4


Consequences of
Child Abuse and Neglect

Since the 1993 National Research Council (NRC) report on child abuse and neglect was issued, dramatic advances have been made in understanding the causes and consequences of child abuse and neglect, including advances in the neural, genomic, behavioral, psychologic, and social sciences. These advances have begun to inform the scientific literature, offering new insights into the neural and biological processes associated with child abuse and neglect and in some cases, shedding light on the mechanisms that mediate the behavioral sequelae that characterize children who have been abused and neglected. Research also has expanded understanding of the physical and behavioral health, academic, and economic consequences of child abuse and neglect. Knowledge of sensitive periods—the idea that for those aspects of brain development that are dependent on experience, there are stages in which the normal course of development is more susceptible to disruption from experiential perturbations—also has increased exponentially. In addition, research has begun to explore differences in individual susceptibility to the adverse outcomes associated with child abuse and neglect and to uncover the factors that protect some children from the deleterious consequences explored throughout this chapter. An important message is that factors relating to the individual child and to the familial and social contexts in which the child lives, as well as the severity, chronicity, and timing of abuse and neglect experiences, all conspire to impact, to varying degrees, the neural, biological, and behavioral sequelae of abuse and neglect.

This chapter begins by exploring background topics that are important to an understanding of research on the consequences of child abuse and



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4 Consequences of Child Abuse and Neglect S ince the 1993 National Research Council (NRC) report on child abuse and neglect was issued, dramatic advances have been made in un- derstanding the causes and consequences of child abuse and neglect, including advances in the neural, genomic, behavioral, psychologic, and social sciences. These advances have begun to inform the scientific litera- ture, offering new insights into the neural and biological processes associ- ated with child abuse and neglect and in some cases, shedding light on the mechanisms that mediate the behavioral sequelae that characterize children who have been abused and neglected. Research also has expanded under- standing of the physical and behavioral health, academic, and economic consequences of child abuse and neglect. Knowledge of sensitive periods— the idea that for those aspects of brain development that are dependent on experience, there are stages in which the normal course of development is more susceptible to disruption from experiential perturbations—also has increased exponentially. In addition, research has begun to explore differ- ences in individual susceptibility to the adverse outcomes associated with child abuse and neglect and to uncover the factors that protect some chil- dren from the deleterious consequences explored throughout this chapter. An important message is that factors relating to the individual child and to the familial and social contexts in which the child lives, as well as the sever- ity, chronicity, and timing of abuse and neglect experiences, all conspire to impact, to varying degrees, the neural, biological, and behavioral sequelae of abuse and neglect. This chapter begins by exploring background topics that are important to an understanding of research on the consequences of child abuse and 111

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112 NEW DIRECTIONS IN CHILD ABUSE AND NEGLECT RESEARCH neglect, including an ecological framework and methodological attributes of studies in this field. Next is a review of the research surrounding specific outcomes across the neurobiological, cognitive, psychosocial, behavioral, and health domains, many of which can be seen in childhood, adolescence, and adulthood. The chapter then examines outcomes that are specific to adolescence and adulthood, reviews factors that contribute to individual differences in outcomes, and considers the economic burden of child abuse and neglect. The final section presents conclusions. CASCADING CONSEQUENCES Newborns are almost fully dependent upon parents to help them regu- late physiology and behavior. Under optimal conditions, parents buffer young children from stress and serve as “co-regulators” of behavior and physiology (Hertsgaard et al., 1995; Hofer, 1994, 2006). Over time, chil- dren raised by such parents gradually assume these regulatory capacities. They typically enter school well regulated behaviorally, emotionally, and physiologically; thus, being prepared for the tasks of learning to read, write, and interact with peers. For some children, parents cannot fill these roles as buffer and co- regulator effectively. When children have caregivers who cannot buffer them from stress or who cannot serve as co-regulators, they are vulnerable to the vicissitudes of a challenging environment. Although children can cope effectively with mild or moderate stress when supported by a caregiver, conditions that exceed their capacities to cope adaptively often result in problematic short- or long-term consequences. Studies conducted with some nonhuman primate species and rodents have shown that the young are dependent on the parent for help in regulat- ing behavior and physiology (Moriceau et al., 2010). Thus, young infants are dependent on parents fulfilling the functions of carrying, holding, and feeding. The period of physical immaturity and dependence lasts an ex- tended time in humans. Even beyond the point at which young children are physically dependent, they remain psychologically dependent throughout childhood and adolescence. Thus, inadequate or abusive care can have considerable consequences in terms of children’s health and social, psycho- logical, cognitive, and brain development. Children who have experienced abuse and neglect are therefore at increased risk for a number of problematic developmental, health, and mental health outcomes, including learning problems (e.g., prob- lems with inattention and deficits in executive functions), problems relating to peers (e.g., peer rejection), internalizing symptoms (e.g., depression, anxiety), externalizing symptoms (e.g., oppositional defi- ant disorder, conduct disorder, aggression), and posttraumatic stress

