Gender differences in empathy in parents at high- and low-risk of child physical abuse

OBJECTIVES: The present research was designed to study empathy in high-risk parents for child physical abuse. The main objective was to study if high-risk mothers and fathers, compared to low-risk mothers and fathers, presented more Personal distress, less Perspective-taking, less Empathic concern and a deficit in dispositional empathy toward their partner and children. METHOD: Based on their scores on the Abuse Scale of the CAP Inventory [J.S. Milner, The Child Abuse Potential Inventory: Manual, 2nd ed., Psytec Corporation, Webster, NC], 19 (9 fathers and 10 mothers) high- and 26 (12 fathers and 14 mothers) low-risk parents for child physical abuse were selected from a total sample of 331 parents of the Spanish general population. Both groups were statistically matched on sociodemographic variables. The Interpersonal Reactivity Index (IRI) [Catalog of Selected Documents in Psychology 10 (1980) 85] and the Parent/Partner Empathy Scale (PPES) [N.D. Feshbach, N. Caskey, A new scale for measuring parent empathy and partner empathy: factorial structure, correlates and clinical discrimination, 1985] were used to assess dispositional empathy. RESULTS: An interaction between risk status and gender for "Personal distress" and "Perspective-taking" was found. High-risk mothers for child physical abuse showed more "Personal distress" than low-risk mothers and low-risk fathers. High-risk fathers for child physical abuse showed less "Perspective-taking" than low-risk mothers and low-risk fathers. No difference between both groups was found for the IRI "Empathic concern" dimension. Moreover, high-risk, compared to low-risk, parents showed lower scores both on the "Empathy toward the partner" and on the "Empathy toward the child" dimensions of the PPES. No interaction between risk status and gender was found for the PPES dimensions. CONCLUSIONS: Findings of the present study supported the hypothesis that high-risk parents for child physical abuse show a deficit both in general empathy and in empathy toward their family members. Moreover, findings suggested the existence of a different pattern of deficits in empathy for high-risk fathers and high-risk mothers.     

Analog of parental empathy: Association with physical child abuse risk and punishment intentions

Objectives

Current research has been inconsistent in corroborating that parents’ compromised empathy is associated with elevated physical child abuse risk, perhaps in part because of an emphasis on dispositional empathy rather than empathy directed at their own children. Research has also relied on self-reports of empathy that are susceptible to participant misrepresentation. The present study utilized an analog task of parental empathy to investigate the association of parental empathy toward one's own child with physical child abuse potential and with their tendency to punish perceived child misbehavior.

Methods

A sample of 135 mothers and their 4–9 year old children were recruited, with mothers estimating their children's emotional reactions using a behavioral simulation of parental empathy. Mothers also provided self-reports on two measures of child abuse potential, a measure of negative attributions and expected punishment of children using vignettes, as well as a traditional measure of dispositional empathic concern and perspective-taking.

Results

Findings suggest that parental demonstration of poorer empathic ability on the analog task was significantly related to increased physical abuse potential, likelihood to punish, and negative child attributions. However, self-reported dispositional empathy exhibited the pattern of inconsistent associations previously observed in the literature.

Conclusions

Parental empathy appears to be a relevant target for prevention and intervention programs. Future research should also consider similar analog approaches to investigate such constructs to better uncover the factors that elevate abuse risk.     

Empathy and narcissism in a sample of child abuse perpetrators and a comparison sample of foster parents

OBJECTIVE: The purpose of this research was to study the personality variables of empathy and narcissism in a sample of child abuse perpetrators and a comparison sample of foster parents, conceptualized as nonabusive parents, in order to gain further understanding of perpetrators and to provide clues for intervention. METHOD: The sample consisted of two groups: physically and emotionally abusive parents (n=52) and foster parents (n=101). Participants responded to three instruments: the Interpersonal Reactivity Index (IRI), an instrument measuring individual differences in empathy, and two instruments measuring narcissism: the Narcissistic Personality Inventory (NPI) and the Hypersensitivity Narcissism Scale (HSNS). RESULTS: Statistically significant differences were found between the two groups on three of the four subscales of the IRI: perspective-taking, empathic concern, and personal distress. Based on the definition of these subscales, the abusive parents as compared to the foster parents were not able to take the perspective of another or see things from another's viewpoint, showed less warmth, compassion and concern for others, and experienced difficulty in tense interpersonal situations. Statistically significant differences were found for the two groups on three of the six subscales of the NPI: authority, exhibitionism, and superiority, and on the HSNS. The abusive parents demonstrated less self-confidence, a greater lack of impulse control and were more narcissistic than their foster parent counterparts. CONCLUSIONS: The results suggest that it is how the perpetrators experience aversive behavior in their children that may provoke them to physically and emotionally abuse their children. Their self-centeredness in addition to their deficiencies in empathy may cause them to experience their children's misbehavior as an affront to their authority. Implications for treatment are made from this conceptualization of parental abuse.     

