by EJ Klain · 2013 · Cited by 32 — children exposed to violence and psychological trauma learn and provide trauma-informed care and trauma- focused services. Child welfare system stakeholders

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Implementing Trauma -Informed Practices in Child Welfare Eva J. Klain Amanda R. White ABA Center on Children and the Law November 2013 Introduction According to the 2012 Report of the Attorney General™s National Task Force on Children Exposed to Violence, 46 million children living in the United States will have their lives affected by violence, crime, abuse, or psychological trauma this year. 1 The Task Force recommends that every professional or advocate serving children exposed to violence and psychological trauma learn and provide trauma -informed care and trauma -focused services. Child welfare system stakeholders, and the children and families they serve, can greatly benefit from integrating trauma knowledge into their policies and practices and thereby improve outcomes for abused and neglected children. Children in care are more likely to have been exposed to multiple forms of traumatic experiences, such as physical or sexual abuse, neglect, family and/or community violence, trafficking or commercial sexual exploitation, bullying, or loss of loved ones. In addition to the circumstances of abuse or neglect that led to their removal, children may be subject to further stresses after entering the system, including separation from family, friends, and community, as well as the uncertainty of their future. Repetitive and significant encounters with trauma and stress have real consequences for the physical, social, and emotional wellbeing of children. The trauma experienced by chil dren in foster care is often complex and, if left untreated, can permanently affect the growth and development of a child and invite lasting repercussions felt decades later. Symptoms of trauma may include behavioral problems, attention/concentration issue s, separation anxiety, and extreme impulsivity.

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Implementing Trauma -Informed Practices in Child Welfare | State Policy Advocacy and Reform Center 2 A growing body of scientific literature indicates the success of trauma -informed child welfare systems in treating child traumatic stress. Trauma -informed systems are structured with an understanding of the causes and effects of traumatic experiences, along with practices intended to support recovery rather than exacerbate vulnerabilities. Trauma -informed practices include educating all stakeholders engaged with children and families, systematically screening children entering care, and dedicating resources to the provision of trauma -specific interventions. Trauma -specific interventions go beyond treating the symptoms of trauma, such as mental health disorders, and focus on the interplay between trauma and it s consequences. This approach includes providing children with a sense of control and hope, and requires the involvement of all stakeholders working with the child, including caseworkers, lawyers, judges, providers, birth parents , and caregivers (foster pa rents and kinship caregivers). Such trauma -informed practices present an excellent opportunity for improving child welfare outcomes. This brief will highlight the effects of trauma on child wellbeing and provide practice recommendations and examples of spe cific initiatives to guide transformation of the system. The Effects of Trauma on Children in Foster Care Stress elicits mental and physical responses that become problematic when they interfere with the ability to function and engage with others. Child hood traumatic stress is the psychological and biological responses resulting from a child™s inability to cope with an overwhelming situation. 2 These overwhelming experiences are referred to as traumatic events or trauma. Children can be exposed to trauma in a number of ways. Some children experience a single acute traumatic episode. Acute trauma is a short -lived experience tied to a particular place or time. 3 Examples of acute trauma include natural disasters, serious accidents, gang shootings, school viol ence, or the loss of a loved one. 4 In response to these traumatic events, children may experience feelings of helplessness and distress. 5 Children also may experience chronic trauma , or prolonged exposure over a long period of time to traumatic situations. Examples of chronic trauma involve prolonged physical or sexual abuse, exposure to family violence, or war. 6 Childhood traumatic stress resulting from this type of exposure may include intense feelings of distrust, fear for personal safety, guilt, and sha me. 7 Unfortunately, some children are exposed to multiple or prolonged forms of trauma, also known as complex trauma. Research reveals that children exposed to one form of violence are more likely to have had multiple exposures to violence. The 2011 Nati onal Survey of Children™s Exposure to Violence (NatSCEV II), the second comprehensive national survey designed to assess the full spectrum of children™s direct and indirect exposure to violence, focused on the experiences of youth age d 17 years and younger. 8 NatSCEV II found that 57.7 percent of its total sample reported experiencing or witnessing at least one form of violent exposure. 9 Almost half (48.4 percent ) of the sample had been exposed to more than one form of specific victimization, while 15.1 percent experienced six or more forms , and 4.9 percent had exposure to ten or more. 10 These high levels of exposure are particularly worrisome. About 11 percent of the sample directly experienced six or more forms of violence and abuse, also known as polyv ictimization. 11 Children experiencing polyvictimization are more distressed than other victims in general, but also display more distress tha n those victims who experience frequent victimization of a single type. 12 Children entering the foster care system a re more likely to be victims of complex trauma and polyvictimization. The National Child Traumatic Stress Network (NCTSN) conducted a study examining the association between complex trauma and psychosocial outcomes for youth in foster care. 13 Information

