Integrative Literature Review

https://doi.org/10.1037/aca0000440

Creativity

Creativity researchers have most regularly described creativity as consisting of two qualities, namely originality/novelty and mean- ingfulness/usefulness (Amabile, 1996; Feist, 2017; Runco & Jaeger, 2012; Sternberg, 1988). A creative endeavor must not only be dif- ferent from what has been previously performed in a given domain but also useful. In this case, the term “usefulness” can also mean beautiful or provocative for artwork and literature. Some have argued that the term “usefulness” could be replaced by the word “meaningful” (Feist, 2017). With this change in terminology, the need to qualify “useful” as also beautiful or provocative is no longer necessary. Products of both art and science can be meaningful, whereas a piece of artwork would not necessarily be useful. Mean- ingful makes clear that the meaning is in the evaluator, and this can be the general public, experts, peers, or historians, among others. In the last 10 years, however, a few creativity researchers have

argued for three, rather than two, factor definitions of creativity. Simonton (2013, 2016), for example, has proposed a logical quan- titative model whereby a creative idea or solution is a multiplica- tive function its originality, utility, and surprisingness. More formally, and omitting the i subscript for each individual idea, cre- ativity c = (1 – probability p) utility u (1 – prior knowledge of util- ity v) and where p, u, v, and c each range from 0 to 1. The compelling aspect of this formulation is its multiplicative function, whereby any value of 0 for p, u, or v results in an idea that is not at all creative.

Psychopathology and Creativity

Research and theory on psychopathology and creativity are growing and contentious. A recent edited volume entitled Creativ- ity and Mental Illness captures the history, current state of the field, and the wide range of views on the topic (Kaufman, 2017). Although the ancient Greeks (Aristotle in particular) were the first people in the Western world to examine the nature of creativity and its association with “melancholia,” it was not until the Roman- tics in literature in the 1830s that the argument was made for any connection between serious mental affliction and creative genius (Becker, 2017). The modern literature on the topic was jumpstarted in the 1980s and

1990s with the work of Andreasen, Jamison, Richards, and Ludwig. In her early investigations, Andreasen (1978, 1987) reported qualified relationships between creativity, especially literary creativity, and men- tal illness, making use of historical, familial, and genetic studies. Jami- son (1996) reported historical, biographical, and literary evidence for the association between artistic creativity and mood disorders, most specifically bipolar disorder. Jamison et al., (1980) also examined the relationship between creativity and bipolar illness in noncreative peo- ple and found that the hypomanic period led to heightened creativity. Richards and colleagues (1988) also found that it was mild levels of mania (hypomania) and bipolar (cyclothymia) that were most strongly associated with creative thinking. Large-scale biographical examina- tions by Ludwig and Post in the 1990s reported associations between artistic creativity and lifetime rates of mental illness. Ludwig (1992, 1995) examined more than 1,000 eminent professionals, including, but not limited to, artists, writers, scientists, and musicians and revealed that extremely creative individuals, especially in the visual and literary arts, exhibited elevated rates of various lifetime psychopathologies.

Post (1994) also drew a similar conclusion from biographical analysis of more than 200 world-famous creative people. The sample in this study was restricted to deceased subjects of biographies reviewed by the New York Times. These biographies were then examined for signs of psychopathology in each eminent professional and correlated with each domain of expertise. The results showed that people who excelled at creative endeavors such as poetry and fiction writing experienced higher rates of psychopathology than scientists or politicians.

To be sure, partly owing to inconsistent empirical results, not all scholars agree there is a connection between high levels of creativ- ity and psychopathology (Sawyer, 2011; Schlesinger, 2009, 2017; Thys et al., 2014). The most outspoken and harshest critique comes from Schlesinger (2009, 2012, 2017). She essentially dis- misses the entire field and literature on creativity and “madness” as based on nothing more than poorly conducted and flawed research (e.g., biographies are dismissed as little more than “gos- sip”), even going so far as to call it a “hoax” (Schlesinger, 2012). She takes particular issue with three of the key figures in the field, Andreasen, Jamison, and Ludwig. Andreasen (1987) had too few participants, relied on personal relationships with participants, and overgeneralized results. Jamison’s (1996) “autopsy subjects” of 166 deceased artists, writers, and musicians is challenged. Schle- singer critiques three of the 166 subjects (Michelangelo, Emerson, and Cole Porter) and yet fails to provide a more general and struc- tured critique of the participant selection. Her methodological criticisms have some validity because no research is without limi- tations and flaws, but Schlesinger does her arguments a disservice when she makes many absolutist statements that no one really claims, such as the supposedly common belief that “no one receives the gift of genius without the curse of depression” (Schle- singer, 2017, p. 60) or that much of the research gets propagated without people reading the original articles.

