Impact of Behavioral Genetic Evidence on the Perceptions and Dispositions of Child Abuse Victims

Abstract

Behavioral genetic research is beginning to elucidate some of the genetic contributions to human behaviors—including criminal and other problematic behaviors—and their interactions with environmental influences. One of the most studied of these interactions involves low-activity alleles of the monoamine oxidase A (MAOA) gene, which appear to increase the risk of antisocial behavior among males in the wake of childhood maltreatment. Some scholars have suggested that decisions about disposition of child abuse victims should be shaped by these findings, but the extent of public support for such approaches has not been assessed. In this study, a representative sample of the U.S. population (N=250) was presented with a vignette about a child physically abused by his mother, who was tested for the presence of an allele that increases the risk of future impulsive violent behavior. Participants were asked about their views regarding the child's disposition, including return to his mother, and medical or psychological treatment. Although participants thought that genetic data should be taken into account, the presence of an allele that increases risk of impulsive violent behavior did not affect views regarding the child's return to his mother. However, it did increase respondents' willingness to provide the child with medical treatment and their view of the child as dangerous to other children. The findings suggest that behavioral genetic evidence has effects on perceptions of dangerousness and tendencies to view problems as medical, but that the public is cautious about the use of genetic findings in child abuse adjudications.

Introduction

The field of behavioral genetics is expanding our understanding of causal influences on human behavior. For several decades, researchers using twin and family studies have known of the significant heritability of a variety of behavioral traits, ranging from shyness to vocational interests [1]. More recently, with the development of advanced techniques in molecular genetics, a growing number of genes have been associated with adult and child temperament and personality, behavioral traits, and mental disorders [2,3,4]. Combining genetic techniques with neuroimaging has permitted researchers to begin to illuminate the brain pathways underlying these effects [5]. These findings have challenged the idea that human beings are blank slates shaped entirely by their environment [6].

In addition to augmenting our understanding of the roots of behavior, advances in behavioral genetics may have implications for governmental policy and attributions of responsibility in everyday life in at least three ways. First, by showing that behaviors are partly caused by factors that are outside our conscious awareness and control, behavioral genetics can impact questions of criminal and personal responsibility for past behavior [7,8]. Second, it can affect decisions regarding prospective interventions when an individual is discovered to have genetic risk factors for problematic behaviors prior to engaging in such behaviors [9]. Lastly, advances in behavioral genetics have heightened policy questions regarding when and how behavioral genetic data should be gathered while appropriately protecting the freedom and privacy of individuals [10].

A particularly pertinent example of the ways in which behavioral genetics can raise these issues is illustrated by studies demonstrating the effect of variant alleles of the gene encoding monoamine oxidase A (MAOA), an enzyme that degrades monoamine neurotransmitters. After a pedigree study demonstrated that the absence of MAOA, coded for by a gene on the X chromosome, was associated with increased rates of impulsive and aggressive criminal behavior among men in a extended family in the Netherlands [11], a similar effect of reduced, but not absent, MAOA levels was found in a longitudinal epidemiologic study of a birth cohort in Dunedin, NZ [12]. Subjects with an allele associated with reduced MAOA activity (often referred to as MAOA-L) were 9.8 times as likely to be convicted of a violent offense as adults, but only if they also had a history of maltreatment as children: a classic gene × environment interaction [13]. Subsequent studies in males have largely confirmed [14,15,16,17,18,19,20,21,22,23,24,25], but in some cases failed to confirm [26,27,28,29,30,31, these findings. Although the studies varied in methods and populations sampled, two meta-analyses have supported the association between MAOA and anti-social behavior by maltreated boys [15,32]. Thus, within the sample of victims of child abuse, a variant of the MAOA gene appears to constitute a significant prospective risk factor for violent behavior, a known consequence of child abuse [33].

Even as potential mechanisms of the effects of low MAOA levels are being sought [34], a variety of potential policy implications of this finding have been discussed. The greater vulnerability of MAOA-L children to abuse has been suggested as justifying a lower threshold for removal from a home where abuse has occurred and a higher threshold for return [35,36], an approach arguably supported by a small number of studies that suggest the possibility of a dose/response relationship between amount of abuse and adverse consequences in these children [37,38]. Commentators have also called for preferential access to treatment services for MAOA-L children on the basis of their heightened vulnerability [35], and in light of data suggesting that strong social supports may buffer the consequences of abuse [39]. It has even been proposed that someone knowingly abusing an MAOA-L child be subject to more severe punishment than other abusers [35].

