AdolescentPsychiatry,OHSU MedicalDirector,LifeworksNW 1

OBJECTIVES OUTLINE

ƒ Reviewwhatisknownabouttheimpactof trauma andtoxic ƒ Definitionandassessmentoftrauma stressondevelopmentandmentalhealth ƒ Treatmentoftrauma ƒ Recognizesomeofthecommonclinicalpresentations ƒ TraumaǦinformedcare of trauma inchildrenandadolescents ƒ Resources ƒ Increaseawarenessaboutthestrategiesandlimitationsof evidencebased trauma specificinterventions

3 4

CASE1:JAMES CASE2:MARIA

ƒ Jamesisa6yearoldboy,currentlyinfostercareinhisfourth ƒ Mariaisa13yearoldgirlwholiveswithhermother.Shecomesin placementsincebeingremovedfrombiologicalparentsabout forawellchildcheckanddescribesseeingashadowyfigure oneyearago.Fosterparentsreportthathehasfrequent especiallyatnight.Shehasfrequentnightmares.Shedescribes “meltdowns”bothathomeandschoolwhenhewillbephysically thoughtsofwantingtohurtherself. aggressiveincludinghittingandkicking.Hehasbeensuspended twicefromschool.Theydescribehimasoppositionaland impulsive.

5 6 OUTLINE

ƒ Definitionandassessmentoftrauma ƒ Treatmentoftrauma ƒ TraumaǦinformedcare ƒ Resources

7 8

https://developingchild.harvard.edu/science/keyǦconcepts/toxicǦstress/ 9 10

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12 RISKFACTORSFORPTSD ƒ Mostchildrenandadolescentswillexperienceatraumaticevent bythetimetheyreachadulthood ƒ ThereportednumbersoftraumaǦexposedchildrenwhodevelop ƒ Traumacharacteristics PTSDvarywidelyacrossstudiesofdifferentpopulationsand ƒ Interpersonalviolence:highestriskofPTSDonset typesoftrauma. ƒ Exposuretowar,historyofdisplacementassociatedwithhighratesof PTSD ƒ Highernumberoftraumaticeventsleadstogreaterriskthanasingle trauma ƒ Childandfamilycharacteristics ƒ Girls2Ǧ3timesmorelikelytodevelopPTSDthanboys ƒ Childrenwithhistoryofothermentaldisordersmorelikelytodevelop PTSDfollowingtraumaexposure ƒ Responsetothetraumaticevent ƒ CognitiveandemotionalresponsesaffectriskforPTSD(higherlevels ofangerorruminationaboutevent,dissociationduringandafter Traumavs.traumaticexperience traumaticeventincreaserisk)

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North,Hong, North,Hong, Downs,PTSD:A Downs,PTSD:A systematic systematic approachto approachto diagnosisand diagnosisand treatment.Current treatment.Current Psychiatry2018 17 Psychiatry2018 18 April;17(4):35Ǧ43. April;17(4):35Ǧ43. North,Hong, North,Hong, Downs,PTSD:A Downs,PTSD:A systematic systematic approachto approachto diagnosisand diagnosisand treatment.Current treatment.Current Psychiatry2018 19 Psychiatry2018 20 April;17(4):35Ǧ43. April;17(4):35Ǧ43.

PEDIATRICCONSIDERATIONS

ƒ Ageanddevelopmentallevelat thetimeofthetrauma ƒ Natureanddurationofthe trauma ƒ Socialsupportfollowingthe trauma

North,Hong,Downs,PTSD:Asystematicapproachtodiagnosisand treatment.CurrentPsychiatry2018April;17(4):35Ǧ43. 21 22

DEVELOPMENTALCONSIDERATIONS: PRESCHOOLPTSDSUBTYPE PRESCHOOL

ƒ TheDSMǦ5introducedanewdevelopmentalsubtypeofPTSDfor ƒ Clingy preschoolchildren(6yearsoldandyounger). ƒ Disorderedattachment ƒ Thisrepresentsthefirstdevelopmentalsubtypeofanexisting ƒ Separationanxiety disorderintheDSM. ƒ Hyperactive/impulsivity ƒ Tantrums/aggression ƒ Criteriaaremorebehaviorallyanchoredanddevelopmentally sensitive. ƒ Stubborn/oppositional ƒ Regression ƒ Studiesshowedthatwhenadevelopmentallysensitivesetof ƒ Somaticcomplaints criteriawereused,approximatelythreetoeighttimesmore childrenqualifiedforthediagnosisofPTSDcomparedtothe ƒ ReǦexperiencingmaymanifestasrepetitiveplay DSMǦIV ƒ Difficultywithsleeporscarydreams

23 24 DEVELOPMENTALCONSIDERATIONS: DEVELOPMENTAL SCHOOLAGE CONSIDERATIONS:ADOLESCENT

ƒ Anger/irritability ƒ Shame/blame ƒ Schoolrefusal ƒ Oppositional/aggressivebehaviorstoregainasenseofcontrol ƒ Poorattention ƒ Schoolavoidance/refusal/truancy ƒ Somaticcomplaints ƒ Drugs/alcohol ƒ Separationanxiety ƒ SelfǦinjuriousurgesandbehavior ƒ Avoidancesymptomsmorecloselyrelatedtoevent/trauma ƒ Revengefantasies(especiallywithdevelopmentalissues/social ƒ Traumarelatedplay(becomesmorecomplexandelaborate) delays/victimsofbullying) ƒ Betterabletounderstandconceptsoffuture,pastmorerealistically ƒ Detachment ƒ Nightmares(maychangefromeventspecifictogeneralizedovertime) ƒ Aggression ƒ Senseofforeshortenedfuturemaytakeformofbeliefthattheywill notreachadulthoodordon’tneedtoplayforthefuture

25 26

Whatcanpediatriciansdo? SincethelasttimeIsawyou,has anythingreallyscaryorupsetting happenedtoyouoryourfamily?

Orforparentsofchildrenunderage8: SincethelasttimeIsawyourchild,hasanythingreallyscaryor upsettinghappenedtoyourchildoranyoneinyourfamily?

Dr.NadineBurkeHarris,CenterforYouth Wellness,SanFrancisco,CA

Cohen,Kelleher,andMannarino,2008. 28

TRAUMAHISTORY RATINGSCALES

ƒ Victimsmaynotbeabletoremembertrauma ƒ Aidinassessment(traumatizedindividualsavoidtalkingabout trauma) ƒ Usetheadultstogetinformation ƒ Canbeusedasabaseline ƒ Usemultipleinformantswhenpossible ƒ Canbeusedtomonitortreatmentresponse ƒ Don’tbeacanopenerwiththechild ƒ Manytopickfrom ƒ Multiplesessionscommonlyrequired ƒ SemiǦstructuredinterviewsvsSelfǦreportmeasures

29 30 SCREENINGFORACESINPRIMARY CARE

https://centerforyouthwellness.org/cywǦaceq/ https://centerforyouthwellness.org/cywǦaceq/

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Additionalinformationaboutscreeningandassessmentmeasures: NationalChildTraumaticStressNetwork (https://www.nctsn.org/treatmentsǦandǦpractices/screeningǦandǦ assessments/measureǦreviews)

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GENERALIZEDANXIETY DEPRESSION DISORDER

ƒ DepressedMoodorIrritability ƒ Restless,keyedup,oronedge ƒ Anhedonia ƒ EasilyFatigued ƒ SignificantWeightChange ƒ DifficultlyConcentrating ƒ SleepDisturbance ƒ Irritability ƒ PsychomotorAgitation ƒ MuscleTension ƒ Fatigue ƒ ƒ FeelingWorthless Sleepdisturbance ƒ DifficultyConcentrating ƒ Suicidalideationsorbehaviors

35 36 ADHD BRIEFREACTIVEPSYCHOSIS

ƒ Squirmyorfidgety ƒ Forgetful ƒ Delusions(alteredsenseofreality) ƒ Can’tsitstill ƒ Distractible ƒ Hallucinations(flashbacks) ƒ Runningaround ƒ PoorConcentration ƒ Disorganizedspeech—frequentderailmentorincoherence ƒ Noisy ƒ Doesnotlisten ƒ Grosslydisorganizedorcatatonic ƒ Drivenbymotor ƒ PoorfollowǦthrough ƒ Chatterbox ƒ Disorganized ƒ Can’twaitturn ƒ Avoidsactivitiesthatrequirefocus ƒ Interruptsoften ƒ Oftenlosesthings ƒ Blurtsoutanswers ƒ Failstoattend

37 38

OUTLINE AFTERTRAUMAEXPOSURE

ƒ Definitionandassessmentoftrauma ƒ Provideeducationabouthow commontheseeventsare ƒ Treatmentoftrauma andaboutcommonphysical ƒ TraumaǦinformedcare andemotionalreactions ƒ Resources ƒ SelfǦcareasawaytoregain controlaftertrauma exposure ƒ Teachingchildrenandparent simplerelaxationtechniques ƒ Monitoringovertimefor PTSDsymptoms

39 40

Brent,Cohen,Strawn, Brent,Cohen,Strawn, Approachtotreating Approachtotreating posttraumaticstress posttraumaticstress disorderinchildrenand disorderinchildrenand adolescents,UpToDate. adolescents,UpToDate.

41 42 TRAUMASPECIFIC TRAUMASPECIFICPSYCHOTHERAPIES: PSYCHOTHERAPIES CORECOMPONENTS

ƒ Multipleoptions BEFOREINTERVENTION ƒ Therapeutic 1. Riskscreening:identifyhighǦ 4. Engagement&address relationship riskclients barriers:ensureclientsreceive matters anadequatedosageof 2. Triage:matchclientstothe ƒ Systemically treatmentinordertomake interventionsthatwillmost oriented sufficient likelybenefitthem therapeuticgains ƒ Goodtreatment cansupport 3. Systematicassessmentand resilienceand treatmentplanning:tailor changebiology interventiontotheneeds, strengths,circumstances,and wishesofindividualclients NCTSN.org

43 SlidecourtesyofMargaretCary,MD 44

TRAUMASPECIFICPSYCHOTHERAPIES: TRAUMASPECIFICPSYCHOTHERAPIES: CORECOMPONENTS CORECOMPONENTS DURINGINTERVENTION DURINGINTERVENTION 1. Motivationalinterviewing: prevention: reduce 7. Parentingskillsto 9. Advocacy onbehalfofthe engageclients posttraumaticstress improvecaregiverǦyouth clienttoimproveclient 2. Psychoeducation: traumaand reactions relationship supportandfunctioning lossreminders,posttraumatic5. Monitor clientprogress outsideofthehome stressreactions,andgrief duringtreatment 8. Maintainingadaptive reactions 6. Evaluate treatment routines athomeand 3. Teachandpracticecoping effectiveness outsideofhome skills:emotionalregulation skills,safetyskills,relapse preventionskills

4. Exposureandresponse NCTSN.org NCTSN.org SlidecourtesyofMargaretCary,MD 45 SlidecourtesyofMargaretCary,MD 46

TRAUMASPECIFIC PCIT PSCYHOTHERAPIES PARENTǦCHILDINTERACTIONTHERAPY

ƒ PCIT:ParentǦChildInteractionTherapy ƒ Agerange:2– 12yr ƒ CBT:CognitiveBehaviorTherapy(TFǦCBT,CBITS) ƒ Conjointchildandcaregiversessions ƒ CPS:CollaborativeProblemSolving ƒ Averagedurationoftreatment:12–20sessions ƒ DBT:DialecticalBehaviorTherapy ƒ Components: ƒ CPP:ChildǦParentPsychotherapy ƒ Skillbuilding:directparentcoaching,parentselfǦcare ƒ EMDR:EyeMovementDesensitization&Reprocessing ƒ Relationshipbuilding:childdirectedinteractions,parentdirected interactions ƒ Theoreticalbasis:AttachmentandBehavioral

http://www.pcit.org/

47 SlidecourtesyofMargaretCary,MD 48 TFǦCBT PCIT TRAUMAFOCUSED COGNITIVEBEHAVIORTHERAPY

8RULESofEFFECTIVECOMMANDS ƒ Agerange:3Ǧ 21yr ƒ DIRECT–“Pleasehandmetheblock”insteadof“Willyouhandmethe block?” ƒ IndividualandConjointSessions ƒ DOTHIS– positivelystated,“Dothis”insteadof“Don’tdothat!” ƒ Averagedurationoftreatment:12–25sessions ƒ ONEatatime– singleactions ƒ Components: ƒ SPECIFIC–“Pleasegetoffthetable”insteadof“Becareful!” ƒ Skillbuilding:relaxation,emotionregulation,cognitivereframing, ƒ AGEǦAPPROPRIATE parenting ƒ POLITE&RESPECTFUL ƒ Traumaprocessing:traumanarrativeandinvivoexposuretotriggers ƒ ONLYWHENNECESSARY ƒ Theoreticalbasis:CognitiveǦBehavioralandFamily ƒ AFTEREXPLANATION– giveconciseexplanationandthencommand.If forgettogiveexplanation,explainonlyaftercommandobeyedtoavoid “whys?” https://tfcbt.musc.edu/

SlidecourtesyofMargaretCary,MD 49 SlidecourtesyofMargaretCary,MD 50

CPS COLLABORATIVEPROBLEM SOLVING

Kidsdowelliftheycan… (vs.kidsdowelliftheywantto)

…andiftheycan’t,adultsneedtofigureoutwhat’s gettingintheway,sowecanhelp.

Brent,Cohen,Strawn, Approachtotreating posttraumaticstress disorderinchildrenand adolescents,UpToDate.

RossGreene,TheExplosiveChild 51 52

MEDICATION ANTIDEPRESSANTMEDICATIONS

ƒ SSRIshavebeenfoundtoreducePTSDsymptomsinadultsbut NoFDAapprovedmedicationsfor donotappeartobeefficaciousinchildrenwithPTSD ƒ Clinicaltrialof10Ǧ17yearoldsreceivingTFǦCBT,randomly PTSDinyouth assignedtoreceiveadjunctivesertraline.Nodifferencein PTSDsymptomreductionbetweenthetwogroupsat12 weeks. ƒ Noclinicaltrialsofotherantidepressants

StrawnandKeeshin,Pharmacotherapyforposttraumaticstress NeurobiologyofEarlyAdversity 53 disorderinchildrenandadolescents,UpToDate. 54 ANTIADRENERGICMEDICATIONS

ƒ Clonidineandguanfacine:NorandomizedclinicaltrialsofalphaǦ ƒ Extendedreleaseclonidine(Kapvay):startat0.1mgatbedtime, 2adrenergicagonistsinchildrenwithPTSD canbeincreasedby0.1mgperweektomaxof0.4mg/day. Administeredtwicedaily,withdosedividedequallyorwith ƒ Uncontrolledtrialsuggeststhatguanfacinemayreduce higherdoseatbedtime.Mustbetaperedtostop. intrusiveandhyperarousalsymptomsinchildrenwithPTSD symptoms ƒ Extendedreleaseguanfacine(Intuniv):startat1mgdaily,can increaseby1mg/week,targetweightǦbaseddoserangeis0.05Ǧ ƒ Generallywelltolerated,mostcommonsideeffectsaredry 0.12mg/kg.Maxdosegenerally4mg/dayinchildren,some mouthandsedation wouldgohigherinadolescents(upto7mg)butshouldbedone ƒ Monitorbloodpressureandpulseatbaselineandduring withcaution.Administeredonceperday,canbeeithermorning treatment orbedtime.Mustbetaperedtostop.

StrawnandKeeshin,Pharmacotherapyforposttraumaticstress StrawnandKeeshin,Pharmacotherapyforposttraumaticstress disorderinchildrenandadolescents,UpToDate. 55 disorderinchildrenandadolescents,UpToDate. 56

ƒ PrazosinǦ casereportsandretrospectivecaseseriesofyouth ƒ Startprazosinat1mg,given30minutesbeforebedtime.Dose suggestthatprazosinmaybeeffectiveandwelltoleratedin canbeincreasedby1mgevery3Ǧ4daysforthefirsttwoweeks, treatingsleepdisturbancesinyouthwithPTSD startinglowerandtitratingupmoreslowlyinyoungerchildrenor inchildrenexperiencinganysideeffects. ƒ Multipleclinicaltrialshavefoundprazosintobeefficaciousand welltoleratedinadultswithPTSDǦassociatedsleep ƒ NoevidenceofadoseǦresponserelationship,butUpToDate disturbances recommendsincreasingthedose,astolerated,toatleast5mg overthecourseof4Ǧ8weeksbeforeconcludingthatitis ineffective ƒ Monitorbloodpressureandpulseatbaselineandduring treatment

ANTIPSYCHOTICS OTHERMEDICATIONS

ƒ Limited,uncontrolledtrialsofsecondǦgenerationantipsychotic ƒ Nogooddataonuseofothermedicationssuchas medicationsinyouthwithPTSDsymptomshavefoundmixed anticonvulsantsforpediatricpatientswithPTSD resultsandhighratesoftreatmentǦemergentadversevents ƒ Sideeffects:weightgain,insulinresistance,dyslipidemia, hyperprolactinemia,extrapyramidalsymptoms ƒ Keepinmind thatchildrenexposedtochildhoodtraumaareat riskforchronichealthproblemsindependentofmedicationuse

ƒ Highlyvariablecourse ƒ Jamesisa6yearoldboy,currentlyinfostercareinhisfourth placementsincebeingremovedfrombiologicalparentsabout ƒ MostadolescentswhodevelopPTSDrecoverfromit,butone oneyearago.Fosterparentsreportthathehasfrequent thirdexperienceachroniccoursethatcanlastmanyyears “meltdowns”bothathomeandschoolwhenhewillbephysically aggressiveincludinghittingandkicking.Hehasbeensuspended ƒ Characteristicsofadolescentswhowereleastlikelytorecover twicefromschool.Theydescribehimasoppositionaland includedthose: impulsive. ƒ Livinginpoverty ƒ HavingcoǦoccurringbipolardisorder ƒ Jamesiscurrentlyprescribedrisperidone1mgBID.Hisfoster parentsandschoolstatethattherisperidonemightbehelping ƒ Experiencedadditionaltraumaticeventsafterthetraumathat himsomewithbehaviorandsleep,althoughhecontinuesto triggeredtheonsetofPTSD havedifficultywithoppositionalandimpulsivebehaviors.Hehas gainedabout10poundssincestartingtherisperidonesixmonths ago.Hehasneverhadanylabwork done.

McLaughlin,K,Posttraumaticstressdisorderinchildrenand adolescents:Epidemiology,pathogenesis,clinicalmanifestations, 61 62 course,assessment,anddiagnosis.UpToDate.

CASE1:JAMES

ƒ Diagnosis: ƒ Arethereanycomorbidpsychiatricdisordersthathaven’tbeen identified? ƒ Treatment: ƒ AreJamesandhisfosterparentsengagedinanytherapy, specificallyanytraumaspecificpsychotherapy? ƒ Ifmedicationsareindicated,haveothermedicationsbeen triedthatmayhaveabettersideeffectprofile?