Parents’ spontaneous evaluations of children and symbolic harmful behaviors toward their child

Parents’ evaluations of children are believed to be a cognitive contributor to their subsequent child-directed harsh or physically abusive behaviors. The current research examined whether parents’ (N = 100) evaluations of children were moderated by either (a) the child behavior on which the evaluation was based and (b) parents’ measured risk for child physical abuse. The study also explored whether parents’ evaluations of children were related to their tendencies to symbolically harm their child. The current study also used a novel method to indirectly assess parents’ evaluations of children: A modified Affect Misattribution Procedure. Contrary to a priori expectations, negative evaluations of children were stronger for parents who were at low risk, relative to high risk, for child physical abuse. Nonetheless, we observed that high-risk parents were more likely than low-risk parents to inflict symbolic harm onto their child. In an exploratory analysis we observed that parents who formed more overall negative evaluations of children engaged in more symbolic harm to their child. Although high-risk parents were more likely to symbolically harm their child than low-risk parents, this effect does not seem to be due to high-risk parents’ negative child evaluations from negative child behaviors.     

Mother-child interactional patterns in high-and low-risk mothers

Objective: The aim of the present study was to determine the extent to which mother-child interactional patterns in high-and low-risk (for child physical abuse) mothers were similar to patterns observed in physically abusive parents.Method: Ten high-risk and 10 demographically similar low-risk mother-child dyads were studied. Trained observers coded maternal-child interaction patterns in the home during five 1-hour periods using the Standardized Observation Codes system.Results: As expected, high-risk mothers made fewer neutral approaches to their children, displayed more negative behaviors toward their children, and made more indiscriminant responses to their children's prosocial behavior. Expected risk group differences were not found in the number of neutral instructions or positive responses, albeit the proportion of positive responses out of the total number of positive and negative responses was higher for low-risk mothers. After control for educational differences, risk group differences remained in the rates of neutral approaches and the number of indiscriminant behaviors made in response to children's prosocial behaviors.Conclusions: The observational data indicated that high-risk mothers display some behaviors similar to those observed in physically abusive mothers. The finding that high-risk mothers made more indiscriminate or noncontingent responses when reacting to their children's prosocial behavior is consistent with a coercive model of child physical abuse.     

Pain tolerance,pain sensitivity,and accessibility of aggression-related schemata in parents at-risk for child physical abuse

This study examined whether parents with varying degrees of child physical abuse (CPA) risk differed in pain tolerance, pain sensitivity, and accessibility of aggression-related schemata. Participants included 91 (51 low CPA risk and 40 high CPA risk) general population parents. Participants were randomly assigned to complete either an easy or a difficult anagram task. Pain tolerance and pain sensitivity were assessed using a cold pressor task. Accessibility of aggression-related schemata was assessed at the outset of the data collection session and at the end of the session using a word completion task. Parents’ self-reported negative affect was assessed three times over the course of the study: baseline, after the anagram task, and after the cold pressor task. As expected, high-risk (compared to low-risk) parents reported higher levels of negative affect at each time point. Moreover, after completing the difficult anagram task, high-risk (compared to low-risk) parents exhibited higher pain sensitivity during the cold pressor task. Following completion of the cold pressor task, high-risk (compared to low-risk) parents exhibited greater accessibility of aggression-related schemata. Collectively, these findings indicate that under certain conditions, high-risk parents experience a confluence of aggression-related risk factors (i.e., negative affect, pain sensitivity, and aggression-related information processes) that may predispose them to aggressive behavior.     

