Introduction
Child abuse and neglect are frequent, perhaps even ordinary, occurrences in most of the world. The World Health Organization estimates that 40 million children under age 15 years around the world suffer from abuse or neglect each year requiring health and social care. Using a broader behavioral definition of parental acts, the UN Secretary-General’s Study of Children and Violence estimated that between 80% and 98% of children are physically punished each year and that one third or more of all children experiencing physical punishment are subjected to severe punishment with an implement. Despite large numbers of children being maltreated, the recognition of child abuse and neglect as a problem is a recent phenomenon in human history, and children might be safer now than in the past. Investigations, both in high and low or in middle-income countries, have demonstrated significant initial and long-term harm. Clinical skills in the recognition of child abuse, even among medical professionals in countries with a history of awareness, are far from ideal, and there are few hours devoted to child abuse in medical curricula even in the United States, which has among the largest clinical literatures on the problem. Among physicians in low- and middle-income countries, there is even less recognition of the problem. ,
Definitions and Culture
The international comparison of child abuse rates in different countries requires understanding cultural norms for parenting behavior. Definitions of what constitutes abusive or neglectful child rearing vary between countries, between professionals, and between communities in the same country. Culture is, in part, a society’s shared understanding of beliefs and behaviors about child rearing and parenting. Culture includes the values, rules, and prohibitions that define acceptable parenting. Different cultures can have and have evolved different rules about acceptable practices (e.g., 24 countries have banned corporal punishment by parents). However, a surprising amount of data are emerging suggesting that persons in many cultures share common working definitions of abuse and that ethnicity might not be among the important determinants of different conceptualizations of abuse.
Korbin et al reviewed studies in which authors presented vignettes of parental discipline to parents in different cultural groups. They noted that there was substantial agreement among community groups in a number of countries about what circumstances were harmful for children. However, there were some notable differences in perspective across societies. In one study they reviewed, the authors reported that Vietnamese parents did not perceive bruising from discipline as abusive, whereas white parents made more of an effort to distinguish spanking from other forms of hitting. Korbin also noted that Asian and Pacific Islander parents were surprised to learn that U.S. law limits parental rights to physically discipline children. This review noted wide variation in parental supervision standards; some groups were less concerned about young children left unattended or left with other young children. The authors did find that there were differences in emphasis in defining abuse in different ethnic groups; African Americans were more likely to think of neglectful acts whereas European Americans were more likely to worry about physical acts.
Some investigators have suggested that different cultures may have such widely divergent views on child rearing that it may not be easy to find cross-cultural agreement on what parenting practices are abusive or neglectful. , There is widespread agreement, however, that child abuse should end and considerable agreement that very harsh discipline practices and sexual abuse are abusive. , The World Health Organization’s (WHO) 1999 Consultation on Child Abuse Prevention produced a definition that was acceptable to the attending group of international delegates: “Child abuse or maltreatment constitutes all forms of physical and/or emotional ill-treatment, sexual abuse, neglect or negligent treatment or commercial or other exploitation, resulting in actual or potential harm to the child’s health, survival, development or dignity in the context of a relationship of responsibility, trust or power.”
In addition to potential variations in defining child abuse among cultures, there are other disagreements on how abuse should be defined that have a conceptual basis. Some might focus on the behaviors or acts of adults in defining abuse whereas others define abuse by the occurrence of harm or the threat of harm to the child. The distinction between behavior and impact or harm becomes even more complicated if the intent of the parent is part of the definition. Some include in the definition of abuse those children inadvertently harmed through actions of a parent regardless of intent whereas others would require that harm be intended. To complicate cross-national comparisons even further, some international literature explicitly includes violence against children in institutional or school settings as child abuse.
Types of Child Maltreatment
This chapter attends only to parental or caregiver acts and omissions that result in harm to the child and does not address commercial exploitation or the abuse of children in institutional settings such as schools or in communities. Specifically, we examine the data, causes, and consequences for four subtypes of child abuse and neglect:
Physical abuse: An act or acts committed by a caregiver, toward a child, which produce either physical harm or have the potential for producing harm.
Sexual abuse: Acts in which a caregiver uses a child for sexual gratification.