Moderating Effects in the Relationship Between Creativity and Psychopathology

The apparent contradictory set of results gains clarity when we begin to look more closely at the reasons for the mixed, moderat- ing, and complex findings. One study, for example, reported that gender moderates the relationship between creativity and psycho- pathology, with positive results only holding for men (Martín-Bru- fau & Corbalán, 2016). More general findings highlight four common moderating effects in the relationship between creativity and psychopathology (Baas et al., 2016; Beaussart et al., 2017; Feist, 2012; Fisher, 2015; Glazer, 2009; Silvia & Kaufman, 2010; Simonton, 2017a, 2019):

• degree of creativity • domain of creativity (art v. science) • degree of psychopathology • domain of psychopathology

Degree of Creativity

Creative achievement exists on a wide spectrum, from minor to major contribution. For decades, researchers who study creativity have realized there is a need for distinguishing levels of creativity. To label someone creative is nearly meaningless if it does not dif- ferentiate historical genius global level creativity from minor, indi- vidual, everyday creativity. As Kaufman and Beghetto (2009)

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argued, there are at least four distinct levels of creativity that are more or less developmental. First, there is mini-c creativity, that is, personal level of creativity, where someone is creating ideas or behaviors that are novel and meaningful to him or her only. If that person goes on to produce novel products, ideas, or behaviors that involve solving everyday problems creatively, we would call that little-c creativity. This could involve activities such as making a new meal, creatively making use of materials around the house to build a play structure, or writing an essay for a class. Next, we move to people who make a living doing creative work, such as writers, musicians, scientists, architects, actors, and painters, but whose acclaim and impact are regional rather than national or international. This is Pro-C creativity, for “professional.” In other words, the circle of people who find it meaningful or useful is rela- tively narrow. It has not yet changed the course of the discipline or started a new branch of the discipline. Lastly, there is Big-C crea- tivity, or genius level or historically significant creativity. These are people who change the course of their fields, may have biogra- phies written about them, and often earn award and recognition from their peers for doing the best work in their field, and some- times are studied by historians. In short, these four levels of the creative spectrum move from smallest to largest social/cultural circle: self, family, region, and nation/world. As we discussed at the outset, there are different degrees of cre-

ativity, different kinds of creativity, and how one defines and measures it matters (Reiter-Palmon & Schoenbeck, 2020). One reason for conflicting results in the literature on creativity and psy- chopathology is the fact that degrees of creativity are conflated. The size of the effect seems to be directly related to the degree or level of creativity, with the effect being largest in Big-C creative samples and smallest in little-c creative people. Moreover, method of research is related to these two levels, with most little-c samples being studied psychometrically or experimentally and Big-C or Pro-C samples being studied historiometrically, biographically, or epidemologically (Johnson et al., 2012; Paek et al., 2016; Rich- ards, 1990; Silvia & Kimbrel, 2010; Taylor, 2017). For example, in a large Swedish national-population sample that included tens of thousands professional (Pro-C) creative artists and scientists, Kyaga and colleagues (2011) reported significant associations between creative professions and being treated for bipolar disorder or having a sibling or parent treated for schizophrenia. Moreover, in a study of an undergraduate (little-c creativity) sample, Silvia and Kimbrel (2010) found that anxiety and depression could only explain 3% of the variance in creative thinking. Finally, Johnson and colleagues (2012) conducted an extensive qualitative review of the literature on bipolar disorder and creativity and found stron- ger effects with Big-C than little-c creativity.

Domain of Creativity (Art Versus Science)

One of the main empirical findings from the literature on creativ- ity and psychopathology is the stronger effect size between artistic than scientific creativity and psychopathology (Damian & Simon- ton, 2015; Ludwig, 1995, 1998; Post, 1994). Trauma, stress, mood disorders, and fear of death each seem to motivate artistic creativity in a way they do not motivate scientific creativity or innovation in business. For instance, Ludwig’s later analyses (Ludwig, 1998) made clear that lifetime rates of psychopathology are mostly ele- vated in the arts compared with the sciences, and in the expressive

arts in particular (writing (fiction and nonfiction), poetry, and visual arts; see Figure 1). The performing artists (musicians and dancers) had moderately elevated rates of psychopathology, whereas the for- mal artists (architects) were not different from the general popula- tion. He argued and reported, therefore, that it is the more expressive, intuitive, and subjective creative professions where psy- chopathology and creativity should be and was most likely to be associated. The more formal, logical, precise, and objective profes- sions should be and were less likely to see psychopathology. In short, in the expressive arts, personal meaning, subjectivity, and emotion play a motivational role in ways not common in the more formal creative professions. Further analysis within the artistic forms revealed consistently higher rates of psychopathology in the emotive/expressionistic styles than in the formal/realism styles. To be sure, these are correlational findings, so whether those with men- tal and mood disorders are drawn to artistic careers or the other way around has yet to be established.