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Implementing Trauma -Informed Practices in Child Welfare | State Policy Advocacy and Reform Center 3 gathered about children in care who were referred for treatment at NCTSN sites demonstrated the high prevalence of complex trauma exposure for this population. 14 Over 70 percent of the sampled children reported experiencing at least two of the traumas constit uting complex trauma, while 11.7 percent reported experiencing all five types researched (sexual abuse, physical abuse, emotional abuse, neglect, and domestic violence) .15 Children who experience multiple forms of trauma tend to have more severe and compli cated reactions, which affect their emotional, behavioral, and cognitive functioning. 16 Initiated in 1995 and ongoing today, the Adverse Childhood Experiences (ACE) Study has linked traumatic childhood events, such as abuse and maltreatment, with increased likelihood of risky behavior and disease. 17 The ACE Study shows that children exposed to fifour or more adverse childhood experiences were four to twelve times more likely to struggle with depression, suicide attempts, alcoholism, and drug abusefl later in li fe. 18 The effects of these experiences on a child™s wellbeing and health can be profound. Not all children experience childhood traumatic stress after exposure to trauma . However, children in foster care often have not had the benefit of safe and stable ho mes that aid in building resiliency. Resiliency, or a child™s capacity to cope with future stress, is a critical part of treating children exposed to trauma. 19 Interventions that work towards building healthy relationships between children and caregivers, p rocessing painful memories, and making the child feel safe allow the child to develop strategies and tools for overcoming future trauma. 20 Children lacking the ability to adapt and handle traumatic events may display the following symptoms of childhood tra umatic stress: 21 Intense and ongoing emotional upset Depression Anxiety Behavioral changes Difficulties at school Problems maintaining relationships Difficulty eating and sleeping Aches and pains Withdrawal Substance abuse, dangerous behaviors, or unhealthy sexual activity among older children Children™s reactions to trauma differ depending on a child™s resiliency and her age. Preschool and young children will likely feel great fear in response to trauma. Young children have not developed the abili ty to know where they can find security and thus their fear extends past the circumstances of the traumatic event. 22 Caregivers may notice a loss of language and a regression in toileting skills, as well as repeated night terrors. 23 Beyond these behavioral r esponses, children who experience trauma during their infant and toddler years are apt to suffer limitations in brain growth. 24 Specifically, exposure to child abuse and neglect can negatively affect the parts of the brain regulating learning and self -contr ol. 25 The brain development of school age children can also be affected by childhood traumatic stress. For example, research associates exposure to domestic violence with lower IQ scores for youth. 26 School -age

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Implementing Trauma -Informed Practices in Child Welfare | State Policy Advocacy and Reform Center 4 children will often become preoccupied with th e traumatic experience, and may feel guilt or shame about their role in the event. 27 They may complain about stomachaches or headaches. 28 Caregivers may observe a change in behavior such as abrupt development of a new fear, inability to sleep well, signs of aggression, or impulsivity. 29 Symptoms of childhood traumatic stress may be most difficult to detect in adolescents who are often considered an emotionally volatile group regardless of trauma exposure. However, adolescents may experience a preoccupation with the traumatic event and internalize their fear, guilt, or shame. 30 Adolescents often worry about being abnormal or weak, and allow the trauma to isolate them from others. 31 They may have thoughts of revenge. These symptoms and others, such as sleep dist urbance, can be masked by late studying or staying up with friends. 32 The repercussions of trauma can be long lasting and extend throughout childhood and into adolescence and adulthood if not appropriately addressed. Children in the child welfare system ar e incredibly susceptible to the long -term effects of childhood traumatic stress because of their high exposure to violence, abuse, and neglect. Furthermore, the lack of a stable, caring caregiver can affect their ability to manage their emotions, behaviors , and relationships. 33 Findings from the NCTSN study show that children in foster care who are exposed to any trauma have an increased risk for mental health issues, such as severe posttraumatic stress and meeting the criteria for at least one mental health diagnosis. 34 Polyvictimization can increase the risk and severity of posttraumatic injury and mental health disorders anywhere from twofold up to tenfold. 