CASE2:MARIA CASE1:MARIA

ƒ Mariaisa13yearoldgirlwholiveswithhermother.Shecomesin ƒ Diagnosis: forawellchildcheckanddescribesseeingashadowyfigure ƒ Arethereanycomorbidpsychiatricdisordersthathaven’tbeen especiallyatnight.Shehasfrequentnightmares.Shedescribes identified? thoughtsofwantingtohurtherself. ƒ Treatment: ƒ IsMariaengagedinanytherapy,specificallyanytrauma ƒ Mariaandhermothertellyouthattheyareworriedshemightbe specificpsychotherapy? “crazy”becausesheis“seeingthings.”WhentalkingwithMaria, shedisclosesthatshewassexuallyassaultedbyapeeraboutone ƒ Ifmedicationsareindicated,whatmightbeanappropriatefirst yearago.Shealsodescribesongoingbullyingbypeers. choice?

65 OUTLINE TRAUMAǦINFORMEDCARE

ƒ Definitionandassessmentoftrauma ƒ Treatmentoftrauma ƒ TraumaǦinformedcare ƒ Resources ƒ Promoteactiveandcreativecoping ƒ Offersupportiveandsaferelationships ƒ CreateaccesstoresourcesforwellǦbeing ƒ Contributetoacompassionate,inclusive, andsafecommunity ƒ Forself,colleagues,clients,peers 67 SlidecourtesyofMargaretCary,MD NeurobiologyofEarlyAdversity 68

UniversalPrecautionsasaCore TraumaInformedConcept “Whathaveyoulivedthrough?” insteadof Presumethateverypersonina “Whatiswrongwithyou?” treatmentsettinghasbeenexposedto abuse,violence,neglect,orother traumaticexperiences.

OUTLINE LOCALRESOURCES

ƒ Definitionandassessmentoftrauma ƒ CollaborativeProblemSolving(CPS)ProgramatOHSU ƒ Treatmentoftrauma ƒ MargaretJohnson,LMSW,OHSUInstructor,Think:Kids ClinicalConsultantandTrainer ƒ TraumaǦinformedcare ƒ ContactdirectlytobenotifiedofupcomingCPSTrainings. ƒ Resources Email:[email protected] ƒ CalendarofCPSTrainingsandEventsinOregon: www.ohsu.edu/cps ƒ PCITlocationsinOregon: ƒ https://www.ohsu.edu/sites/default/files/2019Ǧ06/OregonǦ PCITǦlocationsǦalphabeticalǦ2018_0.pdf

71 72 LOCALRESOURCES ONLINERESOURCES

ƒ OPALǦK ƒ AACAP:FactsforFamilies ƒ TraumaInformedOregon: https://www.aacap.org/aacap/Fa https://traumainformedoregon.org milies_and_Youth/Facts_for_Fa milies/FFFǦGuide/FFFǦGuideǦ TableǦofǦContents.aspx

ƒ AAP:TraumaGuide https://www.aap.org/enǦ us/advocacyǦandǦpolicy/aapǦ healthǦinitiatives/healthyǦfosterǦ careǦamerica/Pages/TraumaǦ Guide.aspx

73 74

ONLINERESOURCES BOOKRECOMMENDATIONS

ƒ CenterforYouthWellness ƒ TheBoywhowasRaisedasaDogandOtherStoriesfromaChild Psychiatrist'sNotebook:WhatTraumatizedChildrenCanTeach https://centerforyouthwellness.org/ UsaboutLoss,Love,andHealing byBruceD.Perry,MD,PhD ƒ TheDeepestWell:HealingtheLongǦTermEffectsofChildhood ƒ NationalChildhoodTraumaticStress Adversity byNadineBurkeHarris,MD Network ƒ AllGod’sChildren:TheBosketFamilyandtheAmerican https://www.nctsn.org/ TraditionofViolence byFoxButterfield

ƒ CenterontheDevelopingChild https://developingchild.harvard.edu/

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THANKYOU!

Questions?

[email protected] Behavioralhealthconcernsare verycommon 20-30% meet criteria for mental disorder1 Additional 40% with impairing or distressing symptoms2 PCPs most likely source of professional help3 Concerns raised in 50–80% of all child medical visits4 The5ŊMinutePsychologist Primary concern in 15-20% of cases5 TranslatingEvidenceŊBasedTherapiestoPrimaryCare

&RVWHOORHWDOArch Gen Psychiatry &RVWHOOR 6KXJDUWPediatrics DATE:March6,2020PRESENTEDBY:AndrewR.Riley,PhD,AssociateProf,Pediatrics (PEU\ %LJODQ Clinical Child and Family Psych Rev 2 )ULHVHWDON Engl J Med :LOOLDPVHWDOPediatrics

SomethingDoesn’tAddUp …yetpoorlyidentified Average well-child visit Under-identified ± 15-20 minutes ± 14-54% sensitivity w/o screening1 ± Behavior: M < 30 second, Med = 01 ± Little change in screening practices since 20042 Average behavioral consult ± 20 minutes

6KHOGULFN0HUFKDQW 3HUULQPediatrics 1RUOLQAcademic Pediatrics 6WHLQAcademic Pediatrics

3 4

Refer? OK,but5minutes?

Nationwide shortage of child mental health providers Challenging, but reason for optimism Insufficient reimbursement models ± A few seconds of conversation can increase the likelihood of <50% referred MH services will access them1-3 smoking cessation1 ± Most needy are the least likely to access services ± Barriers: transportation, child care, leave from work ± Motivational techniques can be employed with minimal 2 Integrated behavioral health helps, but disparities remain time disruption Well-child care is likely the best opportunity to impact MH for many children and families ± Evidence-based “kernels”3

6WHDG%HUJVRQ /DQFDVWHU Cochrane Database of Sys Rev &KLVROP.OLPD*DUGQHU .HOOHKHUAdm Policy Ment Health 0LOOHU 5ROOQLFN Motivational Interviewing: Preparing People for Change, 2nd ed. +DFNHUHWDOPediatrics (PEU\ %LJODQ Clinical Child and Family Psych Rev 5XVKWRQ%UXFNPDQ .HOOHKHUArch Pediatr Adolesc Med 5 6 FindingKernels FindingKernels

Psychological interventions are usually multi- In RCTs, these are collapsed into single variables This allows for evaluating efficacy the package, but not the component packages targeting clusters of symptoms individual components

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BehavioralCare,BiteŊSized FindingKernels Target robust principles of behavior Best available evidence (empirical theory, meta-analyses, and study of of individual components) can guide clinical decision making in time-limited circumstances Utilize well-established 'LIIHUHQWLDODWWHQWLRQ 1RQFRPSOLDQFH mechanisms of change 6WUDWHJLFLJQRULQJ (PRWLRQDOODELOLW\ 7KHUDSHXWLFSOD\ $JJUHVVLRQ (kernels) /LPLWVHWWLQJ +\SHUDFWLYLW\ 5HZDUGV ,PSXOVLYHQHVV 3UREOHPVROYLQJ $UJXPHQWDWLYHQHVV Communicate digestibly and 7LPHRXW 'HILDQFH ,QVWUXFWLRQGHOLYHU\ :KLQLQJ memorably &RQWLQJHQWSUDLVH 'HVWUXFWLRQ 6WUHVVPDQDJHPHQW 7DQWUXPV

Scenario1:TerribleTantrums Technique1:KansasorOz?

Presentation ± Not dangerous, but disruptive behaviors (e.g., tantrums, yelling, Goal: Promote parental whining, excessive crying) attention consistent with authoritative parenting Critical issue ± Inadvertent positive reinforcement via contingent attention – Parental attempts to persuade, soothe, threaten, cajole, etc, backfire. 13 14

15 16

Scenario#2:Dangerousand Destructive Scenario: Persistent problem behavior that cannot be ignored (aggression, destruction, dangerous) Critical issue: Many have tried “time-out” and found it doesn’t work. ± 85% implement time-out sub-optimally (Riley et al. 2016)

17 18 Technique1:2KindsofNothing Nothinggoingon.

Goal: Refine time-out procedures to make them more effective.

Nothinggoingon. Nothingtheycandoaboutit. Wetriedthatanditdidn’twork!

Is there sufficient positive reinforcement (time-in) in place? Is there something going on? Is there something he/she can do about it? ± Escape from TO is most likely reason for ineffectiveness ± Consider walking TO

21 22

Scenario3:TheAvidAvoider Technique4:FingerTrap

Scenario: Older/child adolescent struggling with Goal anxiety (among other things) ± Generate acceptance of uncomfortable thoughts and feelings in order to enable goal- Critical issue: Paradoxical avoidance - the more directed action feeling anxious is avoided, the more disabling it becomes.

23 24 Scenario#4:Chronichealth behaviorstruggles

Scenario: Adolescent/family struggling with health behaviors/self-management

Critical issue: The environment doesn’t encourage healthy behavior, but this is interpreted as indifference or laziness.

25 26

Technique4:FillŊUpsvsOil Changes

Goal ± Build understanding of the behavioral dynamics at play to reduce guilt, and generate empathy.

29 Scenario#5:Adolescent Ambivalence

Scenario: Adolescent/young adult recognize need for change but hesitant to commit… “I’d like to, but…”

Critical issue: If not ready for change, a prescriptive approach may be iatrogenic

“Peoplearegenerallybetter Technique5:RowyourOARS persuadedbythereasons Open ended questions whichtheythemselves discoveredthanbythose Affirmations whichhavecomeintothe Reflective listening mindsofothers.” Summarizing

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FinalThoughts

Behavior change is hard Recognize limitations Find your style Do one thing well ThankYou When in doubt, listen and [email protected] empathize @AndrewRileyPhD ŝƐĐůŽƐƵƌĞ /ŚĂǀĞŶŽĐŽŶĨůŝĐƚŽĨŝŶƚĞƌĞƐƚŝŶƌĞůĂƚŝŽŶƚŽƚŚŝƐƉƌĞƐĞŶƚĂƚŝŽŶ

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DZ,ϮϬϮϬ

KƵƚůŝŶĞ ĂĐŬŐƌŽƵŶĚ

ĂĐŬŐƌŽƵŶĚ ϳƚŚĞŶƚƵƌǇ^ƚ͘:ŽŚŶůŝŵĂĐƵƐ͛Ɛ ƐƚŽƌǇŽĨĂŵŽŶŬ ŝĂŐŶŽƐƚŝĐƌŝƚĞƌŝĂ ^ǇŵƉƚŽŵƐŽĨKĚĞƐĐƌŝďĞĚĂƐĨĂƌďĂĐŬĂƐϭϰϲϳ͕ĞǀŝĚĞŶĐĞŽĨƉŽƐƐĞƐƐŝŽŶďǇƚŚĞĚĞǀŝů ůŝŶŝĐĂů&ĞĂƚƵƌĞƐ ƉŝĚĞŵŝŽůŽŐǇ ZĞůŝŐŝŽƵƐƚĞǆƚƐŽĨϭϲϬϬƐĚĞƐĐƌŝďĞĚ͞ƐĐƌƵƉƵůŽƐŝƚǇ͕͟ĞǆĐĞƐƐŝǀĞĚĞǀŽƚŝŽŶĂŶĚĞǆƚƌĞŵĞƐŽĨƌĞůŝŐŝŽƵƐĚŽƵďƚŝŶŐ

ƚŝŽůŽŐǇΘWĂƚŚŽŐĞŶĞƐŝƐ ^ƚƵĚŝĞĚďǇƉŝŽŶĞĞƌƐŽĨƉƐǇĐŚŝĂƚƌǇ͞ĂƌůtĞƐƚƉŚĂů ĂŶĚWŝĞƌƌĞ:ĂŶĞƚ͟ĂƐĞĂƌůǇĂƐϭϴϯϴ ŽŵŽƌďŝĚŝƚŝĞƐ KƐǇŵƉƚŽŵƐǁĞƌĞŶŽƚĞĚďǇ&ƌĞƵĚĞĂƌůǇŽŶŝŶŚŝƐǁŽƌŬ͕ŶŶĂ&ƌĞƵĚĂƚƚƌŝďƵƚĞĚƚŽĞŐŽĚĞĨŝĐŝƚƐĂŶĚĐŽŶĨůŝĐƚŝŶŐĚƌŝǀ ŽƵƌƐĞĂŶĚƉƌŽŐŶŽƐŝƐ ǀĂůƵĂƚŝŽŶ KǁĂƐŵŽǀĞĚĨƌŽŵ͞ĂŶǆŝĞƚǇĚŝƐŽƌĚĞƌƐ͟ŝŶ^DͲ/sdZƚŽ͞KďƐĞƐƐŝǀĞͲŽŵƉƵůƐŝǀĞƐƉĞĐƚƌƵŵĚŝƐŽƌĚĞƌƐ͟ŝŶ^DͲϱ͘ KƚŚĞƌĚŝĂŐŶŽƐŝƐŝŶƚŚŝƐĐĂƚĞŐŽƌǇŝŶĐůƵĚĞďŽĚǇĚǇƐŵŽƌƉŚŝĐĚŝƐŽƌĚĞƌ͕ŚŽĂƌĚŝŶŐĚŝƐŽƌĚĞƌ͕ƚƌŝĐŚŽƚŝůůŽŵĂŶŝĂĂŶĚĞǆĐŽƌŝĂ dƌĞĂƚŵĞŶƚ ĚŝƐŽƌĚĞƌ ŽŽŬƌĞĐŽŵŵĞŶĚĂƚŝŽŶ

^DͲϱŝĂŐŶŽƐƚŝĐƌŝƚĞƌŝĂ ^DͲϱŝĂŐŶŽƐƚŝĐƌŝƚĞƌŝĂ

͘WƌĞƐĞŶĐĞŽĨŽďƐĞƐƐŝŽŶƐ͕ĐŽŵƉƵůƐŝŽŶƐ͕ŽƌďŽƚŚ͗ ͘dŚĞŽďƐĞƐƐŝŽŶƐŽƌĐŽŵƉƵůƐŝŽŶƐĂƌĞƚŝŵĞͲĐŽŶƐƵŵŝŶŐ;Ğ͘Ő͕͘ƚĂŬĞŵŽƌĞƚŚĂŶϭŚŽƵƌƉĞƌĚĂǇͿŽƌĐĂƵƐĞĐůŝŶŝĐĂůůǇ ƐŝŐŶŝĨŝĐĂŶƚĚŝƐƚƌĞƐƐŽƌŝŵƉĂŝƌŵĞŶƚŝŶƐŽĐŝĂů͕ŽĐĐƵƉĂƚŝŽŶĂů͕ŽƌŽƚŚĞƌŝŵƉŽƌƚĂŶƚĂƌĞĂƐŽĨĨƵŶĐƚŝŽŶŝŶŐ͘ KďƐĞƐƐŝŽŶƐĂƌĞĚĞĨŝŶĞĚďǇ;ϭͿĂŶĚ;ϮͿ͗

ϭͿ ZĞĐƵƌƌĞŶƚĂŶĚƉĞƌƐŝƐƚĞŶƚƚŚŽƵŐŚƚƐ͕ƵƌŐĞƐ͕ŽƌŝŵĂŐĞƐƚŚĂƚĂƌĞĞǆƉĞƌŝĞŶĐĞĚ͕ĂƚƐŽŵĞƚŝŵĞĚƵƌŝŶŐƚŚĞĚŝƐƚƵƌďĂŶĐĞ͕ĂƐŝŶƚƌƵƐŝǀĞĂŶĚ ͘dŚĞŽďƐĞƐƐŝǀĞͲĐŽŵƉƵůƐŝǀĞƐǇŵƉƚŽŵƐĂƌĞŶŽƚĂƚƚƌŝďƵƚĂďůĞƚŽƚŚĞƉŚǇƐŝŽůŽŐŝĐĂůĞĨĨĞĐƚƐŽĨĂƐƵďƐƚĂŶĐĞŽƌĂŶŽƚŚĞƌ ƵŶǁĂŶƚĞĚ͕ĂŶĚƚŚĂƚŝŶŵŽƐƚŝŶĚŝǀŝĚƵĂůƐĐĂƵƐĞŵĂƌŬĞĚĂŶǆŝĞƚǇŽƌĚŝƐƚƌĞƐƐ ŵĞĚŝĐĂůĐŽŶĚŝƚŝŽŶ͘

