Psychology: Conceptions of Psychopathology

Conceptions of Psychopathology

• A conception of psychopathology is not a theory of psychopathology, but rather an attempt to define what is considered psychopathological and what is not.
• It does not try to explain psychological phenomena, but rather tells us what is considered pathological and needs to be explained.

Conceptions of Psychopathology: Varieties

• Statistical deviance: considers abnormal behaviors as those that are statistically infrequent.
• Maladaptive (dysfunctional) behavior: views psychopathology as behaviors that are not just statistically abnormal but also maladaptive or dysfunctional.
• Distress and disability: involves subjective distress and disability, including unpleasant feelings and restrictions in ability.
• Social deviance: views psychopathology as behavior that deviates from social or cultural norms.
• “Dyscontrol” or “dysregulation”: considers psychopathology as maladaptive patterns of behavior that are not within a person's ability to control or self-regulate.
• Harmful dysfunction: considers psychopathology as a harmful dysfunction that is caused by a failure of a psychological mechanism to perform a natural function for which it was evolutionarily designed.

Statistical Deviance

• A "common sense" conception of psychopathology, considering abnormal behaviors as those that are infrequent.
• Merits: has common sense appeal, lends itself to accepted methods of measurement, and gives it some scientific respectability.
• Problems: considers only one "side" of the deviation to be problematic, and involves subjectivity in determining how far away someone is from the norm.

Maladaptive (Dysfunctional) Behavior

• Considers psychopathology as behaviors that are not just statistically abnormal but also maladaptive or dysfunctional.
• Benefits: has common sense appeal, and is consistent with the way laypersons use words like "pathology", "disorder", and "illness".
• Drawbacks: involves inherent subjectivity, and judgments of adaptiveness and maladaptiveness are logically unrelated to measures of statistical deviation.

Distress and Disability

• Involves subjective distress and disability, including unpleasant feelings and restrictions in ability.
• People who seek mental health treatment usually are not getting what they want out of life, feeling inhibited or restricted by their situation or limitations.
• Difficulties: different people define personal distress and disability in vastly different ways, and people differ in their thresholds for how much distress or disability they can tolerate before seeking help.

Social Deviance

• Views psychopathology as behavior that deviates from social or cultural norms.
• Benefits: in line with common sense, and we tend to view psychopathological people as thinking, feeling, and doing things that most other people do not do.
• Drawbacks: norms for socially normal or acceptable behavior are not derived scientifically, but instead are based on cultural values and historical practices.

“Dyscontrol” or “Dysregulation”

• Considers psychopathology as maladaptive patterns of behavior that are not within a person's ability to control or self-regulate.
• Problems: draws an artificial line between "within control" (voluntary) and "out of control" (involuntary), and research suggests that most behaviors are automatic and therefore involuntary.

Harmful Dysfunction

• Criteria for psychopathology: (1) it is negative or harmful according to cultural values, and (2) it is caused by a dysfunction.
• Presumably grounded in evolutionary psychology, acknowledges that the conception of mental disorder is influenced strongly by social and cultural values, and proposes a scientific, factual, and objective core that is not dependent on social and cultural values.
• Benefits: acknowledges that the conception of mental disorders must include a reference to social norms, and tries to anchor the concept of mental disorder in a scientific theory.
• Drawbacks: based on value judgments, and is a "moving target".

The DSM and ICD Definitions of Mental Disorder

• The DSM and ICD are psychiatric classification systems that define mental disorder.
• The DSM defines mental disorder as a syndrome characterized by clinically significant disturbance in cognition, emotion regulation, or behavior that reflects a dysfunction in psychological, biological, or developmental processes.
• The ICD defines mental disorder as a clinically recognizable set of symptoms or behavior associated with distress and interference with personal functioning.

The DSM and ICD Definitions of Mental Disorder: Problems

• Major problem is subjectivity, as who determines what is "clinically significant" and how do we determine whether a particular response to an event is "expectable" or "culturally approved"?

Categories versus Dimensions

• The difficulty in most conceptions of psychopathology is that they are categorical models that attempt to describe guidelines for distinguishing between individuals who are normal or abnormal.
• The dimensional model views normality and abnormality as lying along a continuum, and psychological disorders are extreme variants of normal psychological phenomena.