Evaluations, attributions, affect, and disciplinary choices in mothers at high and low risk for child physical abuse

OBJECTIVE: The present study investigated several components of a social information-processing model of child physical abuse. The main objective was to examine the extent to which high-risk, relative to low-risk, mothers differed in their evaluations, attributions, negative affect, and disciplinary choices for children's behavior, and to explore whether these differences may be expressed in interactions between risk status and mitigating information. METHOD: Nineteen high- and 19 matched low-risk mothers' evaluations of children transgressions, attributions, affect, and choices of disciplinary techniques were examined using six vignettes depicting a child engaging in moral, conventional, and personal transgressions. One-half of the vignettes contained mitigating information and one-half did not. High- and low-risk mothers were chosen based on their potential for physical child abuse. A three-factor (2 x 3 x 2) design was used to assess the dependent variables. RESULTS: As expected, high-risk, relative to low-risk, mothers reported more hostile intent, stable and global attributions, aversiveness, annoyance, and use of power-assertion discipline. A risk group by type of transgression interaction was found for evaluation and indifference and a risk group by mitigating information interaction was found for evaluation of wrongness, internal attributions, and aversiveness. A risk by type of transgression by mitigating information interaction was found for global/specific attributions, aversiveness, and indifference toward child transgressions. CONCLUSIONS: Results support a social information processing model of child physical abuse, which suggests that high-risk, compared to low-risk, mothers process child-related information differently and use more power-assertive disciplinary techniques.     

Emotion recognition in fathers and mothers at high-risk for child physical abuse

Objective

The present study was designed to determine whether parents at high risk for physical child abuse, in comparison with parents at low risk, show deficits in emotion recognition, as well as to examine the moderator effect of gender and stress on the relationship between risk for physical child abuse and emotion recognition.

Methods

Based on their scores on the Abuse Scale of the CAP Inventory (Milner, 1986), 64 parents at high risk (24 fathers and 40 mothers) and 80 parents at low risk (40 fathers and 40 mothers) for physical child abuse were selected. The Subtle Expression Training Tool/Micro Expression Training Tool ( [Ekman, 2004a] and [Ekman, 2004b]) and the Diagnostic Analysis of Nonverbal Accuracy II (Nowicki & Carton, 1993) were used to assess emotion recognition.

Results

As expected, parents at high risk, in contrast to parents at low risk, showed deficits in emotion recognition. However, differences between high- and low-risk participants were observed only for fathers, but not for mothers. Whereas fathers at high risk for physical child abuse made more errors than mothers at high risk, no differences between mothers at low risk and fathers at low risk were found. No interaction between stress, gender, and risk status was observed for errors in emotion recognition.

Conclusions and practice implications

The present findings, if confirmed with physical abusers, could be helpful to further our understanding of deficits in processing information of physically abusive parents and to develop treatment strategies specifically focused on emotion recognition. Moreover, if gender differences can be confirmed, the findings could be helpful to develop specific treatment programs for abusive fathers.     

Reading between the lines: Implicit assessment of the association of parental attributions and empathy with abuse risk

ObjectiveResearchers in the child maltreatment field have traditionally relied on explicit self-reports to study factors that may exacerbate physical child abuse risk. The current investigation evaluated an implicit analog task utilizing eye tracking technology to assess both parental attributions of child misbehavior and empathy.MethodBased on the observation that readers experience comprehension difficulty when encountering passages inconsistent with their beliefs, an eye tracker gauged the extent of difficulty parents experienced reading vignettes that inappropriately characterized a child as culpable for misbehavior and that presented a non-empathic child interaction.ResultsResults suggest self-reports of attributions and empathy are related to both child abuse potential and discipline intentions; however, the eye tracking analog for empathy correlated with abuse potential but not punishment decisions whereas the analog for attributions correlated with punishment decisions but not abuse potential.ConclusionsSuch contrasts between self-report and analog assessment underscore the need for continued research studying theorized abuse risk constructs using alternative approaches to better identify the important risk markers associated with elevated child abuse risk and to minimize methodological overlap.     