Other scholars have reported similar patterns whereby scientists suffer relatively low lifetime rates of psychopathology, whereas the other professions, especially the arts, had elevated rates of mental illness compared with base-rates in the general population (Damian & Simonton, 2015; Post, 1994; Simonton, 2014). A bio- graphical replication of the mental health status of 40 jazz musi- cians from the 1940s and 1950s replicated Ludwig’s basic finding (Wills, 2003). Wills found elevated rates on chemical dependency, mood disorders, and anxiety disorders in jazz musicians. Heroin addiction was also elevated in Will’s jazz sample, with 52% sam- ple having heroin problems at some point during their lives.

The one exception to this general finding with scientists may be autism-spectrum disorder (ASD), predominantly in the high-func- tioning range (Baron-Cohen et al., 2007; Billington et al., 2007; Focquaert et al., 2007; Thomson et al., 2015; Wei et al., 2017). We should point out, however, that most of this research on ASD and science and technology is with interest and careers in STEM (sci- ence, technology, engineering, and math) and not necessarily highly creative scientists and technologists. We are interested in examining whether this relationship holds at high levels of scientific achieve- ment and creativity.

Although Ludwig (1992) argued that psychopathology explained very little variance in terms of scientific achievement, there are cer- tain circumstances where psychopathology may exist in scientific creativity. A good demonstration of this is the analysis by Ko and Kim (2008) of 76 scientific geniuses from Simonton’s sample. Ko and Kim predicted and found that the relationship between scien- tific creativity and psychopathology would be moderated by the kind of contribution the scientist made, namely whether it preserved or rejected paradigms. Specifically, scientists without pathology were more creative when they made paradigm-preserving than par- adigm-rejecting contributions. Paradigm-preserving is a contribu- tion that advances but does to change a field’s direction. Paradigm- rejecting contributions do in fact change a field’s direction. Those with psychopathology, especially psychotic disorders, were more creative (based on biographical/encyclopedia index ratings) when they made paradigm-rejecting rather than paradigm-preserving contributions. In addition, this moderator analysis more than doubled the variance explained (18% vs 8%) by psychopathol- ogy in scientific creativity compared with Ludwig’s (1992) sam- ple. An implication of these results is that psychopathology may

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be detrimental to their creative contribution only to scientists who make paradigm preserving contributions. Taylor (2017) discussed important ways how art and science

may be different: art requires less formal education and has more flexible work schedules (Simonton, 2010; Simonton & Song, 2009) and hence does not exclude people with mood disorder; poets, writers, and so forth more likely to experience trauma, men- tal health problems in childhood; Ludwig (1998) suggests “occu- pational drift” owing to emotional expressiveness required for different professions. In addition, we argue for internal versus external experiences and meaning and understanding. That is, art —especially the expressive arts of literature and visual arts—is of- ten based in internal emotional/traumatic/stressful personal experi- ences that lead to a need/motive to understand, give meaning to, or to express these experiences in artistic form, whether it be music, dance, poetry, visual art, or fiction writing (Akinola & Mendes, 2008; Gardner, 1973; Forgeard et al., 2017; Thomson, 2017). It may not always be traumatic experiences, but at the least involves a need or desire to express one’s perceptions of the world and their place in it (Forgeard et al., 2017). Science, on the other hand, is of- ten driven by a need to understand and figure out the external world, especially in the physical sciences. Scientists most often ask: “What is that? Why? How can we explain that?” That is a

search for meaning and understanding, to make sense of one’s external rather than world.

Degree of Psychopathology

It has become clear with the accumulation of research that high levels of mental illness are generally at odds with high levels of creativity in any field, including art. Even when creativity and ill- ness go together in certain people, it is mostly during periods of relative calm and milder dysfunction that creative behavior may coexist with pathology. In short, there is a nonlinear relationship between illness and creativity, with mild to moderate levels of pa- thology being most associated with creative achievement (Abra- ham, 2017; Acar et al., 2018; Feist, 2012; Kinney & Richards, 2017; Simonton, 2017a; Swain & Swain, 2017; Wuthrich & Bates, 2001). Jamison’s well-known book Touched With Fire (Jamison, 1996), for instance, presented historical evidence for an associa- tion between bipolar disorder and creativity, especially in literature (i.e., Big-C creative people). However, she also made clear that it was those with milder forms (cyclothymia) that were most crea- tive. Other researchers have come to the same conclusion, namely that the relationship between creativity and bipolar disorder, schiz- ophrenia, and schizotypy is mostly curvilinear (Acar et al., 2018; Cox & Leon, 1999; Gostoli et al., 2017; LeBoutillier et al., 2014;

Figure 1 Categories of the Arts and Sciences and Prevalence of Mental Illness

Note. Dark Gray: . 70%. Light Gray: . 60% , 70% White: , 60%. Adapted from Ludwig, 1998. See the online article for the color version of this figure.

