The Role of Psychopathology and Emotion Regulation in the Intergenerational Transmission of Childhood Abuse: A Family Study.

Previous studies have shown that parents with a history of childhood abuse are at increased risk of perpetrating child abuse. To break the cycle of childhood abuse we need to better understand the mechanisms that play a role. In a cross-sectional extended family design including three generations (N = 250, 59% female), we examined the possible mediating role of parental psychopathology and emotion regulation in the association between a history of childhood abuse and perpetrating child abuse. Parents' own history of childhood abuse was associated with perpetrating abuse toward their children, and externalizing (but not internalizing) problems partially mediated this association statistically. Implicit and explicit emotion regulation were not associated with experienced or perpetrated abuse. Findings did not differ across fathers and mothers. Findings underline the importance of (early) treatment of externalizing problems in parents with a history of childhood abuse, to possibly prevent the transmission of child abuse.

The role of emotion recognition in the intergenerational transmission of child maltreatment: A multigenerational family study.

BACKGROUND: Understanding how child maltreatment is passed down from one generation to the next is crucial for the development of intervention and prevention strategies that may break the cycle of child maltreatment. Changes in emotion recognition due to childhood maltreatment have repeatedly been found, and may underly the intergenerational transmission of child maltreatment. OBJECTIVE: In this study we, therefore, examined whether the ability to recognize emotions plays a role in the intergenerational transmission of child abuse and neglect. PARTICIPANTS AND SETTING: A total of 250 parents (104 males, 146 females) were included that participated in a three-generation family study. METHOD: Participants completed an emotion recognition task in which they were presented with series of photographs that depicted the unfolding of facial expressions from neutrality to the peak emotions anger, fear, happiness, and sadness. Multi-informant measures were used to examine experienced and perpetrated child maltreatment. RESULTS: A history of abuse, but not neglect, predicted a shorter reaction time to identify fear and anger. In addition, parents who showed higher levels of neglectful behavior made more errors in identifying fear, whereas parents who showed higher levels of abusive behavior made more errors in identifying anger. Emotion recognition did not mediate the association between experienced and perpetrated child maltreatment. CONCLUSIONS: Findings highlight the importance of distinguishing between abuse and neglect when investigating the precursors and sequalae of child maltreatment. In addition, the effectiveness of interventions that aim to break the cycle of abuse and neglect could be improved by better addressing the specific problems with emotion processing of abusive and neglectful parents.

Investigating bottlenecks hampering the adoption of water quality-enhancing practices for sustainable land management in Ireland.

The scaling of adopted measures on farms is often proposed however, the factors that inform non-adoption of advised measures are typically overlooked. Better understanding of these factors could offer important insights for overcoming these bottlenecks and therefore offer important potential with respect to addressing agri-environmental challenges. We investigated the factors hampering the adoption of sustainable land management practices advised by the main agricultural extension of Ireland. A large qualitative dataset (N = 760) containing farmers' reasons for rejection of advised practices was analysed to identify bottlenecks for adoption. Our research showed that rejection can be explained by different underlying reasons. While subsidies exist for the implementation of sustainable land management practices, incentives to implement are insufficient and costs remain the main barrier for the adoption of the sustainable land management practices. Additionally, land ownership challenges and the aging farming population hamper the adoption of sustainable land management practices. Next to an analysis of the reasons for rejection of all advised practices, we investigated three often advised sustainable land management practices in-depth: implementation of riparian buffer zones, preventing cattle access to watercourses and implementation of a nutrient management plan. The differences in barriers for adoption between these practices showed the need for nuanced communication in order to enhance uptake. In order to reach water quality targets through enhanced uptake of sustainable land management practice, advice should be framed and tailored to farmer objectives.

Treating Saddlebag Deformity after Massive Weight Loss: Vertical versus Lower Body Lift.