Interpretations of child compliance in individuals at high- and low-risk for child physical abuse

OBJECTIVE: Our studies compared individuals at high- and low-risk for child physical abuse on measures of social information processing. METHOD: Two studies were conducted using similar methods. Twenty-eight childless women in Study 1 and 36 mothers in Study 2 read vignettes of parent-child interactions in which the child's level of compliance was difficult to interpret. Participants were asked a series of questions about the child's behavior and their own reactions. RESULTS: Accuracy and bias in identifying compliant behavior were assessed using a signal detection paradigm. In both samples, high- and low-risk participants did not differ in their overall accuracy in identifying children's behaviors. However, they used different evaluation standards such that high-risk participants were biased toward seeing more noncompliance and low-risk participants were biased toward seeing more compliance. High- and low-risk participants also made different types of errors in interpreting children's behavior. Low-risk participants were more likely to misinterpret noncompliant behavior as compliant, and there was a trend for high-risk participants to not perceive compliant behavior when it occurred. There were no differences in reported disciplinary responses in either study and the results for affective reactions were mixed. CONCLUSIONS: Specific differences in social information processing between high- and low-risk individuals replicated across samples, suggesting a reliable association between evaluation standards and risk of child physical abuse. However, the absence of differences in reported discipline and inconsistent findings on affective reactions indicate the need to identify the mechanism through which cognition influences parenting behavior.     

The Relations of Parental Characteristics and Practices to Children''s Vicarious Emotional Responding

We examined the relation of parental empathy-related characteristics and emotion-related child-rearing practices to third and sixth graders' vicarious emotional responding. Children's heart rate, skin conductance, facial, and self-reported reactions to a sympathy-inducing film were assessed, as were their dispositional sympathy, empathy, and self-monitoring. Parental sympathy was positively related to low levels of personal distress in same-sex children and, for both parents, with sons' dispositional sympathy or empathy. Parental emphasis on problem-focused coping strategies when their sons were anxious was positively correlated with indexes of sons' situational and dispositional sympathy. Same-sex parental restrictiveness in regard to the control of inappropriate, hurtful emotional displays was associated with sons' and daughters' dispositional and situational sympathy, whereas maternal restrictiveness in regard to emotions that are unlikely to hurt others was correlated with nonverbal indexes of personal distress and self reports of low distress. Parental emphasis on control of the child's own negative emotion was associated with children's self-monitoring.     

Physical child abuse and social change. Judicial intervention in families in The Netherlands, 1960-1995

OBJECTIVE: To show changes in the way juvenile judges and judicial child protection workers deal with physical child abuse in the period 1960-1995 in the Netherlands. METHOD: The study is based on an analysis of files on adolescent and younger children placed by juvenile judges in the Dutch judicial child protection system during the 1960s, 1970s, 1980s, and 1990s. RESULTS: The prevalence of very severe physical violence against children was lower in the recent files than in the older files. Spanking and other minor violence acts were noted more often than in the older files. In the 1960s files, the parents talked still rather openly about the physical punishments they used in child rearing. In spite of the growing attention for and increasing concern about child abuse among professionals, judicial child protection workers intervened less harshly in recent cases of physical child abuse than in the 1960s. CONCLUSION: The decrease in severe physical child abuse may indicate that physical child abuse is actually becoming a less serious problem in the Dutch judicial child protection system. But that may not be the case because of the increased reluctance of parents to report and changes in intervention practices. Other than expected, the growing sensibility for child abuse did not mean more effective control by judicial child protection workers. Possible reasons for these changes are discussed, including the strengthening of the position of perpetrators in law proceedings and the emancipation of children and women in society.     

Parents’ perception of child behavior,parenting stress,and child abuse potential: Individual and partner influences

Based on the Social Information Processing model of parenting risk for child abuse, the present study examined the associations between mothers’ and fathers’ perception of child behavior and child abuse potential, as well as whether parenting stress mediates the association between these constructs. Two hundred and fifty-nine mother-father couples raising preschool children answered the Child Behavior Checklist (CBCL), the Parenting Stress Index (PSI), and the Child Abuse Potential Inventory (CAPI). The results of dyadic path analysis showed that perception of child behavior was related to heightened parenting stress and abuse potential in both mothers and fathers. Concerning partner effects, we found that mothers’ perception of child behavior problems was positively associated with fathers’ parenting stress and that the higher the mothers’ distress, the higher the fathers’ risk of physical abuse. Finally, parenting distress partially mediated the association between parents’ perception of child behavior and child abuse potential, with mothers’ perception of their children as problematic showing a significant indirect effect through distress on their own abuse risk and on fathers’ CAP as well. These findings suggest that parental distress may represent a critical mechanism by which parents’ negative views of their children contribute to abuse potential. Moreover, mothers seem to influence fathers’ tendency towards abusive behaviors.     

