Blunted Affect Research Articles

Comparison of Subjective Facial Emotion Recognition and "Facial Emotion Recognition Based on Multi-Task Cascaded Convolutional Network Face Detection" between Patients with Schizophrenia and Healthy Participants.

Patients with schizophrenia may exhibit a flat affect and poor facial expressions. This study aimed to compare subjective facial emotion recognition (FER) and FER based on multi-task cascaded convolutional network (MTCNN) face detection in 31 patients with schizophrenia (patient group) and 40 healthy participants (healthy participant group). A Pepper Robot was used to converse with the 71 aforementioned participants; these conversations were recorded on video. Subjective FER (assigned by medical experts based on video recordings) and FER based on MTCNN face detection was used to understand facial expressions during conversations. This study confirmed the discriminant accuracy of the FER based on MTCNN face detection. The analysis of the smiles of healthy participants revealed that the kappa coefficients of subjective FER (by six examiners) and FER based on MTCNN face detection concurred (κ = 0.63). The perfect agreement rate between the subjective FER (by three medical experts) and FER based on MTCNN face detection in the patient, and healthy participant groups were analyzed using Fisher's exact probability test where no significant difference was observed (p = 0.72). The validity and reliability were assessed by comparing the subjective FER and FER based on MTCNN face detection. The reliability coefficient of FER based on MTCNN face detection was low for both the patient and healthy participant groups.

Balanced time perspective and its relationship with clinical and cognitive symptoms in schizophrenia

The adaptive function of balanced time perspective is widely acknowledged within positive psychology, yet little is known regarding the expression of time perspective in clinical populations and its relation to clinical features. The current study aimed to examine the nature of time perspective in schizophrenia and to determine whether alterations in balanced time perspective is associated with maladaptive outcomes in terms of clinical and cognitive symptoms. A total of 104 patients with schizophrenia and 93 matched healthy controls participated in this study. Time perspective, negative symptoms, working memory and response inhibition was measured. Results showed that patients with schizophrenia manifested lower balanced time perspective with marginal significance in the context of impaired working memory but intact response inhibition. Correlation analyses revealed that deviation from balanced time perspective in schizophrenia was negatively associated with working memory capacity, as well as positively associated with negative symptoms such as affective blunting and anhedonia. Our findings point to working memory impairments as a candidate cognitive mechanism underpinning the deviation from balanced time perspective in schizophrenia. We further demonstrate a link between deviation from balanced time perspective and clinical symptomatology in schizophrenia, offering potential avenues for remediation strategies.

Psychological health, wellbeing and COVID-19: Comparing previously infected and non-infected South African employees.

Most COVID-19 and work-related well-being research is centred around the adverse effects on employees' psychological well-being and is not focused on the work-related well-being of those infected by SARS-CoV-2. Furthermore, COVID-19 and work-related well-being research is generally aimed at healthcare workers. The current study focused on investigating the difference in the level of burnout, anxiety, depression and stress between previously infected and uninfected participants. This study used a cross-sectional survey design and non-probability quota sampling to collect data. A retrospective pre-post design was used to determine the difference between the level of burnout of the participants before and after infection. Working adults in South Africa were targeted and divided into those previously infected (n = 245) and those not yet infected with COVID-19 (n = 221). Participants completed questionnaires relating to burnout, depression, anxiety, and stress. A comparison of means revealed a significant increase in burnout after being infected. Infected participants had significantly higher burnout, anxiety, depression, and stress levels than their non-infected counterparts. Emotional exhaustion, withdrawal, and stress were the most prevalent psychological ill-health problems. The results of this study indicated that a SARS-CoV-2 infection has a detrimental impact on participants' psychological well-being and mental health compared to their own initially reported levels of burnout before infection, as well as compared to the levels of burnout, depression, anxiety and depression of the non-infected participants. Based on the findings, specific recommendations to industrial psychologists were made to manage the psychological impact of COVID-19 on employees.