Emotional abuse: The failure of a caregiver to provide a developmentally appropriate and supportive environment or acts that themselves have an adverse effect on the emotional health and development of a child. Restrictions of movement, belittling, denigrating, scapegoating, threatening, scaring, discriminating, ridiculing, or other nonphysical forms of hostile or rejecting treatment are all examples of emotional abuse.
Neglect and negligent treatment: Neglect is the failure of a caregiver to provide for the child in health, education, emotional development, nutrition, shelter, or safe living conditions when the caregiver is in a position to provide for the child. Neglect is usually distinguished from poverty in that neglect can occur only when there are resources reasonably available to the family or caretakers that are not offered to the child.
Fatal Abuse
Young children are at greatest risk for child abuse homicide. Rates for children 0 to 4 years of age are more than twice the rates for children ages 5 to 14 years around the world. WHO estimated 85,000 child abuse homicides among children less than 15 years of age in 1998. Children under 4 from Eastern Mediterranean low- and middle-income countries have the highest rates at 14.8 per 100,000 for boys and 16.4 per 100,000 for girls. India is the next highest region with rates of 10.1 and 13.6 per 100,000 for boys and girls, respectively. Girls tend to be at higher risk of child abuse homicide. The contrast is most stark in China with rates for girls ages 0 to 4 of 15.7 per 100,000, nearly double that of boys (7.9 per 100,000). Although it seems that gender would be among the most significant risk factors for infant homicide internationally, published research indicates a surprising uniformity of risk factors for infant homicide around the world, in countries as disparate as Fiji, Cameroon, and the United States. Most child abuse homicides are to the infants of young, poor, unmarried mothers. ,
Many infant deaths around the world are not routinely investigated, so it is difficult to determine child abuse homicide rates with precision in many countries. Infant deaths can be incorrectly attributed to infectious disease or malnutrition by caregivers and by health workers in countries that have limited diagnostic test access and little access to routine autopsies. A recent study in one U.S. state reported 5 fatalities in 100,000 children in the first year of life from abusive head trauma. In contrast, 2.6% of parents of young children in that region reported shaking as a form of discipline. In several low- and middle-income countries, rates of shaking have been reported above 25% in the first 2 years of life. Shaking is postulated to account for a significant portion of unexplained infant mortality, mental retardation, and learning disabilities in low- and middle-income countries. Child abuse fatalities are far more numerous than stated in official estimates from vital records in countries where studies of infant death have been more closely examined. The leading causes of death from child abuse are, in order, abusive head trauma, blunt abdominal trauma, and suffocation.
Nonfatal Abuse
The recent UN study on children and violence demonstrated that child abuse and neglect are global phenomena. They occur in every country and civilization that has been studied. The majority of systematic studies have focused on physical and sexual abuse; less is known about neglect, emotional abuse, and other forms of maltreatment in low- and middle-income countries. At least 26 countries collect official statistics on reported abuse.
The majority of countries have no legal or social systems with responsibility for responding or monitoring child abuse and neglect. Case reports or case series of child abuse have been published in many countries, indicating increased professional or public awareness to this problem. Recent population-based surveys have been completed in a number of countries including Australia, Brazil, Canada, Chile, China, Costa Rica, Egypt, El Salvador, Ethiopia, Guatemala, Honduras, India, Israel, Kenya, Mexico, New Zealand, Nicaragua, Norway, Philippines, Portugal, South Africa, South Korea, Spain, Uganda, the United States, and Zimbabwe.
Physical Abuse
An estimated 40 million children around the world suffer from abuse or neglect and need health and social intervention. In the United States, for 2006, 777,000 children were confirmed to be victims of either abuse or neglect and, of these, 142,000 were victims of physical abuse. The physical abuse rate was 1.9 in 100,000 children that year. Despite over 30 years of mandatory reporting of child abuse, it is almost certain that these statistics underestimate actual abuse in the United States. A 1995 Gallup poll asked a national sample of U.S. parents about disciplining their own children in the previous year. The study authors reported an abuse rate of 49 per 1000 children when defining abuse as hitting the child with an object someplace other than on the buttocks, kicking the child, beating the child up, and threatening the child with a knife or a gun. This and a similar study from a two-state probability sample in 2002 found a more than twentyfold difference in substantiated abuse and parent reports of abuse. ,
International research suggests that the rates for physical abuse may be higher in low- and middle-income countries. A study from Egypt described high rates of beating and fractures. In a cross-sectional survey of children in Egypt, 37% were beaten or tied up and 26% of children reported physical injuries such as fractures, loss of consciousness or permanent disability from a beating. In South Korea, severe violence (defined by the authors as kicking, beating, biting, throwing, or threatening with a knife or a gun more than two times a month) was reported by 69 of 1000 fourth and fifth graders. As high as these child-reported rates appear, parent reports indicate even higher rates: South Korean parents reveal whipping children at a rate of 67%, or hitting, kicking, or beating their children at a rate of 45%.