Attitudes of Turkish parents, pediatric residents, and medical students toward child disciplinary practices

OBJECTIVE: The aims of the study were to: determine the attitudes of parents, pediatric residents, and medical students from a Turkish population toward childhood disciplinary methods; ascertain the association of participants' abusive childhood history with their attitudes toward discipline; and assess their attitudes about disciplinary actions, which should be reported as abuse. METHOD: A cross-sectional survey was conducted in Ankara University School of Medicine, Department of Social Pediatrics. Sixty-five parents, 39 pediatric residents, and 106 medical students completed a questionnaire (Survey of Standards of Discipline). This questionnaire was designed to measure sociodemographic characteristics, attitudes toward childhood disciplinary practices, and abusive childhood experiences. There were 43 different disciplinary acts in this questionnaire. The participants were expected to give responses to these acts in three categories: (a) acceptable as discipline; (b) unacceptable as discipline; and (c) unacceptable as discipline-would report to authorities as child abuse. Based on the responses to this questionnaire, we developed the Severity Scale. Using this scale, physical severity scores, verbal severity scores, and total severity scores were measured for each participant. RESULTS: None of the participants accepted life-threatening practices as discipline, but some declared certain abusive disciplinary practices as acceptable. Some forceful disciplinary methods were not considered as reportable by participants. All severity scores of both residents and students were found to be higher than those of the parents (for verbal severity scores p=.042). Also, both verbal and physical severity scores of parents with one child were higher than those of parents with two children (for verbal severity scores p=.044). Ninety-one participants (43.3%) indicated that beating was an acceptable form of discipline. Of parents, 66.9% reported abusive childhood history by their own criteria. Of medical students with an abusive childhood experience, 56.5% accepted beating as appropriate (p=.001). Both verbal and physical severity scores were found to be higher in participants with abusive childhood history. CONCLUSIONS: Abusive childhood history and lack of education regarding appropriate discipline techniques are linked to the acceptance of certain physical discipline practices. Turkey's cultural and traditional norms may be associated with the use of physical punishment, and in some cases, physical abuse. The lack of awareness of abusive discipline methods among physicians constitutes problems for child protection and must be addressed. Thus, educational programs on child disciplinary practices are required to provide an increased awareness of child abuse among health professional trainees and parents in Turkey.     

Relationships among parental beliefs in corporal punishment, reported stress, and physical child abuse potential.

OBJECTIVE: The present study examined the extent to which parental belief in the value of corporal punishment moderates the association between level of parenting stress and physical child abuse potential. Based on existing theory, it was expected that levels of parenting stress would be positively associated with physical child abuse potential among parents who reported high levels of belief in the value of corporal punishment. METHOD: Forty-one parents (25 general population and 16 at-risk parents) were assessed for belief in the value of corporal punishment, level of parenting stress, and physical child abuse potential using self-report measures. After removal of respondents due to response distortion or missing data, the final sample consisted of 31 parents with valid and complete protocols. Based on their responses on the study measures, respondents were categorized as either high or low on belief in corporal punishment and parenting stress. RESULTS: Level of parenting stress was positively associated with physical child abuse potential. As expected, the interaction of parenting stress and belief in the value of corporal punishment was significant. Level of parenting stress was positively associated with physical child abuse potential among parents who reported high levels of belief in the value of corporal punishment. In contrast, level of parenting stress was not associated with physical child abuse potential among parents who reported low belief in the value of corporal punishment. CONCLUSIONS: The present findings are consistent social information processing and stress and coping models of the etiology of physical child abuse, and underscore the importance of considering both parental cognitions and levels of parenting stress in assessing potential for physical child abuse.     

