Group Treatment of Sexually Abused Adolescent Girls: A Review of Outcome Studies

Transcription

1 The American Journal of Family Therapy, 35: , 2007 Copyright Taylor & Francis Group, LLC ISSN: print / online DOI: / Group Treatment of Sexually Abused Adolescent Girls: A Review of Outcome Studies KATHERINE A. AVINGER and REBECCA A. JONES Georgia School of Professional Psychology, Atlanta, Georgia, USA The developmental issues of adolescence make their treatment issues distinctly different from those of either adults or children (Cole & Putnam, 1992). Group treatment is considered an ideal modality for adolescent victims of child sexual abuse (CSA) because of adolescents emphasis on peer relationships in their struggle for identity development (Corder, 2000). A review of outcome studies from 1985 to 2005 revealed only 10 studies that specifically addressed group therapy for sexually abused girls ages 11 to 18. The groups reviewed varied in length of treatment, treatment setting, research methodology and treatment model, including cognitive behavioral, psycho-educational, psychodrama, multidimensional, and Rogerian/humanistic groups. Only 4 utilized comparison or control groups. Seven of the groups took place in outpatient settings, while 3 took place in inpatient or residential settings. Psychodrama models resulted in decreases in depressive symptoms, while cognitive behavioral groups and multidimensional groups incorporating graduated exposure were associated with PTSD symptom reduction. While none of the studies reported significant changes in externalizing behavior, at least according to parent reports, several group models resulted in significant reductions in group members self-reported anxiety symptoms and increases in self-reported self-esteem. INTRODUCTION The unique developmental issues of adolescence make their treatment issues distinctly different from those of either adults or children (Cole & Putnam, 1992). As children reach adolescence and begin experiencing physical and Address correspondence to Rebecca A. Jones, Georgia School of Professional Psychology, 990 Hammond Drive, Building 2, Suite 400, Atlanta, GA rjones@argosyu.edu 315

2 316 K. A. Avinger and R. A. Jones hormonal changes in their bodies, the sexual nature of abuse takes on new meaning. By connecting teens with peers who face similar problems, groups can address the shame and secrecy associated with sexual abuse (Corder, 2000). Hazzard, King, and Webb (1986) also describe a buffering effect of the group format, in that the issues and feelings about sexual abuse can be addressed without as much self-disclosure. Further, teens who have been sexually abused often find it easier to establish trust and rapport with each other in a group setting, depending less heavily on the adult than in individual therapy. This paper reviews 10 outcome studies published between 1985 and 2005 of group therapy for female adolescent victims of CSA (See Table 1). Only studies including pre and post test measures were included. A search of the extant literature revealed 3 studies with pre and post tests and control groups and an additional 7 studies without control groups. Subjects in these studies range from 11 to 18 years of age. EMPIRICAL LITERATURE REVIEW Overview of Studies The treatment models used in these studies vary in length, theoretical orientation, treatment setting, and number of group members. Treatment groups ranged from 6 to 24 sessions, and length of sessions ranged from 1 to 5 hours per session. Theoretical models varied. Two of the studies (Sinclair et al., 1995; Cohen & Mannarino, 1992) used trauma-focused cognitive behavioral therapy (CBT) model. Two more studies (Carbonell & Parteleno-Barehmi, 1999; MacKay, Gold, & Gold, 1987) used a psychodrama model. Another two studies (Lindon & Nourse, 1994; Thun, Sims, Adams, & Webb, 2002) used a multidimensional model, which included sharing of abuse stories, psychotherapy, coping skills teaching, and an element of sex education. Other group models included a Rogerian/humanistic model (Baker, 1987), an Eriksonian model (Kruczek & Vitanza, 1999), a dynamic group model (Kitchur & Bell, 1989), and an unspecified model incorporating an element of sex education (Verleur, Hughes, & de Rios, 1986). Such variability in study groups complicates the task of drawing conclusions about the relationship between various group models and outcome. Group sizes in the studies ranged from 4 to 16 adolescents, with 3 studies leaving group size unspecified (Baker, 1987; Cohen & Mannarino, 1992; Kruczek & Vitanza, 1999). Group size could influence efficacy of treatment in that the intimacy of the group and the amount of individual attention provided to each member diminishes in larger groups. However, larger groups might also provide greater opportunity for normalization of experience than smaller groups. Method of referral and location of treatment are also important variables in studies of group treatment. Three studies involved outpatient treatment