Clinical validation of the nursing diagnosis decreased diversional activity engagement in patients with diabetes

Background Diagnostic accuracy studies are important to identify the best set of defining characteristics for a given nursing diagnosis. The reliability of nursing inferences can be increased by using clinical indicators with high prediction capacity helping nurses to be more accurate in their clinical practice. Objective To clinically validate the nursing diagnosis Decreased diversional activity engagement in adult patients with diabetes. Method A diagnostic accuracy study with a cross-sectional design was carried out patients with type 2 diabetes. A latent class model with random effects was used to measure the sensitivity and specificity. Results The diagnosis of Decreased diversional activity engagement was present in 62.2% of the patients. The defining characteristics with high sensitivity (good indicators for confirmation) were discontent with situation, physical deconditioning, and altertion in mood. Boredom, flat affect, discontent with situation, and frequent naps were the defining characteristics with the highest specificity values. These factors are considered good integrating components of the diagnosis under investigation in patients with diabetes. Conclusion The nursing diagnosis decreased diversional activity engagement is frequent in patients with diabetes, and discontent with situation can be considered a good predictor of its occurrence due to its high values of specificity and sensitivity. Impact The use of accurate clinical indicators in the diagnostic reasoning of nurses contributes to the achievement of outcomes centered on the patient's human responses.

ODP299 Cabergoline Administration Markedly Improves Cognitive Impairment Associated with Macroprolactinoma

Abstract Introduction Prolactinomas classically present with galactorrhea, infertility, or hypogonadal symptoms. However cognitive impairment is rare presentation. We describe a man with a macroprolactinoma presenting with significant cognitive dysfunction which improved remarkably with cabergoline treatment. Case History A 21-year-old man with no significant past medical history presented to the hospital for evaluation of seizure-like activity. His father noted him limping earlier in the day and witnessed him fall and hit his head, while his brother reported involuntary convulsions and decreased awareness earlier that week. The patient himself had been complaining of blurry vision for 3 months for which he was prescribed glasses. Initial head CT demonstrated a 3.4×4.3×3.4cm cystic mass in the sella, 3.9×3.2×2.6 cm mass in the right basal ganglia and 2.7×2.3×3cm mass in the right temporal lobe. His prolactin was elevated at 16326 ng/mL. He was empirically started on dexamethasone due to concern for cerebral edema and was admitted. Surgery was recommended given the severity of his presentation, but the patient declined and he was discharged on cabergoline 1.5mg/week, dexamethasone taper, hydrocortisone 15mg/day, and levetiracetam 1000mg twice daily. On initial outpatient endocrinology evaluation 3 weeks later, he required the use of a wheel chair. Examination was notably for markedly flat affect, slurred speech, decreased attention span requiring frequent re-direction during the interview but he was otherwise oriented to person, time, and place. Neurological examination was noted for 4/5 muscle weakness throughout, facial asymmetry, decreased facial sensation, and an antalgic gait. He was recommended for expedited neurosurgical evaluation but he again declined. Laboratory drawn at this time showed a prolactin of 1946 ng/mL and total testosterone of 45 ng/dL, but he had normal thyroid and growth hormone axis (adrenal axis was not assessed as he was on dexamethasone taper). Carbergoline was titrated with further improvement in his prolactin levels. Four months after initial presentation, he reported enrolling in college with resolution of any cognitive and neurological deficits. Fourteen months after presentation, serum prolactin was 34 ng/mL on 4mg cabergoline per week and he is active in college and regularly plays basketball. Discussion Prolactinomas are incidentally detected or found as a result of workup for galactorrhea, infertility, or low libido. Typically, goals for treatment are to relieve compressive effects along the optic chiasm or to restore gonadal function. Acute cognitive decline should also be considered when there is a macroprolactinoma, and serial monitoring for improvement may be considered a clinical marker along with MRI imaging and prolactin levels. In this case, the patient had marked cognitive dysfunction on initial presentation but after 3 months of treatment had almost complete recovery as evidenced by his re-enrolling in college classes successfully. Presentation: No date and time listed

Heritability of Sound Processing Deficits in Autism: Neural Insights

Heritability of Sound Processing Deficits in Autism: Neural Insights

Abnormal Brain Iron Accumulation is a Rare Finding in Down Syndrome Regression Disorder

BackgroundDown syndrome regression disorder (DSRD) is characterized by the sudden loss of adaptive function, cognitive-executive function, and language with abnormal sleep and/or motor control. MethodsClinical, laboratory, and imaging data from three individuals with DSRD and iron on brain imaging were reviewed. ResultsThree patients with Down syndrome presented with new onset of flat affect, depression, reduced speech, and other neurological symptoms consistent with DSRD. Magnetic resonance imaging showed abnormal iron accumulation in the basal ganglia, as well as calcification in two cases. Molecular diagnostic testing for neurodegeneration with brain iron accumulation was negative in the two individuals tested. ConclusionsThese individuals presented suggest that a subset of individuals with DSRD have abnormal brain iron accumulation. Motor control symptoms reported in DSRD, such as stereotypies and parkinsonism, may reflect this basal ganglia involvement. The presence of abnormal brain iron should not delay or preclude diagnosis and treatment for DSRD.