Since public attitudes towards behavioral genetic findings are likely to have a significant impact on the adoption or rejection of such recommendations, explorations of popular attitudes and beliefs have begun. Several commentators have suggested that a large portion of the public is likely to fall prey to simplistic views of genetics, including the idea that genes, more than other properties of a person, constitute the nature of individuals themselves (genetic essentialism) and that genes determine people's destiny and are the primary cause of their behavior (genetic determinism) [40]. To date, attitudes towards behavioral genetic data have been studied primarily in the context of determinations of responsibility and punishment for criminal behavior, and the impact of such data has been less than many experts have anticipated or, in some cases, advocated [41].

A study of state trial court judges found that after hearing a description of a case of aggravated battery by a psychopathic defendant, those judges who were exposed to genetic and other biological data to support the diagnosis of psychopathy indicated that they would impose less severe sentences on the perpetrator. However, this difference, although significant, was small in absolute magnitude—one less year in prison, on average [42]. In a second study, which surveyed a representative sample of the U.S. adult population, evidence of a genetic predisposition to impulsive behavior did not lead to a significant change in the seriousness of the crime of which subjects would convict the defendant or the length of sentence imposed, although it did make respondents more fearful of the perpetrator [43]. Thus, to this point, the available evidence suggests a relatively limited impact of behavioral genetic data on views of responsibility for behavior.

Given the suggestions that abused children should be treated differently when they carry an MAO-L allele, we wanted to explore public views on this issue. In this paper we report the results of a survey of a nationally representative sample of the U.S. adult population. (The first part of the survey, which focused on public attitudes about the effects of behavioral genetic evidence on criminal responsibility and punishment, has been reported previously [43]). Here, in particular, we explore their views as to the appropriateness of genetic testing in the context of child abuse, and the proper inferences to be drawn from data regarding an abused child's MAOA activity, including whether the child should be returned to the care of a previously abusive parent and whether treatment should be made available. Additionally, these data may offer a perspective on how members of the public reason about genetic information more generally.

Methods

Participants

The participant panel was drawn by Knowledge Networks (KN), based on sampled households from its KnowledgePanel^®, a probability-based web panel designed to be representative of the population of the U.S. Members of the KnowledgePanel^® are recruited through a combination of list-assisted random digit dialing and address-based sampling techniques. Panel members are invited to take about one survey per week, with an average duration of 10 to 15 minutes per survey. KN has an incentive system to encourage participation, and to provide modest compensation for the time involved. Further details about the panel make-up, recruitment procedures, and incentives for participants have been reported previously ⁴³ and additional details can be found at: http://www.knowledgenetworks.com/knpanel/index.html.

The target population for this study consisted of non-institutionalized adults age 18 and over residing in the Northeast, Midwest, and West of the U.S., as defined by the U.S. Census. Emailed invitations were sent to 371 randomly selected KnowledgePanel^® participants, with the sampling adjusted as described above, over a one-month period in July and August 2011, with reminders to non-responders sent on day three of the field period. Four additional email reminders were sent to non-responders on days 12, 15, 22, and 27. Recipients of invitations were asked to click on a link that would take them to the questionnaire on the KN system; the questionnaire took an average of 12 minutes to complete. In addition to the usual KN incentives, participants were eligible to win an in-kind prize through a monthly KN sweepstakes.

Procedure and Design

KnowledgePanel^® participants who clicked on a hyperlink that took them to the online survey first saw a screen with a brief description of the study and were asked to indicate their voluntary consent to participate by advancing to the next screen. Procedures for the study were approved by the New York State Psychiatric Institute's Institutional Review Board (IRB).

After reading and responding to a series of questions about a vignette on criminal responsibility and punishment ⁴³, participants were asked to consider a different situation. The second vignette, data from which are reported here, described a 7 year-old boy, Ted, who was a victim of an episode of physical abuse by his mother. (See Appendix for the complete text of the vignette and associated questions.) Participants were asked to rate their agreement or disagreement on a 4-point Likert scale (strongly disagree-disagree-agree-strongly agree) with a series of statements regarding whether Ted should be removed from his mother's care and should be tested for a gene that, like MAOA, has a variant that can increase the risk that victims of child abuse will be violent as adults.