Social Constructionism and Conceptions of Psychopathology

• Social constructionism involves accepting the idea that psychopathology is an abstract idea that is not scientifically constructed but socially constructed.
• The social constructionist perspective can be contrasted with the essentialist perspective, which assumes that there are natural categories and that all members of a given category share important characteristics.
• In the social constructionist view, reality cannot be separated from the way that a culture makes sense of it, and categories of psychopathology represent not what people are but rather the ways that people think about and attempt to make sense of differences among people.

What is Developmental Psychopathology?

• Developmental Psychopathology (DP) is the study of the origins and course of individual patterns of behavioral maladaptation, regardless of age of onset, causes, transformations, and complexity.
• The primary focus of DP is to study the processes underlying continuity and change in patterns of both adaptive and maladaptive behavior from an interdisciplinary approach.

General Principles of Development

• Holism: Development consists of inter-related domains that exert transactional effects, influencing development in other areas.
• Directedness: Children are active shapers of their environment, and their unique developmental trajectory is the result of interactions among genetic influences, prior experiences, and adaptations to environmental influences.
• Differentiation of modes and goals: With development, children's behavior becomes more flexible with increased organization and differentiation, promoting adaptation to complex environmental demands.
• Mobility of behavioral function: Earlier, more undifferentiated forms of behavior become hierarchically integrated into later forms of behavior, and may re-emerge under stress, producing behaviors that appear regressed.
• Development is the interaction of genetic and environmental influences plus prior adaptations, with developmental cascades having a fanning-out effect across different developmental systems.

Mutual Influence of Typical and Atypical Development

• Psychopathology is defined as developmental deviation, and understanding what is normative is crucial in defining atypical or abnormal behavior.
• The adaptive or maladaptive nature of specific behaviors depends on the context and outcome, and the interpretation of behavior as adaptive or maladaptive can only be defined with respect to its ultimate end points or outcomes.

Developmental Pathways Perspective

• Disorder arises from a pattern of deviations from normative development that has evolved over time.
• Repeated difficulty with mastering specific developmental tasks increases the likelihood of future maladjustment.
• Equifinality: Multiple pathways can lead to a single outcome, and individuals may start from distinct points in their developmental origins and experience varying influences to produce similar outcomes.
• Multifinality: Individuals may begin at a common starting point, but the resultant pathways may diverge to produce different outcomes.
• The nature of change: Despite early adversity, change is thought to be possible at any juncture in development, and pathology is not a stable entity.
• Developmental Psychopathology considers the dynamic transactions that occur among developing systems, affecting the course of development.

Continuity

• The way an individual develops in a domain progresses in an orderly fashion that follows developmental principles of growth.
• The linkages between early experience and later disorder may operate directly or indirectly, influencing later functioning and disorder.

Comorbidity

• Comorbidity is the co-existence of two or more disorders, viewed as a failure of the categorical system to characterize accurately particular patterns of behavioral disturbance.
• Instances of symptom overlap may be due to shared risk factors, comorbid association, unique syndromes, or the occurrence of one disorder increasing the risk for another.

Risk and Resilience

• Risk research examines multiple levels of analysis, considering interactive models rather than main effects models.
• Resilience is a dynamic developmental process in which environmental factors interact with child characteristics to produce positive outcomes or competence despite adverse conditions.

Cultural Issues

• Research and practice must take into account cultural norms, socialization practices, and values when considering whether a particular behavior represents a maladaptive response to the dominant culture's demands.

What is Developmental Psychopathology?

• Developmental Psychopathology (DP) is the study of the origins and course of individual patterns of behavioral maladaptation, regardless of age of onset, causes, transformations, and complexity.
• The primary focus of DP is to study the processes underlying continuity and change in patterns of both adaptive and maladaptive behavior from an interdisciplinary approach.

General Principles of Development

• Holism: Development consists of inter-related domains that exert transactional effects, influencing development in other areas.
• Directedness: Children are active shapers of their environment, and their unique developmental trajectory is the result of interactions among genetic influences, prior experiences, and adaptations to environmental influences.
• Differentiation of modes and goals: With development, children's behavior becomes more flexible with increased organization and differentiation, promoting adaptation to complex environmental demands.
• Mobility of behavioral function: Earlier, more undifferentiated forms of behavior become hierarchically integrated into later forms of behavior, and may re-emerge under stress, producing behaviors that appear regressed.
• Development is the interaction of genetic and environmental influences plus prior adaptations, with developmental cascades having a fanning-out effect across different developmental systems.