SUMMARY: The saddlebag deformity remains a persistent and difficult-to-treat problem after body-contouring surgery. A new way to handle the saddlebag deformity is with the vertical lower body lift (VLBL). This retrospective cohort study evaluated the overall reconstruction outcome of the VLBL in 16 patients (32 saddlebags) and compared it to standard lower body lift (LBL). The BODY-Q and the Pittsburgh Rating Scale (PRS)-Saddlebag Scale were used in the evaluation process. Surgical outcomes regarding the saddlebag deformity were in favor of the VLBL technique in patients with marked saddlebag deformity. A 1.16 decrease in mean PRS saddlebag score (relative change of 61.7%) was observed for the VLBL group versus a mean decrease of 0.29 (relative change of 21.6%) in the LBL group. BODY-Q end point and change in scores did not differ between the VLBL and LBL groups at 3-month follow-up, but at 1-year follow-up, they were in favor of the VLBL group in the body appraisal domain. Patients were highly satisfied with the contour and appearance of their lateral thigh, despite the extra scarring caused by this novel technique. Therefore, the authors advise clinicians to consider performing a VLBL instead of the standard LBL in patients with notable saddlebag deformities after massive weight loss. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

Protein quality of soy and the effect of processing: A quantitative review.

There is a growing demand for plant-based protein-rich products for human consumption. During the production of plant-based protein-rich products, ingredients such as soy generally undergo several processing methods. However, little is known on the effect of processing methods on protein nutritional quality. To gain a better understanding of the effect of processing on the protein quality of soy, we performed a quantitative review of in-vivo and in-vitro studies that assessed the indispensable amino acid (IAA) composition and digestibility of varying soy products, to obtain digestibility indispensable amino acids scores (DIAAS) and protein digestibility corrected amino acid scores (PDCAAS). For all soy products combined, mean DIAAS was 84.5 ± 11.4 and mean PDCAAS was 85.6 ± 18.2. Data analyses showed different protein quality scores between soy product groups. DIAAS increased from tofu, soy flakes, soy hulls, soy flour, soy protein isolate, soybean, soybean meal, soy protein concentrate to soymilk with the highest DIAAS. In addition, we observed broad variations in protein quality scores within soy product groups, indicating that differences and variations in protein quality scores may also be attributed to various forms of post-processing (such as additional heat-treatment or moisture conditions), as well as study conditions. After excluding post-processed data points, for all soy products combined, mean DIAAS was 86.0 ± 10.8 and mean PDCAAS was 92.4 ± 11.9. This study confirms that the majority of soy products have high protein quality scores and we demonstrated that processing and post-processing conditions can increase or decrease protein quality. Additional experimental studies are needed to quantify to which extent processing and post-processing impact protein quality of plant-based protein-rich products relevant for human consumption.

Feasibility and performance of smartphone-based daily micro-surveys among patients recovering from cancer surgery.

AIMS: Daily micro-surveys, or the high-frequency administration of patient-reported outcome measures (PROMs), may provide real-time, unbiased assessments of health-related quality of life (HRQoL). We evaluated the feasibility and accuracy of daily micro-surveys using a smartphone platform among patients recovering from cancer surgery. METHODS: In a prospective study (2017-2019), patients undergoing cancer surgery downloaded a smartphone application that administered daily micro-surveys comprising five randomly selected items from the Short Form-36 (SF-36). Micro-surveys were administered without replacement until the entire SF-36 was administered weekly. The full-length SF-36 was also administered preoperatively and 4, 12, and 24 weeks postoperatively. We assessed response and completion rates between the micro-surveys and full-length SF-36, as well as agreement of responses using Bland-Altman (B&A) analyses. RESULTS: Ninety-five patients downloaded the application and were followed for a mean of 131 days [SD ± 85]. Response rates for the full-length SF-36 and micro-surveys was 76% [95%CI 69, 83], and 34% [95%CI 26, 39]. Despite lower response rates, more SF-36 surveys were collected using the daily micro-surveys compared to the intermittent full-length SF-36 (9.9 [95%CI 8.4, 12.6] vs. 3.0 [95%CI 2.8, 3.3], respectively). B&A analyses demonstrated lack of agreement between micro-surveys and SF-36. However, agreement improved with higher micro-survey completion rate. Eighty-five percent of participants reported that daily micro-surveys were not burdensome. CONCLUSION: This study suggests that collection of daily micro-surveys among patients recovering from cancer surgery is feasible using smartphones in the early postoperative period. Future implementation of daily micro-surveys may more granularly describe momentary HRQoL changes through a greater volume of self-reported survey data.

Child maltreatment and parent-offspring interaction: A multigenerational extended family design.