ϮͿ dŚĞŝŶĚŝǀŝĚƵĂůĂƚƚĞŵƉƚƐƚŽŝŐŶŽƌĞŽƌƐƵƉƉƌĞƐƐƐƵĐŚƚŚŽƵŐŚƚƐ͕ƵƌŐĞƐ͕ŽƌŝŵĂŐĞƐ͕ŽƌƚŽŶĞƵƚƌĂůŝǌĞƚŚĞŵǁŝƚŚƐŽŵĞŽƚŚĞƌƚŚŽƵŐŚƚŽƌĂĐƚŝŽŶ ͘dŚĞĚŝƐƚƵƌďĂŶĐĞŝƐŶŽƚďĞƚƚĞƌĞǆƉůĂŝŶĞĚďǇƚŚĞƐǇŵƉƚŽŵƐŽĨĂŶŽƚŚĞƌŵĞŶƚĂůĚŝƐŽƌĚĞƌ ;ŝ͘Ğ͕͘ďǇƉĞƌĨŽƌŵŝŶŐĂĐŽŵƉƵůƐŝŽŶͿ ŽŵƉƵůƐŝŽŶƐĂƌĞĚĞĨŝŶĞĚďǇ;ϭͿĂŶĚ;ϮͿ͗ ^ƉĞĐŝĨŝĞƌƐ͗ tŝƚŚŐŽŽĚŽƌĨĂŝƌŝŶƐŝŐŚƚ͗ dŚĞŝŶĚŝǀŝĚƵĂůƌĞĐŽŐŶŝǌĞƐƚŚĂƚŽďƐĞƐƐŝǀĞͲĐŽŵƉƵůƐŝǀĞĚŝƐŽƌĚĞƌďĞůŝĞĨƐĂƌĞĚĞĨŝŶŝƚĞůǇŽƌƉƌŽďĂďůǇŶŽƚƚƌƵĞŽƌƚŚĂƚƚŚĞǇŵ ϭͿ ZĞƉĞƚŝƚŝǀĞďĞŚĂǀŝŽƌƐ;Ğ͘Ő͕͘ŚĂŶĚǁĂƐŚŝŶŐ͕ŽƌĚĞƌŝŶŐ͕ĐŚĞĐŬŝŶŐͿŽƌŵĞŶƚĂůĂĐƚƐ;Ğ͘Ő͕͘ƉƌĂǇŝŶŐ͕ĐŽƵŶƚŝŶŐ͕ƌĞƉĞĂƚŝŶŐǁŽƌĚƐƐŝůĞŶƚůǇͿ ƚŚĂƚƚŚĞ ŽƌŵĂǇŶŽƚďĞƚƌƵĞ ŝŶĚŝǀŝĚƵĂůĨĞĞůƐĚƌŝǀĞŶƚŽƉĞƌĨŽƌŵŝŶƌĞƐƉŽŶƐĞƚŽĂŶŽďƐĞƐƐŝŽŶŽƌĂĐĐŽƌĚŝŶŐƚŽƌƵůĞƐƚŚĂƚŵƵƐƚďĞĂƉƉůŝĞĚƌŝŐŝĚůǇ͘ tŝƚŚƉŽŽƌŝŶƐŝŐŚƚ͗ dŚĞŝŶĚŝǀŝĚƵĂůƚŚŝŶŬƐŽďƐĞƐƐŝǀĞͲĐŽŵƉƵůƐŝǀĞĚŝƐŽƌĚĞƌďĞůŝĞĨƐĂƌĞƉƌŽďĂďůǇƚƌƵĞ ϮͿ dŚĞďĞŚĂǀŝŽƌƐŽƌŵĞŶƚĂůĂĐƚƐĂƌĞĂŝŵĞĚĂƚƉƌĞǀĞŶƚŝŶŐŽƌƌĞĚƵĐŝŶŐĂŶǆŝĞƚǇŽƌĚŝƐƚƌĞƐƐ͕ŽƌƉƌĞǀĞŶƚŝŶŐƐŽŵĞĚƌĞĂĚĞĚĞǀĞŶƚŽƌƐŝƚƵĂƚŝŽŶ͖ ŚŽǁĞǀĞƌ͕ƚŚĞƐĞďĞŚĂǀŝŽƌƐŽƌŵĞŶƚĂůĂĐƚƐĂƌĞŶŽƚĐŽŶŶĞĐƚĞĚŝŶĂƌĞĂůŝƐƚŝĐǁĂǇǁŝƚŚǁŚĂƚƚŚĞǇĂƌĞĚĞƐŝŐŶĞĚƚŽŶĞƵƚƌĂůŝǌĞŽƌƉƌĞǀĞŶƚ͕ŽƌĂƌĞ tŝƚŚĂďƐĞŶƚŝŶƐŝŐŚƚͬĚĞůƵƐŝŽŶĂůďĞůŝĞĨƐ͗ dŚĞŝŶĚŝǀŝĚƵĂůŝƐĐŽŵƉůĞƚĞůǇĐŽŶǀŝŶĐĞĚƚŚĂƚŽďƐĞƐƐŝǀĞͲĐŽŵƉƵůƐŝǀĞĚŝƐŽƌĚĞƌďĞůŝĞĨƐĂƌĞƚƌƵĞ͘ ĐůĞĂƌůǇĞǆĐĞƐƐŝǀĞ͘ dŝĐͲƌĞůĂƚĞĚ͗ dŚĞŝŶĚŝǀŝĚƵĂůŚĂƐĂĐƵƌƌĞŶƚŽƌƉĂƐƚŚŝƐƚŽƌǇŽĨĂƚŝĐĚŝƐŽƌĚĞƌ EŽƚĞ͗ zŽƵŶŐĐŚŝůĚƌĞŶŵĂǇŶŽƚďĞĂďůĞƚŽĂƌƚŝĐƵůĂƚĞƚŚĞĂŝŵƐŽĨƚŚĞƐĞďĞŚĂǀŝŽƌƐŽƌŵĞŶƚĂůĂĐƚƐ͘ ůŝŶŝĐĂů&ĞĂƚƵƌĞƐ ůŝŶŝĐĂů&ĞĂƚƵƌĞƐ

WƌĞƐĞŶƚŝŶŐƉƌŽďůĞŵƐĂƌĞǀĂƌŝĂďůĞ͗ƚĞŵƉĞƌƚĂŶƚƌƵŵƐ͕ĚĞĐůŝŶĞŝŶƐĐŚŽŽůƉĞƌĨŽƌŵĂŶĐĞ͕ƉŽŽƌƐĐŚŽŽůĂƚƚĞŶĚĂŶĐĞ͕ ŚŝůĚƌĞŶƚĞŶĚƚŽŚĂǀĞŝƐŽůĂƚĞĚĂŶĚŝĚŝŽƐǇŶĐƌĂƚŝĐĨƵŶĐƚŝŽŶĂůĚĞĨŝĐŝƚƐǁŚŝĐŚŵĂǇďĞƐĞǀĞƌĞďƵƚĚŽŵĂŝŶƐƉĞĐŝĨŝĐĂŶĚ ĨŽŽĚƌĞĨƵƐĂů͕ĚĞƌŵĂƚŝƚŝƐ͕ĐůŽŐŐĞĚƚŽŝůĞƚ͕ƌƵŶŶŝŶŐŽƵƚŽĨĐůĞĂŶŝŶŐƐƵƉƉůǇ ǀĂƌŝĂďůĞ͘ KďƐĞƐƐŝŽŶƐ͗ DŽƐƚŽŵŵŽŶŽďƐĞƐƐŝŽŶƐ͗ĐŽŶƚĂŵŝŶĂƚŝŽŶ͕ƐĂĨĞƚǇŽĨƐĞůĨĂŶĚŽƚŚĞƌƐ͕ĞǆĂĐƚŶĞƐƐŽƌƐǇŵŵĞƚƌǇ͕ƌĞůŝŐŝŽƵƐ WĂƌĞŶƚƐĂƌĞŽĨƚĞŶŝŶǀŽůǀĞĚŝŶĐůĞĂŶŝŶŐŽƌĐŚĞĐŬŝŶŐ͕ƌĞĂƐƐƵƌĂŶĐĞƐĞĞŬŝŶŐ͞ǀĞƌďĂůĐŚĞĐŬŝŶŐ͕͟ĐŽǀĞƌŝŶŐĚĞĨŝĐŝƚƐ͘ ƐĐƌƵƉƵůŽƵƐŶĞƐƐ ^ĞǆƵĂůĂŶĚĂŐŐƌĞƐƐŝǀĞƉƌĞŽĐĐƵƉĂƚŝŽŶƐůĞƐƐĐŽŵŵŽŶ <ŝĚƐŐĞƚĂŶŐƌǇǁŝƚŚƉĂƌĞŶƚƐƐĞĞŬŝŶŐŚĞůƉ͕ƉĂƌĞŶƚƐǁĂŶƚƚŽďĞůŝĞǀĞŝƚ͛ƐũƵƐƚĂƉŚĂƐĞ͘ KŶĞƐƚƵĚǇĨŽƵŶĚďŽǇƐƚŽďĞŵŽƌĞůŝŬĞůǇƚŽŚĂǀĞƐĞǆƵĂůŽďƐĞƐƐŝŽŶƐĂŶĚŐŝƌůƐƚŽŚĂǀĞŚŽĂƌĚŝŶŐƐǇŵƉƚŽŵƐ DŽƐƚĐĂƐĞƐŚĂǀĞĂŐƌĂĚƵĂůŽŶƐĞƚ KďƐĞƐƐŝŽŶĂůƐůŽǁŶĞƐƐʹ ŵŽƚŽƌƐůŽǁŶĞƐƐŝŶƐĞǀĞƌĞK ŽŵƉƵůƐŝŽŶƐ͗ KƐǇŵƉƚŽŵƐǁĂǆĂŶĚǁĂŶĞ͕ĂŶĚ ĐŚĂŶŐĞŽǀĞƌƚŝŵĞ DŽƐƚŽŵŵŽŶĐŽŵƉƵůƐŝŽŶƐŝŶĂĚŽůĞƐĐĞŶƚƐ͗ĐůĞĂŶŝŶŐ͕ƌĞƉĞĂƚŝŶŐĂĐƚŝŽŶƐƵŶƚŝůŝƚĨĞĞůƐ͞ƌŝŐŚƚ͕͟ĐŚĞĐŬŝŶŐƌŝƚƵĂůƐ DŽƐƚĐŚŝůĚƌĞŶĂƌĞƵŶĂďůĞƚŽƐƉĞĐŝĨǇǁŚĂƚƚŚĞŝƌƌŝƚƵĂůƐĂƌĞŝŶƚĞŶĚĞĚƚŽĂǀĞƌƚ͕ďĞǇŽŶĚĂǀĂŐƵĞŝĚĞĂŽĨƐŽŵĞƚŚŝŶŐďĂĚ ŚĂƉƉĞŶŝŶŐ͘dŚĞƌĞŝƐĐŽŵŵŽŶůǇůĂĐŬŽĨǁĞůůͲĚĞǀĞůŽƉĞĚŽďƐĞƐƐŝŽŶƐ

ƉŝĚĞŵŝŽůŽŐǇ ƚŝŽůŽŐǇͬWĂƚŚŽŐĞŶĞƐŝƐ

WĞĚŝĂƚƌŝĐKWƌĞǀĂůĞŶĐĞ͗ϭͲϮй 'ĞŶĞƚŝĐĐŽŵƉŽŶĞŶƚ͗ ŚŝŐŚĐŽŶĐŽƌĚĂŶĐĞƌĂƚĞ͕ŚŝŐŚĞƌƌĂƚĞŝŶĨŝƌƐƚͲĚĞŐƌĞĞƌĞůĂƚŝǀĞƐ ŚŝůĚŚŽŽĚKŝƐDĂůĞƉƌĞĚŽŵŝŶĂŶƚ;ϯ͗ϮD͗&ͿǁŝƚŚƉƌĞƉƵďĞƌƚĂůĂŐĞŽĨŽŶƐĞƚϲͲϭϮ͘ϱǇĞĂƌƐ͘ĚƵůƚ͗ƐůŝŐŚƚĨĞŵĂůĞ ƉƌĞƉŽŶĚĞƌĂŶĐĞƐƉĞĂƌŝŶůĂƚĞĂĚŽůĞƐĐĞŶĐĞ zŽƵŶŐĂŐĞŽĨŽŶƐĞƚŝƐĂƐƐŽĐŝĂƚĞĚǁŝƚŚŐƌĞĂƚĞƌĨĂŵŝůŝĂƌŝƚǇ ZĞƐĞĂƌĐŚŚĂƐƐŚŽǁŶƐŽŵĞŐĞŶĞƚŝĐĂƐƐŽĐŝĂƚŝŽŶƚƌĞŶĚƐ͕͘ůŝŬĞůǇŵƵůƚŝƉůĞŐĞŶĞƐŽĨƐŵĂůůĞĨĨĞĐƚ ŐĞŽĨĐůŝŶŝĐĂůƉƌĞƐĞŶƚĂƚŝŽŶŽŶĂǀĞƌĂŐĞϮǇĞĂƌƐĂĨƚĞƌŽŶƐĞƚ ŶǀŝƌŽŶŵĞŶƚĂůĨĂĐƚŽƌƐ͗ EŽĚŝĨĨĞƌĞŶĐĞŝŶƉƌĞǀĂůĞŶĐĞďĂƐĞĚŽŶƌĂĐĞͬĞƚŚŶŝĐŝƚǇŽƌŐĞŽŐƌĂƉŚǇ ŚŝŐŚĞƌƌĂƚĞŽĨƉĞƌŝŶĂƚĂůƚƌĂƵŵĂ;ƐŚŽƵůĚĞƌĚǇƐƚŽĐŝĂ͕ďƌĞĞĐŚ͕ĨŽƌĐĞƉƐ͕ƉƌŽůŽŶŐĞĚŚǇƉŽǆŝĂͿŝŶŵĂůĞƐǁŝƚŚĞĂƌůŝĞƌŽŶƐĞƚ ŽĨK ^ĞǆŽƌĂŐĞŽĨŽŶƐĞƚĚŽŶŽƚƉƌĞĚŝĐƚƐĞǀĞƌŝƚǇŽĨŝůůŶĞƐƐ ,ŝŐŚĞƌƌĂƚĞƐŽĨŵŽƚŚĞƌƐƌĞƋƵŝƌŝŶŐŵĞĚŝĐĂůĐĂƌĞĚƵƌŝŶŐƉƌĞŐŶĂŶĐǇ WĞĚŝĂƚƌŝĐKŝƐŵŽƌĞĨĂŵŝůŝĂůĂŶĚŐĞŶĞƌĂůůǇŚĂƐĂďĞƚƚĞƌƉƌŽŐŶŽƐŝƐ ŵŽŶŐƐƚĐŚŝůĚƌĞŶǁŝƚŚK͕ƚŚŽƐĞǁŝƚŚĂĚǀĞƌƐĞƉĞƌŝŶĂƚĂůĞǆƉĞƌŝĞŶĐĞƐŚĂǀĞĞĂƌůŝĞƌĂŐĞŽĨŽŶƐĞƚ͕ŵŽƌĞƐĞǀĞƌĞ ƐǇŵƉƚŽŵƐ͕ŝŶĐƌĞĂƐĞĚƌŝƐŬĨŽƌĐŽŵŽƌďŝĚŝƚǇ KŝƐƵŶĚĞƌƌĞĐŽŐŶŝǌĞĚĂŶĚƵŶĚĞƌĚŝĂŐŶŽƐĞĚŝŶǇŽƵƚŚ WƌĞĐŝƉŝƚĂƚŝŶŐWƐǇĐŚŽƐŽĐŝĂůĞǀĞŶƚƐ͗ ŚŝůĚŚŽŽĚŽŶƐĞƚKŽĐĐƵƌƐŝŶĂƚůĞĂƐƚϯϬͲϱϬйŽĨĐĂƐĞƐǁŝƚŚK ƉŚǇƐŝĐĂůŽƌƐĞǆƵĂůĂƐƐĂƵůƚ tŝƚŶĞƐƐŝŶŐĚŽŵĞƐƚŝĐǀŝŽůĞŶĐĞ ϮƉĞĂŬƐŽĨŝŶĐŝĚĞŶĐĞĨŽƌKĂĐƌŽƐƐůŝĨĞƐƉĂŶ͗ƉƌĞĂĚŽůĞƐĐĞŶĐĞĂŶĚĞĂƌůǇĂĚƵůƚůŝĨĞΕϮϭǇƌƐ ĞŝŶŐŚŽŵĞĂůŽŶĞĚƵƌŝŶŐĂĨŽƌĐĞĚďƌĞĂŬŝŶŐĂŶĚĞŶƚĞƌŝŶŐ

ƚŝŽůŽŐǇͬWĂƚŚŽŐĞŶĞƐŝƐ WE^ƌŝƚĞƌŝĂ

ƵƚŽͲŝŵŵƵŶĞĞƚŝŽůŽŐǇ͗ WƌĞƐĞŶĐĞŽĨKĂŶĚͬŽƌĂƚŝĐĚŝƐŽƌĚĞƌ;ĚŝĂŐŶŽƐĞĚĂĐĐŽƌĚŝŶŐƚŽ^Dʹ ŝĂŐŶŽƐƚŝĐĂŶĚ^ƚĂƚŝƐƚŝĐĂůDĂŶƵĂůŽĨ /ŶϭϵϴϬƐE/,ŶŽƚĞƐĂƐƵďƐĞƚŽĨĐŚŝůĚƌĞŶǁŝƚŚKǁŝƚŚĂďƌƵƉƚͲŽŶƐĞƚĨŽůůŽǁŝŶŐŝŶĨĞĐƚŝŽŶƐ DĞŶƚĂůŝƐŽƌĚĞƌƐͿ >ĞĚƚŽĚĞǀĞůŽƉŵĞŶƚŽĨWĞĚŝĂƚƌŝĐƵƚŽŝŵŵƵŶĞEĞƵƌŽƉƐǇĐŚŝĂƚƌŝĐŝƐŽƌĚĞƌƐƐƐŽĐŝĂƚĞĚǁŝƚŚ^ƚƌĞƉƚŽĐŽĐĐĂů/ŶĨĞĐƚŝŽŶƐ WĞĚŝĂƚƌŝĐŽŶƐĞƚ;ďĞƚǁĞĞŶϯǇĞĂƌƐĂŶĚƚŚĞďĞŐŝŶŶŝŶŐŽĨƉƵďĞƌƚǇͿ ;WE^ͿŝŶϭϵϵϴĂŶĚWĞĚŝĂƚƌŝĐĐƵƚĞͲŽŶƐĞƚEĞƵƌŽƉƐǇĐŚŝĂƚƌŝĐ^ǇŶĚƌŽŵĞ;WE^ͿŝŶϮϬϭϬ ƉŝƐŽĚŝĐĐŽƵƌƐĞŽĨƐǇŵƉƚŽŵƐĞǀĞƌŝƚǇǁŝƚŚĂďƌƵƉƚŽŶƐĞƚŽƌĚƌĂŵĂƚŝĐĞǆĂĐĞƌďĂƚŝŽŶƐ DĂũŽƌďƌĂŝŶƐƚƌƵĐƚƵƌĞƐĐĞŶƚƌĂůƚŽK͗KƌďŝƚŽĨƌŽŶƚĂůĐŽƌƚĞǆ͕ĂŶƚ͘ŝŶŐƵůĂƚĞĐŽƌƚĞǆ͕ĐĂƵĚĂƚĞĂŶĚƚŚĂůĂŵƵƐ ^ǇŵƉƚŽŵƐĞǆĂĐĞƌďĂƚŝŽŶƐŵƵƐƚďĞƚĞŵƉŽƌĂůůǇƌĞůĂƚĞĚƚŽ',^;'ƌŽƵƉƐƚƌĞƉƚŽĐŽĐĐĂůŝŶĨĞĐƚŝŽŶͿ͕ŝ͘Ğ͕͘

EĞƵƌŽƚƌĂŶƐŵŝƚƚĞƌƐŬŶŽǁŶƚŽďĞŝŶǀŽůǀĞĚŝŶK͗ŐůƵƚĂŵĂƚĞ͕ĚŽƉĂŵŝŶĞ͕ƐĞƌŽƚŽŶŝŶ ĂƐƐŽĐŝĂƚĞĚǁŝƚŚƉŽƐŝƚŝǀĞƚŚƌŽĂƚĐƵůƚƵƌĞĂŶĚͬŽƌĞůĞǀĂƚĞĚĂŶƚŝͲ',^ĂŶƚŝďŽĚǇ

ĨDZ/ŝŶϮϬϬϬ͕ĞůĞǀĂƚĞĚŐůƵƚĂŵĂƚĞůĞǀĞůŝŶƚŚĞĐĂƵĚĂƚĞŶƵĐůĞŝŽĨϭϭƚƌĞĂƚŵĞŶƚͲŶĂŢǀĞĐŚŝůĚƌĞŶ͕ŶŽƌŵĂůŝǌĞĚǁŝƚŚ ƐƐŽĐŝĂƚŝŽŶǁŝƚŚŶĞƵƌŽůŽŐŝĐĂůĂďŶŽƌŵĂůŝƚŝĞƐ;ŵŽƚŽƌŝĐŚǇƉĞƌĂĐƚŝǀŝƚǇĂŶĚĂĚǀĞŶƚŝƚŝŽƵƐŵŽǀĞŵĞŶƚƐ͕ŝŶĐůƵĚŝŶŐ ƚƌĞĂƚŵĞŶƚ ĐŚŽƌĞŝĨŽƌŵŵŽǀĞŵĞŶƚƐŽƌƚŝĐƐͿ WE^ƌŝƚĞƌŝĂ ŽŵŽƌďŝĚŝƚŝĞƐ