35 Without intervention, children whose behavioral and emotional development are impacted by trauma ar e more vulnerable to negative outcomes such as dropping out of school, substance abuse, delinquency, and lower job attainment as adults. 36 In addition to the physical, mental , and developmental ramifications of trauma for individual child wellbeing and heal th, trauma also represents a huge financial cost for society. Children suffering from trauma will likely have a loss of productivity over their lifespans , and public systems, such as child welfare, social services, law enforcement, juvenile justice, and ed ucation, may also carry the burden of these costs. 37 The Benefits of Trauma -Informed Practices Given the significant impact of trauma exposure on child wellbeing and growth, child welfare systems must serve children from a trauma -informed perspective. Thi s framework requires advocates, administrators, and staff to be aware of trauma and its effects, to offer appropriate trauma screenings and assessments, and provide trauma -specific treatments. Furthermore, the Administration for Children and Families, U.S. Department of Health and Human Services, issued an Information Memorandum to state, tribal, and territorial child welfare agencies to focus on social and emotion wellbeing and fulfill the requirement under the Child and Family Services Improvement and Inn ovation Act 38 to include a description in their state plans of how they will screen for and treat emotional trauma associated with maltreatment and removal of children in foster care. 39 Trauma -informed care redirects attention from treating symptoms of trau ma (e.g., mental health disorders, behavioral problems) to treating the underlying causes and context of trauma. 40 Trauma -specific interventions include medical, physiological, psychological, and psychosocial therapies provided by a trained professional th at aid in the recovery from adverse trauma exposures. 41 Treatments are designed to maximize a child™s

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Implementing Trauma -Informed Practices in Child Welfare | State Policy Advocacy and Reform Center 5 sense of physical and psychological safety, develop coping strategies, and increase a child™s resilience. These treatments allow children to attain a sense of balance, make strides in meeting developmental benchmarks, heal deep emotional scars, and achieve stability in their foster placements. 42 A number of promising and evidence -based interventions address skill development, affect regulation, and build res iliency. The Office of Justice Programs (OJP), U.S. Department of Justice, reviews specific interventions based on whether evidence shows them to achieve their intended outcomes when implemented with fidelity. Several of the treatment programs OJP has rate d as either effective or promising include: 43 Child -Parent Psychotherapy (CPP): A dyadic intervention designed to allow parents and caregivers to develop secure relationships with their young children (up to age 5) and help form health y attachments. Trauma Affect Regulation: Guide For Education and Therapy (TARGET): An intervention, often used with youth in juvenile detention facilities, that provides participants with a seven -step sequence of skills for managing trauma -induced responses. Trauma -Focus ed Cognitive -Behavior Therapy (TF -CBT): A combination of individual and joint therapy sessions for children and parents or caregivers that focuses on reducing emotional/behavioral issues resulting from childhood traumatic stress. Cognitive Behavioral Inter vention for Trauma in Schools (CBITS): Designed for students in grades three through high school, CBITS works on learning coping skills, decreasing symptoms of posttraumatic stress disorder , and improving relationships with others. Parent -Child Interaction Therapy (PCIT): Geared towards children exposed to substance s prior to birth or to physical abuse, PCIT works with parents to learn skills for improving family relations. Trauma and Grief Component Therapy for Adolescents (TGC T -A): Works with adolescents to understand the effects of trauma on their behavior and strengthen self -regulation and coping skills. Provision of trauma -specific interventions is one component of effectively working with children experiencing childhood traumatic stress. To achieve the f ull benefits of trauma -informed care, systemic changes must incorporate best practices. Participating agencies and systems must take a collaborative approach to instituting trauma -informed practices. The Chadwick Trauma -Informed Systems Project defines a trauma -informed child welfare system as: 44 – one in which all parties involved recognize and respond to the varying impact of traumatic stress on children, caregivers, and those who have contact with the system. Programs and organizations within the system infuse this knowledge, awareness, and skills into their organizational cultures, policies, and practices. They act in collaboration, using the best available science, to facilitate and support resiliency and recovery. A number of different models incorp orate a trauma -focused delivery system. Each successful model recognizes that involving all stakeholders (e.g. , caseworkers, administrators, service providers, judges, attorneys, parents, and caregivers ) in the process of developing and implementing a trau ma-informed system greatly increases the capacity to effectively serve traumatized children. Collaboration will result in increased awareness, a greater capacity to overcome design and implementation obstacles, and a broader range of resources. Ultimately, a more effective system will allow more children in care to receive the support necessary to overcome the effects of childhood traumatic stress and thrive at home or in their placements.