In the current study, the associations between multiple types of child maltreatment (CM), parent-offspring interactions, and family cohesion were examined in an extended family study. A total of 366 parent-offspring pairs from 137 nuclear families participated. Parents (Mage = 52.8 years, age range: 26.6-88.4 years, 57% female) reported about perpetrated CM and offspring (Mage = 25.7 years, range: 7.5-65.5 years, 58% female) about experienced CM during their childhood. Parent-offspring interactions were observed during a conflict interaction task. Cohesion within the nuclear family was observed during a playful tower building task. Results showed that parents and offspring displayed more aversive behavior in parent-offspring dyads characterized by higher levels of child abuse, but not in dyads characterized by higher levels of child neglect. In addition, less dyadic affective similarity was observed in parent-offspring dyads characterized by higher levels of child neglect, whereas dyadic affective similarity was higher in dyads characterized by higher levels of child abuse. Findings imply that interventions focused on parent-offspring interactions with a somewhat different content for neglectful and abusive families may be efficacious for families in the child welfare system. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

The PRS Rainbow Classification for Assessing Postbariatric Contour Deformities.

BACKGROUND: There is a need for a reliable classification system to grade contour deformities and to inform reimbursement of body contouring surgery after massive weight loss. We developed the PRS Rainbow Classification, which uses select photographs to provide standardized references for evaluating patient photographs, to classify contour deformities in postbariatric patients. To assess the reliability of the PRS Rainbow Classification to classify contour deformities in massive weight loss patients. METHODS: Ten independent experienced plastic surgeons, 7 experienced medical advisors of the healthcare insurance company, and 10 laypersons evaluated 50 photographs per anatomical region (arms, breast, abdomen, and medial thighs). Each participant rated the patient photographs on a scale of 1-3 in an online survey. The inter-observer and the intra-observer reliabilities were determined using intra-class correlation coefficients (ICCs). The ICC analyses were performed for each anatomical region. RESULTS: Inter-observer reliability was moderate to good in the body regions "arms," "abdomen," "medial thighs," with mean ICC values of 0.678 [95% confidence interval (CI), 0.591-0.768], 0.685 (95% CI, 0.599-0.773), and 0.658 (95% CI, 0.569-0.751), respectively. Inter-observer reliability was comparable within the 3 different professional groups. Intra-observer reliability (test-retest reliability) was moderate to good, with a mean overall ICC value of 0.723 (95% CI, 0.572-0.874) for all groups and all 4 body regions. CONCLUSIONS: The moderate to good reliability found in this study validates the use of the PRS Rainbow Classification as a reproducible and reliable classification system to assess contour deformities after massive weight loss. It holds promise as a key part of instruments to classify body contour deformities and to assess reimbursement of body contouring surgery.

Correction: Intergenerational transmission of child maltreatment using a multi-informant multi-generation family design.

[This corrects the article DOI: 10.1371/journal.pone.0225839.].

Not the Root of the Problem-Hair Cortisol and Cortisone Do Not Mediate the Effect of Child Maltreatment on Body Mass Index.

BACKGROUND: Experiencing maltreatment during childhood exerts substantial stress on the child and increases the risk for overweight and obesity later in life. The current study tests whether hair cortisol-a measure of chronic stress-and its metabolite cortisone mediate the relation between abuse and neglect on the one hand, and body mass index (BMI) on the other. METHOD: The sample consisted of 249 participants aged 8 to 87 years (M = 36.13, SD = 19.33). We collected data on child abuse and neglect using questionnaires, measured cortisol and cortisone concentrations in hair, and BMI. In a structural model, the effects of abuse and neglect on hair cortisol, hair cortisone, and BMI were tested, as well as the covariance between hair cortisol and BMI, and hair cortisone and BMI. RESULTS: Within the sample, 23% were overweight but not obese and 14% were obese. Higher levels of experienced abuse were related to higher cortisone concentrations in hair (ß = 0.24, p < .001) and higher BMI (ß = 0.17, p =.04). Neglect was not related to hair cortisol, hair cortisone, or BMI. Hair cortisol and cortisone did not mediate the association between maltreatment, and BMI. Sensitivity analyses demonstrate the same pattern of results in a subsample of adult participants currently not living with their parents. However, in younger participants who were still living with their parents, the associations between abuse and cortisone (ß = 0.14, p =.35) and abuse and BMI (ß = 0.02, p =.92) were no longer significant. CONCLUSION: These findings confirm that experiencing abuse is related to higher BMI but suggest that hair cortisol and cortisone are not the mechanism underlying the association between child maltreatment and BMI. This is the first study to show abuse may be associated to elevated concentrations of hair cortisone-evidence of long-term alterations in chronic stress levels. Future research may benefit from exploring the effects of maltreatment on weight gain in longitudinal designs, including measures of other potential mediators such as eating as a coping mechanism, and more direct indicators of metabolic health.