Eastern European reports of physical discipline and abuse yield similar estimates for rates of child victimization. Romanian children reported a rate of 4.6% for severe and frequent physical abuse including being hit with an object, being burned, or being deprived of food. Nearly half of Romanian parents (47%) admitted to beating their children “regularly” and almost 16% reported beating their children with objects. A recent national study of parents in Georgia reported nearly 50% of children were spanked, shaken, or had their hair pulled or ears twisted in the last year.
Sexual Abuse
The prevalence and incidence of sexual abuse and other forms of maltreatment have been difficult to study and compare across national samples. Definitions, methods, and measures vary widely. Most of the research into sexual abuse comes from countries in North America and Western Europe. In most cases, incidence is determined by report to social services or criminal justice authorities. Victims of sexual abuse can also be counted when they present to a health care setting. However, the fundamental flaw in these approaches is that most cases of sexual abuse are only known to the perpetrator and the victim. A population-based survey of parents in the United States found that they acknowledged sexual abuse of their children 15 times more than official reports indicated. One nationally representative survey of parents in the United States indicated that 1.9% of boys and girls were sexually abused in the last year and 5.7% ever. The discrepancy between official reports and survey estimates might be due to unreported sexual abuse, sexual abuse reclassified as other types of abuse or neglect, or sexual abuse that is unsubstantiated or deemed not to be under the purview of child protective services. Even parent-report data are limited. It only reveals the cases of sexual abuse known to the parent being interviewed. Adolescent and adult retrospective data suggest that real rates are far higher still. Comparisons between studies are further constrained as some studies attempt to gather lifetime prevalence data whereas others attempt to ascertain incidence in the past year.
A number of studies have been done around the world surveying adolescent and adult populations about history of sexual abuse. A large study of middle-aged adults in the United States ( n = 17,337) pooling people with private health insurance found that 24.7% of women and 16.0% of men reported sexual abuse (defined with a series of four questions pertaining to [1] touching and fondling the respondent; [2] forcing the respondent to touch or fondle the perpetrator; [3] attempt at any type of intercourse (oral, anal, or vaginal); and [4] actual completion of any type of intercourse). These results are similar to estimates from studies in Europe, South America, and Africa, although national population-based survey estimates of child sexual abuse victimization on these continents are rare. A recent three-country survey in Africa, using a systematic sample of urban young adults, reported far higher rates of sexual abuse. The study reported rates of 53% in Uganda, 44% in Kenya, and 42% in Ethiopia, defined as unwanted sexual touch. Alarming rates of rape were noted, including 43% in Uganda, 30% in Ethiopia, and 26% in Kenya.
Adolescents have been surveyed in several studies regarding their history of sexual abuse. There are several advantages to this approach. Adolescents can be surveyed in school settings with appropriate permission and collaboration, thus are a relatively captive audience resulting in a lower cost and a higher response rate. Furthermore, since adolescents are required to be in school in many countries up to a specific age, sampling through school systems facilitates easy access to a generalizable sample. Perhaps even more important, adolescents are closer to the events of childhood and may be more accurate in their memory of abusive trauma and less subject to recall bias. A final reason that adolescents make such an important target is that their sexual abuse history is much closer to the current reality in any national setting. That is to say, if middle-aged women report sexual abuse that occurred 20 to 40 years ago, the impact of changes in public policy and prevention cannot hope to be ascertained for many decades. However, sexual abuse peaks in adolescence, so studies of adolescents can best be used to measure the current population experience with sexual abuse.