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Implementing Trauma -Informed Practices in Child Welfare | State Policy Advocacy and Reform Center 6 Resources on Evidence -Based Interventions The listed intervention s are examples of treatment that have been evaluated for efficacy in treating trauma. For more information on these treatments and others, please visit the following websites: National Institute of Justice: Children Exposed to Violence SAMHSA: National Registry of Evidence -Based Programs and Practices Models of Trauma -Informed Practices As awareness of trauma -informed care has increased, a number of courts and agencies have adopted new and innovative practices designed to implement responsive practices. The child welfare agency, juvenile dependency and delinquency court system, and legal representation and advocacy models descr ibed below offer opportunities for consideration and implementation in other jurisdictions. The NCTSN Learning Collaboratives and Child Welfare Trauma Training Toolkit are a model and accompanying resource offered by the NCTSN to improve child welfare practices in a variety of practice settings. 45 The Learning Collaboratives allow NCTSN sites to form teams to work on implementing best practices, using the Learning Collaborative Toolkit, an 11 module course, as the guide. 46 The To olkit helps sites to determine goals, measurements, and evaluations of their implemented strategies. In June 2013 a Breakthrough Series Collaborative reported on the use of trauma -informed practices to improve foster placement stability in nine NCTSN sites nationwide. 47 Teams used the Child Welfare Trauma Training Toolkit to educate new staff on best practices. 48 Strategies include using trauma -informed screening tools, raising foster parent awareness, identifying resources for training, and using trauma -info rmed language. NCTSN sites that implemented these practices saw an improvement in the stability of children™s foster placements. For more information , visit the NCTSN Learning Collaboratives website and the NCTSN Child Welfare Trauma Toolkit . St. Aemilian -Lakeside (SAL) Œ Milwaukee 49 is a human services organization that has for the past five years embraced a trauma -informed philosophy. Under contract since 2009, SAL has provided case management and intensive in -home services for the Bureau of Milwaukee Child Welfare. Beginning with the training of its clinical staff, SAL has expanded a trauma -informed perspective into all of its core child welfare practices. The organization believes that all parts of the system must be aware of the effects of trauma in order to operate efficiently and cohesively. Staff members are asked to l ook at each child for potential traumatic stress, so children are routinely assessed for trauma exposure. During treatment, the daily relationship between child and caregiver is given primary focus. Families are taught positive ways to respond to children™ s traumatic stress. SAL also recognizes the importance of providing support to their staff in order to protect the health and wellbeing of workers from secondary trauma. For more information , visit the SAL website .