Participants were then told that Ted was tested for the gene in question. Half of the sample, selected at random, was informed that Ted was found to have the form of the gene that puts him at risk for impulsivity and violence (hereafter “high-risk allele”), and half were told that he did not have that form of the gene (hereafter “low-risk allele”). They were then asked to rate their agreement with statements that addressed potential implications of and responses to the genetic finding and Ted's disposition.

To determine whether participants attended to the key elements of the case, they were asked a question about the nature of the genetic test. Nineteen participants (7.6%) failed to answer this question correctly. Statistical analyses were performed with and without this group, but since results did not differ when this group was removed, data from the entire sample are reported here.

Statistical Analysis

Statistical analyses were based on data subject to a post-stratification adjustment. Prior to drawing a sample for a particular study, KN corrects known sources of deviation from an equal probability of selection (e.g., historical oversampling of particular geographic areas) by base weight sampling. A second adjustment is then made to correct for non-response and non-coverage bias in the overall panel membership, based on distribution of demographic variables in the most recent Current Population Survey (April 2011) conducted by the U.S. Bureau of Labor Statistics and Bureau of the Census. Once the sample is selected, the survey fielded, and all study data collected and finalized, a post-stratification process is used to adjust for any survey non-response as well as any non-coverage or under- and over-sampling resulting from the study-specific sample design. Variables included in this final adjustment are Gender, Age, Race/Hispanic Ethnicity, Education, Census Region, Metropolitan Area, and Internet Access.

To simplify the analysis, the 4-point Likert scale used to indicate responses to all items was collapsed into two categories (agree/strongly agree, disagree/strongly disagree). Non-responders for each question were removed from the analysis for that question. Weighted chi-squared tests were used for all analyses, using SPSS software. The study was powered to detect a medium correlation of r=0.5 in each of the 2 × 2 tables. With 244 subjects, we had 88% power to detect such a correlation at the 5% level of significance (PASS software).

Results

Two hundred fifty participants responded to the invitation to participate, yielding a response rate of 67%. Demographics of the respondents are presented in Table 1. The modal participant was white, married, middle-aged, middle-class, and living in a major metropolitan area. There was roughly equal male/female distribution, and a bit under a third of respondents indicated the presence of a child under 18 in their household.

Table 1. Demographics of Participants (n=250).

Male	49.2% (n=123)
Average age	48.9 years (SD = 1.1)
Race
White, non-Hispanic	75.2% (n=188)
Hispanic	10.4% (n=26)
Black	8.8% (n=22)
Other	5.6% (n=14)
Marital Status
Married or living with partner	64.0% (n=160)
Never married	19.6% (n=49)
Divorced or Widowed	16.4% (n=41)
Median Household Size	2
Has at least one child under 18	29.0% (n=73)
Median household income	$60,000 - $74,999
Residence (U.S. Census Bureau region)
Northeast	30.0% (n=75)
Midwest	36.0% (n=90)
West	34.0% (n=85)
Major metropolitan area	81.6% (n=204)

There were no statistically significant differences between the two groups with regard to age, race/ethnicity, gender, household size, and the presence or absence of children in the household. The randomized groups were significantly different on measures of education (χ²(n=228, df=3) = 11.271, p = 0.010) and marital status (χ²(n=229, df=5) = 15.752, p = 0.008). Regarding education, those in the group that was told that Ted had the high-risk allele were more likely to have completed high school or college, while those in the low-risk allele group were more likely to have had some high school or college experience without receiving a diploma or degree. With regard to marital status, those in the group that was told that Ted has the high-risk allele were more likely to be divorced, separated, or living with a partner, while those informed that Ted had the low-risk allele were more likely to be married, widowed, or never married.

Participants' Views on Removal from the Mother's Home and Genetic Testing

Just over one half (n=133, 54%) of the participants, on the basis of the initial description of the episode of abuse, agreed that Ted should be taken from his mother's house. Those respondents with children in the home were less likely to agree that Ted should be removed from his mother (χ²(n=230, df=1) = 7.100, p = 0.008). Table 2 shows the extent of participants' agreement that Ted should be tested to determine if he has the specific form of the gene that would increase his risk of manifesting violent behavior in adulthood. A substantial majority (71%, n=173) would have wanted Ted to receive the genetic test if the decision had been in their hands. This result was associated with the age of the participants, with older survey takers (i.e., 45 years old and older) more likely to want Ted tested (χ²(n=243, df=3) = 13.90, p = 0.003). Despite this preference, the majority chose to allow Ted's grandmother to make the decision, and did not think that the courts should order Ted to be tested over her objections. Respondents with children in the home were less likely to agree to have Ted tested over his grandmother's objections (χ²(n=223, df=1) = 6.200, p = 0.013).