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Ruiter & Johnson, 2015). For instance, Kinney and Richards (2017) reported support for the nonlinear inverted-U hypothesis in which creative thought and behavior were maximum at mild levels of bipolar disorder (cyclothymia) and were relatively low at the low and high ends of the disorder. Moreover, it was first degree relatives of those suffering from bipolar who tended to exhibit highest levels of creativity. After reviewing literature on affective traits and creativity, Feist

proposed a quadratic model of mental health and creativity, that makes clear the complex relationship (cf. Feist, 2012; see Figure 2). The peaks of creativity tend to be with little and moderate levels of psychopathology, with valleys of creativity coming when psycho- pathology is low-medium and again high (cf. Feist, 2012).

Domain of Psychopathology

Not only degree but also domain of pathology matters. In gen- eral, it is clear from research that particular forms of psychopathol- ogy are more associated with high levels of creative achievement than other forms. The milder forms of mood disorders, including depression and bipolar disorder as well as milder forms of psy- chotic disorders (schizotypy), appear to be among the more robust correlates of creative achievement.

Mood Disorders

Of all psychological disorders, perhaps none is more often empiri- cally connected to creativity than mood disorders, especially bipolar depression (and its less severe offshoot, cyclothymia). The general finding is there is an elevated rate of bipolar disorder exists among creative people compared with general population (Andreasen, 1987; Andreasen & Glick, 1988; Fodor & Laird, 2004; Furnham, Batey, Anand, & Manfield, 2008; Gostoli et al., 2017; Jamison, 1996; Jami- son et al., 1980; Johnson et al., 2012; Johnson, Murray, et al., 2015; Johnson, Tharp, et al., 2015; Nowakowska et al., 2005; Ramey & Weisberg, 2004; Richards, 1994; Taylor, 2017). Taylor’s (2017)

meta-analysis of studies published between 1987 and 2014 that examined mood disorders (bipolar, cyclothymia, major depression) in creative samples reported a Hedges g = .64 (95% CI [.45, .82]), meaning creative people are nearly two thirds of a standard deviation higher in mood disorder than noncreative people. When examining simple correlational studies on creativity scales and mood disorder in students and adults, however, Taylor (2017) reported a very small effect (g = .09; 95% CI [.01, .17]). In short, the effect size was mod- erated by level of creativity. Flaherty (2005) reviewed a large range of neuroscientific evidence suggesting that frontal-temporal-limbic brain activity as well as dopaminergic activation are implicated in the relationship between creative drive and mood disorders. More specif- ically, Flaherty proposed a two-dimensional model with frontal-tem- poral activity being on the x axis and dopaminergic activity being on the y axis. As abnormal temporal lobe activity and dopaminergic ac- tivity both increase, mania, psychosis, and creative drive increase. As abnormal frontal activity increases and dopaminergic activity decreases, creative blocks become more likely.

The relationship holds in the other direction too. Other studies have reported higher rates of creativity among bipolar patients (Richards, 1994; Richards et al., 1988; Santosa et al., 2007; Simeo- nova et al., 2005). For example, when compared with healthy con- trols, patients with bipolar disorder scored higher on the Barron- Welsh Art Scale (BWAS) measure of creativity (Santosa et al., 2007; Simeonova et al., 2005). Of note, however, is Taylor’s (2017) finding that people with mood disorder are not necessarily more creative than those without mood disorder (g = .08; 95% CI [�.00, .16]). Kaufmann and Kaufmann (2017) reviewed research on the complex association between mood, mood disorders, and creative thought and behavior. Both positive and negative affect and mood can be associated with creativity.

An important qualification to the bipolar-creativity connection is that it seems to be more mania than depression that is associated with creative thought and behavior (Andreasen & Glick, 1988; Jamison, 1996; Jamison et al., 1980). Given the quickness and

Figure 2 Nonlinear Model of Degree of Creativity and Psychopathology

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fluency of ideas that occur during mania, its relationship with crea- tivity is understandable (Jamison, 1996; Richards, 1994). Moreover, numerous studies support the idea that milder hypomanic states are most clearly correlated to creative thinking and achievement (Furn- ham et al., 2008; Ruiter & Johnson, 2015; Schuldberg, 1990). The relationship between unipolar depression and creativity is

less robust than bipolar. Paek and colleagues (2016) conducted a meta-analysis that included 27 studies that reported results on depression and creativity. These 27 studies consisted of 103 effect sizes on over 14,000 participants. The mean effect size was essen- tially zero (r = .04; 95% CI [�.08, .16]). Silvia and Kimbrel (2010) reported the same very small effects between depression and various forms of creativity in a college student sample. Some research that broke nonclinical depression down into components of rumination, self-reflective pondering, and brooding found that rumination and self-reflective pondering but not brooding were associated with creativity (Verhaeghen et al., 2005, 2014). Note, however, that all of these studies were conducted with students and were little-c creative samples. Similar small effects between trait anxiety and creativity have

been reported (Silvia & Kimbrel, 2010). For example, Paek and col- leagues (2016) also included in their meta-analysis research 32 studies that reported results on anxiety and creativity. These 32 studies consisted of 60 effect sizes on more than 15,000 partici- pants. As was true with depression, the mean effect size between anxiety and creativity was not significantly different from zero (r = �.05; 95% CI [�.16, .06]). Psychotic Disorders