Two recent examples of surveying adolescence for history of sexual abuse come from China and Sweden. In Henan province, 21.9% of girl adolescents in a professional school program reported at least one type of sexual abuse prior to the age of 16 using a 12-item questionnaire. Sexual abuse was defined as an unwanted sexual experience for the child. This study did not include boys. In Sweden, a large representative national sample of boys and girls was surveyed about sexual behavior using an instrument including 10 questions on sexual abuse. In this study, the authors inquired about only those acts that were forced; the estimates of sexual abuse were 11.2% among girls and 3.2% among boys. The study successfully recruited a population of out-of-school adolescents, a modification that is essential for national estimates because out-of-school adolescents in Sweden report nearly twice the lifetime prevalence of sexual abuse. A survey of children in Ukraine reported that nearly 20% of teenagers have been sexually abused. A study of adolescents from Geneva reported lifetime sexual abuse rates at 34% for girls and 11% for boys. Emphasizing the importance of how the wording of questions alters estimates, another Swiss survey of adolescent girls using fewer questions and a more restrictive definition noted a somewhat lower rate (18%) for reported sexual abuse. These studies are difficult to compare because of divergent definitions, varying measures, varying contexts, and sampling frames.
Some studies have attempted to compare adult and child responses to surveys about sexual abuse. A survey of 1500 Romanian families obtained data from both children and adults. In this study 0.1% of parents admitted to sexually abusing their children while 9.1% of children report having been sexually abused. One of the great challenges in comparing children and parents’ survey response is the referent time period and possible perpetrators. The question asked of children included sexual victimization by anyone.
Men report a history of sexual abuse ranging from 1% to 19% among published studies of adults giving retrospective histories. International lifetime prevalence rates for child sexual victimization using adult reports range from 0.8%, using rape as the definition, to 45% using a much wider definition lifetime history of sexual abuse. In international journals in the 1990s the mean lifetime prevalence rate of childhood sexual victimization of women as girls was 19% and men as boys was 7%. This variation in published prevalence estimates could mask real differences in risk in different cultures or result from differences in the conduct of the studies. ,
Neglect
The cross-cultural study of neglect is challenged by issues related to blame or locus of control. Some authors deem failure to meet basic needs of childhood as neglect, without placing blame on parents, government, or conditions of a local community. Others have focused on parental omissions in providing care. In the United States, laws generally define a child as being neglected only when the child has been harmed by an omission in care. Other authors include harm from parental omissions in care as part of the definition of abuse.
Many societal conditions such as exposure to toxic chemicals or war can be more dangerous for children than parental omissions in care. Because definitions are varied and research in neglect is far less common, it is difficult to estimate the global dimensions of the problem. In Kenya, adults asked to define child abuse most commonly cite abandonment and neglect. In the United States, 60% of reports for child maltreatment are for neglect and the rate of neglect is 7 in 1000 children.
Psychological Abuse
Cultural factors influence the use of parental discipline techniques and the frequency with which discipline includes psychological or emotional harms or threats. Psychological abuse itself is difficult to define, since the consequences are likely to be very different by context and by the age of the child. Surveys about child discipline demonstrate that yelling or screaming at children is common (over 80%) across many countries. , Cursing children and calling them names is also common, with 15% being the lowest rate reported by parents in a single country among a recent multinational study. Rates for threats of abandonment and locking a child out of the home were widely divergent among countries.
Understanding and developing prevention strategies and interventions for psychological or emotional abuse remain a major international challenge. The same threat might be much more traumatic to children in a country where that threat is unusual than it would be if the child frequently hears such threats from the parents of friends.
Ecological Context
The causes of abuse are related to social interactions in families and communities. The ecological theory is the most widely adopted explanatory model by which to understand child maltreatment. There are four contributory spheres of influence in this model: (1) child characteristics; (2) caregiver and family characteristics; (3) community characteristics; and (4) the social, economic, and cultural characteristics of society. The interplay of these factors can lead to abuse in one circumstance and not in another. Each of the factors appearing below has been linked to child abuse or neglect in more than one study. However, the factors listed might be only statistically associated and not causally linked.
Children Characteristics
Young child age is a consistent and strong risk factor for child physical abuse. Child abuse homicide is most common among young infants. The peak ages of abuse vary somewhat between countries and cultures. Physical abuse is most common in the United States between 6 and 12 years of age, and similarly in India between 6 and 11. In China, however, the peak of physical abuse is between 3 and 6. , Sexual abuse is consistently most common during adolescence.