ďƌƵƉƚ͕ĚƌĂŵĂƚŝĐŽŶƐĞƚŽĨŽďƐĞƐƐŝǀĞͲĐŽŵƉƵůƐŝǀĞĚŝƐŽƌĚĞƌŽƌƐĞǀĞƌĞůǇƌĞƐƚƌŝĐƚĞĚĨŽŽĚŝŶƚĂŬĞ sĞƌǇĐŽŵŵŽŶ͕ƉƌĞƐĞŶƚŝŶŵŽƌĞƚŚĂŶϱϬйŽĨĐĂƐĞƐ

ŽŶĐƵƌƌĞŶƚƉƌĞƐĞŶĐĞŽĨĂĚĚŝƚŝŽŶĂůŶĞƵƌŽƉƐǇĐŚŝĂƚƌŝĐƐǇŵƉƚŽŵƐ͕;ǁŝƚŚƐŝŵŝůĂƌůǇƐĞǀĞƌĞĂŶĚĂĐƵƚĞŽŶƐĞƚͿ͕ DŽƐƚĐŽŵŵŽŶĐŽŵŽƌďŝĚŝƚŝĞƐ͗ ĨƌŽŵĂƚůĞĂƐƚƚǁŽŽĨƚŚĞĨŽůůŽǁŝŶŐƐĞǀĞŶĐĂƚĞŐŽƌŝĞƐ͗ ϭ͘ ŶǆŝĞƚǇ dŝĐĚŝƐŽƌĚĞƌƐͲ ŝŶĐƌĞĂƐĞĚƌŝƐŬǁŝƚŚĞĂƌůŝĞƌĂŐĞŽĨŽŶƐĞƚŽĨK͕ƌĞŵŝƚƐǁŝƚŚĂŐĞ Ϯ͘ ŵŽƚŝŽŶĂůůĂďŝůŝƚǇĂŶĚͬŽƌĚĞƉƌĞƐƐŝŽŶ ϯ͘ /ƌƌŝƚĂďŝůŝƚǇ͕ĂŐŐƌĞƐƐŝŽŶ͕ĂŶĚͬŽƌƐĞǀĞƌĞůǇŽƉƉŽƐŝƚŝŽŶĂůďĞŚĂǀŝŽƌƐ DŽŽĚĚŝƐŽƌĚĞƌƐ ϰ͘ ĞŚĂǀŝŽƌĂů;ĚĞǀĞůŽƉŵĞŶƚĂůͿƌĞŐƌĞƐƐŝŽŶ ŶǆŝĞƚǇĚŝƐŽƌĚĞƌƐͲ ŝŶĐƌĞĂƐĞĚƌŝƐŬǁŝƚŚĞĂƌůŝĞƌĂŐĞŽĨŽŶƐĞƚŽĨK ϱ͘ ĞƚĞƌŝŽƌĂƚŝŽŶŝŶƐĐŚŽŽůƉĞƌĨŽƌŵĂŶĐĞ;ƌĞůĂƚĞĚƚŽĂƚƚĞŶƚŝŽŶͲĚĞĨŝĐŝƚͬŚǇƉĞƌĂĐƚŝǀŝƚǇĚŝƐŽƌĚĞƌ΀,΁ͲůŝŬĞ ƐǇŵƉƚŽŵƐ͕ŵĞŵŽƌǇĚĞĨŝĐŝƚƐ͕ĐŽŐŶŝƚŝǀĞĐŚĂŶŐĞƐͿ ŝƐƌƵƉƚŝǀĞďĞŚĂǀŝŽƌƐ ϲ͘ ^ĞŶƐŽƌǇŽƌŵŽƚŽƌĂďŶŽƌŵĂůŝƚŝĞƐ ϳ͘ ^ŽŵĂƚŝĐƐŝŐŶƐĂŶĚƐǇŵƉƚŽŵƐ͕ŝŶĐůƵĚŝŶŐƐůĞĞƉĚŝƐƚƵƌďĂŶĐĞƐ͕ĞŶƵƌĞƐŝƐ͕ŽƌƵƌŝŶĂƌǇĨƌĞƋƵĞŶĐǇ ,ʹ ŝŶĐƌĞĂƐĞĚƌŝƐŬǁŝƚŚĞĂƌůŝĞƌĂŐĞŽĨŽŶƐĞƚŽĨK ^ǇŵƉƚŽŵƐĂƌĞŶŽƚďĞƚƚĞƌĞǆƉůĂŝŶĞĚďǇĂŬŶŽǁŶŶĞƵƌŽůŽŐŝĐŽƌŵĞĚŝĐĂůĚŝƐŽƌĚĞƌ͕ƐƵĐŚĂƐ^ ŽŵŽƌďŝĚŝƚǇŝŶĐƌĞĂƐĞƐƌŝƐŬŽĨƌĞůĂƉƐĞŽĨKǁŝƚŚŵĞĚŝĐĂƚŝŽŶĚŝƐĐŽŶƚŝŶƵĂƚŝŽŶ

ŽƵƌƐĞĂŶĚWƌŽŐŶŽƐŝƐ ǀĂůƵĂƚŝŽŶ

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ŶǆŝĞƚǇĚŝƐŽƌĚĞƌƐ WƌŝŵĂƌǇƉƐǇĐŚŽƚŝĐŝůůŶĞƐƐĞƐ ƌĞĐƵƌƌĞŶƚƚŚŽƵŐŚƚƐŝŶĂŶǆŝĞƚǇĚŝƐŽƌĚĞƌƐĂƌĞƵƐƵĂůůǇĂďŽƵƚƌĞĂůͲůŝĨĞĐŽŶĐĞƌŶƐĂŶĚͬŽƌƐŽĐŝĂůƐŝƚƵĂƚŝŽŶƐ͕͕ǁŚĞƌĞĂƐƚŚĞ KǀĞƌǀĂůƵĞĚŝĚĞĂƚŝŽŶĂŶĚĚĞůƵƐŝŽŶĂůƚŚŝŶŬŝŶŐŝŶKǁŝƚŚƉŽŽƌŝŶƐŝŐŚƚ ŽďƐĞƐƐŝŽŶƐŽĨKƵƐƵĂůůǇŝŶĐůƵĚĞĐŽŶƚĞŶƚƚŚĂƚŝƐŽĚĚ͕ŝƌƌĂƚŝŽŶĂů͕ŽƌŽĨĂƐĞĞŵŝŶŐůǇŵĂŐŝĐĂůŶĂƚƵƌĞ ƐƐĞƐƐŝŶƐŝŐŚƚǁŚĞŶĂŶǆŝĞƚǇŝƐŵŝŶŝŵƵŵ ĐŽŵƉƵůƐŝŽŶƐĂƌĞŶŽƚƉƌĞƐĞŶƚŝŶĂŶǆŝĞƚǇĚŝƐŽƌĚĞƌƐďƵƚĂǀŽŝĚĂŶĐĞŝƐ EĂƚƵƌĞŽĨŽďƐĞƐƐŝŽŶĂůŝĚĞĂƚŝŽŶŝƐŶŽƚĂƐĂƚǇƉŝĐĂů KƐǇŵƉƚŽŵƐƐŽŵĞƚŝŵĞƐŚĞƌĂůĚĂƉƌŝŵĂƌǇƉƐǇĐŚŽƚŝĐŝůůŶĞƐƐ

ǀĂůƵĂƚŝŽŶʹ ŝĨĨĞƌĞŶƚŝĂůŝĂŐŶŽƐŝƐ dƌĞĂƚŵĞŶƚWůĂŶŶŝŶŐ

dŝĐŝƐŽƌĚĞƌ /ŶĚŝǀŝĚƵĂůĨĞĂƚƵƌĞƐŽĨƚŚĞĐŚŝůĚŚĂǀĞŝŵƉŽƌƚĂŶƚŝŵƉůŝĐĂƚŝŽŶƐĨŽƌƚƌĞĂƚŵĞŶƚƉůĂŶŶŝŶŐ

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ŽůůĂďŽƌĂƚŝŽŶǁŝƚŚƐĐŚŽŽůŝƐĂŬĞǇƉĂƌƚŽĨƚƌĞĂƚŵĞŶƚŝŶƚĞƌǀĞŶƚŝŽŶƐ

dƌĞĂƚŵĞŶƚKƉƚŝŽŶƐ dƌĞĂƚŵĞŶƚWůĂŶŶŝŶŐ

DĞĚŝĐĂƚŝŽŶƐ͗ DŝůĚKƐǇŵƉƚŽŵƐĂŶĚŶŽŝŵƉĂŝƌŵĞŶƚĐŽƵůĚďĞŵŽŶŝƚŽƌĞĚ͘/ĨƌĞůĂƚĞĚƚŽƐƚƌĞƐƐŽƌƐ͕ĐĂŶĐŽŶƐŝĚĞƌƚŚĞƌĂƉǇ ^ĞƌŽƚŽŶŝŶZĞƵƉƚĂŬĞ/ŶŚŝďŝƚŽƌƐ ƵŐŵĞŶƚĂƚŝŽŶǁŝƚŚŶĞƵƌŽůĞƉƚŝĐƐ͕ďĞŶǌŽĚŝĂǌĞƉŝŶĞƐ DŝůĚƚŽŵŽĚĞƌĂƚĞKŝŶƚŚĞĂďƐĞŶĐĞŽĨĐŽŵŽƌďŝĚŝƚǇ͕ĐĂŶďĞƚƌĞĂƚĞĚǁŝƚŚdĂůŽŶĞĂƐƚŚĞĨŝƌƐƚůŝŶĞƚƌĞĂƚŵĞŶƚ

WƐǇĐŚŽƚŚĞƌĂƉǇĂůŽŶĞ͗ tŚĞŶƚŽƐƚĂƌƚǁŝƚŚŵĞĚŝĐĂƚŝŽŶƐ͗ƐĞǀĞƌĞƐǇŵƉƚŽŵƐ͕ƚŝŵĞ͕ĞǆƉĞŶƐĞ͕ĞĨĨŽƌƚ͕ĂŶǆŝĞƚǇĂƐƐŽĐŝĂƚĞĚǁŝƚŚd͕ d͗ƉĂƌƚǁŝƚŚŽƵƚͬZWŝƐůĞƐƐĞĨĨĞĐƚŝǀĞ KƚŚĞƌƚǇƉĞƐŽĨƚŚĞƌĂƉǇƐƵĐŚĂƐd;ĐĐĞƉƚĂŶĐĞĂŶĚŽŵŵŝƚŵĞŶƚdŚĞƌĂƉǇͿŽƌD;ƚƚĞŶƚŝŽŶŝĂƐDŽĚŝĨŝĐĂƚŝŽŶͿ ƵŶĂǀĂŝůĂďŝůŝƚǇŽĨƚŚĞƌĂƉŝƐƚ͕ĐŚŝůĚ͛ƐůĂĐŬŽĨƐƵĨĨŝĐŝĞŶƚĐŽŐŶŝƚŝǀĞŽƌĞŵŽƚŝŽŶĂůŵĂƚƵƌŝƚǇŽƌůĂĐŬŽĨĨĂŵŝůǇƐƵƉƉŽƌƚ͕ ŚĂǀĞŶŽƚďĞĞŶƐǇƐƚĞŵĂƚŝĐĂůůǇƐƚƵĚŝĞĚĂƐŵŽŶŽƚŚĞƌĂƉǇŝŶƉĞĚŝĂƚƌŝĐƉŽƉƵůĂƚŝŽŶ ƉƌĞƐĞŶĐĞŽĨĐŽŵŽƌďŝĚĚĞƉƌĞƐƐŝŽŶ͕ĂŶǆŝĞƚǇĂŶĚĚŝƐƌƵƉƚŝǀĞďĞŚĂǀŝŽƌƐ ŽŵďŝŶĞĚƚƌĞĂƚŵĞŶƚ͗ DĂŶǇĐůŝŶŝĐŝĂŶƐƉƌĞĨĞƌĐŽŵďŝŶĞĚƚƌĞĂƚŵĞŶƚĂƐƚŚĞĨŝƌƐƚůŝŶĞƚƌĞĂƚŵĞŶƚ /ŶĚŝǀŝĚƵĂůƚŚĞƌĂƉǇ͗ƐƵƉƉŽƌƚŝǀĞ͕ƐŬŝůůƐͲďƵŝůĚŝŶŐ͕ĐƌĞĂƚĞĂƐĞŶƐĞŽĨŵĂƐƚĞƌǇ &ĂŵŝůǇƚŚĞƌĂƉǇ͗&ĂŵŝůǇƉƐǇĐŚŽƉĂƚŚŽůŽŐǇŝƐŶĞŝƚŚĞƌŶĞĐĞƐƐĂƌǇŶŽƌƐƵĨĨŝĐŝĞŶƚĨŽƌƚŚĞŽŶƐĞƚŽĨKƐǇŵƉƚŽŵƐďƵƚ ĨĂŵŝůŝĞƐĂĨĨĞĐƚĂŶĚĂƌĞĂĨĨĞĐƚĞĚďǇƚŚĞĚŝƐŽƌĚĞƌ͘,ŝŐŚĞǆƉƌĞƐƐĞĚĞŵŽƚŝŽŶƐĞǆĂĐĞƌďĂƚĞƐǆ͕ĐĂůŵĂŶĚƐƵƉƉŽƌƚŝǀĞĨĂŵŝůǇ ŵĂǇŝŵƉƌŽǀĞŽƵƚĐŽŵĞ͘,ĞůƉǁŝƚŚĞŶƚĂŶŐůĞŵĞŶƚ͘ &ĂŵŝůǇƐƵƉƉŽƌƚŐƌŽƵƉƐ dƌĞĂƚŵĞŶƚͲ d dƌĞĂƚŵĞŶƚͲ d WƌŽŐŶŽƐƚŝĐŝŶĚŝĐĂƚŽƌƐŽĨŐŽŽĚƌĞƐƉŽŶƐĞ dƌĞĂƚŵĞŶƚŽĨĐŚŽŝĐĞĨŽƌŵŝůĚƚŽŵŽĚĞƌĂƚĞKƐǇŵƉƚŽŵƐ DŽƌĞĚƵƌĂďůĞĞĨĨĞĐƚĂƐĐŽŵƉĂƌĞĚƚŽŵĞĚŝĐĂƚŝŽŶ ŵŽƚŝǀĂƚĞĚƉĂƚŝĞŶƚ dĂĚĚĞĚƚŽƐƚĂďůĞŵĞĚŝĐĂƚŝŽŶƌĞŐŝŵĞŶĞŶŚĂŶĐĞƐƚŚĞƌĞƐƉŽŶƐĞ ƉƌĞƐĞŶĐĞŽĨŽǀĞƌƚƌŝƚƵĂůƐĂŶĚĐŽŵƉƵůƐŝŽŶƐ dƌĞĚƵĐĞƌĞůĂƉƐĞƌĂƚĞǁŚĞŶŵĞĚŝĐĂƚŝŽŶŝƐĚŝƐĐŽŶƚŝŶƵĞĚ ĂďŝůŝƚǇƚŽŵŽŶŝƚŽƌĂŶĚƌĞƉŽƌƚƐǇŵƉƚŽŵƐ dƌĞĂƚŵĞŶƚŝƐϭϯͲϮϬƐĞƐƐŝŽŶƐĂŶĚŝŶĐůƵĚĞϯĞůĞŵĞŶƚƐ͗ ĂďƐĞŶĐĞŽĨĐŽŵƉůŝĐĂƚŝŶŐĐŽŵŽƌďŝĚĐŽŶĚŝƚŝŽŶƐ ϭ͘ /ŶĨŽƌŵĂƚŝŽŶŐĂƚŚĞƌŝŶŐ WƌŽŐŶŽƐƚŝĐŝŶĚŝĐĂƚŽƌƐŽĨƉĂƌƚŝĂůŽƌŶŽŶƌĞƐƉŽŶƐĞ Ϯ͘ ,ŝĞƌĂƌĐŚǇͲďĂƐĞĚƚŚĞƌĂƉŝƐƚĂƐƐŝƐƚĞĚŐƌĂĚĞĚĞǆƉŽƐƵƌĞĂŶĚƌĞƐƉŽŶƐĞƉƌĞǀĞŶƚŝŽŶ;ͬZWͿ͗ǆƉŽƐƵƌĞƌĞĚƵĐĞƐƉŚŽďŝĐ ĞǆƚĞŶƐŝǀĞĐŽŵŽƌďŝĚŝƚǇ ĂŶǆŝĞƚǇĂŶĚZWƌĞĚƵĐŝŶŐƌŝƚƵĂůƐ ĨĂŵŝůǇĐŽŶĨůŝĐƚŝŶƚĞŐƌĂƚŝŶŐǁŝƚŚd ϯ͘ ,ŽŵĞǁŽƌŬĂƐƐŝŐŶŵĞŶƚ ĞǀĞůŽƉŵĞŶƚĂůĐŽŶƐŝĚĞƌĂƚŝŽŶƐ ĐŽŐŶŝƚŝǀĞůŝŵŝƚĂƚŝŽŶĂƐŝŶĞǆƚƌĞŵĞǇŽƵŶŐĂŐĞ͕ŝŶƚĞůůĞĐƚƵĂůĚŝƐĂďŝůŝƚǇ͕^ ŚŝůĚŶĞĞĚƐƚŽďĞǁŝůůŝŶŐƚŽƉĂƌƚŝĐŝƉĂƚĞ ůĞƐƐĞĨĨĞĐƚŝǀĞŝŶŬŝĚƐǁŝƚŚŽďƐĞƐƐŝŽŶƐŽŶůǇ ͞ƚŽŽůŬŝƚ͗͟ƌĞůĂǆĂƚŝŽŶ͕ĐŽŐŶŝƚŝǀĞƚŚĞƌĂƉǇ͕ƵƐĞŽĨƐǇƐƚĞŵĂƚŝĐƌĞŝŶĨŽƌĐĞŵĞŶƚƚŽŚĞůƉǁŝƚŚĐŽŵƉůŝĂŶĐĞ ĚĚŵĞĚŝĐĂƚŝŽŶŝĨŶŽƌĞƐƉŽŶƐĞĂĨƚĞƌϮͲϰǁĞĞŬƐŽƌƉĂƌƚŝĂůƌĞƐƉŽŶƐĞĂĨƚĞƌϰͲϳǁĞĞŬƐ ZĞƐĞĂƌĐŚůŽŽŬŝŶŐĂƚĂƵŐŵĞŶƚŝŶŐdǁŝƚŚͲǇĐůŽƐĞƌŝŶĞ ;ƉĂƌƚŝĂůŐůƵƚĂŵĂƚĞĂŐŽŶŝƐƚͿ