3 TABLE 1 Empirical Studies on Group Therapy for Sexually Abused Adolescent Girls Setting/Referral Type of Total Assessment Significant Study Subjects Source Design Group Hours Measures Improvements Verleur et al. (1986) Ages N = 30 Baker (1987) Ages N = 39 MacKay, Gold & Gold (1987) Kitchur & Bell (1989) Cohen & Mannarino (1992) Lindon & Nourse (1994) Ages N = 5 Ages N = 7 Ages N = 20 Ages N = 6 Sinclair et al. (1995) Ages N = 43 Carbonell & Parteleno- Barehmi (1999) Ages N = 26 Residential Group vs. Residential Pre/Post Outpatient. CPS referred Group vs. Individual Pre/Post Focus on self-esteem, sex-education. Rogerian Humanistic CSI, APSWS Self-esteem and sexual knowledge in group only. 9 Piers-Harris, IPAT anxiety & depression scales Outpatient Group Only Pre/Post Drama Therapy 32 to 40 BDI, SCL-90, TSBI, Outpatient CPS referred Outpatient. Residential and outpatient referrals Outpatient CPS referred ASQ, SSQ, Marlowe-Crowne Group better than individual in self-esteem only. Depression, psychotic thinking, hostility Group Only Pre/Post Dynamic 24 Piers-Harris, CBCL Self-esteem. Group Only Pre/Post Structured CBT 12 CDI, TSCC Anxiety, PTSD, anger, dissociation, sexual concerns. Group Only Pre/Post, 6-month follow-up Residential Group Pre/Post Trauma-Focused CBT Outpatient. Teacher, parent, and self referred Group vs. Arts and Crafts Waitlist Pre/Post Multidimensional 16 Self-statement questionnaire, qualitative data 20 CBCL, YSR, RADS, SPPA Psychodrama 20 YSR, qualitative data from group notes and participant feedback. Self-esteem, trust, relationships, behavior, guilt, shame Internalizing, externalizing, PTSD Withdrawn behavior, anxiety, depression, self-efficacy. APSWS = Anatomy Physiology Sexual Awareness Scale; ASQ = Attributional Style Questionnaire; BDI = Beck Depression Inventory; CBCL = Child Behavior Checklist; CDI = Child Depression Inventory; CSI = Coopersmith Self-esteem Inventory; IPAT = Institute for Personality and Ability Testing; Marlowe-Crowne = Marlowe-Crowne Social Desirability Scale; OSIQ-R = Offer self-image Questionnaire - Revised; Piers-Harris = Piers-Harris Self-Concept Scale; RADS = Reynolds Adolescent Depression Scale; SCL-90 = Symptom Checklist; SPPA = Self-Perception Profile for Adolescents; SSQ = Social Support Questionnaire; TRF = Teacher Report Form of the CBCL; TSBI = Texas Social Behavior Inventory; TSCC = Trauma Symptom Checklist for Children; YSR = Youth Self Report of the CBCL. 317