Efficacy and Risk Factor Analysis of DBT Therapy for PTSD-Related Symptoms in Mainland Chinese College Students Based on Data Mining.

Posttraumatic stress disorder (PTSD) is a mental disorder characterized by a delayed onset and long-lasting psychiatric disorder in an individual due to unusual threatening or catastrophic stressful events, characterized by repeated experiences of the situation, avoidant behaviors, emotional numbness, hypervigilance, and other mental symptoms. It seriously affects the occupational, psychological, and social functions of the human body, leads to a decrease in the quality of life, and brings a greater economic burden to the patients themselves, their families, and the society. It has attracted widespread attention worldwide. Due to social transformation and fierce competition, college students are increasingly exposed to various stressful or traumatic events, and PTSD is becoming more and more obvious. Therefore, this study took a university student as the research object, analyzed the risk factors of PTSD, and used the method of data mining to analyze the effectiveness of DBT therapy and completed the following work: (1) this paper introduces the research status of PTSD pathogenesis at home and abroad and expounds the treatment methods and research results of DBT. (2) The basic principle of BPNN is introduced, the weight and threshold of BPNN are screened by genetic algorithm, and the best weight and threshold after screening are given to BPNN. A GA-BP model is constructed to improve the learning quality of BPNN. (3) The optimal parameters of the model are selected through experiments, and the model is verified by the collected data. The results show that the model has superiority in evaluating the effectiveness of DBT therapy. Then, it was proved by experiments that DBT therapy has a good effect in the treatment of PTSD. Finally, the influencing factors of PTSD were analyzed one by one through the experimental results.

The Impact of COVID-19 Lockdowns in a Sample of Outpatients in a Mental Health Department of a Metropolitan Hospital in Milan

Background and Objectives: Italy was the first country in Europe to face the coronavirus 2019 (COVID-19) pandemic and its consequences, which led to two phases of severe restrictions for its population. This study aims to estimate the connections between the trauma of the COVID-19 emergency and the clinical features of a sample of outpatients in a Milan Community Mental Health setting, comparing the first (April 2020) and second lockdowns (November 2020). Materials and Methods: The sample included 116 consecutive outpatients recruited in April 2020 and 116 in November 2020. The subjects were evaluated with Clinical Global Impression Severity (CGI-S), Brief Psychiatric Rating Scale (BPRS-18), and Impact of Event Scale-Revised (IES-R). Results: The IES-R identified 47.4% participants in April and 50% in November with clinical scores over the cut-off. The network analysis of BPRS-18 and IES-R depicted the connection among different symptoms; in April, Unusual Thought Content, Anxiety, and Somatic Concern represented the most central items, and the strongest connections were found between Uncooperativeness and Hostility, Blunted Affect and Emotional Withdrawal, and IES-Intrusion and IES-Arousal. In the November group, the most central items were represented by Conceptual Disorganization and Emotional Withdrawal, whereas the strongest connections were found between IES-Arousal and IES-Intrusion, Excitement and Grandiosity, and Unusual Thought Content and Conceptual Disorganization. Conclusions: Our findings show continued high distress levels and increased psychological burdens during the second phase of restrictions; this could be described as “pandemic fatigue”, a general psychological weariness due to pandemic-related restrictions, as well as a lack of motivation to comply with them. As mental health professionals, our mission during these difficult times has been to keep community psychiatry services accessible, with particular regard to vulnerable and marginalized populations.