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Implementing Trauma -Informed Practices in Child Welfare | State Policy Advocacy and Reform Center 8 advocates potentially identify different types of traumatic experience and symptoms of trauma in their child clients, as well as identify services that may be most beneficial to address their needs. For more information see the resource guide online . Similarly, Legal Services for Children (LSC) Œ San Francisco seeks to fill the gap in lawyers™ knowledge of how trauma sensitivity can inform thei r daily practice. LSC proposes a model of child representation that integrates trauma awareness into every aspect of legal practice, focusing on relationships, advocacy, and coordination of care. In the first phase of its work, LSC has developed practice recommendations addressing how lawyers can build attorney -client relationships that are sensitive to the vulnerabilities of youth who have experienced trauma and can increase their engagement with their legal case. Moving forward, LSC intends to incorporat e best practices regarding how trauma knowledge can strengthen legal advocacy by enhancing lawyers™ understandings of their clients™ motivations, behaviors, and needs, and promote a collaborative, holistic response to clients in crisis, including through a ppropriate referrals to trauma -specific services and/or participation in multidisciplinary teams. 56 Trauma -Informed Practice Recommendations A tremendous amount of progress has been made in understanding the effects of trauma and the best practices for addressing childhood traumatic stress. As the above models demonstrate, there are a number of ways that child welfare systems can incorporate trauma -informed methods into their daily procedures and practices. Evaluations, such as the research conducted by the NCTSN, affirm the value of these practices. The following are five trauma -informed practice recommendations for child welfare systems, courts, advocates, and staff. Implementing these recommendations can improve the short and long -term health and wellb eing of children in care. Educate stakeholders about the effects of trauma on children and families, as well as effective trauma -specific treatments. A trauma -informed system requires awareness of trauma™s impact and consequences. Individuals and organiza tions must understand trauma before they can attempt to address it. The Attorney General™s Task Force on Children Exposed to Violence recommends that fievery professional and advocate serving children exposed to violence and psychological trauma learns and provides trauma -informed care and trauma -focused services.fl 57 Therefore, courts, advocates, child welfare agencies, and service providers need to understand what trauma is, how it manifests itself, what its effects are, and finally, how to treat it. Agencies and task forces should consider bringing in experts to explain how trauma may affect the behavior, development, and reactions of children. Additionally, professionals in the legal, judicial, behavioral health, and social services fields need to und erstand how their specific role can be used to improve outcomes for youth. This calls for more specific training on trauma -informed daily practices involving youth, families, and caregivers so that professionals involved with the family can effectively adv ocate for the services their clients need. Practitioners should also receive continuing education and support beyond initial training. Model curricula such as the NCTSN™s Child Welfare Trauma Training Toolkit are available to inform and train professiona ls. Dissemination of this vital information can include conferences and summits, brown -bag lunch trainings, and internal website postings. Child welfare systems can also designate and train trauma experts within their agencies to provide in -house expertise and consultation with other staff.

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Implementing Trauma -Informed Practices in Child Welfare | State Policy Advocacy and Reform Center 9 Ensure that children entering the child welfare system are screened and assessed for trauma. Given the benefit of trauma -specific treatment for allowing children to recover from trauma, it is essential that affected children in care be appropriately identified as in need of these services. The process for identifying children involves systematic scre ening and assessm ent . Screening tools are short standardized instruments administered to a specific at -risk population, such as all children entering the child welfare system. The goals of a screening instrument are to recognize the urgent needs of a child and identify criteria that signal the need for further services and evaluation. While screening has traditi onally been conducted by mental health providers, case workers can perform initial screenings of youth, and are an excellent front line resource for reaching youth. Often this practice can be incorporated into current child welfare intake procedures by add ing several key questions or revising current questions. 58 Once a child has been identified as in need of trauma -informed services, he should undergo a more rigorous assessment. An assessment is more comprehensive than a screening, and typically involves s peaking with multiple individuals who interact with the child, e.g., birth parents, other caregivers, teachers. 59 Assessments are important for fully understanding the nature and extent of the child™s traumatic stress, as well as for referring children into appropriate services. They should be conducted by a qualified and credentialed provider and should be tailored to the age and cognitive abilities of the child. 60 Using an appropriate assessment will allow children to receive the most effective trauma -speci fic treatment. A number of different screening and assessment tools have been developed over the past twenty years. Some tools have been designed specifically for children, while others are adaptations of trauma -focused instruments developed for adults. These instruments range from very broad, short five -minute surveys to very specific, two -hour long interviews. 