4 318 K. A. Avinger and R. A. Jones of girls referred by local child protective agencies (Lindon & Nourse, 1994; Kitchur & Bell, 1989; Baker, 1987). Three studies provided treatment to inpatient and residential clients (Verleur et al., 1986; Sinclair et al. 1995; Kruczek &Vitanza, 1999). Cohen and Mannarino (1992) included girls referred while living in residential treatment facilities along with girls living at home and being seen on an outpatient basis. Carbonell and Parteleno-Barehmi (1999) provided treatment in a middle school setting to girls who were identified by their parents or teachers as needing trauma-related services. Thun et al. (2002) recruited from a pool of sexually abused high school drop-outs in a GED preparation program, and provided treatment on an outpatient basis. In sum, 6 of the 10 studies reviewed provided treatment on an outpatient basis. The treatment milieu of a residential facility is likely to impact the outcome measures of inpatient groups positively, since girls in this setting have access to intensive therapeutic services outside of group. Unfortunately, none of the 3 studies conducted in inpatient and residential treatment facilities included comparison groups. Thus, conclusions cannot be drawn with regard to the extent to which these group treatments add to the effectiveness of other factors in the therapeutic residential setting. Treatment Models Corder (2000) and James (1994) provided some guidelines that are useful for any group treatment model used with sexually abused adolescent girls. James (1994) emphasizes the importance of tailoring treatment to adolescent clients developmental level, including age, intellect, and emotional maturity. James (1994) also advised therapists to be responsive to the clients readiness to process their trauma, so as to allow them a sense of empowerment in their therapy. Developmental homogeneity may be more important than age in groups, since a lower functioning group member may take up a disproportionate amount of the therapist s attention, and is at risk for being scapegoated by other group members (Corder, 2000; Hazzard, et al., 1986). Groups should also be limited to one gender, according to Corder (2000), since sexual topics are more difficult to discuss in mixed gender groups. James (1994) suggests that parents need to be educated as to what their children may be experiencing so as not to retraumatize them. Corder (2000) advocates having non-offending parents or other adult caregivers present for several sessions of the group, especially those regarding family-related issues. Hazzard and colleagues. (1986) add that warning parents that adolescents may have behavioral flare-ups before they begin to improve may help to reduce attrition during group work. TRAUMA-FOCUSED CBT Two ofthe studies reviewed (Sinclair et al., 1995; Cohen & Mannarino, 1992) used a trauma-focused CBT model. Much of trauma-focused group CBT as

5 Group Treatment of Sexually Abused Adolescent Girls 319 described by Foy et al. (2001) involves the telling and processing of group members trauma stories, as well as cognitive restructuring around group members perceptions of cause and effect and meaning in relation to their traumas. The emphasis is on graduated exposure to the trauma and teaching of coping skills. Several creative exercises are utilized to provide exposure and coping skills training and practice (Corder, 2000). MULTIDIMENSIONAL MODEL The multidimensional model of group therapy described by Lindon and Nourse (1994) was also implemented in a study by Thun et al. (2002). Lindon and Nourse (1994) described three main components of the model: a skills component, a psychotherapeutic component, and an educational component. The skills component focused on teaching relaxation, anxiety management, assertiveness, goal-setting, social skills, and problem-solving skills. In the psychotherapeutic component, group members received controlled amounts of exposure to the traumatic experience through various formats, and processed trauma-related emotions and cognitions in group. These techniques are similar to graduated exposure techniques found in CBT groups as described by Corder (2000) and Hazzard and colleagues (1986). The educative component of the treatment involved teaching about human sexuality, sexual anatomy and physiology, and methods of contraception. The aim of this component was to decrease feelings of shame and betrayal the girls might feel about their bodies. PSYCHODRAMA MODEL The psychodrama model, described by Carbonell and Parteleno-Berehmi (1999), focused on giving adolescent girls the opportunity to process the trauma through their senses, using a reenactment dramatization which each girl directed. The warm-up phase was a time for the girls to bond, develop agroup culture, and learn theatrical skills and core concepts. During the action phase, each girl was given the opportunity to stage, direct, and act out what happened to her. During this reenactment, the therapists had opportunities to reframe the events of the trauma in more adaptive ways. Each client was also given the opportunity to create new, positive endings to her story, in hopes of restoring a sense of personal control to the clients. Alternative formats were offered when a reenactment seemed too overwhelming for a client. During the final phase of each session, the girls had the opportunity to share their experiences of the dramatization and any feelings it brought up for them. Carbonell and Parteleno-Berehmi (1999) advised that, in the sharing phase, it is important for therapists to allow for emotional processing of material without becoming overly analytical about it.