Mutual Influence of Typical and Atypical Development

• Psychopathology is defined as developmental deviation, and understanding what is normative is crucial in defining atypical or abnormal behavior.
• The adaptive or maladaptive nature of specific behaviors depends on the context and outcome, and the interpretation of behavior as adaptive or maladaptive can only be defined with respect to its ultimate end points or outcomes.

Developmental Pathways Perspective

• Disorder arises from a pattern of deviations from normative development that has evolved over time.
• Repeated difficulty with mastering specific developmental tasks increases the likelihood of future maladjustment.
• Equifinality: Multiple pathways can lead to a single outcome, and individuals may start from distinct points in their developmental origins and experience varying influences to produce similar outcomes.
• Multifinality: Individuals may begin at a common starting point, but the resultant pathways may diverge to produce different outcomes.
• The nature of change: Despite early adversity, change is thought to be possible at any juncture in development, and pathology is not a stable entity.
• Developmental Psychopathology considers the dynamic transactions that occur among developing systems, affecting the course of development.

Continuity

• The way an individual develops in a domain progresses in an orderly fashion that follows developmental principles of growth.
• The linkages between early experience and later disorder may operate directly or indirectly, influencing later functioning and disorder.

Comorbidity

• Comorbidity is the co-existence of two or more disorders, viewed as a failure of the categorical system to characterize accurately particular patterns of behavioral disturbance.
• Instances of symptom overlap may be due to shared risk factors, comorbid association, unique syndromes, or the occurrence of one disorder increasing the risk for another.

Risk and Resilience

• Risk research examines multiple levels of analysis, considering interactive models rather than main effects models.
• Resilience is a dynamic developmental process in which environmental factors interact with child characteristics to produce positive outcomes or competence despite adverse conditions.

Cultural Issues

• Research and practice must take into account cultural norms, socialization practices, and values when considering whether a particular behavior represents a maladaptive response to the dominant culture's demands.

Here are the study notes in bullet points:

Introduction to the Human Brain and Neurotransmitters

• The human brain comprises 50-100 billion neurons that form connections to other neurons and influence behavior.
• Neurotransmitters play a crucial role in various cognitive processes and behaviors.

Neurotransmitters

• Acetylcholine: found throughout the brain and muscle tissue, involved in muscle contraction, attention, and memory.
• Dopamine: involved in reward, reinforcement, motor function, and cognition; many drugs of abuse target dopamine pathways.
• Epinephrine and Norepinephrine: formed from dopamine, involved in fight-or-flight and fear responses, arousal, and alertness.
• GABA: inhibits neural firing, primary inhibitory neurotransmitter in the adult brain, and has excitatory effects early in development.
• Glutamate: primary excitatory neurotransmitter in the adult brain, involved in various roles, and linked to mental disorders.
• Serotonin: derived from tryptophan, involved in emotional regulation, and targeted by antidepressants.

Neurobiological Foundations: Neural Systems for Emotion

• Key brain structures and networks involved in emotions: brainstem, hypothalamus, amygdala, insula, anterior cingulate cortex, ventromedial prefrontal cortex, and somatosensory cortices.

Neurobiological Foundations: Right-Hemisphere Structures

• Right-hemisphere structures are important for emotion processing, particularly the right temporal and parietal regions.
• Damage to these regions can impair emotional responsiveness and emotion recognition.

Neurobiological Foundations: Amygdala and Limbic System

• The amygdala is a key component of the limbic system, involved in emotion-related functions.
• The amygdala receives highly processed sensory input and has reciprocal connections with various brain structures.
• The amygdala is critical for linking perception to emotional response and modulating cognition, memory, and attention.

Neurobiological Foundations: Ventromedial Prefrontal Cortex (vmPFC)

• The vmPFC is involved in higher-order emotional processing, moral reasoning, social conduct, and decision-making.

Neurobiological Foundations: Basal Ganglia

• The basal ganglia, particularly on the right, are involved in emotion processing and the recognition of facial emotional expressions.

Genes and Behavior

• Genetic factors contribute to the development of psychological disorders, but genes do not directly code for specific behaviors.