61 The benefit of having a wide range of tools from which to choose is that agencies and providers can find resources that best suit their needs and systems. 62 Child welfare advocates can visit the Administration for Children and Families™ Child Welfare Information Gateway for more information on different screening and assessment tools. 63 Federal child welfare agencies and law also support the use of screening and assessment for trauma. The federal Children™s Bureau considers screening critical for development of a treatment plan and stresses the need for a complete trauma history for each child who enters the system. 64 The 2011 Child and Family Service s Improvement and Innovation Act requires states to identify protocols for screening for and treating emotional trauma associated with maltreatment and removal. 65 States have a unique opportunity to integrate trauma screening into their systems by promoting interagency collaboration among child welfare, mental health, and Medicaid agencies. 66 Federal law requires Medicaid to offer Early and Periodic Screening, Diagnosis and Treatment (EPSDT) to all covered children, which includes mental health assessment and services. 67 Medicaid and child welfare agencies can work together to ensure that appropriate trauma screenings and assessments are incorporated into the EPSDT benefit for eligible children. On a local level, dependency courts can also encourage systematic screening by requiring that all children entering the system have at minimum a screening, and requiring full and thorough child trauma histories. This practice will allow judges to make better informed treatment and placement decisions. Also, individuals w ith access to children™s trauma assessments and histories must understand the instruments being used. 68 Assessments are often performed by mental health professionals, so it is the responsibility of any non – clinicians using the results to understand the cha racteristics of the assessment. Mental health providers will

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Implementing Trauma -Informed Practices in Child Welfare | State Policy Advocacy and Reform Center 10 play a pivotal role in ensuring that appropriate , full trauma assessments are completed. Thus it is vital that the provider community be trained to use trauma -specific assessments. Resources for Screening and Assessment Tools While it is imperative for child -serving agencies to institute systematic screening and assessment processes, finding the appropriate evaluation tool is equally as important. Fortunately there are a number of evidence -based tools available for use and modification. Agencies should work with clinicians to determine which screening and assessment tools will best suit the needs of their syst em and population. The following sources list a number of instruments that agencies may consider: Child Welfare Information Gate way : Screening and Assessment of Child Trauma The California Evidence -Based Clearin ghouse for Child Wel fare: Screening and Assessment T ools for Child Welfare Refer children to appropriate evidence -based, trauma -specific treatments. Once an assessment shows that a child is in need of trauma -specific services, it is necessary to refer her to appropriate treatment. Specific treatment strategies have been developed for children and youth exposed to violence and trauma, so a key part of referring children into appropriate services is being aware of what evidence -based treatments are available in the community. Research organizations, such as the Centers for Disease Control, have evaluated the efficacy of various methods of treating trauma. 69 In addition to the Off ice of Justice Programs reviews mentioned earlier, the California Evidence -Based Clearinghouse for Child Welfare , SAHMSA™s National Registry of Evidence -Based Programs and Practices , and the Agency for Healthcare Research and Quality also review many trauma treatments for children. Advocates can use resources such as th ese to identify appropriate programs and skilled therapists in their own jurisdictions. This information can be collected within the child welfare agency and shared with caseworkers for use as a reference. 70 At the same time, child welfare agencies in coll aboration with other stakeholders can work to increase trauma treatment capacity within their communities. Such an effort involves finding clinicians who are trained or willing to be trained in evidence -based, trauma -specific treatments. 71 Agencies can assi st in capacity building by offering education courses for clinicians and instituting policies requiring training. For instance, agency policy could state that agency -contracted group homes are required to provide mandatory staff training on trauma -specific interventions. 72 Attorneys and judges can also influence capacity by speaking with the service providers they encounter in court about service availability and advocating for trauma -specific program development. 73 Provide information and trauma -related services to birth families and caregivers. Helping children recover from trauma depends not only on access to quality treatment, but also on daily interactions with caregivers and families. Birth, foster care, kinship care, and adoptive families can play a vital role in a child™s recovery. These important individuals in the child™s life should be included in the planning and provision of services, as appropriate, to foster recovery and resilience. Foster caregivers should be educated on the effects of traum a. Once caregivers understand why a child may act in a certain way, they can be better equipped to handle a child™s trauma symptoms and possible responses to trauma triggers (something that sets off a memory or flashback to the event that caused the origin al trauma). Such knowledge can also help stabilize placement. 74 Examples of how agencies can bolster caregiver knowledge include incorporating

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