6 320 K. A. Avinger and R. A. Jones Efficacy of Group Treatments A variety of outcome measures were used in categories including anxiety, depression, self-esteem, trauma symptoms, knowledge of sexual anatomy and physiology, and internalizing and externalizing behaviors. Many studies measured outcomes on more than one of these factors. PTSD AND GENERAL ANXIETY SYMPTOMS Three studies (Cohen & Mannarino, 1992; Lindon & Nourse, 1994; Sinclair et al., 1995) reported on measures of trauma symptoms, but none of these studies utilized control groups. All three studies reported significant improvement in PTSD and trauma symptoms. Symptoms of PTSD are generally classified as those of avoidance of certain sensory or cognitive reminders of the trauma, arousal, including agitation, irritability, hypervigilance and heightened startle response, and reexperiencing of the trauma through flashbacks and nightmares. Both Cohen and Mannarino (1992) and Sinclair and colleagues (1995) used trauma-focused cognitive behavioral approaches, and Lindon and Nourse (1994) utilized a multi-dimensional model, which also contains graduated exposure to the trauma, though not labeled as such. Despite lack of controls, these results provide preliminary support for trauma-focused CBT as an effective intervention for alleviating symptoms of PTSD. Other studies that provided exposure to the trauma did not include PTSD measures. Five studies (Baker, 1987; Carbonell & Parteleno-Barehmi, 1999; Cohen & Mannarino, 1992; Lindon & Nourse, 1994; MacKay et al., 1987) measured anxiety symptoms more generally. Of these, three studies (Carbonell & Parteleno-Barehmi, 1999; Cohen & Mannarino, 1992; Lindon & Nourse, 1994) reported finding significantly reduced anxiety symptoms from pretest to post-test. The study of a psychodrama group (Carbonell & Parteleno- Barehmi, 1999) also found significant improvement in anxiety symptoms in comparison to a control group. The study by Baker (1987) utilized a Rogerian/humanistic approach and found that anxiety symptoms were reduced by group treatment, but not significantly more than by individual treatment. MacKay and colleagues (1987) study of a drama therapy group with no control group found nonsignificant improvements in anxiety levels, possibly due to the small sample size. These results appear to indicate that many models of group therapy are associated with decreases in self-reported anxiety symptoms to a moderate degree. DEPRESSION Five studies (Baker, 1987; Carbonell & Parteleno-Barehmi, 1999; Cohen & Mannarino, 1992; MacKay et al., 1987; Sinclair et al., 1995) utilized depression outcome measures. Of these studies, only the psychodrama therapy

7 Group Treatment of Sexually Abused Adolescent Girls 321 group study (Carbonnell & Parteleno-Barehmi, 1999; MacKay et al., 1987) found significant improvement in depression scores. In their controlled study Carbonell and Parteleno-Barehmi s (1999) psychodrama group was associated with significantly greater decreases in depression than an arts and crafts waitlist group. MacKay et al. s (1987) psychodrama group also yielded improvements in depressive symptoms from pretest to post-test, as measured by group members average scores on the Beck Depression Inventory (BDI). There was no evidence that humanistic/rogerian or trauma-focused CBT groups alleviated depressive symptoms. There may be something about the way the psychodrama allows the girls to create a happier ending for themselves and process trauma with all five senses that contributes to decreased depressive symptoms. OTHER INTERNALIZING SYMPTOMS Sinclair and colleagues (1995) measured anxiety and depression symptoms together as internalizing symptoms in a study without a control group. The authors found significant improvement in internalizing symptoms using a trauma focused cognitive behavioral model. Lindon and Nourse (1994) used qualitative measures of change in their study of a multidimensional treatment approach. Despite the similarity of the sharing of traumatic experiences in this model to those used in the trauma focused CBT model, the multidimensional model did not label these exercises as graduated exposure. Lindon and Nourse s findings included increased ability to trust, decreased feelings of guilt and shame, and improved relationships with family and peers. SELF ESTEEM Six studies (Baker, 1987; Carbonell & Parteleno-Barehmi, 1999; Kitchur & Bell, 1989; Lindon & Nourse, 1994; MacKay, et al., 1987; Sinclair et al., 1995; Verleur, et al., 1986) reported on measures of self-esteem. Of these studies, Baker (1987), Carbonell and Parteleno-Barehmi (1999), and Verleur et al. (1986) used comparison groups, while the other three studies did not. All 6 of these studies found significant improvements in this area. Overall, it appears that group treatments using humanistic, psychodynamic, multidimensional, trauma-focused CBT, or psychodrama models are associated with improvement in self-esteem among victims of child sexual abuse. Given that 3 of the studies utilized comparison groups, this appears to be a robust finding. CONDUCT PROBLEMS Behavior problems were measured in two studies without control groups (Kitchur & Bell, 1989; Sinclair et al., 1995). The Sinclair et al. (1995) study