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CONSEQUENCES OF CHILD ABUSE AND NEGLECT 113 disorder (PTSD). As adults, these children continue to show increased risk for psychiatric disorders, substance use, serious medical illnesses, and lower economic productivity. This chapter highlights research supporting the association between these outcomes, among others, and experiences of child abuse and ne- glect. The potential dramatic and pervasive consequences of child abuse and neglect underscore the need for research to illuminate the myriad pathways by which these ill effects manifest in order to guide treatment and intervention efforts. However, it is important to note at the outset that not all abused and neglected children experience problematic out- comes. As discussed in the section on individual differences later in this chapter, a body of research is devoted to uncovering the factors that dis- tinguish children who do not experience problematic outcomes despite facing significant adversity in the form of abuse or neglect. Further, as discussed in Chapter 6, the past two decades have seen substantial growth in proven models for treatment of the consequences of child abuse and neglect, indicating that these effects are potentially reversible and that there is opportunity to intervene throughout the life course. BACKGROUND Several key concepts need to be considered in attempting to under- stand potential pathways that lead from abuse and neglect to the various consequences discussed in this chapter and the context in which those consequences manifest. First, positive and negative influences found among individual child characteristics, within the family environment, and in the child’s broader social context all interact to predict outcomes related to child abuse and neglect. Second, child abuse and neglect occur in the con- text of a child’s brain development, and their potential effects on developing brain structures can help explain the onset of certain negative outcomes. Fi- nally, abused and neglected children often are exposed to multiple stressors in addition to experiences of abuse and neglect, and potential consequences may manifest at different points in a child’s development. Therefore, the most rigorous research on this topic attempts to account for the many fac- tors that may be confounded with abuse or neglect. Ecological Framework Since 1993, transactional-bioecological or ecological models have guided attempts to conceptualize the relative contributions of risk and protective factors to children’s developmental outcomes, particularly in re- lation to child abuse and neglect (Belsky, 1993; Cicchetti and Lynch, 1993; Cicchetti and Toth, 1998). Versions of this approach consider the develop-

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114 NEW DIRECTIONS IN CHILD ABUSE AND NEGLECT RESEARCH ment of the child in the context of the broader social environment in which he or she functions, within the context of a family; in turn, children and families are embedded in a larger social system that includes communities, neighborhoods, and cultures. The assumption underlying these models is that behavior is complex, and development is multiply determined by char- acteristics of the individual, parents and family, and neighborhood and/or community and their interactions. In examining the role of contextual factors in the onset of consequences due to child abuse and neglect, Cicchetti and Lynch’s (1993) ecological/ transactional model is particularly useful because it successfully incorpo- rates multiple etiological frameworks (Lynch and Cicchetti, 1998). This model is based on Belsky’s (1980, 1993) ecological model and Cicchetti and Rizley’s (1981) transactional model. It expands on these models by highlighting the nature of interaction among risk factors and the ecology in which child maltreatment occurs. The ecological/transactional model describes four interrelated, mutually embedded categories that contribute to abuse and neglect and the potential associated consequences: • Ontogenic development—Reflects factors within the individual that influence the achievement of competence and adaptation. • Microsystem—Defined as the “immediate context” (i.e., the fam- ily) in which the child experiences abuse or neglect, including the bidirectional influence of parent and child characteristics and other relationships (such as marriage) that may impact parent-child in- teractions directly or indirectly. • Exosystem—The exo- and macrosystemic levels reflect social or cul- tural forces that contribute to and maintain abuse or neglect. The exosystem encompasses the effects of broader societal systems (e.g., employment, neighborhoods) on parent and child functioning. • Macrosystem—Mirrors temporally driven, sociocultural ideologies (e.g., cultural views of corporal punishment), or a “larger cultural fabric,” that inevitably shape functioning at all other levels. It is represented by social attitudes (such as attitudes toward violence or the value of children). The model is based on the fact that a child’s multiple ecologies influ- ence one another, affecting the child’s development. Thus, the combined influence of the individual, family, community, and larger culture affect the child’s developmental outcomes. Parent, child, and environmental charac- teristics combine to shape the probabilistic course of the development of abused and neglected children. At higher, more distal levels of the ecology, risk factors increase the like- lihood of child maltreatment. These environmental systems also influence