dƌĞĂƚŵĞŶƚʹ ^ĞƌŽƚŽŶŝŶZĞƵƉƚĂŬĞ/ŶŚŝďŝƚŽƌƐ dƌĞĂƚŵĞŶƚͲ ^^Z/Ɛ

ůŽŵŝƉƌĂŵŝŶĞ ^ƚĂƌƚůŽǁ͕ŐŽƐůŽǁ ƐŝŐŶŝĨŝĐĂŶƚůǇƐƵƉĞƌŝŽƌƚŽƉůĂĐĞďŽĂŶĚŽƚŚĞƌdƐ͕ŵŽĚĞƌĂƚĞŝŵƉƌŽǀĞŵĞŶƚŝŶϳϱйďǇǁĞĞŬϱ &ĂŝƌƚƌŝĂů͗ĂĚĞƋƵĂƚĞĚŽƐĞĨŽƌϭϬͲϭϮǁĞĞŬƐ͘DĂŶǇĚŽŶŽǁƐŚŽǁƌĞƐƉŽŶƐĞĨŽƌϲͲϭϬǁĞĞŬƐ͘DŽƐƚĐĂƐĞƐĐŽŶƚŝŶƵĞƚŽ ŽƐĞ͗ϯŵŐͬŬŐƉĞƌĚĂǇĨŽƌϯŵŽŶƚŚƐEdϱŵŐͬŬŐŽƌϮϱϬŵŐͬĚĂǇĚƵĞƚŽƌŝƐŬŽĨƚŽǆŝĐŝƚǇ͕<'ĐŚĂŶŐĞƐ͕ĂŶĚƐĞŝǌƵƌĞƐ ŝŵƉƌŽǀĞĚƵƌŝŶŐƚŚĞĨŝƌƐƚϯŵŽŶƚŚƐ ^ŝĚĞĞĨĨĞĐƚƐ͗ĂŶƚŝĐŚŽůŝŶĞƌŐŝĐ͕ĂŶƚŝŚŝƐƚĂŵŝŶŝĐ ^^Z/Ɛʹ ĨŝƌƐƚůŝŶĞƚƌĞĂƚŵĞŶƚ &ĂŝůƵƌĞƚŽƌĞƐƉŽŶĚƚŽŽŶĞ^^Z/ĚŽĞƐŶŽƚƉƌĞĚŝĐƚƌĞƐƉŽŶĚƚŽĂŶŽƚŚĞƌ^^Z/ ^ĞƌƚƌĂůŝŶĞ͕ĨůƵǀŽǆĂŵŝŶĞ͕ĨůƵŽǆĞƚŝŶĞĂƌĞ&ͲĂƉƉƌŽǀĞĚ ^ǁŝƚĐŚĂĨƚĞƌϭϬͲϭϮǁĞĞŬƐ͕ƐǁŝƚĐŚĂŐĂŝŶƚŽĂŶŽƚŚĞƌ^^Z/ŽƌůŽŵŝƉƌĂŵŝŶĞ EŽĚĂƚĂƚŽĐŽŵƉĂƌĞĞĨĨŝĐĂĐǇ͘WŝĐŬďĂƐĞĚŽŶƐŝĚĞĞĨĨĞĐƚƉƌŽĨŝůĞĂŶĚĐŽŵŽƌďŝĚŝƚŝĞƐ EŽĚĂƚĂƚŽĐŽŵƉĂƌĞƐǁŝƚĐŚŝŶŐǁŝƚŚĂƵŐŵĞŶƚĂƚŝŽŶ &ůƵŽǆĞƚŝŶĞ͗ƐƚĞĂĚǇƐƚĂƚĞŝƐŶŽƚƌĞĂĐŚĞĚĨŽƌϮͲϯǁĞĞŬƐĂŶĚŶŽƚĐŽŵƉůĞƚĞůǇĞůŝŵŝŶĂƚĞĚĨŽƌƵƉƚŽϲǁĞĞŬƐʹ ĂǀĂŝůĂďůĞŝŶ ^ƵďƐƚĂŶƚŝĂůŶƵŵďĞƌŽĨƉĂƚŝĞŶƚƐĚŽŶŽƚƌĞƐƉŽŶĚŽƌŚĂǀĞƌĞƐŝĚƵĂůƐǇŵƉƚŽŵƐ ůŝƋƵŝĚĨŽƌŵ WƌĞĚŝĐƚŽƌƐŽĨƌĞƐƉŽŶƐĞŝƐůĂƌŐĞůǇƵŶŬŶŽǁŶ ^ŝĚĞĞĨĨĞĐƚƐ͗ŶĂƵƐĞĂ͕ŚĞĂĚĂĐŚĞ͕ƚƌĞŵŽƌ͕'/ĐŽŵƉůĂŝŶƚƐ͕ĚƌŽǁƐŝŶĞƐƐ͕ŝŶƐŽŵŶŝĂ͕ĂŬĂƚŚŝƐŝĂ͕ĚŝƐŝŶŚŝďŝƚŝŽŶ͕ĂŐŝƚĂƚŝŽŶ͕ ŚǇƉŽŵĂŶŝĂ͕͞ĨƌŽŶƚĂůůŽďĞƐǇŶĚƌŽŵĞ͗͟ĂƉĂƚŚǇĂŶĚͬŽƌĚŝƐŝŶŚŝďŝƚŝŽŶ͕ŽĐĐĂƐŝŽŶĂůůǇǁŽƌƐĞŶƚŝĐƐ /ŶĚŝǀŝĚƵĂůƐǁŝƚŚĐŽŵŽƌďŝĚŽƌĨĂŵŝůǇŚŝƐƚŽƌǇŽĨƚŝĐĚŝƐŽƌĚĞƌŵĂǇŶŽƚƌĞƐƉŽŶĚĂƐǁĞůůƚŽƚŚĞ^^Z/Ɛ :ŝƚƚĞƌŝŶĞƐƐƐǇŶĚƌŽŵĞŵĂǇŐŽĂǁĂǇĂĨƚĞƌϭϬĚĂǇƐ

dƌĞĂƚŵĞŶƚͲ ƵŐŵĞŶƚĂƚŝŽŶ dƌĞĂƚŵĞŶƚͲ DĂŝŶƚĞŶĂŶĐĞ

ƵŐŵĞŶƚĂƚŝŽŶŝƐƌĞƐĞƌǀĞĚĨŽƌƚƌĞĂƚŵĞŶƚƌĞƐŝƐƚĂŶƚĐĂƐĞƐ EŽĐůĞĂƌƚŝŵĞ;ϭϮͲϭϴŵŽŶƚŚƐĨŽůůŽǁŝŶŐƐĂƚŝƐĨĂĐƚŽƌǇƌĞƐƉŽŶƐĞͿ dƌĞĂƚŵĞŶƚƌĞƐŝƐƚĂŶƚ͗ĨĂŝůƵƌĞƚŽƌĞƐƉŽŶĚƚŽĂƚůĞĂƐƚϮŵŽŶŽƚŚĞƌĂƉŝĞƐĂƐǁĞůůĂƐĐŽŵďŝŶĞĚƚƌĞĂƚŵĞŶƚǁŝƚŚĂƚůĞĂƐƚ WĞƌŝŽĚŝĐĚŝƐĐŽŶƚŝŶƵĂƚŝŽŶƚƌŝĂůƐĂƌĞĂĚǀŝƐĂďůĞ;ĚĞĐƌĞĂƐĞďǇϮϱйƋϮŵŽŶƚŚƐͿ͕ďƵƚŵĂŶǇƌĞƐƉŽŶĚĞƌƐƌĞƋƵŝƌĞŽŶŐŽŝŶŐ ƉĞƌƐŝƐƚĞŶƚŵŽĚĞƌĂƚĞƐǇŵƉƚŽŵƐ ŵĂŝŶƚĞŶĂŶĐĞƚƌĞĂƚŵĞŶƚ ƵŐŵĞŶƚĂƚŝŽŶŽƉƚŝŽŶƐ͗ ŽƵďůĞďůŝŶĚĚŝƐĐŽŶƚŝŶƵĂƚŝŽŶƐƚƵĚǇ͕ϴϵйŽĨĐŚŝůĚƌĞŶĂŶĚĂĚŽůĞƐĐĞŶƚƉĂƚŝĞŶƚƐǁŝƚŚĚƌĂǁŶĨƌŽŵůŽŶŐƚĞƌŵ ůŽŵŝƉƌĂŵŝŶĞн^^Z/͗ŚĞĐŬ<'͕ǁĂƚĐŚĨŽƌĚƌƵŐͲĚƌƵŐŝŶƚĞƌĂĐƚŝŽŶƐ;ŵŽŶŝƚŽƌĐůŽŵŝƉƌĂŵŝŶĞůĞǀĞůͿ ĐůŽŵŝƉƌĂŵŝŶĞƌĞůĂƉƐĞĚǁŝƚŚŝŶϮŵŽŶƚŚƐ͕ĐŽŵƉĂƌĂďůĞƌĂƚĞŽďƐĞƌǀĞĚŝŶĂĚƵůƚƐǁŝƚŚŝŶϳͲϭϮǁĞĞŬƐĨƌŽŵĐůŽŵŝƉƌĂŵŝŶĞ ůŽŶĂǌĞƉĂŵǁĂƐĨŽƵŶĚƚŽďĞƐƵƉĞƌŝŽƌƚŽƉůĂĐĞďŽŝŶĂĚƵůƚƐ͘ĞŵŝŶĚĨƵůŽĨƚŚĞĂƐƐŽĐŝĂƚĞĚƌŝƐŬŽĨǁŝƚŚĚƌĂǁĂů͕ ŽƌĨůƵǀŽǆĂŵŝŶĞ ĚĞƉĞŶĚĞŶĐǇ͕ĂŶĚĚŝƐŝŶŚŝďŝƚŝŽŶ dŵĂǇĚĞĐƌĞĂƐĞƚŚĞŶĞĞĚĨŽƌůŽŶŐƚĞƌŵƉŚĂƌŵĂĐŽƚŚĞƌĂƉǇ͘ŽďŽŽƐƚĞƌƐĞƐƐŝŽŶƐŽƌŝŶƚƌŽĚƵĐĞdŝĨƐǇŵƉƚŽŵƐ ^^Z/ƐнŶƚŝƉƐǇĐŚŽƚŝĐƐǁĞƌĞĨŽƵŶĚƚŽďĞƐƵƉĞƌŝŽƌƚŽƉůĂĐĞďŽŝŶĂĚƵůƚƐ͘ĂƌĞĨƵůůǇĂƐƐĞƐƐƌŝƐŬƐͬďĞŶĞĨŝƚƐ ǁŽƌƐĞŶǁŝƚŚŵĞĚŝĐĂƚŝŽŶƚĂƉĞƌ ŽŶŽƚƐƚŽƉĂďƌƵƉƚůǇ͗'/ĚŝƐƚƵƌďĂŶĐĞ͕,͕ĚŝǌǌŝŶĞƐƐ͕ŵĂůĂŝƐĞ͕ŝŶƐŽŵŶŝĂ KĐŽŵŽƌďŝĚǁŝƚŚďŝƉŽůĂƌĚŝƐŽƌĚĞƌ͗ĨŽĐƵƐŽŶƚƌĞĂƚŝŶŐŵŽŽĚĞƉŝƐŽĚĞƐĨŝƌƐƚ DŽŶŝƚŽƌďŽƚŚƉĂƚŝĞŶƚĂŶĚƉĂƚĞŶƚƌĞƉŽƌƚ KĂŶĚ,͗ĨŽĐƵƐŽŶƚƌĞĂƚŝŶŐKĨŝƌƐƚ͘ŽŶƐŝĚĞƌĂůƉŚĂͲϮĂŐŽŶŝƐƚƐ͕ĂƚŽŵŽǆĞƚŝŶĞ͕ďƵƉƌŽƉŝŽŶĨŽƌ, WĞƌŝŽĚŝĐĂůůǇŵŽŶŝƚŽƌĨŽƌĐŽŵŽƌďŝĚŝƚŝĞƐ KĂŶĚdŝĐƐ͗ĐŽŶƐŝĚĞƌĂƵŐŵĞŶƚĂƚŝŽŶǁŝƚŚĂŶƚŝƉƐǇĐŚŽƚŝĐƐ͕ĐůŽŶŝĚŝŶĞ͕ĐůŽŵŝƉƌĂŵŝŶĞ͘DŽŶŝƚŽƌYdĐ KƚŚĞƌƚƌĞĂƚŵĞŶƚƐ WĞĚŝĂƚƌŝĐKdƌĞĂƚŵĞŶƚ^ƚƵĚǇ;WKd^Ϳ

WŽƚĞŶƚŝĂůƉŚĂƌŵĂĐŽůŽŐŝĐĂůƚƌĞĂƚŵĞŶƚƐŝŶĐůƵĚĞƌŝůƵǌŽůĞ ;ĂŶƚŝͲŐůƵƚĂŵĂƚĞƌŐŝĐĚƌƵŐͿ͕ͲĐǇĐůŽƐĞƌŝŶĞ ĂƐĂŶĂĚũƵŶĐƚƚŽ 'ŽĂů͗dŽĞǀĂůƵĂƚĞƚŚĞĞĨĨŝĐĂĐǇŽĨdĂůŽŶĞ͕ƐĞƌƚƌĂůŝŶĞĂůŽŶĞ͕ŽƌdĂŶĚƐĞƌƚƌĂůŝŶĞĐŽŵďŝŶĞĚ͕ĂƐŝŶŝƚŝĂůƚƌĞĂƚŵĞŶƚ ĨŽƌĐŚŝůĚƌĞŶĂŶĚĂĚŽůĞƐĐĞŶƚƐǁŝƚŚK͘ d͕ŬĞƚĂŵŝŶĞĂŶĚŵĞŵĂŶƚŝŶĞ͘ ƉƌŽƉŚǇůĂĐƚŝĐĂŶƚŝďŝŽƚŝĐƐ ĞƐŝŐŶ͕ƐĞƚƚŝŶŐ͕ĂŶĚƉĂƌƚŝĐŝƉĂŶƚƐ͗dŚĞWĞĚŝĂƚƌŝĐKdƌĞĂƚŵĞŶƚ^ƚƵĚǇ͕ĂďĂůĂŶĐĞĚ͕ŵĂƐŬĞĚƌĂŶĚŽŵŝǌĞĚĐŽŶƚƌŽůůĞĚ ƚƌŝĂůĐŽŶĚƵĐƚĞĚŝŶϯĂĐĂĚĞŵŝĐĐĞŶƚĞƌƐŝŶƚŚĞhŶŝƚĞĚ^ƚĂƚĞƐĂŶĚĞŶƌŽůůŝŶŐĂǀŽůƵŶƚĞĞƌŽƵƚƉĂƚŝĞŶƚƐĂŵƉůĞŽĨϭϭϮ /s/'͕ƉůĂƐŵĂƉŚĞƌĞƐŝƐ ƉĂƚŝĞŶƚƐĂŐĞĚϳƚŚƌŽƵŐŚϭϳǇĞĂƌƐǁŝƚŚĂƉƌŝŵĂƌǇŝĂŐŶŽƐƚŝĐĂŶĚ^ƚĂƚŝƐƚŝĐĂůDĂŶƵĂůŽĨDĞŶƚĂůŝƐŽƌĚĞƌƐ͕&ŽƵƌƚŚ ĚŝƚŝŽŶĚŝĂŐŶŽƐŝƐŽĨKĂŶĚĂŚŝůĚƌĞŶΖƐzĂůĞͲƌŽǁŶKďƐĞƐƐŝǀĞͲŽŵƉƵůƐŝǀĞ^ĐĂůĞ;zͲK^ͿƐĐŽƌĞŽĨϭϲŽƌŚŝŐŚĞƌ͘ WĂƚŝĞŶƚƐǁĞƌĞƌĞĐƌƵŝƚĞĚďĞƚǁĞĞŶ^ĞƉƚĞŵďĞƌϭϵϵϳĂŶĚĞĐĞŵďĞƌϮϬϬϮ͘ ^ƚƵĚŝĞĚŝŶĂĚƵůƚƐďƵƚŶŽƚĐŚŝůĚƌĞŶ͗ /ŶƚĞƌǀĞŶƚŝŽŶƐ͗WĂƌƚŝĐŝƉĂŶƚƐǁĞƌĞƌĂŶĚŽŵůǇĂƐƐŝŐŶĞĚƚŽƌĞĐĞŝǀĞdĂůŽŶĞ͕ƐĞƌƚƌĂůŝŶĞĂůŽŶĞ͕ĐŽŵďŝŶĞĚdĂŶĚ /sůŽŵŝƉƌĂŵŝŶĞ ƐĞƌƚƌĂůŝŶĞ͕ŽƌƉŝůůƉůĂĐĞďŽĨŽƌϭϮǁĞĞŬƐ͘ WƐǇĐŚŽƐƵƌŐĞƌǇ͗ĞĞƉƌĂŝŶ^ƚŝŵƵůĂƚŝŽŶ DĂŝŶŽƵƚĐŽŵĞŵĞĂƐƵƌĞƐ͗ŚĂŶŐĞŝŶzͲK^ƐĐŽƌĞŽǀĞƌϭϮǁĞĞŬƐĂƐƌĂƚĞĚďǇĂŶŝŶĚĞƉĞŶĚĞŶƚĞǀĂůƵĂƚŽƌŵĂƐŬĞĚ dƌĂŶƐĐƌĂŶŝĂůŵĂŐŶĞƚŝĐƐƚŝŵƵůĂƚŝŽŶ ƚŽƚƌĞĂƚŵĞŶƚƐƚĂƚƵƐ͖ƌĂƚĞŽĨĐůŝŶŝĐĂůƌĞŵŝƐƐŝŽŶĚĞĨŝŶĞĚĂƐĂzͲK^ƐĐŽƌĞůĞƐƐƚŚĂŶŽƌĞƋƵĂůƚŽϭϬ͘ ZĞƐƵůƚƐ͗ŽŵďŝŶĞĚƚƌĞĂƚŵĞŶƚƉƌŽǀĞĚƐƵƉĞƌŝŽƌƚŽdĂůŽŶĞĂŶĚƚŽƐĞƌƚƌĂůŝŶĞĂůŽŶĞ͕ǁŚŝĐŚĚŝĚŶŽƚĚŝĨĨĞƌ ĨƌŽŵĞĂĐŚŽƚŚĞƌ͘^ŝƚĞĚŝĨĨĞƌĞŶĐĞƐĞŵĞƌŐĞĚĨŽƌdĂŶĚƐĞƌƚƌĂůŝŶĞďƵƚŶŽƚĨŽƌĐŽŵďŝŶĞĚƚƌĞĂƚŵĞŶƚ͕ ƐƵŐŐĞƐƚŝŶŐƚŚĂƚĐŽŵďŝŶĞĚƚƌĞĂƚŵĞŶƚŝƐůĞƐƐƐƵƐĐĞƉƚŝďůĞƚŽƐĞƚƚŝŶŐͲƐƉĞĐŝĨŝĐǀĂƌŝĂƚŝŽŶƐ͘