8 322 K. A. Avinger and R. A. Jones of a trauma-focused CBT group found significant improvement in behavior problems from pre to post test on a self-report but not a parent report measure. In a study of dynamic group therapy, Kitchur and Bell (1989) did not find significant changes in externalizing behavior on a parent report measure. The power of this study was reduced by the very low sample size. These studies provide no consistent evidence that either dynamic or traumafocused CBT groups are effective interventions for decreasing problematic behaviors in sexually abused adolescent girls. OTHER MEASURES Verleur et al. (1986) conducted a controlled study of an unspecified group therapy model that utilized a sex education component and measured changes in knowledge of sexual anatomy and physiology. In this study, sex education was hoped to alleviate the girls feelings of having been betrayed by their bodies during the abuse. Scores on the measure of sexual knowledge improved significantly at posttest for the treatment group but not for the control group. The two psychodrama studies (MacKay et al., 1987; Carbonell & Parteleno-Barehmi, 1999) measured guilt and shame, utilizing qualitative measures and specific items on the BDI. Both reported decreases in guilt and shame. Clearly this is a preliminary finding. In Kruczek and Vitanza s (1999) Eriksonian inpatient group, which did not utilize a control group, the authors were unable to find significant improvement in the group members coping skills. Given the short-term nature of Kruczek and Vitanza s group, this lack of significant improvement may indicate that coping skills need to be actively taught and practiced over a longer period of time. Kruczek and Vitanza (1999) also found significant improvements in adaptive functioning in their group. However, since this group was conducted in an inpatient setting, these results may have been due to other therapeutic factors in the inpatient treatment setting. Other qualitative measures were used in individual studies. For example, in their psychodrama groups, Carbonell and Parteleno-Barehmi (1999) reported that group members reported an improved sense of resolution with regard to the abuse in comparison to the wait-listed arts and crafts control group. In their multidimensional group study without a control group, Lindon and Nourse also reported improved ability to trust and improved family relationships, using qualitative measures. Limits of Research The most obvious limitation of research on group treatment of sexually abused adolescent girls is the relative dearth of studies that apply strictly to this topic 10 studies in 20 years. Small sample sizes inhibited many studies

9 Group Treatment of Sexually Abused Adolescent Girls 323 ability to detect even small improvements. One solution to this problem is to use the same pre and post measures on more than one group, and to analyze and present multiple groups data at once. SUMMARY Despite the limitations listed above, several tentative conclusions can be drawn from the research. For example, both trauma-focused CBT and multidimensional group therapy may be effective interventions for alleviating PTSD symptoms. Both models include an element of graduated exposure, although the multidimensional model did not label their approach as such. Thus, graduated exposure appears to be a healing aspect of therapy for PTSD symptoms in this population. Studies of four models found significant decreases in self-reported anxiety symptoms. One study (Baker, 1987) found that humanistic/rogerian group treatment was as effective as individual treatment in alleviating selfreported anxiety. In general, group therapy seems to be effective in treating anxiety symptoms in this population. Both studies on the effectiveness of psychodrama models provide some evidence to support the use of this model in alleviating depressive symptoms. There may be something about the way the psychodrama groups allow the girls to create a happier ending for themselves and process the experience in all five senses that alleviates the depression. Both studies of trauma-focused CBT groups (Cohen & Mannarino, 1992; Sinclair et al., 1995) reported no significant decrease in depression. All seven groups that measured self-esteem showed significant improvement in this area. Thus, it appears that group treatment of sexually abused adolescent girls using any of the models represented in this review is associated with improvement in self-esteem among group members. No evidence was generated that group therapy is an effective intervention for decreasing problematic behaviors in sexually abused adolescent girls. Given that oppositional behaviors, aggression, and running away were noted by Adams-Tucker (1982) as significant problems for child and adolescent victims of CSA, it will be important for future studies to include measures of conduct. This literature review provided very preliminary evidence that adding a sex education component may increase participants knowledge and even reduce guilt and shame. Further research in this area is clearly warranted. Based on qualitative data, two psychodrama studies reported that group members reported decreased feelings of guilt and shame. Such qualitative data provide direction for future research. Given the association between sexual abuse and shame (James, 1994), it may be particularly important to include standardized measures of guilt and shame in future research with this population.