Empowering College Students to Decrease Digital Distraction Through the Use of Self-Regulated Learning Strategies

Most college students have grown up using technology and consequently, they are proficient with its many uses and applications. The use of this technology provides many benefits to college students’ learning, both in and out of the classroom. However, despite the numerous benefits of technology, these digital activities can also lead to much digital distraction. Digital distractions may include Internet surfing, watching movies, checking texts, reading, and sending emails, and perusing social media. These digital distractions often result in limited attention and engagement during class, as well as less learning and academic achievement overall. Digital distraction can result from such factors as anxiety and depression, motivational variables, the need to keep up and the fear of missing out, emotional numbing and procrastination as well as an overreliance on multitasking. It is suggested here that the use of self-regulated learning (SRL) strategies may be effective in assisting college students in avoiding digital distractions, both in and out of the classroom. SRL strategies include forethought, planning, activation; monitoring, control and reflection on the learner’s cognition, motivation/affect, and behavior. Through the use of these SRL strategies, college students may be taught to decrease digital distractions and, thus, experience higher levels of learning and academic performance.

Mapping post-traumatic stress disorder symptoms and quality of life among residents of Wuhan, China after the COVID-19 outbreak: A network perspective

ObjectivesThe Coronavirus Disease 2019 (COVID-19) outbreak may have a long-term impact on mental health in the general population. This study examined inter-relationships between post-traumatic stress disorder symptoms (PTSS) and quality of life (QOL) in Wuhan residents after the COVID-19 outbreak using network approach. MethodsA cross-sectional survey was conducted between May 25 and June 18, 2020. PTSS and QOL were measured using Chinese versions of the Post -Traumatic Stress Disorder Checklist - Civilian Version and the World Health Organization Quality of Life Questionnaire - brief version, respectively. ResultsA total of 2598 participants were included. A network analysis revealed “Avoiding reminders”, “Feeling emotionally numb”, “Avoiding thoughts”, “Hypervigilance”, and “Reliving experiences” as the most central (influential) nodes in PTSS network models both before and after controlling for covariates. The connection between “Avoiding thoughts” and “Avoiding reminders” had the strongest edge. Three symptom communities were detected and can be summarized as “re-experiencing and avoidance”, “negative changes in thinking and mood”, and “hyperarousal”. The bridge symptoms connecting PTSS and QOL were “Sleep disturbances”, “Irritability”, and “Loss of interest”. LimitationsLimitations included the cross-sectional study design, self-report measures in data collection, and lack of follow-ups beyond the initial phase of the pandemic. ConclusionsPTSS were common among Wuhan residents even after the initial COVID-19 outbreak had passed. Attention should be paid to lingering symptoms of avoiding reminders, emotional numbness, avoiding thoughts, hypervigilance, and reliving experiences in treating PTSS related to the COVID-19 outbreak.

Psychometric properties of the Social Behavior Questionnaire (SBQ) in a longitudinal population-based sample

We assessed the psychometric properties of the Social Behavior Questionnaire (SBQ), a 30-item questionnaire evaluating social (e.g., disruptive behaviors, bullying) and emotional problems (e.g., anxiety, depression) among children aged 3.5–12 years. Children (n = 1,950, 50.21% boys) were drawn from the Quebec Longitudinal Study of Child Development. Mothers reported the frequency with which children presented social and emotional behaviors from 3.5 to 8 years of age, and teachers from 6 to 12 years. We assessed internal structure using Confirmatory Factor Analysis, reliability using Cronbach’s alpha, and convergent and discriminant validity using a multitrait-multimethod (MTMM) approach. The six-factor (emotional distress, withdrawal, impulsive/hyperactive/inattentive, disruptive behaviors, prosocial behaviors, and peer relationships difficulties) structure of the SBQ showed good fit from ages 3.5 to 12 years. Reliability estimates were good to excellent (alphas > .7), and MTMM showed good convergent and discriminant validity. Overall, the SBQ presented good psychometric properties with a large population-based sample aged 3.5–12 years. Further studies should assess its screening potential by investigating its convergent validity with diagnostic information.

Does treatment delay for blunt cerebrovascular injury affect stroke rate?: An EAST multicenter study