Genes and Behavior: A Primer on Genetics

• Genes are long molecules of DNA located on chromosomes, which are inherited from parents.
• Chromosomes are numbered from 1 to 22, with the 23rd pair determining sex.

Genes and Behavior: Twin and Family Studies

• Twin studies are used to quantify genetic influence on psychological disorders by comparing concordance rates among monozygotic and dizygotic twins.

Methods and Approaches: Lesion Method

• The lesion method involves observing systematic changes in personality or behavior after damage to specific brain structures.
• The method is used to explore the association between focal brain damage and impairment in psychological functions.

Methods and Approaches: Functional Neuroimaging

• Functional neuroimaging methods, such as PET and fMRI, are used to index neural activity across brain regions.
• These methods can be used to make inferences about underlying neural activity during changes in psychological or behavioral state.

Methods and Approaches: Methods of Gene Discovery

• Molecular genetics involves identifying specific genetic variants implicated in psychopathology.
• Genome-wide association studies, copy-number variants, and epigenetic effects are used to understand the genetic basis of psychological disorders.### Methods and Approaches: Characterization and Measurement of Personality & Psychopathology
• Endophenotype: a marker of mental disorder that is closer to underlying etiology (e.g., gene products, neural circuits) than clinical status.

Disorders and Conditions: Schizophrenia

• Genome-wide association studies have implicated as many as 8,300 common genetic variants in the etiology of schizophrenia.
• Many genetic effects implicated in schizophrenia may be related to abnormalities in basic neuronal architecture, organization, and communication.
• Schizophrenia has long been described as a disorder of brain connectivity.
• Symptoms of schizophrenia likely arise as a result of problematic connectivity and activation in structures that span across multiple neural circuits.

Disorders and Conditions: Internalizing Disorders

• Different forms of internalizing psychopathology (e.g., depression, anxiety, and fear) are strongly related to one another phenotypically.
• Internalizing disorders share common genetic and environmental etiologies with each other and with generalized negative emotionality.
• Many neurobiological models of internalizing psychopathology can be conceptualized in terms of stress response.
• Different forms of internalizing disorders have unique features that differentiate them, such as distress disorders (e.g., depression) and fear disorders (e.g., phobias).

Disorders and Conditions: Psychopathy and Pseudopsychopathy

• Perhaps the greatest disturbances of personality and social behavior, absent a macroscopic brain lesion, are those that occur in psychopaths.
• Pseudopsychopathy is a personality disturbance acquired in adulthood after the onset of brain damage, which entails antisocial behavior.
• Pseudopsychopathic behaviors are related to damage to the ventromedial prefrontal cortex (vmPFC).
• The vmPFC sector contains key structures supporting the acquisition of appropriate social conduct and moral behavior.

Disorders and Conditions: Substance-use Disorders

• The precise neural substrates involved in one drug of abuse are different from that of another.
• Despite this diversity, many substance use problems are mediated through common pathways.
• Different substances often share similar biological risk factors, including genetic risk factors.
• Many of these risk factors are shared with other forms of psychopathology, especially externalizing psychopathology.
• Neurobiological accounts of substance-use disorder focus on dopaminergic pathways, especially the mesolimbic and mesocortical dopamine systems.
• Individuals with substance-use problems have greater brain activity in the nucleus accumbens (NA) when exposed to substances of abuse, and exhibit lower dopamine binding in that region.

Disorders and Conditions: Neurodevelopmental Disorders

• There is strong evidence for the genetic contribution to ADHD, with heritability estimates ranging from 70-75%.
• Small but significant associations have been found between ADHD and genes related to dopamine neurotransmission.

Here are the study notes in bullet points:

Introduction to the Human Brain and Neurotransmitters

• The human brain comprises 50-100 billion neurons that form connections to other neurons and influence behavior.
• Neurotransmitters play a crucial role in various cognitive processes and behaviors.

Neurotransmitters

• Acetylcholine: found throughout the brain and muscle tissue, involved in muscle contraction, attention, and memory.
• Dopamine: involved in reward, reinforcement, motor function, and cognition; many drugs of abuse target dopamine pathways.
• Epinephrine and Norepinephrine: formed from dopamine, involved in fight-or-flight and fear responses, arousal, and alertness.
• GABA: inhibits neural firing, primary inhibitory neurotransmitter in the adult brain, and has excitatory effects early in development.
• Glutamate: primary excitatory neurotransmitter in the adult brain, involved in various roles, and linked to mental disorders.
• Serotonin: derived from tryptophan, involved in emotional regulation, and targeted by antidepressants.