10 324 K. A. Avinger and R. A. Jones Overall, the studies suggest that adolescents may need groups shaped for their particular symptom constellation. For example, depressed clients may benefit from some aspects of the psychodrama model. Similarly, for clients experiencing PTSD symptoms, only models providing some form of graduated exposure have been empirically supported. Some symptoms, such as low self-esteem and anxiety, appear to be helped by most models of group therapy. REFERENCES Achenbach, T. (1991a). Manual for the Child Behavior Checklist/4-18 and 1991 Profile. Burlington, VT: University of Vermont. Achenbach, T. (1991b). Manual for the Youth Self-Report and 1991 Profile. Burlington, VT: University of Vermont. Adams-Tucker, C. (1982). Proximate effects of sexual abuse in childhood: A report on 28 children. American Journal of Psychiatry, 10(139), Baker, C. R. (1987). A comparison of individual and group therapy as treatment for sexually abused adolescent females. Dissertations and Abstracts International, B, Beck, A. (1978). Beck Inventory. Philadelphia: Centre for Cognitive Therapy. Berliner, L., & Ernst, E. (1984). Group work with pre-adolescent sexual assault victims. In R. Stuart & J. G. Greer (Eds.), Victims of Sexual Aggression: Children, Women, and Men (pp ). New York: Van Nostrand Rheinhold. Briere, J. (1996). Professional manual for the Trauma Symptoms Checklist for Children (TSCC). Odessa, FL: Psychological Assessment Resources. Briere, J (2002). Treating adult survivors of severe childhood abuse and neglect: Further development of an integrative model. In J. E. B. Meyers, L. Berliner, J. Briere, C. T. Hendrix, T. Reid, & C. Jenny (Eds.) (2002). The APSAC Handbook on Child Maltreatment (2nd Ed.). Newbury, CA: Sage Publications. Carbonell, D. M., & Parteleno-Barehmi, C. (1999). Psychodrama groups for girls coping with trauma. International Journal of Group Psychotherapy, 49(3), Cohen, J. A., & Mannarino, A. P. (1992). The effectiveness of short-term structured group for sexually abused girls: A pilot study. Paper presented at a lecture series on therapy for sexually abused children, University of Pittsburgh. Cole, P. M., & Putnam, F. W. (1992). Effect of incest on self and social functioning: A developmental psychopathology perspective. Journal of Consulting and Clinical Psychology, 60(2), Coopersmith, S. (1981). Self-esteem inventories. Palo Alto, CA: Consulting Psychologists Press. Corder, B. F. (2000). Structured psychotherapy groups for sexually abused children and adolescents. Sarasota, FL: Professional Resource Press. Derogatis, L., Lipman, R., & Covi, L. (1973). SCL-90: An outpatient psychiatric rating scale Preliminary report. Psychopharmacology Bulletin, 9, DeYoung, M., & Corbin, B. A. (1994). Helping adolescents tell: A guided exercise for trauma-focused sexual abuse treatment groups. Child Welfare, 73(2),

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12 326 K. A. Avinger and R. A. Jones Piers, E. V. (1984). Piers-Harris Children s Self-Concept Scale: Revised manual. Los Angeles, CA: Western Psychological Services. Reynolds, W. M. (1987). Reynolds Adolescent Depression Scale: Professional manual. FL: Psychological Assessment Resources. Ross, G., & O Carroll, P. (2004). Cognitive behavioral psychotherapy intervention in childhood sexual abuse: Identifying new directions from the literature. Child Abuse Review, 13, Sinclair, J. J., Larzelere, R. E., Paine, M., Jones, P., Graham, K., & Jones, M. (1995). Outcome of group treatment for sexually abused adolescent females living in agroup home setting: Preliminary findings. Journal of Interpersonal Violence, 10(4), Stark, K. D., Rouse, L. W., & Livingston R. (1991). Treatment of depression during childhood and adolescence: Cognitive-behavioral procedures for the individual and family. In Kendall, P. C. (Ed.), Child & Adolescent Therapy: Cognitive- Behavioral Procedures. New York: Guilford Press. Stauffer, L. B., & Deblinger, E. (1996). Cognitive behavioral groups for nonoffending mothers and their young sexually abused children: A preliminary treatment outcome study. Child Maltreatment, 1(1), Thun, D., Sims, P. L., Adams, M. A., & Webb, T. (2002). Effects of group therapy on female adolescent survivors of sexual abuse: A pilot study. Journal of Child Sexual Abuse, 11(4), Verleur, D., Hughes, R. E., & de Rios, M. D. (1986). Enhancement of self-esteem among female adolescent incest victims: A controlled comparison. Adolescence, 21(84),

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