WKd^ WĞĚŝĂƚƌŝĐKdƌĞĂƚŵĞŶƚ^ƚƵĚǇͲWŚĂƐĞ//

dŚĞƌĂƚĞŽĨĐůŝŶŝĐĂůƌĞŵŝƐƐŝŽŶĨŽƌĐŽŵďŝŶĞĚƚƌĞĂƚŵĞŶƚǁĂƐϱϯ͘ϲй͖ĨŽƌdĂůŽŶĞ͕ϯϵ͘ϯй͖ĨŽƌƐĞƌƚƌĂůŝŶĞĂůŽŶĞ͕ KďũĞĐƚŝǀĞ͗dŽĞǆĂŵŝŶĞƚŚĞĞĨĨĞĐƚƐŽĨĂƵŐŵĞŶƚŝŶŐ^Z/ƐǁŝƚŚdŽƌĂďƌŝĞĨĨŽƌŵŽĨd Ϯϭ͘ϰй͖ĂŶĚĨŽƌƉůĂĐĞďŽ͕ϯ͘ϲй͘ ĞƐŝŐŶ͕ƐĞƚƚŝŶŐ͕ĂŶĚƉĂƌƚŝĐŝƉĂŶƚƐ͗ϭϮͲǁĞĞŬƌĂŶĚŽŵŝǌĞĚĐŽŶƚƌŽůůĞĚƚƌŝĂůĐŽŶĚƵĐƚĞĚĂƚϯĂĐĂĚĞŵŝĐŵĞĚŝĐĂůĐĞŶƚĞƌƐ ďĞƚǁĞĞŶϮϬϬϰĂŶĚϮϬϬϵ͕ŝŶǀŽůǀŝŶŐϭϮϰƉĞĚŝĂƚƌŝĐŽƵƚƉĂƚŝĞŶƚƐďĞƚǁĞĞŶƚŚĞĂŐĞƐŽĨϳĂŶĚϭϳǇĞĂƌƐǁŝƚŚKĂƐĂƉƌŝŵĂƌǇ ĚŝĂŐŶŽƐŝƐĂŶĚĂzͲK^ƐĐŽƌĞŽĨϭϲŽƌŚŝŐŚĞƌĚĞƐƉŝƚĞĂŶĂĚĞƋƵĂƚĞ^Z/ƚƌŝĂů͘ /ŶƚĞƌǀĞŶƚŝŽŶƐ͗WĂƌƚŝĐŝƉĂŶƚƐǁĞƌĞƌĂŶĚŽŵůǇĂƐƐŝŐŶĞĚƚŽϭŽĨϯƚƌĞĂƚŵĞŶƚƐƚƌĂƚĞŐŝĞƐ͗DD;ϳƐĞƐƐŝŽŶƐͿ͕DDн/Ͳd;ϳ ƐĞƐƐŝŽŶƐͿ͕DDнd;ϳƐĞƐƐŝŽŶƐŽĨDDƉůƵƐϭϰĐŽŶĐƵƌƌĞŶƚƐĞƐƐŝŽŶƐŽĨdͿ͘/ŶĐŽŶƚƌĂƐƚƚŽd͕/ͲdĚŝĚŶŽƚŝŶĐůƵĚĞ͗;ϭͿ ƚŚĞƌĂƉŝƐƚͲĂƐƐŝƐƚĞĚĞǆƉŽƐƵƌĞ͖;ϮͿŝŵĂŐŝŶĂůĞǆƉŽƐƵƌĞ͖ĂŶĚ;ϯͿĚŝĚĂĐƚŝĐƉĂƌĞŶƚƐĞƐƐŝŽŶƐ͘ DĂŝŶŽƵƚĐŽŵĞŵĞĂƐƵƌĞƐ͗ZĞƐƉŽŶĚĞƌƐƚĂƚƵƐĂƐĚĞĨŝŶĞĚĂƐĂƉŽƐƚͲƚƌĞĂƚŵĞŶƚzͲK^ƌĞĚƵĐƚŝŽŶŽĨϯϬйŽƌŐƌĞĂƚĞƌ ĐŽŵƉĂƌĞĚƚŽďĂƐĞůŝŶĞ͖ĐŚĂŶŐĞŝŶĐŽŶƚŝŶƵŽƵƐzͲK^ƚŽƚĂůƐĐŽƌĞŽǀĞƌϭϮǁĞĞŬƐ͘ ZĞƐƵůƚƐ͗DDнdǁĂƐƐƵƉĞƌŝŽƌƚŽDDĂŶĚƚŽDDн/ͲdŽŶĂůůŽƵƚĐŽŵĞŵĞĂƐƵƌĞƐ͘ /ŶƚŚĞƉƌŝŵĂƌǇ/ddĂŶĂůǇƐŝƐ͕ϲϴ͘ϲйŝŶDDнdǁĞƌĞĐŽŶƐŝĚĞƌĞĚƌĞƐƉŽŶĚĞƌƐ͕ǁŚŝĐŚǁĂƐƐŝŐŶŝĨŝĐĂŶƚůǇďĞƚƚĞƌƚŚĂŶƚŚĞϯϰ͘ϬйŝŶDDн/Ͳ d͕ĂŶĚϯϬ͘ϬйŝŶDD͘ EEdǁŝƚŚDDнdǀĞƌƐƵƐDDƚŽƐĞĞŽŶĞĂĚĚŝƚŝŽŶĂůZ^WKE^ĂƚtĞĞŬϭϮ͕ŽŶĂǀĞƌĂŐĞ͕ǁĂƐĞƐƚŝŵĂƚĞĚĂƐϯ͖ĨŽƌDDнdǀĞƌƐƵƐ DDн/ͲdƚŚĞEEdǁĂƐĂůƐŽĞƐƚŝŵĂƚĞĚĂƐϯ͖ĨŽƌDDн/ͲdǀĞƌƐƵƐDDƚŚĞEEdǁĂƐĞƐƚŝŵĂƚĞĚĂƐϮϱ͘ ŽŶĐůƵƐŝŽŶƐ͗ŵŽŶŐƉĂƚŝĞŶƚƐĂŐĞĚϳƚŽϭϳǇĞĂƌƐǁŝƚŚKĂŶĚƉĂƌƚŝĂůƌĞƐƉŽŶƐĞƚŽ^Z/ƵƐĞ͕ƚŚĞĂĚĚŝƚŝŽŶŽĨdƚŽ ŵĞĚŝĐĂƚŝŽŶŵĂŶĂŐĞŵĞŶƚĐŽŵƉĂƌĞĚǁŝƚŚŵĞĚŝĐĂƚŝŽŶŵĂŶĂŐĞŵĞŶƚĂůŽŶĞƌĞƐƵůƚĞĚŝŶĂƐŝŐŶŝĨŝĐĂŶƚůǇŐƌĞĂƚĞƌƌĞƐƉŽŶƐĞƌĂƚĞ͕ ǁŚĞƌĞĂƐĂƵŐŵĞŶƚĂƚŝŽŶŽĨŵĞĚŝĐĂƚŝŽŶŵĂŶĂŐĞŵĞŶƚǁŝƚŚƚŚĞĂĚĚŝƚŝŽŶŽĨŝŶƐƚƌƵĐƚŝŽŶƐŝŶdĚŝĚŶŽƚ͘

WKd^Ͳ// ŽŽŬZĞĐŽŵŵĞŶĚĂƚŝŽŶ

dĂůŬŝŶŐďĂĐŬƚŽKʹ :ŽŚŶDĂƌĐŚ tŚĂƚƚŽĚŽǁŚĞŶǇŽƵƌďƌĂŝŶŐĞƚƐƐƚƵĐŬʹ ĂǁŶ,ƵĞďŶĞƌ hƉĂŶĚŽǁŶƚŚĞǁŽƌƌǇŚŝůůʹ ƵƌĞĞŶ WŝŶƚŽtĂŐŶĞƌ tŚĂƚƚŽĚŽǁŚĞŶǇŽƵƌĐŚŝůĚŚĂƐKďƐĞƐƐŝǀĞͲŽŵƉƵůƐŝǀĞŝƐŽƌĚĞƌʹ ƵƌĞĞŶ tĂŐŶĞƌ ^ƚĂŶĚŝŶŐhƉƚŽKǁŽƌŬďŽŽŬĨŽƌŬŝĚƐʹ dǇƐŽŶZƵĞƚĞƌ dŚĞdǁŽƌŬďŽŽŬĨŽƌdĞĞŶƐǁŝƚŚKʹ ƵƌŝƚĂ KŶĂ &ƌĞĞŝŶŐǇŽƵƌĐŚŝůĚĨƌŽŵKʹ dĂŵĂƌŚĂŶƐŬǇ dƵƌƚůĞƐĂůůƚŚĞǁĂǇĚŽǁŶʹ :ŽŚŶ'ƌĞĞŶ hŶĚĞƌZŽƐĞͲdĂŝŶƚĞĚ^ŬŝĞƐʹ >ŽƵŝƐĞ'ŽƌŶĂůů ǀĞƌǇƚŚŝŶŐŝƐĂŶŵĞƌŐĞŶĐǇʹ :ĂƐŽŶĚĂŵ<ĂƚǌĞŶƐƚĞŝŶ ZĞĨĞƌĞŶĐĞƐ

ŵĞƌŝĐĂŶĐĂĚĞŵǇŽĨŚŝůĚĂŶĚĚŽůĞƐĐĞŶƚWƐǇĐŚŝĂƚƌǇWƌĂĐƚŝĐĞWĂƌĂŵĞƚĞƌƐĨŽƌƚŚĞĂƐƐĞƐƐŵĞŶƚĂŶĚƚƌĞĂƚŵĞŶƚŽĨ ĐŚŝůĚƌĞŶĂŶĚĂĚŽůĞƐĐĞŶƚƐǁŝƚŚŽďƐĞƐƐŝǀĞͲĐŽŵƉƵůƐŝǀĞĚŝƐŽƌĚĞƌ͘:ŵĐĂĚ ŚŝůĚĚŽůĞƐĐ WƐǇĐŚŝĂƚƌǇϱϭ;ϭͿ͗ϵϴͲϭϭϯ͕ ϮϬϭϮ ŵĞƌŝĐĂŶWƐǇĐŚŝĂƚƌŝĐƐƐŽĐŝĂƚŝŽŶ͗ŝĂŐŶŽƐƚŝĐĂŶĚ^ƚĂƚŝƐƚŝĐĂůDĂŶƵĂůŽĨDĞŶƚĂůŝƐŽƌĚĞƌƐ͕ϱƚŚ ĚŝƚŝŽŶ͘ƌůŝŶŐƚŽŶ͕s͕ ŵĞƌŝĐĂŶWƐǇĐŚŝĂƚƌŝĐƐƐŽĐŝĂƚŝŽŶ͕ϮϬϭϯ ŚŝůĚĂŶĚĚŽůĞƐĐĞŶƚWƐǇĐŚŝĂƚƌǇdŚĞƐƐĞŶƚŝĂůƐ͕ϮŶĚ ĚŝƚŝŽŶ͕ŚĂƉƚĞƌϵ͕ŚĞŶŐ͘< DǇĞƌƐ͘<͕WŚŝůĂĚĞůƉŚŝĂ͕W͕ >ŝƉƉŝŶĐŽƚƚtŝůůŝĂŵƐΘtŝůŬŝŶƐ͕ϮϬϭϮ ƵůĐĂŶ͛Ɛ ƚĞǆƚďŽŽŬŽĨŚŝůĚĂŶĚĚŽůĞƐĐĞŶƚƉƐǇĐŚŝĂƚƌǇ͕ϮŶĚ ĚŝƚŝŽŶ͕ŚĂƉƚĞƌϭϳ͕ƵůĐĂŶ͘D͕ƌůŝŶŐƚŽŶ͕s͕ŵĞƌŝĐĂŶ WƐǇĐŚŝĂƚƌŝĐƐƐŽĐŝĂƚŝŽŶ͕ϮϬϭϱ

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dŚĂŶŬǇŽƵ͊ ƵůůǇŝŶŐ͖ŶŽƚŚĞƌ

ϯƌĚŶŶƵĂůWĞĚŝĂƚƌŝĐDĞŶƚĂů,ĞĂůƚŚ hƉĚĂƚĞ͕DĂƌĐŚϮϬϮϬ

ũŝƚ:ĞƚŵĂůĂŶŝ͕D͘͘ WƌŽĨĞƐƐŽƌĂŶĚŝƌĞĐƚŽƌ ŝǀŝƐŝŽŶŽĨŚŝůĚĂŶĚĚŽůĞƐĐĞŶƚWƐǇĐŚŝĂƚƌǇ͕ KƌĞŐŽŶ,ĞĂůƚŚΘ^ĐŝĞŶĐĞhŶŝǀĞƌƐŝƚǇ

tŚĂƚŝƐďƵůůǇŝŶŐ͍ Information Sources: tŚŽŝƐĂƚƌŝƐŬ

ŽǌĞƌŽƚŽůĞƌĂŶĐĞƉŽůŝĐŝĞƐĂŶĚĞǆƉƵůƐŝŽŶǁŽƌŬ͍ ;,ŝŶƚ͙͘EŽͿ Youth Voice Project (Stan Davis and

^ŚŽƵůĚǀŝĐƚŝŵƐďĞĂƐŬĞĚƚŽΗŵĞĚŝĂƚĞΗǁŝƚŚ Charisse Nixon, Ph.D.) DĂŝŶWŽŝŶƚƐ ďƵůůŝĞƐ;ŚŝŶƚ͘͘͘EŽͿ www.Stopbullying.gov ,ŽǁĚŽǁĞŚĞůƉƚŚĞƚĂƌŐĞƚƐ͕ďǇƐƚĂŶĚĞƌƐĂŶĚ ƉĞƌƉĞƚƌĂƚŽƌƐŽĨďƵůůǇŝŶŐ www.violencepreventionworks.org (Dan Olweus, PhD) ,ŽǁĐĂŶǇŽƵŝĚĞŶƚŝĨǇǀŝĐƚŝŵƐŝŶǇŽƵƌŽĨĨŝĐĞ

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:$7&+(' %((1$ %((1$ %8//<,1* 7$5*(7$1' %8//< %<67$1'(5 25 ModesofBullying Types: Physical: hitting kicking spitting pushing…

Verbal: taunting, name calling, verbal 'LUHFW ,QGLUHFW threats of harm, sexual comments $JJUHVVLYHEHKDYLRUWKDWLVIDFH %HKLQGWKHVFHQHV WRIDFH Relational: Social isolation, rumors, posting embarrassing information \ images. Studentswhoarebulliedmay: StudentsWhoBullyMay:

Have damaged clothing Have positive attitude towards violence Have unexpected cuts and bruises Strong need to dominate Have few friends Seem afraid to go to school Impulsive, aggressive, reactive Take the long way to school Lack empathy Lose interest or begin to do poorly in school Defiance towards adults Seem sad and moody Involved in other antisocial behavior Frequent headaches abdominal pain Bad dreams and trouble sleeping Tend to be stronger and larger Loss of weight Be more likely to report access to guns. Seem anxious and have low self-esteem

www.violencepreventionworks.org www.violencepreventionworks.org

StanDavisandCharisseNixon,Ph.D. YouthVoiceProject 2007 StanDavisandCharisseNixon,Ph.D. 11,893 youth in 5th YouthVoiceProject 2007 to 12th grade completed a survey.

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EFFECTS OF BULLYING

BULLYINGISVIOLENCEANDCANBECOME HowMuchAreStudentsEffectedby ANADVERSECHILDHOODEXPERIENCEFOR Bullying ALLINVOLVED (StanDavisandCharisseNixon,Ph.D.YouthVoiceProject)

0LOG:KDWWKH\GLGERWKHUHGPHRQO\DOLWWOH Exposure to toxic stress in the absence of supportive relationships can lead to ACE’s 0RGHUDWH,WERWKHUHGPHTXLWHDELW and related sequelae

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PROTECTIVE FACTORS

WhichStrategiesmadethings BetterorWorse? StanDavisandCharisseNixon,Ph.D. STRATEGIESINTHESCHOOLS YouthVoiceProject Told an adult at home Told an adult at school Made a joke about it Told a friend(s) Hit them or fought them Made plans to get back at them Reminded myself that it's not my fault Walked away Told the person how I felt Told the person or people to stop Did nothing Pretended it didn't bother me TheOlweusBullyingPrevention Program(OBPP) “OBPP was successful in reducing all forms of being bullied and bullying others—verbal, physical, indirect, sexual, and electronic/cyberbullying”.

Olweus, D., Limber, S.P. & Breivik, K. Addressing Specific Forms of Bullying: A Large-Scale Evaluation of the Olweus Bullying Prevention Program. Int Journal of Bullying Prevention 1, 70– 84 (2019).

OlweusKeyComponents OlweusBullyingPrevention School-Level ProgramResultsover1schoolyear ± Committee,trainings,questionnaire,introduce rules,kickoff Olweus, D. (2005). A useful evaluation design, and effects of the Olweus Bullying Prevention Program. Psychology, Crime Classroom Level & Law, 11, 389-402 Olweus, D. (2007). ± Postrules,regularclassmeetingswithstudents andparents Percent Victims: reduced by Individual Level 42% (to 8.3%) ± Supervisestudents,interveneimmediately,meet withstudentsandparents,individualintervention Percent Bullies: reduced by plans 52% (to 3.1%) Community level ± Committeeparticipation,spreadmessagesand principles. www.violencepreventionworks.org

OBPPReductioninBullyingOver8 Months Olweus,D.,Limber,S.P.&Breivik,K.AddressingSpecificFormsofBullying:ALargeŊScaleEvaluationofthe Summary:WhatMakesThings OlweusBullyingPreventionProgram. IntJournalofBullyingPrevention 1, 70–84(2019). Better

accessing support IURPSHHUVDQGDGXOWV ZDVWKHPRVWKHOSIXO VWUDWHJ\WRPDNHWKLQJV EHWWHU “SCHOOLTOPRISONPIPELINE”

Expellingyouthleadstofurtherrisksof functionalandemotionaldeterioration, communityaggression/revenge fantasiesandactions,completed suicideandimprisonment.

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AdditionalWaystoMakes ThingsWorse Youth in special education, youth of color (except for Asian American youth), and males reported that adults told them not to tattle more often than did youth not in special education, white or female students. Interviewstrategies InYourOffice

Ask about Bullying When: (PSDWKHWLF/LVWHQLQJ Unexplained somatic concerns School Avoidance 3UDLVH Symptoms of Depression Symptoms of Anxiety

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Interview

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ResourcesfromScreenagersfor YouthandParents https://www.screenagersmovie.com/antibullyingŊcampaigns

Pacer.org socialmediahelpline.com Thetrevorproject.com itgetsbetter.org loveislouder.com

dŚĂŶŬǇŽƵ LearningDisorders:What arethey,whenshouldyou beconcerned,andwhat Nofinancialdisclosuresorconflicts Disclosures canyourecommend ofinterest

KristenMackiewiczSeghete,PhD AssistantProfessor DepartmentofPsychiatry OHSU

1) UnderstandtheDSMǦ5 definitionofaSpecificLearning Disorder(SLD)andDSMǦ5 criteriaforaSLD

2) IdentifypotentialsignsofaSLD 1) UnderstandtheDSMǦ5 Learning inyourpatientsatdifferentages Learning definitionofaSpecificLearning andappropriatefollowǦup Objectives referrals Objectives Disorder(SLD)andDSMǦ5 criteriaforaSLD 3) Understanddifferentevaluation processesandidentifywhatyou asaproviderandyourpatient (family)canexpecttoreceive fromanevaluation

“Specificlearningdisorder,asthe nameimplies,isdiagnoseswhen therearespecificdeficitsinan individual’sabilitytoperceiveor A) Persistent(>6months)difficulty processinformationefficientlyand Diagnostic acquiringkeystoneacademic DSMǦ5 accurately…andischaracterizedby Criteria skills persistentandimpairingdifficulties withlearningfoundational academicskillsinreading,writing, and/ormath.”