Neurobiological Foundations: Neural Systems for Emotion

• Key brain structures and networks involved in emotions: brainstem, hypothalamus, amygdala, insula, anterior cingulate cortex, ventromedial prefrontal cortex, and somatosensory cortices.

Neurobiological Foundations: Right-Hemisphere Structures

• Right-hemisphere structures are important for emotion processing, particularly the right temporal and parietal regions.
• Damage to these regions can impair emotional responsiveness and emotion recognition.

Neurobiological Foundations: Amygdala and Limbic System

• The amygdala is a key component of the limbic system, involved in emotion-related functions.
• The amygdala receives highly processed sensory input and has reciprocal connections with various brain structures.
• The amygdala is critical for linking perception to emotional response and modulating cognition, memory, and attention.

Neurobiological Foundations: Ventromedial Prefrontal Cortex (vmPFC)

• The vmPFC is involved in higher-order emotional processing, moral reasoning, social conduct, and decision-making.

Neurobiological Foundations: Basal Ganglia

• The basal ganglia, particularly on the right, are involved in emotion processing and the recognition of facial emotional expressions.

Genes and Behavior

• Genetic factors contribute to the development of psychological disorders, but genes do not directly code for specific behaviors.

Genes and Behavior: A Primer on Genetics

• Genes are long molecules of DNA located on chromosomes, which are inherited from parents.
• Chromosomes are numbered from 1 to 22, with the 23rd pair determining sex.

Genes and Behavior: Twin and Family Studies

• Twin studies are used to quantify genetic influence on psychological disorders by comparing concordance rates among monozygotic and dizygotic twins.

Methods and Approaches: Lesion Method

• The lesion method involves observing systematic changes in personality or behavior after damage to specific brain structures.
• The method is used to explore the association between focal brain damage and impairment in psychological functions.

Methods and Approaches: Functional Neuroimaging

• Functional neuroimaging methods, such as PET and fMRI, are used to index neural activity across brain regions.
• These methods can be used to make inferences about underlying neural activity during changes in psychological or behavioral state.

Methods and Approaches: Methods of Gene Discovery

• Molecular genetics involves identifying specific genetic variants implicated in psychopathology.
• Genome-wide association studies, copy-number variants, and epigenetic effects are used to understand the genetic basis of psychological disorders.### Methods and Approaches: Characterization and Measurement of Personality & Psychopathology
• Endophenotype: a marker of mental disorder that is closer to underlying etiology (e.g., gene products, neural circuits) than clinical status.

Disorders and Conditions: Schizophrenia

• Genome-wide association studies have implicated as many as 8,300 common genetic variants in the etiology of schizophrenia.
• Many genetic effects implicated in schizophrenia may be related to abnormalities in basic neuronal architecture, organization, and communication.
• Schizophrenia has long been described as a disorder of brain connectivity.
• Symptoms of schizophrenia likely arise as a result of problematic connectivity and activation in structures that span across multiple neural circuits.

Disorders and Conditions: Internalizing Disorders

• Different forms of internalizing psychopathology (e.g., depression, anxiety, and fear) are strongly related to one another phenotypically.
• Internalizing disorders share common genetic and environmental etiologies with each other and with generalized negative emotionality.
• Many neurobiological models of internalizing psychopathology can be conceptualized in terms of stress response.
• Different forms of internalizing disorders have unique features that differentiate them, such as distress disorders (e.g., depression) and fear disorders (e.g., phobias).

Disorders and Conditions: Psychopathy and Pseudopsychopathy

• Perhaps the greatest disturbances of personality and social behavior, absent a macroscopic brain lesion, are those that occur in psychopaths.
• Pseudopsychopathy is a personality disturbance acquired in adulthood after the onset of brain damage, which entails antisocial behavior.
• Pseudopsychopathic behaviors are related to damage to the ventromedial prefrontal cortex (vmPFC).
• The vmPFC sector contains key structures supporting the acquisition of appropriate social conduct and moral behavior.