Table 2. Participants' Opinions about Whether to Obtain Genetic Testing.

Item	Agree
If I were Ted's grandmother, I would want to have Ted tested for this gene (n=243)	71% (n=173)
If the grandmother won't consent, I think the court or state should require that Ted be tested (n=235)	34% (n=81)

Participants' Views on Use of Genetic Information and Disposition

Table 3 summarizes participants' responses after being told that the genetic test had been performed and what the results were. A majority of respondents (60%, n=144), regardless of what they had been told about the outcome of the test, wanted the court to consider the genetic evidence in determining whether to return Ted to his mother.

Table 3. Participants' Opinions about the Implications of the Results of Genetic Testing for Ted's Disposition.

Item	Ted has the high-risk allele Agree	Ted has the low-risk allele Agree
The courts should consider [the genetic test] result in determining whether it is in Ted's best interests to return to live with his mother	64% (n=79)	54% (n=65)	(χ2(n = 244, df=1) = 2.785, p = 0.095)
The court should compel Ted to undergo some form of psychological treatment or counseling	76% (n=93)	67% (n=82)	(χ2(n = 244, df=1) = 2.445, p = 0.118)
Ted should be given medications that have been proven to help with impulsive behavior	50% (n=60)	17% (n=21)	(χ2(n = 241, df=1) = 28.8, p < 0.001)
Ted represents a danger to other kids in any potential foster home	36% (n=44)	14% (n=16)	(χ2(n = 239, df=1) = 16.5, p < 0.001)
The court should now return Ted to live with his mother	83% (n=101)	90% (n=110)	(χ2(n = 244, df=1) = 2.838, p = 0.092)

Asked whether Ted should be compelled to undergo psychological treatment or counseling, a substantial majority of the participants (72%, n=175) agreed that he should, with responses not differing significantly by whether Ted was described as having the high-risk or low-risk allele (χ²(n = 244, df=1) = 2.445, p = 0.118). Responses to this item differed by participants' ages, with those between 30 and 44 less likely to agree to psychological counseling than those in all other age groups (i.e., 18-29, 45-59, and 60+) (χ²(n = 244, df=3) = 9.327, p = 0.025). In contrast, only a minority of respondents (34%, n=81) agreed that Ted should be given medications that have been proven to help with impulsive behavior, with those participants who were told that Ted has the high-risk allele three times as likely to agree with giving him medications (χ²(n = 241, df=1) = 28.8, p < 0.001).

With regard to perceptions of Ted's dangerousness, although overall only a minority thought that Ted represented a danger to other children (25%, n=60), those who were told that Ted has the high-risk allele were significantly more likely to believe that he was dangerous (χ²(n = 239, df=1) = 16.5, p < 0.001). Regardless of the results of the genetic testing, a substantial majority endorsed allowing Ted to return to live with his mother (86%, n=211) after she had undergone six months of rehabilitation. Responses to this item were associated with participants' age, with those under 30 less likely to agree with returning Ted (χ²(3, n = 244) = 22.0, p < 0.001).

Except where noted, responses to all items showed no association with age, gender, race/ethnicity, marital status, level of education, household size, or presence of children under 18 in the home.

There was no significant association between believing that the court should use the genetic test results in determining whether Ted should be returned to his mother and agreeing that Ted should be returned (χ²(n = 246, df=1) = 0.900, p = 0.34). However, those who believed that Ted would pose a danger to other children in a potential foster home were more likely to agree with giving Ted medications that have been proven to help with impulsive behavior (χ²(n = 223, df=1) = 53.489, p < 0.001). Lastly there was also a significant association between the two “treatment” variables: those respondents who thought Ted should be given medications were significantly more likely to want him to receive psychological treatment (χ²(n = 226, df=1) = 14.897, p < 0.001).