Sex of child is a risk factor for some types of abuse. Girls are generally at higher risk for infanticide, sexual abuse, educational and nutritional neglect, and prostitution worldwide. Boys, in contrast, are at higher risk for abusive head trauma in the United States and for harsh physical discipline.
The reasons for variation between countries in the peak age of abuse and the differential rates of types of abuse by child sex have not been well studied. Some variation may be due to acceptable parenting standards, discipline strategies, available resources, and patterns of care giving such as the use of extended families for care taking. The cultural differences in the role and value of women likely affect the rates of sexual abuse and female infanticide.
Caregiver and Family Characteristics
Gender as a risk for the perpetration of abuse has been evaluated in a number of types of studies in various countries. Women more often report using harsh physical punishment, and children more often report violence by a mother or female caretaker. In most countries, women have more responsibility for raising children and therefore for discipline and care. They also have more exposure to children in terms of time. In the United States, single mothers are more likely to self-report the use of harsh physical discipline than mothers in two-parent families. In contrast, men perpetrate more abuse resulting in severe injury. This increase in risk may not be due to men’s behavior or discipline practices, but simply due to the relative importance of strength in causing severe injuries. Sexual abuse offenders are predominantly male regardless of victim gender. Rates of male perpetrators for female victims range from 92.0% to 99.2%. For male victims the range is between 63.2% and 85.7%. ,
Parents with a personal history of being abused as children appear to be at higher risk of abusing their own children. Domestic violence and child abuse appear to be very strongly linked. They share many of the same ecological risk factors. Domestic violence has been reported as a risk factor in many countries including Colombia, China, Egypt, Fiji, India, Mexico, and the United States. As many as half of abuse victims have concurrent domestic violence in their homes. , There is increasing interest in the relationship between domestic violence and child abuse in the research and policy arenas in many countries. Further work is need to understand the effect on children of exposure to both child abuse and domestic violence.
Parents with less support and more life stress have children at higher risk for abuse. Maternal mental health problems, especially depression, increase a child’s risk for abuse. Substance abuse by a parent or other household member places a child at increased risk of abuse. Finally, household crowding increases a child’s risk for being abused. The effects of risk factors such as maternal mental health problems, household substance abuse, poverty, illiteracy, and household crowding are closely related, and further work will be needed to understand the role of each of these in diverse cultural contexts.
Community Context
Poverty is a strong risk factor for all types of maltreatment across diverse cultures. Two exceptions to this finding have been demonstrated in studies in which higher income urban families had higher rates of physical abuse. , In the United States, one study found that the poorest families (incomes <$10,000/year) reported rates of physical and sexual abuse three times that of middle- and high-income families (incomes >$50,000/year).
High neighborhood cohesion and the closely related phenomenon of social capital have been shown to be protective factors for child maltreatment in two studies from high-income countries. , Children in neighborhoods with less social capital have more behavioral and psychological symptoms. Social networks, a component of social capital, have also been shown to decrease the risk of child maltreatment.
Societal Context
The society-level risk for child maltreatment is important and complex. Factors that may mediate the risk of child maltreatment include the following: education, child support, child labor, mandatory reporting laws, laws related to corporal punishment, special criminal justice systems, value and role of children (especially girls), national health systems, home visiting services, educated health providers, larger social conflicts, and war. These issues have been unexamined as they relate to child abuse in most countries but fit well into an ecological model for understanding and preventing abuse. , To study these factors would require comprehensive societal level comparative research using similar measures and definitions. Some societal level factors can compromise parental abilities to care for children (e.g., poor access to health services and education) whereas others such as access to home visiting and health care may enhance parental abilities. Research is needed to examine the effect of social policy changes to enhance parenting and assist families. One example is the child care allowances and tax credits offered to parents in some countries. Research is also needed regarding the impact of aggressive pregnancy prevention policies. Perinatal home visiting programs provide important support and education for parents. Some programs have shown success in randomized trials in preventing abuse and neglect in addition to other important outcomes affecting the lives of children and families. International comparative research could be the most powerful method of exploring how societal context decreases or increases the risk of abuse.