BackgroundThe purpose of this study was to analyze injury characteristics and stroke rates between blunt cerebrovascular injury (BCVI) with delayed vs non-delayed medical therapy. We hypothesized there would be increased stroke formation with delayed medical therapy. MethodsThis is a sub-analysis of a 16 center, prospective, observational trial on BCVI. Delayed medial therapy was defined as initiation >24 hours after admission. BCVI which did not receive medical therapy were excluded. Subgroups for injury presence were created using Abbreviated Injury Scale (AIS) score >0 for AIS categories. Results636 BCVI were included. Median time to first medical therapy was 62 hours in the delayed group and 11 hours in the non-delayed group (p < 0.001). The injury severity score (ISS) was greater in the delayed group (24.0 vs the non-delayed group 22.0, p < 0.001) as was the median AIS head score (2.0 vs 1.0, p < 0.001). The overall stroke rate was not different between the delayed vs non-delayed groups respectively (9.7% vs 9.5%, p = 1.00). Further evaluation of carotid vs vertebral artery injury showed no difference in stroke rate, 13.6% and 13.2%, p = 1.00 vs 7.3% and 6.5%, p = 0.84. Additionally, within all AIS categories there was no difference in stroke rate between delayed and non-delayed medical therapy (all N.S.), with AIS head >0 13.8% vs 9.2%, p = 0.20 and AIS spine >0 11.0% vs 9.3%, p = 0.63 respectively. ConclusionsModern BCVI therapy is administered early. BCVI with delayed therapy were more severely injured. However, a higher stroke rate was not seen with delayed therapy, even for BCVI with head or spine injuries. This data suggests with competing injuries or other clinical concerns there is not an increased stroke rate with necessary delays of medical treatment for BCVI.

A-234 Psychopathology as a Factor in Failed Performance Validity Testing

Abstract Objective: Evidence of incomplete effort is sometimes attributed to common symptoms of depression, anxiety, or somatic preoccupations. The objective of this study was to examine the role of mood disturbance severity in failed performance validity testing (PVT) in referrals to a memory disorders clinic. Participants and Method: 164 non-compensation-seeking referrals, 66% women, 84% white non-Hispanic, were divided into two groups (n = 82) based on passed or failed PVT results. Participants had an average age 60.4 ± 15.7 and education 14.9 ± 2.9 years. However, 51% of participants had diagnoses of depression and anxiety. Protocols were screened for performance invalidity using Reliable Digit Span and Digit Span SS. Results: MMPI-2 content scales were factor analyzed (PCA/varimax) yielding three factors: Internalizing, Externalizing, and Thought Dysfunction. Mean scores on the three MMPI-2 factors were contrasted across the failed PVT and passed PVT samples. No significant differences emerged (all ps &amp;gt;.13). Mean scores on the MMPI-2 validity scales (F, Fb, Fp, and FBS) were also compared. No significant differences emerged (all ps &amp;gt; .29). Conclusions: Although it is often believed that psychological symptoms such as motivational inertia, apathy and indifference, emotional withdrawal and isolation, preoccupations and distractibility, and acting out tendencies contribute to incomplete effort and failed PVT, these results failed to support such a perspective. They are consistent with other published results that suggest that self-report validity on SVTs can be largely independent of performance validity. This proposition might be setting-specific. In this memory disorders clinic setting, psychopathology showed no measurable impact on effort or performance validity.

Emotional numbing in PTSD is associated with lower amygdala reactivity to pain.

Posttraumatic stress disorder (PTSD) is associated with altered pain perception, namely increased pain threshold and higher pain response. While pain consists of physiological and affective components, affective components are often overlooked. Similar patterns of increased threshold-high response in PTSD were shown in response to emotional stimuli, i.e., emotional numbing. As both emotional numbing and pain processing are modulated by the amygdala, we aimed to examine whether individuals diagnosed with PTSD show lower amygdala activation to pain compared with combat controls, and whether the amygdala responses to pain correlates with emotional numbing. To do so, two independent samples of veterans (original study: 44 total (20 PTSD); conceptual replication study: 40 total (20 PTSD)) underwent threat conditioning, where a conditioned stimulus (CS+; visual stimulus) was paired with an unconditioned stimulus (US; electric-shock). We contrasted the amygdala activity to the CS + US pairing with the CS+ presented alone and correlated it with emotional numbing severity. In both samples, the PTSD group showed a robust reduction in amygdala reactivity to shock compared to the Combat Controls group. Furthermore, amygdala activation was negatively correlated with emotional numbing severity. These patterns were unique to the amygdala, and did not appear in comparison to a control region, the insula, a pivotal region for the processing of pain. To conclude, amygdala response to pain is lower in individuals with PTSD, and is associated with emotional numbing symptoms. Lower amygdala reactivity to mild pain may contribute to the "all-or-none" reaction to stressful situations often observed in PTSD.