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CONSEQUENCES OF CHILD ABUSE AND NEGLECT 115 what takes place at more proximal ecological levels, such as when risk and protective factors determine the presence or absence of maltreatment within the family environment. Overall, concurrent risk factors at the various ecological levels (e.g., cultural sanction of violence, community violence, low socioeconomic status, loss of job, divorce, parental substance abuse, maladaptation, and/or child psychopathology) act to increase or decrease the likelihood that abuse will occur. The manner in which children handle the challenges associated with maltreatment is seen in their own ontogenic development, which shapes their ultimate adaptation or maladaptation. Although the overall pattern is that risk factors outweigh protective factors, there are infinite permutations of these risk variables across and within each level of the ecology, providing multiple pathways to the sequelae of child abuse and neglect. Types of Evidence Many studies of the consequences of abuse and neglect have been conducted with methodologies ranging from prospective to retrospective designs, from observational measures to self-report, and from experimental to case-controlled designs to no-control designs. The strongest conclusions could be reached with experimental designs whereby children would be randomly assigned to different abusive or neglectful experiences; however, this is obviously neither desirable nor possible. Nonhuman studies involving primates and other species have al- lowed experimental assessment of different rearing conditions that may parallel human conditions of neglect and abuse (e.g., Sanchez, 2006; Suomi, 1997). One salient human study involved random assign- ment of children abandoned to institutions to high-quality foster care (a randomized controlled trial of foster care as an alternative to institutional care) (Nelson, 2007). In this prospective, longitudinal study, known as the Bucharest Early Intervention Project, 136 children abandoned at or around the time of birth and then placed in state-run institutions were ex- tensively studied when they ranged in age from 6 to 31 months (mean age = 21 months), as was a sample of 72 never-institutionalized children who lived with their families in the greater Bucharest community. Following the baseline assessment, half of the institutionalized children were randomly assigned to a high-quality foster care program that the investigators created, financed, and maintained, and half were randomly assigned to remain in care as usual (institutional care). These children were followed extensively through age 12 (for discussion, see Fox et al., 2013; Nelson et al., 2007a,b; Zeanah et al., 2003). Although at first glance it may not be obvious why the study of children reared in institutions is relevant to a report on child abuse and neglect, institutional care, which affects as many as 8 million