Intergenerational transmission of child maltreatment using a multi-informant multi-generation family design.

In the current study a three-generational design was used to investigate intergenerational transmission of child maltreatment (ITCM) using multiple sources of information on child maltreatment: mothers, fathers and children. A total of 395 individuals from 63 families reported on maltreatment. Principal Component Analysis (PCA) was used to combine data from mother, father and child about maltreatment that the child had experienced. This established components reflecting the convergent as well as the unique reports of father, mother and child on the occurrence of maltreatment. Next, we tested ITCM using the multi-informant approach and compared the results to those of two more common approaches: ITCM based on one reporter and ITCM based on different reporters from each generation. Results of our multi-informant approach showed that a component reflecting convergence between mother, father, and child reports explained most of the variance in experienced maltreatment. For abuse, intergenerational transmission was consistently found across approaches. In contrast, intergenerational transmission of neglect was only found using the perspective of a single reporter, indicating that transmission of neglect might be driven by reporter effects. In conclusion, the present results suggest that including multiple informants may be necessary to obtain more valid estimates of ITCM.

Estimating the Heritability of Experiencing Child Maltreatment in an Extended Family Design.

Child-driven genetic factors can contribute to negative parenting and may increase the risk of being maltreated. Experiencing childhood maltreatment may be partly heritable, but results of twin studies are mixed. In the current study, we used a cross-sectional extended family design to estimate genetic and environmental effects on experiencing child maltreatment. The sample consisted of 395 individuals (225 women; Mage = 38.85 years, rangeage = 7-88 years) from 63 families with two or three participating generations. Participants were oversampled for experienced maltreatment. Self-reported experienced child maltreatment was measured using a questionnaire assessing physical and emotional abuse, and physical and emotional neglect. All maltreatment phenotypes were partly heritable with percentages for h2 ranging from 30% (SE = 13%) for neglect to 62% (SE = 19%) for severe physical abuse. Common environmental effects (c2) explained a statistically significant proportion of variance for all phenotypes except for the experience of severe physical abuse (c2 = 9%, SE = 13%, p = .26). The genetic correlation between abuse and neglect was ρg = .73 (p = .02). Common environmental variance increased as socioeconomic status (SES) decreased (p = .05), but additive genetic and unique environmental variances were constant across different levels of SES.

Deriving an overall appearance domain score by applying bifactor IRT analysis to the BODY-Q appearance scales.

PURPOSE: With the BODY-Q, one can assess outcomes, such as satisfaction with appearance, in weight loss and body contouring patients using multiple scales. All scales can be used independently in any given combination or order. Currently, the BODY-Q cannot provide overall appearance scores across scales that measure a similar super-ordinate construct (i.e., overall appearance), which could improve the scales' usefulness as a benchmarking tool and improve the comprehensibility of patient feedback. We explored the possibility of establishing overall appearance scores, by applying a bifactor model to the BODY-Q appearance scales. METHODS: In a bifactor model, questionnaire items load onto both a primary specific factors and a general factor, such as satisfaction with appearance. The international BODY-Q validation patient sample (n = 734) was used to fit a bifactor model to the appearance domain. Factor loadings, fit indices, and correlation between bifactor appearance domain and satisfaction with body scale were assessed. RESULTS: All items loaded on the general factor of their corresponding domain. In the appearance domain, all items demonstrated adequate item fit to the model. All scales had satisfactory fit to the bifactor model (RMSEA 0.045, CFI 0.969, and TLI 0.964). The correlation between the appearance domain summary scores and satisfaction with body scale scores was found to be 0.77. DISCUSSION: We successfully applied a bifactor model to BODY-Q data with good item and model fit indices. With this method, we were able to produce reliable overall appearance scores which may improve the interpretability of the BODY-Q while increasing flexibility.