Important adverse events to be evaluated in antidepressant trials and meta-analyses in depression: a large international preference study including patients and healthcare professionals

BackgroundNon-serious adverse events (NSAEs) should be captured and reported because they can have a significant negative impact on patients and treatment adherence. However, the reporting of NSAEs in randomised controlled...

Anger without a voice, anger without a solution: Parent–child triadic processes and the experience of caring for a child with a diagnosis of autism

The paper offers an exploration of triadic attachment dynamics in families with a child with a diagnosis of autism. The Meaning of the Child (MotC) framework was employed as part of a multiple case study design with 18 parents (9 couples) in order to examine their representation of parenting and relationship with their child. The MotC analysis employed concepts of parental sensitivity, mentalisation and reflective functioning, and a triadic, analysis was added to consider the family relational processes. The findings indicate that the parents were significantly influenced by the use of a dominant ‘autism discourse’. ‘Autism’ in their child presented a severe challenge for them and could foster a sense of disempowerment and emotional withdrawal. Locating the difficulties as reflecting ‘autism’ could also serve to detour conflicts between the parents, and in the parents themselves, trapping the family in unresolved anger or fear that could neither be named nor its impact addressed. Autism discourse tended to rob the actions of family members of interpersonal meaning, rendering conflict fixed and unalterable and requiring them to mask the deep feelings inherent in these relational ruptures. The analysis included an exploration of the parents’ own childhood attachment histories which revealed that the parents were also driven by corrective scripts in wishing to form better relationships with their child than had been their own childhood experiences of parenting. A sense of failure to achieve these added to their sense of disappointment and frustration, but also indicated potential avenues for positive changes and growth.

Still Mrs. B.-An Ode to Personhood During the Pandemic.

Still Mrs. B.-An Ode to Personhood During the Pandemic.

Cluster analysis of negative symptoms identifies distinct negative symptom subgroups

The heterogeneity of schizophrenia has been acknowledged for decades because of the diverse presentation of symptoms, illness course, and treatment response noted between individuals diagnosed with the disorder. Cluster analysis has been used as a statistical method to determine whether schizophrenia subgroups might be identified based on symptom heterogeneity. However, there is very limited research examining whether heterogeneity in negative symptoms might be useful in establishing schizophrenia subtypes, particularly research examining newer models of negative symptoms based on five latent constructs including anhedonia, asociality, avolition, blunted affect, and alogia. The Brief Negative Symptom Scale was used to assess the five negative symptoms domains in a sample of 220 outpatients diagnosed with schizophrenia or schizoaffective disorder. Cluster analysis supported a four-cluster solution, comprising clusters of subjects with low negative symptoms (LNS), severe negative symptoms (SNS), and two clusters with moderate negative symptoms, one with predominantly elevated blunted affect (BA) and one with elevated avolition (AV). The LNS, SNS, BA, and AV clusters significantly differed on external validators including clinical characteristics, neurocognition, and functional outcome. Findings suggest that schizophrenia heterogeneity can be parsed according to negative symptom subtypes that have distinct clinical and neuropsychological profiles. Implications for diagnosis and treatment are discussed.

A network analysis of post-traumatic stress among youth aging out of the foster care system

Network analysis is increasingly being used to explore interrelationships between symptoms of post-traumatic stress (PTS); nevertheless, no study to date has applied network theory to explore PTS in youth who are transitioning from foster care to independence. The present study estimated Adaptive LASSO and relative importance networks of PTS symptoms using the CIDI-PTSD Short Form (CIDI-SF) index from the Multi-Site Evaluation of Foster Youth Programs Study (2001–2010). Graph-theoretic algorithms including community detection and minimum spanning tree (MST; a unique, acyclic subnetwork with a fixed number of connections) were implemented to identify interconnected network symptom clusters. Two symptoms of emotional numbing (restricted affect and feeling detached) and two symptoms of intrusive reexperiencing (flashbacks, distressing dreams) emerged as the most important items in the network. The MST algorithm further revealed a backbone structure of PTSD that was centered on negative evaluations of the future. Feedback loops within the network were identified as well as symptoms that were highly predictive and potentially causal. Results strongly suggest that emotional numbing is a central aspect of psychopathology following experiences of complex trauma and home removal that merits special consideration in the diagnostic and treatment evaluation process of youth involved in the foster care system.