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116 NEW DIRECTIONS IN CHILD ABUSE AND NEGLECT RESEARCH children around the world, can involve an extreme and specific form of neglect—broad-spectrum psychosocial deprivation. Therefore, neglectful institutional care settings can serve as a model system for understanding the effects of neglect on brain development. The neglect experienced by children in such settings should not serve as a proxy for the type of neglect experienced by noninstitutionalized children in the United States, who are more likely to experience neglect in such domains as food, shelter, clothing, or medical care rather than broad-spectrum psychosocial de- privation. Nevertheless, this study can provide important insight into the effects of neglect on behavioral and neurological development because of its randomized, controlled, and longitudinal nature. The discussion in this chapter necessarily relies primarily (although not exclusively) on the strongest nonexperimental studies conducted. These studies involve longitudinal prospective designs, which assess child abuse and neglect objectively at the time of occurrence and assess outcomes longitudinally. A good example is the study of Widom and colleagues (1999), which followed a large cohort of abused and neglected children and a matched comparison sample from childhood into adulthood. Other examples include the studies of Johnson and colleagues (1999, 2000), Noll and colleagues (2007), and Jonson-Reid and colleagues (2012). Retrospec- tive designs that ask participants to recall whether abuse and neglect were experienced are more troublesome because recall of child abuse and neglect can be affected by a variety of factors and open to a number of potential biases (Briere, 1992; Offer et al., 2000; Ross, 1989; Widom, 1988). Results of studies based on treatment samples of adults who experienced maltreat- ment as children may be potentially biased because not all victims of child abuse and neglect seek treatment as adults, and because people who do seek treatment may have higher rates of problems than people who do not seek treatment (Widom et al., 2007a). When participants are asked to report on conditions such as current depression and previous history of child abuse and neglect, the added problem of shared method variance arises. On the other hand, use of official records raises the problem of underreporting (Gilbert et al., 2009a). The federal government has supported an effort, launched since the 1993 NRC report was issued—the National Survey of Child and Adoles- cent Well-Being (NSCAW)—to expand understanding of the consequences of child abuse and neglect. This study includes use of multiple data sources and record reviews, as well as interviews with children and youth who have experienced child abuse and neglect, their caretakers, and child welfare workers. Several of its findings are discussed in Chapter 5. This chapter contains an extensive review of the more recent bio- logically based studies of child abuse and neglect because of the important advances that have been made in this area. To the extent possible, the

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CONSEQUENCES OF CHILD ABUSE AND NEGLECT 117 discussion relies on findings from studies characterized by the greatest methodological rigor. Despite recent methodological advances, researchers face many chal- lenges in attempting to understand the short- and long-term consequences of the various types of child abuse and neglect (e.g., physical abuse, sexual abuse, neglect from caregivers) for child functioning and development. One of those challenges is teasing apart the impact of child abuse and neglect from that of other co-occurring factors. For example, children involved with child protective services because of neglect or abuse often face a num- ber of overlapping and concurrent risk factors, including poverty, prenatal substance exposure, and parent psychopathology, among others (Dubowitz et al., 1987; Lyons et al., 2005; McCurdy, 2005). These concurrent risk factors can make it particularly difficult to draw causal inferences about the specific consequences of abuse and neglect for children’s functioning, but need to be disentangled from the specific effects of abuse and neglect (Widom et al., 2007a). Controlling for other relevant variables becomes vi- tal, since failure to take such family variables into account may result in re- porting spurious relationships (Widom et al., 2007a). Some studies consider and covary other risk factors, and some do not. Considering the course of abuse and neglect may also be particularly important, as Jonson-Reid and colleagues (2012) found that the number of child abuse and neglect reports powerfully predicted adverse outcomes across a range of domains. Finding: Risk factors that co-occur with child abuse and neglect, such as poverty, prenatal substance exposure, and parent psychopathology, can confound attempts to draw causal inferences about the specific consequences of abuse and neglect for children’s functioning. These fac- tors need to be controlled for in studies seeking to identify the specific consequences of child abuse and neglect. NEUROBIOLOGICAL OUTCOMES An adequate caregiver is needed to support developing brain architec- ture and the developing ability to regulate behavior, emotions, and physiol- ogy for young children. When children experience abuse or neglect, such development can be compromised. The effects of abuse and neglect are seen especially in brain regions that are dependent on environmental input for optimal development, and on aspects of functioning especially susceptible to environmental input. Early in development, infants are completely reli- ant on input from their caregivers for help in regulating arousal, neuro- endocrine functioning, temperature, and other basic functions. With time and with successful experiences in co-regulation, children increasingly take over these functions themselves. Abuse and neglect represent the absence