APA.(2013).DSMǦ5.pg.32. Reading x Delayedsitewordlearning x Effortfulreading x Omissions,guessing,transposing A) Persistent(>6months)difficulty x Blends acquiringkeystoneacademic x Comprehension skills Math x Memorizingmathfacts Diagnostic B) Academicskillsaresubstantially Examples x Numbersense Criteria (andquantifiably)below x Procedures expectedlevels x Reasoning/storyproblems x Functionalacademics C) Apparentinearlyschoolyears Writing D) Learningdifficultiesarespecific x Spelling (unexpectedunderachievement) x Grammar x Capitalization,spacing,alignment

Coredeficitsmaycontributeto specificacademicdifficultiesin multipledomains

Learning 2)IdentifypotentialsignsofaSLD RootCause Objectives inyourpatientsatdifferentages andappropriatefollowǦup referrals

Notformallydiagnosableuntilsome x Difficultylearningand/orfollowing formalacademictraining rhyminggames x Unabletolearnthealphabet,names ofletters,orsoundsofletters However,manychildrencanshow Preschool Developmental earlywarningsigns Warning x Strugglestolearnroteinformation Course Signs* (e.g.,daysoftheweek) x Difficultylearningtocount x Frequentlymispronouncewords x Poorgraphomotorskills

*Thesearenotpredictiveandcanbepresentwithinnormaldevelopmentaswell x Unabletolearnsitewords x Transposinglettersandnumbers x Unabletolearntowritewords–even Symptomswillemergemore whencopyingdirectly prominentlyinkindergarten,which x Unabletosoundoutshortwords willresultinextrasupports,a“wait Developmental andsee”response,orgounnoticed Kindergarten x Continuedstrugglestolearngrowing Course Signs* roteinformation x Resistancetoreadingand/orwriting work x Difficultydecipheringwrittenwork x Notabletomasternumericalsense x Poormathreasoning/comprehension

*Thesearenotpredictiveandcanbepresentwithinnormaldevelopmentaswell

x Poorreadingfluency x Continuedtransposing x Substitutionsandomissionscontinue Bymiddleschool,manyadolescents x Maycomprehendwithcontextualcues mayhavemasteredthemore x Poorspelling basic/automaticprocessesbutstill x Difficultywithmemorizing strugglewhentheymustbe multiplicationtablesandlongdivision implementedquicklyorunder Elementary x Rotememorydifficulties Developmental higherdemands Course x Hardtimedefiningvocabularywords Course x Resistancetoschoolwork x Schoolrefusal x Inconsistentcapitalization,punctuation, grammar,andspacing x Hardtimewithconceptualand/or proceduralmath x Misalignmentofwrittenmathproblems

Whattodo 3)Understanddifferentevaluation youdowhen Learning processesandidentifywhatyou youhave Objectives asaproviderandyourpatient concerns? (family)canexpecttoreceive fromanevaluation 1) SchoolEvaluations x 60schooldayrules 2) PsychoeducationalEvaluation x Atschoolsdiscretionwhetherornot x Goodfitwhentheprimary toproceed questionisrelatedtoschool x Schoolselectsappropriate performanceand/orSLD Typesof evaluations Typesof Evaluations: Evaluations: x Typicallyincludesintellectualand x Goal:determinewhetherornot achievementtesting Sch0ol childiseligibleforoneof11IEP Private x Goal:describecognitiveand Evaluations categories(SLDisone)basedon Evaluations standardizedcriteria academicstrengthsand weaknesses x IEP=additionalservices(pullǦouts), specializedlearningcenter,aide, x Providehelpfulrecommendations etc.ANDaccommodations fortheschoolsetting x 504Plan=accommodationsONLY

3) NeuropsychologicalEvaluation x Goodfitwhendifferentialdiagnosisis needed(e.g.,R/OADHD)or presentationismorecomplexdueto medical,psychiatric,and/or Typesof behavioralhistory Evaluations: x Comprehensiveevaluationof Private cognitivefunctioning,notjust Evaluations achievement,includingexecutive function x Goals:1)describecognitivestrengths andweaknesses,2)diagnostics,and 3)providebroaderscopeof recommendations

Questions? 1) UnderstandtheDSMǦ5 definitionofaSpecificLearning Disorder(SLD)andDSMǦ5 criteriaforaSLD 2) IdentifypotentialsignsofaSLD Learning inyourpatientsatdifferentages andappropriatefollowǦup Objectives referrals 3) Understanddifferentevaluation processesandidentifywhatyou asaproviderandyourpatient (family)canexpecttoreceive fromanevaluation [email protected] 'LVFORVXUHV

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ŶŽƌĞǆŝĂEĞƌǀŽƐĂĂƐhŶŚĞĂůƚŚǇŽƉŝŶŐ ŶŽƌĞǆŝĂEĞƌǀŽƐĂǀƐ͘ƵůŝŵŝĂEĞƌǀŽƐĂ ^ƚƌĂƚĞŐǇ hŶĚĞƌǁĞŝŐŚƚǀƐ͘EŽƌŵĂůtĞŝŐŚƚͬKǀĞƌǁĞŝŐŚƚ &ĞĞůƐŝŶĐŽŶƚƌŽů͕ƐĂĨĞ͕ĂĐĐŽŵƉůŝƐŚĞĚ ŐŽƐǇŶƚŽŶŝĐǀƐ͘ŐŽĚǇƐƚŽŶŝĐ DĂůŶƵƚƌŝƚŝŽŶŶƵŵďƐĂŶǆŝĞƚǇ͕ƵŶĐŽŵĨŽƌƚĂďůĞĨĞĞůŝŶŐƐ͕ ĚŝƐƚƌĞƐƐ͕ĞƚĐ͘ KǀĞƌĐŽŶƚƌŽůůĞĚǀƐ͘ǇƐƌĞŐƵůĂƚĞĚ WƚĨĞĞůƐŚĞͬƐŚĞŚĂƐĨŽƵŶĚƚŚĞŝƌŝĚĞŶƚŝƚǇ ůƵƐƚĞƌƉĞƌƐŽŶĂůŝƚǇƚƌĂŝƚƐǀƐ͘ůƵƐƚĞƌ ƉĞƌƐŽŶĂůŝƚǇƚƌĂŝƚƐ ǆĞƌĐŝƐĞŚĂƐďĞĞŶƐĞĞŶ͞ĂŚǇƉŽŵĂŶŝĐĚĞĨĞŶƐĞĂŐĂŝŶƐƚ ĂĨĞĂƌŽĨĚĞƉƌĞƐƐŝŽŶ͕ĂĨŽƌŵŽĨŵĂƐŽĐŚŝƐƚŝĐƐĞůĨͲ /ŶƚƌŽǀĞƌƚĞĚǀƐ͘ǆƚƌŽǀĞƌƚĞĚ ƉƵŶŝƐŚŵĞŶƚ͕ĂŐŽĂůŽƌŝĞŶƚĞĚƉƵƌƐƵŝƚŽĨĂĐŚŝĞǀĞŵĞŶƚ ĞŶǇĨĂŵŝůǇĐŽŶĨůŝĐƚǀƐ͘ǆĂŐŐĞƌĂƚĞ&ĂŵŝůǇĐŽŶĨůŝĐƚ ƐĞƌǀŝŶŐŶĂƌĐŝƐƐŝƐƚŝĐͬĞǆŚŝďŝƚŝŽŶŝƐƚŝĐĐŽŶĐĞƌŶƐ͕ŽƌĂƐĂ ŐĞŶĞƌĂůŵĞĐŚĂŶŝƐŵĨŽƌƌĞŐƵůĂƚŝŶŐƐƵĐŚƚĞŶƐŝŽŶƐƚĂƚĞƐ ĂƐĂŶǆŝĞƚǇ͕ĂŶŐĞƌ͕ĂŶĚƚŚĞůŝŬĞ͟;:ŽŚŶƐŽŶ͕ϭϵϴϰ͕Ɖ͘ϮϰͿ͘

ŶŽƌĞǆŝĂEĞƌǀŽƐĂ WƌĞƐĞŶƚĂƚŝŽŶŽĨŶŽƌĞǆŝĂEĞƌǀŽƐĂ

ĐŽŵƉůĞǆƉŚǇƐŝŽůŽŐŝĐĂŶĚƉƐǇĐŚŽůŽŐŝĐĂů WƌŝŽƌƚŽǁĞŝŐŚƚůŽƐƐ͕ƉĂƚŝĞŶƚǁĂƐƵŶĐŽŵŵŽŶůǇǁĞůůͲ ƉŚĞŶŽƚǇƉĞƚŚĂƚŝƐ͞ƵŶĚĞƌƐƚŽŽĚ͟ŽƌŝŶƚĞƌƉƌĞƚĞĚǀŝĂ ŵĂŶŶĞƌĞĚ͕ĚƵƚŝĨƵů͕ƐĞůĨͲĚŝƐĐŝƉůŝŶĞĚ͕ĐŽŶƐĐŝĞŶƚŝŽƵƐ͕ ƐŚŝĨƚŝŶŐĐƵůƚƵƌĂůǀĂůƵĞƐ ƵŶĞĂƐǇǁŝƚŚĐŚĂŶŐĞ͕ƉƌŽŶĞƚŽĂŶǆŝŽƵƐǁŽƌƌǇ͕ĂŶĚ ĂƚƚĞŶƚŝǀĞƚŽŽƚŚĞƌƐ dŚĞĐŽƌĞĐŚĂƌĂĐƚĞƌŝƐƚŝĐƐŽĨEĐĂŶďĞƵŶĚĞƌƐƚŽŽĚ ĂƐĂĚĂƉƚŝǀĞƚƌĂŝƚƐƚŚĂƚŚĂǀĞĞǀŽůǀĞĚǀŝĂŶĂƚƵƌĂů ƐĞůĞĐƚŝŽŶ /ůůƐƵŝƚĞĚĨŽƌƚŚĞƐƵĚĚĞŶŶĞƐƐŽĨƉƵďĞƌƚĂůĐŚĂŶŐĞ͕ EŽƚƐŝŵƉůǇĂƌĞƐƵůƚŽĨƉƐǇĐŚŽůŽŐŝĐĂůĐŽŶĨůŝĐƚŽƌĂ ďŽƚŚƉŚǇƐŝĐĂůůǇĂƐǁĞůůĂƐƚŚĞŵǇƌŝĂĚŽĨ ĚĞƐŝƌĞƚŽďĞĨĂƐŚŝŽŶĂďůǇƚŚŝŶ ĚĞǀĞůŽƉŵĞŶƚĂůĐŚĂůůĞŶŐĞƐŽĨĂĚŽůĞƐĐĞŶƚůŝĨĞ͘ WƌĞƐĞŶƚĂƚŝŽŶŽĨŶŽƌĞǆŝĂEĞƌǀŽƐĂ ^ŝƌtŝůůŝĂŵ'Ƶůů;ϭϴϭϲͲϭϴϵϬͿ

/ŶŝƚŝĂůǁĞŝŐŚƚůŽƐƐŝƐŽĨƚĞŶŝŶŶŽĐĞŶƚ͖ /ƚƐĞĞŵĞĚŚĂƌĚůǇƉŽƐƐŝďůĞƚŚĂƚĂďŽĚǇƐŽǁĂƐƚĞĚ Ͳ ĞĂƚŝŶŐ͞ŚĞĂůƚŚŝĞƌ͟ĂĨƚĞƌƚĂŬŝŶŐŶƵƚƌŝƚŝŽŶĐŽƵƌƐĞ ĐŽƵůĚƵŶĚĞƌŐŽƚŚĞĞǆĞƌĐŝƐĞǁŚŝĐŚƐĞĞŵĞĚ ĂŐƌĞĞĂďůĞ Ͳ ŝůůŶĞƐƐĐĂƵƐĞĚƵŶŝŶƚĞŶĚĞĚǁĞŝŐŚƚůŽƐƐ dŚĞŝŶĐůŝŶĂƚŝŽŶŽĨƚŚĞƉĂƚŝĞŶƚƐŚŽƵůĚŝŶŶŽǁĂǇďĞ WƌŝŽƌƚŽŵĂůŶƵƚƌŝƚŝŽŶ͕ƉĂƚŝĞŶƚďĞĐŽŵĞƐĐŽŶƐƵŵĞĚ ĐŽŶƐƵůƚĞĚ͙ƚŚĞƚĞŶĚĞŶĐǇŽĨƚŚĞƉŚǇƐŝĐŝĂŶƚŽ ǁŝƚŚĐĂůŽƌŝĞĐŽƵŶƚŝŶŐ͕ǁĞŝŐŚƚĐŚĞĐŬŝŶŐ͕ŵŝƌƌŽƌ ŝŶĚƵůŐĞƚŚĞƉĂƚŝĞŶƚ͛ƐĐĂƉƌŝĐĞĂŶĚƚŚĞĞŶĚůĞƐƐ ŐĂǌŝŶŐ͕ĂŶĚŝŶƐŝƐƚĞŶĐĞƚŚĂƚĨƵƌƚŚĞƌǁĞŝŐŚƚůŽƐƐŝƐ ƐƚƌĞĂŵŽĨƌĂƚŝŽŶĂůŝǌĂƚŝŽŶƐǁĂƐĚĂŶŐĞƌŽƵƐĂŶĚ ƵƌŐĞŶƚŶĞĞĚ ƐŚŽƵůĚďĞĚŝƐĐŽƵƌĂŐĞĚ͖ĂŶĚƚŚĂƚƉĂƌĞŶƚƐĂƌĞ sĞƌǇƋƵŝĐŬůǇ͕ĂĨƚĞƌĂƐŵĂůůĂŵŽƵŶƚŽĨǁĞŝŐŚƚůŽƐƐ͕ ƐŽŵĞƚŝŵĞƐƚŚĞǁŽƌƐƚĂƚƚĞŶĚĂŶƚƐ ƚŚĞƉĂƚŝĞŶƚŝŶƐŝƐƚƐƚŚĂƚŚĞƌďŽĚǇŝƐƵŶĂĐĐĞƉƚĂďůǇ ůĂƌŐĞ͕ŐƌŽƐƐ͕ĂŶĚƐŚĞŵƵƐƚůŽƐĞǁĞŝŐŚƚ^W

WƐǇĐŚŽĂŶĂůǇƚŝĐdŚĞŽƌŝĞƐŽĨE WƐǇĐŚŽĂŶĂůǇƚŝĐdŚĞŽƌŝĞƐŽĨE

,ŝůĚĞƌƵĐŚ;ϭϵϬϰʹ ϭϵϴϰͿͲ ƉƌŽƉŽƐĞĚƚŚĂƚĨŽŽĚ ,ŝůĚĞƌƵĐŚďƌŽƵŐŚƚĂĐŽŵƉĂƐƐŝŽŶĂƚĞƐƚĂŶĐĞƚŽ ƌĞĨƵƐĂůƌĞƉƌĞƐĞŶƚƐĂƐƚƌƵŐŐůĞĨŽƌƉƐǇĐŚŽůŽŐŝĐĂů ƉĂƚŝĞŶƚƐƐŚĞƐĂǁĂƐĞŶŐĂŐĞĚŝŶĂĚĞƐƉĞƌĂƚĞĨŝŐŚƚ ĂƵƚŽŶŽŵǇĂŶĚĐŽŶƚƌŽů ĂŐĂŝŶƐƚĨĞĞůŝŶŐĞŶƐůĂǀĞĚĂŶĚĞǆƉůŽŝƚĞĚďǇƚŚĞŝƌ ^ŚĞĐŚĂƐƚŝƐĞĚƚŚĞĚŽĐƚŽƌƐĂŶĚƉƐǇĐŚŽƚŚĞƌĂƉŝƐƚƐ͞ǁŚŽ ŵŽƚŚĞƌƐ͘ ĂƉƉƌŽĂĐŚĂŶĚĞǀĂůƵĂƚĞĂŶŽƌĞǆŝĐƉĂƚŝĞŶƚƐŝŶĂĐƌŝƚŝĐĂů ŵĂŶŶĞƌ͕ǁŝƚŚĂĐĞƌƚĂŝŶŐƵĂƌĚĞĚŶĞƐƐĂŶĚƉƌĞũƵĚŝĐĞ͕ ,ĞƌǁŽƌŬƉƌŽǀŝĚĞĚƚŚĞĐŽŶĐĞƉƚƵĂůĨƌĂŵĞǁŽƌŬĨŽƌ ĞǀĞŶĂŶŽƉĞŶĚŝƐůŝŬĞ͘͘͘ĞĐĂƵƐĞŽĨƚŚĞƚŚĞƌĂƉŝƐƚ͛Ɛ ƉƐǇĐŚŽĚǇŶĂŵŝĐĂŶĚĨĂŵŝůǇƐǇƐƚĞŵƐǁŽƌŬƚŚĂƚ ŽĨƚĞŶƵŶĞǆĂŵŝŶĞĚƐƵƐƉŝĐŝŽŶƚŚĂƚƚŚĞƉĂƚŝĞŶƚ͛ƐĚĞŶŝĂů ĨŽůůŽǁĞĚ͘ ŽĨŝůůŶĞƐƐŝŶĚŝĐĂƚĞƐĚŝƐŚŽŶĞƐƚǇ͘͘͘ĂƐŝĨƉĂƚŝĞŶƚƐĐŽƵůĚ ĐŚĂŶŐĞŝƚƚŚƌŽƵŐŚĂŶĂĐƚŽĨǁŝůů͘͟