The psychotic disorders—schizophrenia, schizotypy, schizoaf- fective disorder, among others—also have a complex and not easy to summarize relationship with creativity. With anecdotal excep- tions such as John Nash, full blown schizophrenia is seldom linked to creativity (cf. Nasar, 2011; Rothenberg, 1990). Kyaga and col- leagues (2011) reported that people who had first degree relatives suffering from schizophrenia and bipolar disorder were overrepre- sented in creative professions. Moreover, Eysenck (1993, 1995) proposed and found some support for the idea that the nonclinical personality trait and psychoticism is associated with creative thought and behavior. Psychoticism is a nonpathological rather than clinical personality trait consisting of consistent social isola- tion, aloofness, hostility, and unusual thoughts and behaviors. Feist (1998) found support for this idea in a meta-analysis on the personality correlates of creativity. As numerous scholars have pointed out, however, psychoticism

is too broad and diverse a construct to consistently be related to cre- ative thought and behavior (Batey & Furnham, 2008; Carson et al., 2003; Mason et al., 1995; Nettle, 2006). They argue that psychoti- cism’s specific and somewhat more clinical cousin, schizotypy, is more robustly related to creativity. Schizotypy is a personality dis- order in which subclinical symptoms of psychosis are exhibited, such as unusual experiences, magical thought, eccentric behavior, and cognitive disorganization (Claridge et al., 1996). In little-c crea- tive and Big-C creative samples, schizotypy is associated with crea- tive thought (Acar & Runco, 2012; Acar & Sen, 2013; Baas et al., 2016; Batey & Furnham, 2008; Burch et al., 2006; LeBoutillier et al., 2014; Nettle, 2006; Schuldberg, 1990). Baas and colleagues (2016), for instance, argued for a moderation effect by type of

pathology in the association between creativity and mental illness. More specifically, they proposed and found meta-analytic evidence that approach-based pathologies (positive schizotypy and risk of bipolar) were more strongly and positively associated with high lev- els of creativity. Positive schizotypy consists of unusual experiences and impulsive nonconformity, whereas negative schizotypy consists of cognitive disorganization and withdrawn schizoid traits. In addi- tion, avoidance-based pathologies (e.g., anxiety, negative schizo- typy, and depressive mood) were associated with lower levels of creativity. Similarly, Acar and Sen (2013) in a meta-analysis found small negative effect sizes between creativity and negative schizo- typy (r = �.09; 95% CI [�.12, �.06]; k = 76) and a small positive association with positive schizotypy and creativity (r = .14; 95% CI [.12, .17]; k = 121).

The Current Study

The primary purpose of the current study is to update and attempt to replicate the results of Ludwig (1992, 1995, 1998) and to test a more complex model of creativity and psychopathology. Not only is the Ludwig sample itself over 25 years old, but the subjects examined were required to be deceased, further distancing them from their contemporaries. Therefore, an update and exten- sion of the study is now in order. Additionally, the professional categories proposed in Ludwig (1992, 1995, 1998) required reworking in the current study. For instance, several of the profes- sions listed under social sciences, such as historian and philoso- pher, are not actually sciences at all and are frequently grouped with humanities. The current study also improves on the previous methodology, which was vulnerable to researcher bias owing to the investigator’s awareness of the hypotheses (Ludwig, 1992). Another goal of the current study is to see whether Ludwig’s find- ings from 20 years ago and with a different sample still hold and replicate in a more current sample. More importantly, Ludwig did not compare eminent famous creative people against eminent fa- mous noncreative people, and simply analyzed his data with chi- squares for inequalities between groups. We decided, therefore, to hold fame constant in our comparison group of famous athletes (with published biographies) to determine whether fame more than creativity could explain the presence or absence of mental illness in our sample. In short, by having a control group that was eminent and famous (i.e., biography-worthy) and yet not creative, we could rule out pure fame and eminence as a confounding explanation in any relationship between creativity and psychopathology.

Hypotheses

1. World-class creative artists will have elevated rates of any lifetime mental illness relative to creative scientists and famous athletes (controls).

2. The mental health difference between artists and scientists will be most pronounced on mood/affective disorders (anxiety, depression, bipolar) and chemical dependency, with artists expected to have higher rates than scientists.

3. Creative scientists should show elevated rates of being on the high functioning end of the autism spectrum relative to athlete controls.