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118 NEW DIRECTIONS IN CHILD ABUSE AND NEGLECT RESEARCH of adequate input (as in the case of neglect) or the presence of threatening input (as in the case of abuse), either of which can compromise develop- ment. The following sections present a review of evidence with respect to key neurobiological systems that are altered as a result of abuse and neglect early in life: the hypothalamic-pituitary-adrenal (HPA) axis of the stress re- sponse system; the amygdala, involved in emotion processing and emotion regulation; the hippocampus, involved in learning and memory; the corpus callosum, involved in integrating functions between hemispheres; and the prefrontal cortex, involved in higher-order cognitive functions. The discus- sion begins, however, with a brief overview of brain development. Overview of Neurobiological Development The Construction of the Brain Brain development begins just a few weeks after conception, start- ing with the construction of the neural tube. This is followed by the generation of different classes of brain cells—neurons and glia. Once formed, these immature neurons begin their migratory phase (generally away from the ventricular zone, which is their point of origin) to build the cerebral cortex. Much of cell migration is completed by the end of the second trimester of pregnancy, eventually leading to the construc- tion of the six-layered cerebral cortex. After these immature cells have migrated to their target destination, they can differentiate; that is, they develop cell bodies and processes (axons and dendrites). Once processes have been formed, synapses begin to form; synapses are the connections between neurons that allow for the transmission of signals across the synaptic cleft, which is the small space that exists between two adjacent brain cells, generally between a dendrite and an axon. The synapse per- mits one neuron to communicate with another, and eventually, entire circuits are built, followed by neural networks (i.e., organized units). Finally, some axons in the brain develop a coating called myelin that speeds the flow of information along the length of the axon. Sensory and motor pathways begin to myelinate during the last trimester of pregnancy, whereas association areas of the brain, particularly the pre- frontal cortex, continue to myelinate through the second decade of life. Neural elements (e.g., axons) that are coated with myelin are referred to as white matter, whereas most of the rest of the brain is referred to as grey matter. Many aspects of brain development (particularly those that occur before birth) fall under genetic control (although some are affected by experience—prenatal exposure to neurotoxins such as alcohol being but one example). After birth, however, much of brain development be-

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CONSEQUENCES OF CHILD ABUSE AND NEGLECT 119 comes dependent on experience. For example, although the generation of synapses—which are massively overproduced early in development— is largely under genetic control, the pruning of synapses—which occurs primarily after birth—is largely under experiential control. Thus the prefrontal cortex of the 1-year-old child has many more synapses than the adult brain, but over the next one to two decades, these synapses are pruned back to adult numbers, based largely on experience (Nelson et al., 2011). Neural Plasticity and Sensitive Periods Many aspects of brain development depend on experiences occur- ring during particular time periods, often the first few years of life. These so-called sensitive or critical periods represent vital inflection points in the course of development, such that if specific experiences fail to occur within some narrow window of time (or the wrong experi- ences occur), development can go awry. This leads to the concept that plasticity “cuts both ways,” meaning that if the child is exposed to good experiences, the brain benefits, but if the child is exposed to bad experi- ences or inadequate input, the brain may suffer (Nelson et al., 2011). Prenatally, an example of a bad experience is exposure to neurotoxins such as alcohol or drugs of abuse. An example of a good experience is access to good nutrition, including the many micronutrients that facili- tate brain development (e.g., iron, zinc). Postnatally, the topic of this report represents examples of bad experience (i.e., abuse and neglect). Conversely, examples of good experiences include providing a child with consistent, sensitive caregiving; a nurturing home in general; and adequate stimulation. The Time Course of Development In general, most sensory systems develop early in life; thus the abil- ity to see and to discriminate and recognize faces and speech sounds come on line in the first months and years of life, based on appropri- ate experiences occurring during that time window (e.g., exposure to faces, to speech). This is not surprising given how vitally important these functions are to subsequent development (e.g., language is not learned until children can discriminate the basic units of sound, such as one consonant from another). Critical to the discussion in this chapter, however, is that the functions subserved by some other regions of the brain, most notably the prefrontal cortex—executive control, planning, cognitive flexibility, emotion regulation—have a much more protracted course of development for the simple reason that both synaptogenesis