Streamlining the Assessment of Patient-Reported Outcomes in Weight Loss and Body Contouring Patients: Applying Computerized Adaptive Testing to the BODY-Q.

BACKGROUND: The BODY-Q is a widely used patient-reported outcome measure of surgical outcomes in weight loss and body contouring patients. Reducing the length of the BODY-Q assessment could overcome implementation barriers in busy clinics. A shorter BODY-Q could be achieved by using computerized adaptive testing, a method to shorten and tailor assessments while maintaining reliability and accuracy. In this study, the authors apply computerized adaptive testing to the BODY-Q and assess computerized adaptive testing performance in terms of item reduction and accuracy. METHODS: Parameters describing the psychometric properties of 138 BODY-Q items (i.e., questions) were derived from the original validation sample (n = 734). The 138 items are arranged into 18 scales reflecting Appearance, Quality of Life, and Experience of Care domains. The authors simulated 1000 administrations of the computerized adaptive testing until a stopping rule, reflecting assessment accuracy of standard error less than 0.55, was met. The authors describe the reduction of assessment length in terms of the mean and range of items administered. The authors assessed accuracy by determining correlation between full test and computerized adaptive testing scores. RESULTS: The authors ran 54 simulations. Mean item reduction was 36.9 percent (51 items; range, 48 to 138 items). Highest item reduction was achieved for the Experience of Care domain (56.2 percent, 22.5 items). Correlation between full test scores and the BODY-Q computerized adaptive test scores averaged 0.99. CONCLUSIONS: Substantial item reduction is possible by using BODY-Q computerized adaptive testing. Reduced assessment length using BODY-Q computerized adaptive testing could reduce patient burden while preserving the accuracy of clinical patient-reported outcomes for patients undergoing weight loss and body contouring operations.

A Queensland research support network in emergency healthcare.

PURPOSE: The purpose of this paper is to describe the structure and impact of a Queensland Research Support Network (RSN) in emergency medicine (EM). DESIGN/METHODOLOGY/APPROACH: This paper presents a descriptive summary of EM networks, network evaluations and the structure and development of the Emergency Medicine Foundation's (EMF) RSN in Queensland, including an observational pre- and post-study of research metrics. FINDINGS: In two years, the RSN supported 33 Queensland emergency departments (EDs), of which 14 developed research strategies. There was an increase in research active clinicians, from 23 in 2015 to 181 in 2017. Collaborator engagement increased from 9 in 2015 to 276 in 2017 as did the number of research presentations, from 6 in 2015 to 61 in 2017. EMF experienced a growth in new researchers, with new investigators submitting approximately 60 per cent of grant applications in 2016 and 2017. EMF also received new applications from a further three HHS (taking EMF-funded research activity from 8 to 11 HHS). RESEARCH LIMITATIONS/IMPLICATIONS: This paper describes changes in KPIs and research metrics, which the authors attribute to the establishment of the RSN. However, it is possible that attribution bias plays a role in the KPI improvements. SOCIAL IMPLICATIONS: This network has actively boosted and expanded EM research capacity and capability in Queensland. It provides services, in the form of on-the-ground managers, to develop novice clinician-researchers, new projects and engage entire EDs. This model may be replicated nationwide but requires funding commitment. ORIGINALITY/VALUE: The RSN improves front-line clinician research capacity and capability and increases research activity and collaborations with clear community outcomes. Collaborations were extended to community, primary health networks, non-government organisations, national and international researchers and academic institutions. Evaluating and measuring a network's benefits are difficult, but it is likely that evaluations will help networks obtain funding.

The genetic and environmental etiology of child maltreatment in a parent-based extended family design.