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Method

Subjects and Materials

The list of potential creative and eminent scientists, artists, and athletes for inclusion in the study came from rankings in diction- aries, encyclopedias, and best-of lists. The original list, after merg- ing 163 source lists and removing duplicates, contained 17,689 distinct names. Each “best-of” source list was ranked by a member of the research team (D.D.) on a 3-point scale for trustworthiness, with a 1 being of questionable validity, 2 being more subjective, and a 3 being very trustworthy. The primary criterion for a code of 3 was whether the list was created by experts in the field and/or was of international award such as the Nobel Prize. A code of 2 was awarded if the list were created by professionals in the field (e.g., a poll among more than a hundred contemporary leading physicists conducted by Physics World magazine, Dunani & Rodgers, 1999), whereas a code of 1 was awarded for lists made by amateurs or based on unclear methodology. One such example of an unclear methodology is the “Greatest Mathematicians of All Time” list published on server thetoptens.com.1

Next, an index of eminence was calculated for each potential subject within each domain as a sum of trustworthiness scores of all lists in the domain containing the subject’s name. To prevent overlap with Ludwig’s (1992) sample, subjects must have either died after 1950 or been born before 1980, if they were still alive. The 45 most eminent professionals in each domain were selected as potential subjects in the sample. Individuals who tied for the 45th most eminent position were included in the sample. This pro- cedure led to a total of 766 potential subjects. Professionals in multiple domains were sorted in the category in which they ranked in a higher position. After the list of potential subjects was obtained, the next step

was to determine whether or not a viable and relevant biography was written about that person. When available, e-versions (Kindle) of biographies were purchased. If no e-version was available, hard copies were purchased, had their bindings removed, and were digi- tally scanned via optical character recognition (OCR) conversion. To be selected for study, biographies had to be written for an adult audience and include information on the creator’s personal life and were not solely intellectual or work biographies. Moreover, autobiographies, biographies written by close relatives, biographi- cal chapters, letters, and memoires were excluded. Of the 766 potential subjects, 391 did not have appropriate biographies writ- ten about them, leaving a potential sample of 375. If there were more than one biography written about a person, we chose the one that had the most life-history information. Owing to time and resource constraints, 199 of the 375 biographies were purchased for coding (18% female).2 Analyses revealed that the 199 biogra- phies were representative of the larger 375 sample on proportion of artists, scientists, and athletes as well as proportion of deceased subjects. The proportion of women however increased from 13% to 17.5% in the final sample of 199, v2(1) = 9.45, p = .002. Never- theless, the proportion of women in each subgroup did not change, v2(2) = 1.34, p = .510. In the final sample, there was a higher per- centage of women in the arts than sciences or sports, 28%, 7% and 4% respectively, v2(2) = 16.11, p , .01. The overall sample was 83% White-Caucasian, 13% Black/African American, 2% Latinx,

and 1.5% Asian-Pacific Islander. In 2016 when the data were col- lected, the U.S. demographics were 60% White-Caucasian, 18.5% Latinx, 13% Black/African American, 6% Asian American (U.S. Census Bureau, 2019).

Each subject was placed into either a scientific, artistic, or ath- letic domain. Scientific domains were defined as technology/ invention, mathematics, physics, chemistry, biology/medicine, psychology, and social sciences (anthropology and sociology). Earth scientists (e.g., geologists, oceanographers, climatologists) were excluded because of a lack of biographies. Artistic domains were defined as visual arts, fiction writing, poetry, acting, musical performance, and musical composition. Using these career group- ings, the current sample consisted of 104 artists, 68 scientists, and 27 athletes (see Table 1). The entire sample had a median year of birth of 1919 with an average birth year of 1921. The range of birth years was 1873 to 1979. Of the 199 subjects in the final list, 46 (23%) were alive at end of data collection in 2016. For the 153 participants who had died, the average age of death was 72 (me- dian = 75; mode = 81; range 25 to 98). For the 46 participants who were alive, the average age was 71.70 (median = 73; mode = 75; range 41 to 89). Ninety-three percent of the sample was married at least once (mean age of first marriage = 27.13). There was no ca- reer domain difference in mean age of first marriage. Artists (59%) were more likely to have divorced than scientists (38%).

Procedure

Biography Selection and Preparation

After the subject-pool was narrowed down to subjects who had usable biographies written about them, we purchased each biogra- phy either in digital or bound format. If the book was in bound for- mat, we then detached its binding and scanned the entire body of the text (excluding front- and rear-matter) into readable ORC/digital format. Next, we cleaned the digital books by removing all images, headings, footers, foot notes and most tables and equations.

Pathology Selection

Before ratings of pathologies could be made, the research team discussed and decided which specific diagnostic illnesses would be coded. For this process we mostly followed Ludwig by obtain- ing the original variable list. Ludwig’s team coded mental health status of immediate family members as well as the creative person. We coded only the creative person. Moreover, we also added a few illness categories that we believed Ludwig missed and might be relevant as exploratory analyses, such as Asperger’s syndrome (high functioning autism) and synesthesia. The final list consisted of 19 diagnostic illnesses listed in the Diagnostic and Statistical Manual of Mental Disorders, 5th edition (DSM–5; American Psy- chiatric Association, 2013; see Table 2).