Discussion

In this nationally representative sample of the U.S. adult population, a substantial majority thought that an abused child (“Ted”) should be tested for a gene variant that would increase the risk of later aggressive behavior, and a smaller majority wanted the result to be considered in deciding whether he should be returned to his mother. This finding suggests a generally positive view among most of our respondents about the relevance of behavioral genetic data to decisions being made in the context of child abuse proceedings. Specifically, it indicates a degree of belief in the value of genetic information in predicting future behavior and—combined with greater endorsement of treatment with medication in the presence of the high-risk form of the gene—in pointing to preventive interventions that may reduce the risk of adverse outcomes.

Other aspects of our data, however, suggest somewhat greater caution among the participants in this study with regard to how genetic data should be used. Although a majority endorsed obtaining information on whether Ted was at heightened risk for certain adverse consequences of child abuse, there was no significant effect of the genetic test on the ultimate issue at hand: whether Ted should be reunited with his mother. Regardless of the genetic findings, an overwhelming proportion of respondents strongly favored returning Ted to his mother after she had undergone treatment for her abusive behavior.

To the extent that Ted's having the high-risk allele had an impact on the attitudes of our respondents, it made them more likely to regard Ted as a danger to other children. This is consistent with the finding in the first part of this study that genetic attributions of an adult defendant's violent behavior increased participants' apprehension more than did other explanations of the behavior [43]. To the extent that this apprehension is a result of a belief that Ted's genetic endowment constitutes something fundamental about his character, it may represent a form of genetic essentialism ⁴⁰. It is also consistent with fears of the stigmatizing effect of behavioral genetic information regarding criminal propensities [44].

Concern about Ted's risk of violence towards other children correlated strongly with the belief that he should be given medications to reduce that risk. In part, increased willingness to resort to medication may represent a general tendency to view genetics as medicalizing, i.e., shifting a problem into the medical sphere [45]. A similar finding was observed in the General Social Survey, a population-based survey of non-institutionalized adults in the U.S. When given descriptions of a person with schizophrenia, depression, or alcohol, those who believed that the person's condition had a neurobiological cause were much more likely to support treatment with medications [46]. On the other hand, half the participants in the group that was told Ted had the high-risk allele continued to oppose use of medication. Their reluctance may be consistent with other results of the General Social Survey, in which only a minority of the U.S. adult population endorsed the use of medications in non-suicidal children, even when those children were hostile [47]. It is also consistent with studies showing that psychotherapy is preferred to medication by the general public for the first-line treatment of psychiatric problems [48]. In children, the reluctance to resort to medication may be heightened by frequent media reports of inappropriate and excessive psychopharmacologic treatment [49]. In contrast, a large majority of respondents in both conditions wanted Ted to receive counseling, even though it would be compelled and despite no mention of whether such treatment was likely to be effective.

From a broad perspective, our results are consistent with other reports of the public's desire for their own and their children's genetic information regarding predispositions to behavioral and medical disorders, even in the absence of available interventions to mitigate risk [50,51,52]. This optimistic view of the value of behavioral genetic information may represent a more general pro-innovation bias among the American public, or simply a tendency to value genetic data highly [53]. However, the genetic information itself did not affect respondent's views of the proper disposition of the case, suggesting a less-than-complete embrace of the value of such data when applied to actual decisions—a disjunction noted in other studies of attitudes toward genetic testing as well [54].

In this respect, our respondents' views are in keeping with the majority of commentators, who urge caution in relying on behavioral genetic information in making highly consequential decisions. Among their concerns are the mismatch between legal categories and scientific data, and the risks of miscommunication or misinterpretation of complex biological information [55,56]. As Buckholtz and Meyer-Lindenberg (2014) have argued with regard to effects of the MAOA × child abuse interaction, “More work is needed to determine the formal sensitivity, specificity, and phenotypic selectively of the effect; its robustness to variability in the measurement of maltreatment; the impact of maltreatment exposure duration and timing; and effect of ethnic background…” They also note the conceptual difficulties in applying group data to individual cases. In addition, to our knowledge no data exist regarding whether removal of children from their families and placement in foster care reduces the already acquired risks based on this gene × environment interaction. The realities of the child welfare system, in which abused children are often at risk of further abuse [57], and a commitment to keeping families together whenever possible [58], may legitimately override genetic risk of undefined dimensions.