Disorders and Conditions: Substance-use Disorders

• The precise neural substrates involved in one drug of abuse are different from that of another.
• Despite this diversity, many substance use problems are mediated through common pathways.
• Different substances often share similar biological risk factors, including genetic risk factors.
• Many of these risk factors are shared with other forms of psychopathology, especially externalizing psychopathology.
• Neurobiological accounts of substance-use disorder focus on dopaminergic pathways, especially the mesolimbic and mesocortical dopamine systems.
• Individuals with substance-use problems have greater brain activity in the nucleus accumbens (NA) when exposed to substances of abuse, and exhibit lower dopamine binding in that region.

Disorders and Conditions: Neurodevelopmental Disorders

• There is strong evidence for the genetic contribution to ADHD, with heritability estimates ranging from 70-75%.
• Small but significant associations have been found between ADHD and genes related to dopamine neurotransmission.

Conceptual Contributions

• Definition of culture: Beliefs and practices that pertain to a given ethnocultural group
• Limitations of this definition: Conceives of culture as residing largely within individuals and depicts culture as static and bounded
• Culture involves process and change, constantly in flux both in its regions of origin and as people move around the globe
• Two separate, but related goals of cultural research:
• Studying culture to identify general processes
• Studying culture to identify culture-specific processes

Major Advances

• Incorporation of cultural factors in DSM-IV and continued development of cultural issues in DSM-5
• Publication of the World Mental Health Report
• Release of the U.S. Surgeon General’s Supplemental Report on Mental Health: Culture, Race and Ethnicity
• Completion of the Collaborative Psychiatric Epidemiology Surveys (CPES)

Incorporation of Cultural Factors in DSM-IV/5

• National Institute of Mental Health (NIMH) funded the establishment of a Culture and Diagnosis Work Group
• The work group’s efforts resulted in three main contributions to DSM-IV:
• Inclusion of cultural factors in the expression, assessment, and prevalence of disorders in each of the disorder chapters
• An outline of a cultural formulation of clinical diagnosis to complement the multi-axial assessment
• A glossary of relevant cultural-bound syndromes from around the world
• Cultural considerations for DSM-5 build on the foundation provided by DSM-IV
• Cultural conceptions of distress in the DSM-5 are divided into three categories:
• Cultural syndromes
• Cultural idioms of distress
• Cultural explanation or perceived cause of illness
• DSM-5 includes the Cultural Formulation Interview, which is highly structured and usable by clinicians

Publication of the World Mental Health Report

• The report compiled research from across the world to identify the range of mental health and behavioral problems
• The most significant findings:
• Mental illness and related problems exact a significant toll on the health and wellbeing of people worldwide
• Mental illness produces a greater burden based on a "disability-adjusted life years" index than that from tuberculosis, cancer, or heart disease
• Depressive disorders alone were found to produce the fifth greatest burden for women and seventh greatest burden for men

Surgeon General’s Supplemental Report on Mental Health

• The report focused on the mental health of four main minority groups: American Indians/Alaska Natives, African Americans, Asian Americans/Pacific Islanders, and Latino Americans
• The main message was that “culture counts” and affects all aspects of mental health and illness

Collaborative Psychiatric Epidemiology Surveys (CPES)

• Comprises three nationally representative surveys:
• National Comorbidity Survey-Replication
• National Survey of American Life
• National Latino and Asian American Study
• The contributions of the CPES have been significant, providing nationally representative samples of three major U.S. racial/ethnic minority groups

Disorder-Related Research: Anxiety and Ataques de Nervios

• Ataque de nervios is an idiom of distress, particularly prominent among Latinos from the Caribbean
• Symptoms commonly associated with ataques de nervios include trembling, attacks of crying, screaming uncontrollably, and verbal or physical aggression
• Most episodes occur as a direct result of a stressful life event related to family or significant others
• Prevalence: 16% of the large community sample in Puerto Rico experienced ataques de nervios
• Ataques de nervios were found to be associated with a wide range of mental disorders, particularly anxiety and mood disorders

Disorder-Related Research: Schizophrenia

• The effect of schizophrenia on individuals and communities depends on whether they conceive of the self as autonomous and separate from others or as connected and bound to others
• Culture plays a role in the manner in which families respond to relatives with schizophrenia, which in turn influences the course of illness
• Expressed emotion: criticism, hostility, and emotional involvement
• Mexican American patients who returned to families marked by high warmth were less likely to relapse than those who returned to families characterized by low warmth