Child maltreatment has been associated with various cumulative risk factors. However, little is known about the extent to which genetic and environmental factors contribute to individual differences between parents in perpetrating child maltreatment. To estimate the relative contribution of genetic and environmental factors to perpetrating maltreatment we used a parent-based extended family design. Child-reported perpetrated maltreatment was available for 556 parents (283 women) from 63 families. To explore reporter effects (i.e., child perspective on maltreatment), child reports were compared to multi-informant reports. Based on polygenic model analyses, most of the variance related to the perpetration of physical abuse and emotional neglect was explained by common environmental factors (physical abuse: c2 = 59%, SE = 12%, p = .006; emotional neglect: c2 = 47%, SE = 8%, p < .001) whereas genetic factors did not significantly contribute to the model. For perpetrated emotional abuse, in contrast, genetic factors did significantly contribute to perpetrated emotional abuse (h2 = 33%, SE = 8%, p < .001), whereas common environment factors did not. Multi-informant reports led to similar estimates of genetic and common environmental effects on all measures except for emotional abuse, where a multi-informant approach yielded higher estimates of the common environmental effects. Overall, estimates of unique environment, including measurement error, were lower using multi-informant reports. In conclusion, our findings suggest that genetic pathways play a significant role in perpetrating emotional abuse, while physical abuse and emotional neglect are transmitted primarily through common environmental factors. These findings imply that interventions may need to target different mechanisms dependings on maltreatment type.

An intergenerational family study on the impact of experienced and perpetrated child maltreatment on neural face processing.

Altered processing of emotional faces due to childhood maltreatment has repeatedly been reported, and may be a key process underlying the intergenerational transmission of maltreatment. The current study is the first to examine the role of neural reactivity to emotional and neutral faces in the transmission of maltreatment, using a multi-generational family design including 171 participants of 51 families of two generations with a large age range (8-69 years). The impact of experienced and perpetrated maltreatment (abuse and neglect) on face processing was examined in association with activation in the amygdala, hippocampus, inferior frontal gyrus (IFG) and insula in response to angry, fearful, happy and neutral faces. Results showed enhanced bilateral amygdala activation in response to fearful faces in older neglected individuals, whereas reduced amygdala activation was found in response to these faces in younger neglected individuals. Furthermore, while experienced abuse was associated with lower IFG activation in younger individuals, experience of neglect was associated with higher IFG activation in this age group, pointing to potentially differential effects of abuse and neglect and significant age effects. Perpetrated abusive and neglectful behavior were not related to neural activation in any of these regions. Hence, no indications for a role of neural reactivity to emotional faces in the intergenerational transmission of maltreatment were found.

Parents' experiences of childhood abuse and neglect are differentially associated with behavioral and autonomic responses to their offspring.

Although childhood maltreatment has been shown to compromise adaptive parental behavior, little is known what happens in terms of physiological regulation when parents with a history of childhood maltreatment interact with their offspring. Using a sample of 229 parents (131 women), the present study examined whether childhood maltreatment experiences are associated with parents' behavioral and autonomic responses while resolving conflict with their offspring. Self-reported experienced child maltreatment was measured using a questionnaire assessing abuse and neglect. Parents (Mage  = 52.7 years, rangeage  = 26.6-88.4 years) and their offspring (Mage  = 24.6 years, rangeage  = 7.5-65.6 years) participated in a videotaped parent-offspring conflict interaction task. Parental warmth, negativity, and emotional support were coded. In addition, their pre-ejection period and respiratory sinus arrhythmia were measured as indicators of underlying sympathetic and parasympathetic nervous system reactivity, respectively. Findings demonstrated that experiences of abuse and neglect were associated with behavioral and physiological responses in different ways. Separating these two types of maltreatment in research and in clinical practice might be important.

Pass it on? The neural responses to rejection in the context of a family study on maltreatment.

Rejection by parents is an important aspect of child maltreatment. Altered neural responses to social rejection have been observed in maltreated individuals. The current study is the first to examine the impact of experienced and perpetrated abuse and neglect on neural responses to social exclusion by strangers versus family using a multigenerational family design, including 144 participants. The role of neural reactivity to social exclusion in the intergenerational transmission of maltreatment was also examined. Exclusion by strangers was especially associated with increased activation in the left insula, while exclusion by a family member was mainly associated with increased activation in the ACC. Neural reactivity to social exclusion by strangers in the insula, ACC and dmPFC, was associated with experienced maltreatment but not with perpetrated maltreatment. In abusive parents, altered neural reactivity during exclusion was found in other brain areas, indicating different neural correlates of experienced and perpetrated maltreatment. Hence, no mechanisms could be identified that are involved in the transmission of maltreatment. Hypersensitivity to social rejection by strangers in neglected individuals underscores the importance to distinguish between effects of abuse and neglect and suggests that the impact of experiencing rejection and maltreatment by your own parents extends beyond the family context.