Mediating effects of parental psychological distress and individual-level social capital on the association between child poverty and maltreatment in Japan

Child poverty is well known as a major risk factor for child maltreatment. However, it is not known whether parental psychological distress and individual-level social capital mediate the association. We examined the mediation effect of these two factors on the association between child poverty and maltreatment. In the Adachi Child Health Impact of Living Difficulty (A-CHILD) Study, a questionnaire was administered to all caregivers of first-grade children in every public elementary school in Adachi City between July and November 2015, and valid responses were used for analysis (N = 3944). Logistic and Poisson regression analyses were employed to examine the association between child poverty and maltreatment. Child poverty was defined in this study as meeting one of these criteria: 1) household income less than 3 million yen; 2) deprivation of specific material items that children or the household requires, or 3) experience of being unable to pay for lifeline utilities. Child maltreatment (physical abuse, neglect, and psychological abuse) was answered by parents. We confirmed a robust association between child poverty and maltreatment. Mediation analysis indicated that parental psychological distress mediated more than 60% of the association between child poverty on physical abuse and psychological abuse, while individual-level social capital mediated only 10% of the association with any type of maltreatment. In addition, structural equation modeling analysis revealed that the association was mediated by both parental psychological distress and social capital simultaneously. The findings suggest that supporting parental psychological distress may be an effective intervention to remedy the negative impact of child poverty on maltreatment.     

Physiological responses to non-child-related stressors in mothers at risk for child abuse.

Physical child abusers and adults at risk for child abuse, relative to comparison subjects, are reported to be more physiologically reactive to child-related stressors. It is not known if the reported physiological reactivity is child specific or if physical child abusers and at-risk parents are also more reactive to other types of stressful stimuli. The present study investigated changes in heart rate and skin conductance in response to four types of non-child-related stressors in at-risk and matched low-risk mothers. The four types of stressful stimuli were: a cold pressor; a stressful film depicting industrial accidents; unsolvable anagrams; and an aversive car horn. At-risk mothers, relative to low-risk mothers, had greater and more prolonged sympathetic activation during presentations of the cold pressor and the stressful film, the stimuli rated as the most stressful. The present data, combined with previous findings, support the view that generalized sympathetic activation to both child and non-child-related stressors may serve as a mediator of physical child abuse.     

Multimethod prediction of child abuse risk in an at-risk sample of male intimate partner violence offenders

The vast majority of research on child abuse potential has concentrated on women demonstrating varying levels of risk of perpetrating physical child abuse. In contrast, the current study considered factors predictive of physical child abuse potential in a group of 70 male intimate partner violence offenders, a group that would represent a likely high risk group. Elements of Social Information Processing theory were evaluated, including pre-existing schemas of empathy, anger, and attitudes approving of parent-child aggression considered as potential moderators of negative attributions of child behavior. To lend methodological rigor, the study also utilized multiple measures and multiple methods, including analog tasks, to predict child abuse risk. Contrary to expectations, findings did not support the role of anger independently predicting child abuse risk in this sample of men. However, preexisting beliefs approving of parent-child aggression, lower empathy, and more negative child behavior attributions independently predicted abuse potential; in addition, greater anger, poorer empathy, and more favorable attitudes toward parent-child aggression also exacerbated men’s negative child attributions to further elevate their child abuse risk. Future work is encouraged to consider how factors commonly considered in women parallel or diverge from those observed to elevate child abuse risk in men of varying levels of risk.     

Stressed parents with infants: reassessing physical abuse risk factors.

OBJECTIVE: This study aimed to examine the relationship between a range of potentially adverse psychosocial and demographic characteristics identified in the immediate postpartum period and child physical abuse potential at 7 months. METHOD: Data collected as part of a randomized controlled trial of a nurse home visiting programme for vulnerable families with newborns was used. Women (181) were recruited in the immediate postpartum period. At 7 months, 151 participants were available for evaluation. Potential for child physical abuse was assessed using the Child Abuse Potential (CAP) Inventory. RESULTS: Significant risk indicators identified by univariate analysis were financial stress, elevated Edinburgh Postnatal Depression Scale (EPDS) scores, education level less than 10 years, concern regarding the provision of housing, and domestic violence characterized by verbal and social abuse. There was no association between child abuse potential and sole parenthood, poverty, young maternal age, history of childhood abuse, or psychiatric history. Two variables were found to be of independent significance using a logistic regression model; elevated EPDS and perceived difficulty "making ends meet." CONCLUSIONS: The findings indicate that perceived stress relating to finances, accommodation and relationships in the immediate postpartum period are associated with heightened child physical abuse potential at 7 months. Elevated EPDS in the early postpartum period is also a risk indicator. The outcome of this study suggests that perinatal assessment of child abuse risk is possible and simple and is related to perceived stressors at the time surrounding delivery. This is independent of a range of demographic variables traditionally thought to predict high risk.