Paragraph Selection

After each of the 199 biographies was scanned and cleaned, a linguistic analysis program was created by the second author to

1 For complete Best of Lists, Awards, and Rankings, see https://doi.org/

10.17605/OSF.IO/TFYDK. 2 Raw data are posted on Open Science Framework at https://doi.org/10

.17605/OSF.IO/TFYDK.

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automatically locate and highlight any of the 175 relevant key- words related to 19 mental illness categories (see Appendix A in the online supplemental materials). The initial list was based on words used by Ludwig (1995) but was expanded through a discus- sion between the investigators after a review of the DSM–5 and Stein and colleagues (2010). From either the biographical or pub- lic websites we obtained the following demographic variables: profession/career, date of birth, date of death (if deceased), year of mother’s death, year of father’s death, birth order, race/ethnicity, gender, year of marriage (first), year of marriage (second), country of birth. Two trained graduate students further narrowed the biographical

texts to include only paragraphs relevant for assessment of mental health of subject in question. For example, “depression” may have been tagged by the program, but if it referred to the economic period of the 1930s then that paragraph would be excluded from further rat- ing. Similarly, if key terms were tagged but referred to someone other than the target creator, those paragraphs were also de-selected for further rating.

Pathology Ratings

In the fifth and final step, seven raters were selected and trained to identify possible psychopathologies in each biography excerpt. Raters could only begin once they met the .80 interrater reliability with training data from Ludwig’s (1992, 1995). Poten- tial raters were given paragraphs selected from a biography then asked to code the given reading material for the psychopatholo- gies described above. Ratings were compared against the origi- nal coding data from Ludwig’s study. Interrater reliability was measured using Gwet’s agreement coefficient AC1 (Gwet, 2008), which was preferred over Cohen's kappa coefficient as it pro- vides unbiased estimate even in case of strongly uneven occur- rences of categories (Gwet, 2002; Wongpakaran, Wongpakaran, Wedding, & Gwet, 2013). To keep raters blind and free of any previous bias, the name of the subject in question was replaced with the word “Creator” in all biography excerpts. Subjects were coded for lifetime prevalence of any of 19 psychopathologies.

Psychopathologies were rated on a 3-point scale of not present (0), probable (1), and present (2) if they occurred at any point in the creator’s lifetime. Rating present was used in cases where DSM–5 criteria were clearly met or where the subject was diag- nosed professionally during their lifetime. If not enough infor- mation was given in the biography to provide a clear diagnosis from DSM–5 criteria and yet there was some evidence that a dis- order was suspected, then raters gave that a probable rating. In short, a probable rating was provided whenever there was some but not overwhelming evidence of a disorder. Present was pro- vided when a professional diagnosis was made during the per- son’s lifetime or when the biographical evidence was very clear. During training on the Ludwig sample, if raters initially fell below the .80 reliability criterion, research meetings were held with other raters and the lead researcher (G.J.F.) to discuss dis- crepancies and to reach consensus. For final nontraining ratings, two independent and randomly assigned raters coded each biog- raphy. Any disagreement was adjudicated by a third rater (G.J. F.) to establish the final rating.

Results

Previous and Current Lifetime Rates of Disorders

For sake of comparison, in Table 3 we present the population estimates of lifetime rates of psychological disorders published in the literature. Two studies have reported large-scale national popu- lation estimates of lifetime rates of any disorder. Kessler, Berglund, and colleagues (2005) reported a rate of 46.4% and Lev-Ran and colleagues (2013) reported a rate of 33.7% for any mood, anxiety, personality or psychotic disorder. In this context, the lifetime rate in our sample for creative artists and scientists was 49.7% (85 of 171) and for athletes was 48.1% (13 of 27), v2(2) = 2.39, ns. For artists only, the percentage of “present” cases was 61/103 (59.2%), and for scientists it was 24/68 (35.3%). Over the course of their lifetime, artists were more likely to have at least one form of psychopathol- ogy than scientists, v22(1) = 9.38, p = .002. Artists were not more likely to have a lifetime bout of psychopathology compared with athletes (59% versus 48%, respectively) , v2(1) = 1.07, ns.

When the less exclusive “probable” cases were also included, the frequency of psychopathology increased to 126 of 171 (73.7%) in the creative groups compared with 16 of 27 (59.3%) athletes, v2(1) = 2.39, ns. The observed frequencies on “probable” lifetime psychopa- thology for artists (83%), scientists (59%), and athletes (59%) were

Table 1 Specific Domains and group Sizes

Domain % White N of Men N of Women Total N

Artists 75 29 104 Visual arts 100.0 8 1 9 Fiction writing 85.7 26 9 35 Poetry writing 90.9 9 4 11 Acting 95.0 11 9 20 Music performance 46.2 18 8 26 Music composition 100.0 3 0 3

STEM 63 5 68 Technology/Invention 100.0 9 1 10 Mathematics 100.0 7 0 7 Physics 100.0 19 0 19 Biology/Medicine 100.0 6 1 7 Chemistry 100.0 4 1 5 Psychology 100.0 11 0 11 Social Sciences 100.0 7 2 9