Education of Health Professionals
Many health professionals around the world lack the skills or inclination to identify cases of abuse. The United States has a relatively longer history of recognizing the problem of child abuse, and still they are underprepared and uncomfortable confronting child abuse. A survey of American medical schools observed that while nearly all medical school (95%) include information about child abuse in their curriculum, the median amount of class time spent on child abuse was 2 hours. Only 80% of medical students reported child abuse coursework, and they agreed with the estimate of 2 hours of instruction. Given the complexity of recognizing abuse, it is clear that most students will not be well prepared for this task in the United States. As further evidence of this lack of preparedness, a recent survey of pediatricians demonstrated that 50% were uncomfortable testifying in court about child abuse, and only 30% were comfortable with diagnosing and treating child abuse as part of their professional role. Recent studies have demonstrated significant lack of agreement between physicians of findings indicative of child sexual abuse and a high rate of missed diagnosis on abusive head trauma in children presenting for medical care. , Similarly, two recent studies have shown wide variation in interpretation of abusive clinical scenarios among generalists and specialists. , Anecdotal reports from the faculty of 27 medical schools from low- and middle-income countries participating in the International Clinical Epidemiology Network suggest that the problem may be even greater in other regions of the world. Little or no formal instruction in child abuse has been provided at any of the schools in this group of prestigious medical schools in Asia, Africa, and South America. A study from Turkey observed, “Some pediatricians, in a national conference, resented having to spend unnecessary time to this very local, social, non-medical problem.”
Physicians and other health workers need to be trained to consider child abuse in cases of unexplained injury or child psychological distress. They must interpret histories in the context of the child’s development, recognize the signs and symptoms of child abuse, and distinguish suspicious findings from innocent findings. The medical determination of child abuse needs to be both sensitive and specific. The consequences of missing abuse when it is present (because of low sensitivity) can be grave and even fatal to the child. The consequences of diagnosing abuse in its absence can be grave as well, resulting in severe distress for the family and child and removal of a child from his or her home, as well as great legal and social costs. Social service organizations rely on medical expertise and are not in a position to question medical interpretations of physical abuse findings. Failure to diagnose child abuse and an unwillingness to pursue the diagnosis complicate societal efforts to protect children. Available data suggest that the preparation of physicians for work in this area is inadequate. ,
Future Research
Although the predominance of western publications about the problem of child abuse has led some professionals to describe child abuse as a western problem, this chapter presents data documenting that the problem is of equal or even greater severity in low- and middle-income countries. We have presented data demonstrating that child abuse is more common than many of the infectious diseases for which massive eradication programs have been mounted. Instead of rates of a few cases per thousand, child abuse and neglect affect a much larger percentage of the population and result in significant societal costs. Child abuse is a pervasive and serious global health problem and the data suggest no society is immune.
Providers seeking data about specific countries should consult the United Nation’s Secretary-General’s Report on Children and Violence and the periodic reports issued by the International Society for the Prevention of Child Abuse and Neglect ( http://www.ispcan.org ). In 1996, the Secretary-General called for a global study that would address violence against children in homes and schools in a manner similar to an earlier UN study of war on children. This study was delayed until 2002 when Professor Paulo Pinheiro of Brazil was appointed the Study Director and a Secretariat for the study was established in Geneva. The report was released on October of 2006 and is available for no cost on the Internet. One recommendation of the report was to address the need for more research and better data on the extent and nature of child maltreatment in all nations. Improvements in measurement and expanded efforts at surveillance were called for to assess the extent of the problem and to monitor the impact of changes in policies and services for children.
One way we will better understand child maltreatment around the world is by improved use of common definitions and measures. As part of this effort and in response to the UN World Report, the International Society for the Prevention of Child Abuse and Neglect collaborated with the UN Children’s Emergency Fund to develop and field-test three new survey instruments to ascertain rates of child victimization from parents, young adults, and children. These instruments have since been field-tested in national and multinational studies. The report also calls upon the world’s medical schools to do a better job of educating health professionals in recognizing and responding to child abuse.
We concur with the UN Secretary-General’s report that there appears to be little recognition of child abuse by health professionals in most countries. Governments and academics must ascertain the epidemiology. Effective intervention strategies will need to be developed and disseminated. Prevention efforts and policies must be directed at the children, the caregivers, and the environment before, during, and after occurrences of abuse or neglect. Health professionals must learn to recognize child abuse and neglect. Professional schools in medicine, psychology, education, social work, and public health around the world must include training in this field as a prelude to successful global efforts to reduce or eliminate child abuse.
Stay updated, free articles. Join our Telegram channel
Full access? Get Clinical Tree