WƐǇĐŚŽĂŶĂůǇƚŝĐdŚĞŽƌŝĞƐŽĨE WƐǇĐŚŽĂŶĂůǇƚŝĐdŚĞŽƌŝĞƐŽĨE

'ĞƌĂůĚZƵƐƐĞůů;ϭϵϮϴͲ ϮϬϭϴͿďĞĐĂŵĞĐŽŶǀŝŶĐĞĚƚŚĂƚ ^ĞůĨƉƐǇĐŚŽůŽŐŝƐƚƐƚŚŽƵŐŚƚƚŚĂƚĨĂŝůƵƌĞƐŝŶĞŵƉĂƚŚŝĐ EǁĂƐƚŚĞƌĞƐƵůƚŽĨĂ͞ŵŽƌďŝĚĨĞĂƌ͟ŽĨĨĂƚŶĞƐƐ͕Ă ŵŝƌƌŽƌŝŶŐĂŶĚŝĚĞĂůŝǌĂƚŝŽŶĚƵƌŝŶŐĐŚŝůĚŚŽŽĚǁĞƌĞ ĨŽƌŵƵůĂƚŝŽŶƚŚĂƚďĞĐĂŵĞƉĂƌƚŽĨƚŚĞ^Dʹ/sʹdZ ƌĞƐƉŽŶƐŝďůĞĨŽƌE;'ĞŝƐƚ͕ϭϵϴϰͿ͘ ĐƌŝƚĞƌŝĂ͘ tŽƌŬŝŶŐĨƌŽŵĂĚĞǀĞůŽƉŵĞŶƚĂůŵŽĚĞů͕ƌƚŚƵƌ &ĂŵŝůǇƚŚĞŽƌŝƐƚƐƐĂǁĂĨĂŵŝůǇĂƐƵƐŝŶŐĂŶĂŶŽƌĞǆŝĐ ,ĂŵŝůƚŽŶƌŝƐƉ;ϭϵϴϬͿƉƌŽƉŽƐĞĚƚŚĂƚƐĞůĨͲƐƚĂƌǀĂƚŝŽŶŝƐ ĐŚŝůĚƚŽŵĂŝŶƚĂŝŶƉĂƚŚŽůŽŐŝĐĂůŚŽŵĞŽƐƚĂƐŝƐǁŝƚŚŝŶƚŚĞ ĂŶĂƚƚĞŵƉƚƚŽƌĞŐƌĞƐƐƚŽĂƉƌĞƉƵďĞƌƚĂůƐƚĂƚĞ͘ ĨĂŵŝůǇƐǇƐƚĞŵ;DŝŶƵĐŚŝŶ͕ZŽƐŵĂŶ͕ΘĂŬĞƌ͕ϭϵϳϴ͖ ZĞŐŝŶĂĂƐƉĞƌ;ϭϵϴϯͿŶŽƚĞĚĂŶŝŶƐƚĂďŝůŝƚǇŝŶƐĞůĨͲ WĂůĂǌǌŽůŝ͕ϭϵϳϰͿ͘ ĐŽŶĐĞƉƚĂŵŽŶŐƉĂƚŝĞŶƚƐǁŝƚŚEĂƐĂĚĞĨĞŶƐĞĂŐĂŝŶƐƚ ƐĞǆƵĂůŝƚǇ͕ĂƐĂŶĂƐĐĞƚŝĐƌĞƉƵĚŝĂƚŝŽŶŽĨďŽĚŝůǇƵƌŐĞƐ͕Žƌ ŝŶĂĚƌŝǀĞĨŽƌƚŚŝŶŶĞƐƐ͘ WƐǇĐŚŽĂŶĂůǇƚŝĐdŚĞŽƌŝĞƐŽĨE WƐǇĐŚŽĂŶĂůǇƚŝĐdŚĞŽƌŝĞƐŽĨE ZĞƐĞĂƌĐŚĞƌƐ͕ĨƌƵƐƚƌĂƚĞĚŝŶĂƚƚĞŵƉƚƐƚŽĨŝŶĚĐŽŶƐŝƐƚĞŶƚ dŚĞƌĞŝƐ͕ŝŶĨĂĐƚ͕ŶŽƌĞůĂƚŝŽŶƐŚŝƉďĞƚǁĞĞŶƉĂƚŝĞŶƚƐ͛ ŽǀĞƌƚƉƐǇĐŚŽƉĂƚŚŽůŽŐǇŝŶƉĂƌĞŶƚƐ͕ŚǇƉŽƚŚĞƐŝǌĞĚ ĚŝƐƚƵƌďĂŶĐĞƐŝŶŚƵŶŐĞƌĂŶĚƐĂƚŝĞƚǇĂŶĚŽƚŚĞƌĂƌĞĂƐŽĨ ŚŝĚĚĞŶĚǇƐĨƵŶĐƚŝŽŶ͘ ƉĞƌĐĞƉƚƵĂůĐŽŶĨƵƐŝŽŶŽƌĚĞŶŝĂů;,Ăůŵŝ͕^ƵŶĚĂǇ͕WƵŐůŝƐŝ͕ WĂůĂǌǌŽůŝ;ϭϵϳϰͿǁƌŽƚĞƚŚĂƚƉĂƌĞŶƚƐĐŽŶĐĞĂůĞĚ ΘDĂƌĐŚŝ͕ϭϵϴϵͿ͘ ĚŝƐŝůůƵƐŝŽŶŵĞŶƚǁŝƚŚƚŚĞŵƐĞůǀĞƐĂŶĚƚŚĞŝƌŵĂƌƌŝĂŐĞ ďĞŚŝŶĚĂĨĂĐĂĚĞŽĨƌĞƐƉĞĐƚĂďŝůŝƚǇĂŶĚŐŽŽĚǁŽƌŬƐ͘ ,Ăůŵŝ;ϭϵϵϮͿĐŽŶĐůƵĚĞĚ͕͞ŝƐƚƵƌďĞĚĞĂƚŝŶŐŝŶĞĂƚŝŶŐ ƌƵĐŚ;ϭϵϳϯͿĚĞƐĐƌŝďĞĚƚŚĞĂŶŽƌĞĐƚŝĐ͛ƐƉĂƌĞŶƚƐĂƐ ĚŝƐŽƌĚĞƌĞĚƉĂƚŝĞŶƚƐĐĂŶŶŽƚďĞĚŝƐŵŝƐƐĞĚĂƐŵĞƌĞůǇ ĐŽŶƚƌŽůůŝŶŐ͕ĞǆƉĞƌŝĞŶĐĞĚĞŶǇŝŶŐ͕ĂŶĚĐŽŵƉĞƚŝƚŝǀĞ ƌĞĨůĞĐƚŝŶŐĂŶƵŶĚĞƌůǇŝŶŐƉƐǇĐŚŽĚǇŶĂŵŝĐƚƵƌŵŽŝů͘͟ ĂďŽƵƚǁŚŽǁĂƐŵĂŬŝŶŐƚŚĞŵŽƐƚƐĂĐƌŝĨŝĐĞƐĨŽƌƚŚĞŝƌ ĨĂŵŝůŝĞƐ͘

dŚĞŽƌŝĞƐŽĨE ZĞĐĞŶƚ'ĞŶĞƚŝĐ^ƚƵĚŝĞƐ

ŝŽŵĞĚŝĐĂůdŚĞŽƌŝĞƐ EŝƐƉŽůǇŐĞŶŝĐ ^ŽĐŝĂůdŚĞŽƌŝĞƐ EĂƐƐŽĐŝĂƚĞĚǁŝƚŚK͕D͕ ŶǆŝĞƚǇͬEĞƵƌŽƚŝĐŝƐŵ͕ ^ĐŚŝǌŽƉŚƌĞŶŝĂ͕ĞĚƵĐĂƚŝŽŶĂů ĂƚƚĂŝŶŵĞŶƚ

ŶĐĞƐƚƌĂůƉĂƐƚƐŚĞĚƐůŝŐŚƚŽŶE ŶŽƌĞǆŝĂDŝƌĂďŝůŝƐ

DŝƌĂĐƵůŽƵƐĂďƐĞŶĐĞŽĨ ͞EŽƚŚŝŶŐŝŶďŝŽůŽŐǇŵĂŬĞƐƐĞŶƐĞĞǆĐĞƉƚŝŶƚŚĞ ĂƉƉĞƚŝƚĞ͖͞ŚŽůǇĂŶŽƌĞǆŝĂ͟ ůŝŐŚƚŽĨĞǀŽůƵƚŝŽŶ͘͟ WŝĞƚǇ Ͳ dŚĞŽĚŽƐŝƵƐŽďǌŚĂŶƐŬǇ ƐĐĞƚŝĐŝƐŵ ŽŵƉůŝĂŶƚĂŶĚĚƌŝǀĞŶ WƐǇĐŚŽůŽŐŝĐĂůƐǇŵƉƚŽŵƐ͕ƚŚŽƵŐŚƉĂŝŶĨƵůĂŶĚĞǀĞŶ EŽĨĞĂƌŽĨďĞŝŶŐĨĂƚ ĚĞƚƌŝŵĞŶƚĂů͕ĂƌĞĂůƐŽĚĞĨĞŶƐĞƐͬĂĚĂƉƚĂƚŝŽŶƐ ŶĐĞƐƚƌĂůĚĂƉƚĂƚŝŽŶƐ KŶƚŚĞKƌŝŐŝŶŽĨ^ƉĞĐŝĞƐ͙;ĂƌǁŝŶϭϴϱϵͿ

ĚĂƉƚĞĚƚŽ&ůĞĞ&ĂŵŝŶĞʹ ͞ůůƚŚĞŽƌŐĂŶŝĐďĞŝŶŐƐǁŚŝĐŚŚĂǀĞĞǀĞƌůŝǀĞĚŽŶ ;^ŚĂŶ'ƵŝƐŝŶŐĞƌϮϬϬϯͿ ƚŚŝƐĞĂƌƚŚŚĂǀĞĚĞƐĐĞŶĚĞĚĨƌŽŵƐŽŵĞŽŶĞ &ŽŽĚZĞƐƚƌŝĐƚŝŽŶ͕ĞŶŝĂůŽĨ ƉƌŝŵŽƌĚŝĂůĨŽƌŵ͕ŝŶƚŽǁŚŝĐŚůŝĨĞǁĂƐďƌĞĂƚŚĞĚ͘͟ ^ƚĂƌǀĂƚŝŽŶ͕,ǇƉĞƌĂĐƚŝǀŝƚǇ >ĂƐƚhŶŝǀĞƌƐĂůŽŵŵŽŶŶĐĞƐƚŽƌ;>hͿΕϯ͘ϱ ĞǀŽůǀĞĚŵĞĐŚĂŶŝƐŵƐƚŚĂƚ ďŝůůŝŽŶǇĞĂƌƐĂŐŽ ĞŶĂďůĞĚŶŽŵĂĚŝĐĨŽƌĂŐĞƌƐ ůĞĂǀĞĚĞƉůĞƚĞĚ ůůůŝĨĞĨŽƌŵƐƐƚŽƌĞŐĞŶĞƚŝĐŝŶĨŽƌŵĂƚŝŽŶǀŝĂƚŚĞ ĞŶǀŝƌŽŶŵĞŶƚƐ ƐĂŵĞEĂŶĚZEĐŽĚĞƐ tĞŝŐŚƚůŽƐƐƚƌŝŐŐĞƌƐƚŚĞƐĞ ůůŵŽĚĞƌŶĂŶŝŵĂůƐƐŚĂƌĞϲϯϯϭŐĞŶĞƐƚŚĂƚƚƌĂĐĞƚŽ ĂƌĐŚĂŝĐĂĚĂƉƚŝŽŶƐ ĂĐŽŵŵŽŶĂŶĐĞƐƚŽƌŽǀĞƌϲϱϬŵŝůůŝŽŶǇĞĂƌƐĂŐŽ

ŶĐĞƐƚƌĂůĚĂƉƚĂƚŝŽŶƐ ŶĐĞƐƚƌĂůĚĂƉƚĂƚŝŽŶƐ

͞ZĞĐĞŶƚ͟ĐŽŐŶŝƚŝǀĞ ĚĞǀĞůŽƉŵĞŶƚƐĂůůŽǁƵƐƚŽ ŵĂŬĞƐĞŶƐĞĂŶĚŶŽŶͲ ƐĞŶƐĞŽĨŽƵƌĂĚĂƉƚĂƚŝŽŶƐ

͞DĂŶŝƐŶŽƚĂƌĂƚŝŽŶĂů ĂŶŝŵĂů͖ŚĞŝƐĂ ƌĂƚŝŽŶĂůŝǌŝŶŐĂŶŝŵĂů͘͟ ͸ ZŽďĞƌƚ͘,ĞŝŶůĞŝŶ

ŶĐĞƐƚƌĂůĚĂƉƚĂƚŝŽŶƐ WŽƐƚͲƚƌĂƵŵĂƚŝĐ^ƚƌĞƐƐŝƐŽƌĚĞƌ >ŽǁďŽĚǇŵĂƐƐƐĞůĞĐƚĞĚŝŶďŝƌĚƐĨŽƌƚĂŬĞŽĨĨ͕ dƌƵĞƐƚƌĞƐƐĨƵůĞǀĞŶƚʹ ůŝĨĞƚŚƌĞĂƚĞŶŝŶŐ ƐƉĞĞĚ͕ĂŐŝůŝƚǇ ZĞͲĞǆƉĞƌŝĞŶĐŝŶŐƚŚĞĞǀĞŶƚ ^ƵďŽƌĚŝŶĂƚĞĨŝƐŚƐĞůĨͲŝŵƉŽƐĞĨŽŽĚƌĞƐƚƌŝĐƚŝŽŶƐŽ ǀŽŝĚĂŶĐĞĂŶĚŶƵŵďŝŶŐ ĚŽŵŝŶĂƚĞĨŝƐŚĂƌĞŶŽƚƚŚƌĞĂƚĞŶĞĚ͘^ŽĐŝĂů /ŶĐƌĞĂƐĞĚĂƌŽƵƐĂů ŚŝĞƌĂƌĐŚǇŝƐŵĂŝŶƚĂŝŶĞĚƌĞĚƵĐŝŶŐƌŝƐŬŽĨďĞŝŶŐ EĞŐĂƚŝǀĞƚŚŽƵŐŚƚƐ͕ĨĞĞůŝŶŐƐ͕ĂŶĚŵŽŽĚƐ ƵŶƉƌŽƚĞĐƚĞĚ͘ ZŝƐŬƐĨŽƌĞŶĚƵƌŝŶŐƐǇŵƉƚŽŵƐ ^ŵĂůůƐŝǌĞĐĂŶďĞĂĚĞĨĞŶƐŝǀĞŵŽƌƉŚŽůŽŐǇǁŚĞƌĞ WƌĞͲĞǆŝƐƚŝŶŐŽƌŐĞŶĞƚŝĐƌŝƐŬĨŽƌŵĞŶƚĂůĚŝƐŽƌĚĞƌ ůĂƌŐĞƉƌĞĚĂƚŽƌƐĨĂǀŽƌůĂƌŐĞƉƌĞǇǁŝƚŚŚŝŐŚĞŶĞƌŐǇ WƌŽǆŝŵŝƚǇ ŐĂŝŶ WŽƐƚͲƚƌĂƵŵĂƚŝĐĞŶǀŝƌŽŶŵĞŶƚ ^ƚƵĐŬŝŶƵŶŚĞůƉĨƵůŶĂƌƌĂƚŝǀĞĂďŽƵƚƚƌĂƵŵĂ dƌĞĂƚŵĞŶƚŽĨĂƚŝŶŐŝƐŽƌĚĞƌƐ ĂƌůtŚŝƚĂŬĞƌD

^ƚƌƵĐƚƵƌĞĚDĞĂůWůĂŶ &ĂŵŝůǇͲĂƐĞĚdƌĞĂƚŵĞŶƚ;dŚĞDĂƵĚƐůĞǇDŽĚĞůͿ ŽŐŶŝƚŝǀĞĞŚĂǀŝŽƌĂůdŚĞƌĂƉǇ ǆƉŽƐƵƌĞĂŶĚZĞƐƉŽŶƐĞWƌĞǀĞŶƚŝŽŶdŚĞƌĂƉǇ ŝĂůĞĐƚŝĐĂůĞŚĂǀŝŽƌdŚĞƌĂƉǇ /ŶĚŝǀŝĚƵĂůĂŶĚ'ƌŽƵƉWƐǇĐŚŽƚŚĞƌĂƉǇ DĞĚŝĐĂƚŝŽŶƐ ͞dŚĞƌĞ ĂƌĞ ŶŽ ŝŶĚŝǀŝĚƵĂůƐ ŝŶƚŚĞ ǁŽƌůĚ͕ŽŶůǇ ĨƌĂŐŵĞŶƚƐ ŽĨĨĂŵŝůŝĞƐ͘͟

dƌĞĂƚŵĞŶƚŽĨE ^ĞƌŽƚŽŶŝŶZĞƵƉƚĂŬĞ/ŶŚŝďŝƚŽƌƐ &ƉƉƌŽǀĂůƐ KůĂŶǌĂƉŝŶĞǀƐWůĂĐĞďŽ ƉƉƌŽǀĞĚĨŽƌK ϭϲǁĞĞŬƐ ůŽŵŝƉƌĂŵŝŶĞшϭϬǇĞĂƌƐ &ůƵǀŽǆĂŵŝŶĞшϴǇĞĂƌƐ KůĂŶǌĂƉŝŶĞŝŶĐƌĞĂƐĞĚD/ďǇϬ͘Ϯϱϵ ^ĞƌƚƌĂůŝŶĞшϲǇĞĂƌƐ WůĂĐĞďŽŝŶĐƌĞĂƐĞĚD/ďǇϬ͘Ϭϵϱ &ůƵŽǆĞƚŝŶĞшϳǇĞĂƌƐ EŽĐŚĂŶŐĞŝŶŽďƐĞƐƐŝǀĞƚŚŽƵŐŚƚƐͬďĞŚĂǀŝŽƌƐ ƉƉƌŽǀĞĚĨŽƌĞƉƌĞƐƐŝŽŶ &ůƵŽǆĞƚŝŶĞшϳǇĞĂƌƐ ƐĐŝƚĂůŽƉƌĂŵшϭϮǇĞĂƌƐ ƉƉƌŽǀĞĚĨŽƌEŽŶͲK ƚƚŝĂĞƚĂů;ϮϬϭϵͿ͘ KůĂŶǌĂƉŝŶĞǀĞƌƐƵƐƉůĂĐĞďŽŝŶĂĚƵůƚŽƵƚƉĂƚŝĞŶƚƐǁŝƚŚĂŶŽƌĞǆŝĂ ŶĞƌǀŽƐĂ͗ƌĂŶĚŽŵŝǌĞĚĐůŝŶŝĐĂůƚƌŝĂů͘ ŵĞƌŝĐĂŶ:ŽƵƌŶĂůŽĨWƐǇĐŚŝĂƚƌǇ͕ ϭϳϲ;ϲͿ͕ϰϰϵͲ ŶǆŝĞƚǇ ϰϱϲ͘ ƵůŽǆĞƚŝŶĞшϳǇĞĂƌƐ;'Ϳ

WƌŽǀŝĚĞŶĐĞ^ƚ͘sŝŶĐĞŶƚ WĂƌƚŝĂů,ŽƐƉŝƚĂůĂƚŝŶŐŝƐŽƌĚĞƌƐ dƌĞĂƚŵĞŶƚWƌŽŐƌĂŵ ϵϰϱϬ^tĂƌŶĞƐZŽĂĚ͕^ƵŝƚĞϮϬϬ WŽƌƚůĂŶĚ͕KZϵϳϮϮϱ

ŚƚƚƉƐ͗ͬͬŽƌĞŐŽŶ͘ƉƌŽǀŝĚĞŶĐĞ͘ŽƌŐͬŽƵƌͲ ƐĞƌǀŝĐĞƐͬƉͬƉƌŽǀŝĚĞŶĐĞͲĂĚƵůƚͲĞĂƚŝŶŐͲĚŝƐŽƌĚĞƌƐͲ ƚƌĞĂƚŵĞŶƚͲƉƌŽŐƌĂŵͬĐŽŶƚĂĐƚͲƵƐͬ

^ĐƌĞĞŶŝŶŐǀĂůƵĂƚŝŽŶ͗;ϱϬϯͿϮϭϲͲϮϬϮϱ