With regard to the limitations of this study, using a web-based survey allowed us to obtain a sample statistically representative of the adult population of the U.S., but with the restrictions characteristic of on-line surveys. These include an inability to ensure that the invited person was the one who completed the survey, or that the respondents took the time and care to respond appropriately. However, research on internet surveys indicates good internal consistency, high test-retest reliability, and results similar to those obtained by other means [59,60]. Another limitation of on-line surveys is non-response. Although, as mentioned previously, KnowledgeNetworks® used post-stratification weights to adjust for non-response as a technique for maintaining the representativeness of the data, there is always the possibility that non-response was affected by variables that were not controlled for and thus affected the results. In addition, since this study was based on a single vignette involving an abused child, we cannot rule out the possibility that changes in the wording, length or complexity of the vignette could have altered the findings. Further, the case, although realistic, does not represent the full range of circumstances encountered in the context of child abuse, alterations in which could change the findings as well.

These data provide some preliminary evidence about public perceptions of the utility and implications of behavioral genetic information, specifically in the setting of child abuse. Future research on larger samples is needed to confirm these data and to explore some of the variables that may have mediated the effects that we found. In addition, as the field of behavioral genetics advances, public responses to genetic predictors of future behavior will need to be studied in other contexts and situations. At present—despite suggestions by some commentators that behavioral genetic information should alter our approach to management of cases of abuse—these findings suggest that the desire for such information was accompanied by caution in relying on the data for dispositional decisions.

Appendix

Vignette given to participants

Now we'd like you to consider a different situation

Ted is a 7 year-old child who lives with his mother. While at school, Ted is noted by a teacher to have multiple bruises on his arms and legs. He is examined by the school nurse, who suspects child abuse and reports the case to the state's Child Protective Services (CPS) agency as mandated by state law. A doctor working for CPS conducts a more thorough physical exam of Ted, and the boy is also interviewed by a psychologist. Both specialists believe that Ted has been physically abused.

When his mother is questioned, she admits to having “hit him, but only one time.” The abuse happened over the one day when she was on a drinking binge following a break-up with her boyfriend. She insists that she has otherwise been sober for more than ten years. She describes hitting Ted with her open hand. She is very remorseful about this episode, and explains that she loves her son very much. She fully cooperates with the investigators.

The CPS investigation corroborates the mother's confession and her remorse. A court hearing is held to determine whether Ted should be placed for now in the custody of his grandmother. The court must determine whether it is in Ted's best interests to remain with his mother.

[All questions call for response on 4-point Likert scale: strongly disagree – disagree – agree – strongly agree.]

Q1: Please indicate your agreement or disagreement with the following statement: Ted should be removed from his mother's home for his own good.

At the hearing, Ted is removed from his mother's custody and placed with his grandmother. A staff member at Child Protective Services also begins counseling Ted's grandmother. His grandmother learns that children who are physically abused are far more likely to demonstrate impulsive behavior, including violence and other forms of criminal activity, when they are grown. She also learns that this risk is greater in children who carry a specific form of a gene that affects how chemical signals are sent in the brain. Studies show that up to 85% of children who are abused and have this particular gene display some form of aggressive, violent, or criminal behavior as adults. The grandmother is asked if she wants Ted to have a simple blood test to see if he carries this gene.

Please indicate your agreement or disagreement with the following statements:

Q2. If I were Ted's grandmother, I would want to have Ted tested for this gene

Q3. If the grandmother won't consent, I think the court or state should require that Ted be tested

[Randomization: respondents were randomized to receive one of the following two statements:

Condition 1: His grandmother agrees to have him tested. The test comes back: Ted does carry the form of the gene that puts him at risk for impulsivity and violence.

Condition 2: His grandmother agrees to have him tested. The test comes back: Ted does not carry the form of the gene that puts him at risk for impulsivity and violence.]

Taking into account the new information, please indicate your agreement or disagreement with the following statements:

Q4. The courts should consider this result in determining whether it is in Ted's best interests to return to live with his mother.

Q5. The court should compel Ted to undergo some form of psychological treatment or counseling.

Q6. Ted should be given medications that have been proven to help with impulsive behavior.

Q7. Ted represents a danger to other kids in any potential foster home.

As a condition for the return of her son, Ted's mother is required by the court to attend an alcohol rehabilitation program, an intensive parent-training course, and outpatient therapy. Six months later, after successfully completing these programs and remaining sober, she asks the court for Ted to be returned to her.

Q8. The court should now return Ted to live with his mother.