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120 NEW DIRECTIONS IN CHILD ABUSE AND NEGLECT RESEARCH FIGURE 4-1  The time course of key aspects of brain development. SOURCE: Thompson and Nelson, 2001 (reprinted with the permission of Ameri- can Psychologist). and myelination of these cortical regions do not mature until mid- to late adolescence, perhaps even a bit later. As a result, the sensitive pe- riod for prefrontal cortical functions may be far more prolonged than is the case for sensory functions, extending well into the adolescent period. One example of the differential time course of different brain regions, and perhaps their corresponding sensitive periods, is illustrated in Figure 4-1. These concepts are important to the study of the neurobiological toll of early childhood abuse and neglect because children who experience consid- erable adversity early in life may be exposed to environments/experiences that the species has not come to expect (such as abusive caregivers) or worse, environments that are largely lacking in key experiences (i.e., ne- glect). In both cases, when the expectable environment is violated by either gross alterations in the type of care received or a complete lack of care, subsequent development can be seriously derailed. Hypothalamic-Pituitary-Adrenocortial (HPA) Axis and Biological Regulation There is strong evidence across species that the HPA axis is affected by experiences of early childhood abuse and neglect (e.g., Bruce et al., 2009; Gunnar and Vazquez, 2001; Levine et al., 1993; Shonkoff et al., 2012). Glucocorticoids (cortisol in humans, corticosterone in rodents) are steroid hormones produced as an end product of the HPA system. The HPA axis serves two orthogonal functions: mounting a stress response and maintain-

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CONSEQUENCES OF CHILD ABUSE AND NEGLECT 121 ing a diurnal rhythm. A cascade of events is designed to promote survival behavior by directing energy to processes that are critical to immediate survival (e.g., metabolism of glucose) and away from processes that are less critical to immediate survival, such as immune functioning, growth, digestion, and reproduction (Gunnar and Cheatham, 2003). Glucocorticoids also serve an important role in maintaining circadian patterns of daily activity, such as waking up, sleeping, and energy regulation (Gunnar and Cheatham, 2003). Diurnal species, including humans, have a diurnal pattern of cortisol production that enhances the likelihood of being awake at the same time in the day. In humans, diurnal cortisol levels peak about 30 minutes after waking up, decrease sharply by mid-morning, and continue to decrease gradually until bedtime (Gunnar and Donzella, 2002). The higher morning values of cortisol reflect greater metabolism of glucose early in the day, providing energy for the day’s activities. The HPA axis is highly sensitive to the effects of early experiences. Di- urnal effects typically have been examined as wake-up values and bedtime values because those time points allow assessments of change from nearly the highest reliable waking time point (with 30 minutes post wake-up being the highest) to the lowest waking time point. Daytime values are affected by a number of factors, such as exercise, naps, and travel to work (Larson et al., 1991; Watamura et al., 2002). The most consistent findings involve flatter, more blunted patterns of diurnal regulation among abused or ne- glected children relative to low-risk children (Bernard et al., 2010; Bruce et al., 2009; Dozier et al., 2006; Fisher et al., 2007; Gunnar and Vazquez, 2001). Similar flattened diurnal rhythms have been found in institution- alized children (Bruce et al., 2000; Carlson and Earls, 1997). Flattened diurnal cortisol patterns may reflect down-regulation of HPA axis activity following earlier hyperactivation (Carpenter et al., 2009; Fries et al., 2005). Cicchetti and colleagues (Cicchetti and Rogosch, 2001a,b) examined changes across the day among abused and neglected children attending summer camp. The time points included when children first arrived at camp (at about 9 AM) and before they left camp for the day (at about 4 PM), likely tapping diurnal change within a challenging environment. The au- thors report complex findings regarding cortisol in this setting. Differences were found in some studies related to subtype and/or psychopathology and/ or aggression (Cicchetti and Rogosch, 2001b; Murray-Close et al., 2008). Animal models have been used to study experimentally the effects of ne- glect and abuse on HPA functioning (e.g., Levine et al., 1993). Experiences of abuse or neglect, depending on age of pup/infant, duration, chronicity, and subsequent response of dam/mother differentially affect short- and long-term effects on the HPA axis (Sanchez, 2006). Under naturally occur- ring conditions (about 10 percent of rhesus monkeys abuse their infants), a 1-year-old rhesus monkey that was abused (primarily in the first month of

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