Comparison group 26 1 27 Athletes 55.6 26 1 27

Total 164 35 199

Table 2 List of Rated Psychopathologies

Rated psychopathologies

Adjustment disorder Obsessive-compulsive disorder Alcoholism Paraphilia Anxiety disorder Personality disorder (of any kind) Autism spectrum disorder Posttraumatic stress disorder Conduct disorder Schizophrenia/Psychotic disorders Depression/Depressive disorder Sleep disorders Drug use/dependency Somatic disorder Eating disorder Suicide/Suicide attempt Gambling disorder Synesthesia Kleptomania

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different from chance, v2(2) = 14.68, p = .001. This effects stems from artists having a higher lifetime rate than both scientists, v2(1) = 12.86, p , .001, and athletes, v2(1) = 7.45, p = .006. Even though the overall frequency of any psychopathology was

extraordinarily high, relative frequencies of individual disorders rarely exceeded a few percent. Occurrences higher than 5% were only observed in depression/depressive disorders (26%), alcoholism (16%), drug use/dependency (12%), and anxiety disorder (11%). These compare with the rates of 28.8% for anxiety, 20.8% for mood, and 14.6% for substance abuse in the general population (Kessler et al., 2007; Kessler, Berglund, et al., 2005). For a more sophisticated analyses of these trends, for each listed

psychopathology, a null hypothesis about the uniform distribution of its occurrences in compared groups was tested. In each comparison, a chi-squared test with a Monte Carlo simulated p value was used because it has no assumptions about minimal expected frequencies (estimates were done with 106 replicates; Hope, 1968). We have included both present and probable occurrences of psychopathology without differentiating between them into analysis. Observed frequen- cies for each category and resulting p values are detailed in Table 4. The results suggest that there are unequal frequencies between the do- main of eminent individual and the occurrence of Alcoholism, Drug use/dependency, Gambling disorder, Suicide/suicide attempt and also Depression/depressive disorders, Anxiety disorder, Sleep disorder and Autism spectrum disorder. Note that there were 21 significance tests performed, which results in substantial increase in familywise first type error rate. To keep familywise error rate under 5% Bonferroni corrected p-values can be used. This correction suggests that the fre- quencies in Autism spectrum disorder (pBonf. = .271), Suicide/suicide attempt (pBonf. = . 282), and Gambling disorder (pBonf. = .169) are not different from expected, so we should not consider those results as

conclusive. Finally, 52% of the artists and 24% scientists experienced the loss of a parent in childhood, v2(1) = 15.04, p , .001.

Planned Analyses

Recall, the three main predictions were that compared with athletes and scientists, artists as a whole would have elevated lifetime rates of psychopathology, especially in the mood disorders and substance abuse categories. We also predicted that scientists would have ele- vated rates of high functioning autism compared with athlete controls.

To test these hypotheses, a Bayesian logistic regression3 was used to model the relationship between mental disorder presence and creativity domain. The dependent variable was an occurrence of particular mental disorder. We have used two separate models with differently defined dependent variables for each disorder. In the first one, the present cases only were coded as 1. In the second one, both present and probable cases were coded as 1. The values of the dependent variable were predicted with categorical factor

Table 3 Published Population Estimates of Lifetime Rates of Psychological Disorders

Author(s), Date Disorder Percent of population

Baca-Garcia et al. (2010) Suicide attempted: Male 1.75% Suicide attempted: Female 2.95% Suicide ideation: Male 6.00% Suicide ideation: Female 7.60%

Hudson et al. (2007) Eating disorder: Male 2.80% Eating disorder: Female 5.90%

Lev-Ran et al. (2013) Any mood, anxiety, psychotic, personality disorder 33.7% Kessler, Berglaund, et al. (2005) Anxiety disorder 28.80%

Mood disorder 20.80% Impulse-control disorder 24.80% Substance abuse 14.60% Any disorder 46.40%

Merikangas et al. (2007) Bipolar I 1.00% Bipolar II 1.10% Subthreshold bipolar 2.40%

Nock and Kessler (2006) Suicide (ideation/attempt) 2.70% Perälä et al. (2007) Psychotic disorder (any kind) 2.29% Robins et al. (1984) Any disorder 28.8% to 38.0%

Anxiety disorder 10.4% to 25.1% Substance abuse disorder 15.0% to 18.1% Affect-mood disorder 6.1% to 9.5% Psychotic disorder 1.1% to 2.0% Personality disorder 2.1% to 3.3% Eating disorder 0.0% to 0.1%

Note. Robins et al. (1984), consisted of three samples from New Haven, CT, Baltimore, MD, and St. Louis, MO, and interviews were conducted between 1980 and 1982. Bolded text highlights the overall “any disorder” category.

3 Computations were performed in statistical program R with the

rstanarm package (Stan Development Team, 2016). The student t- distribution with 7 degrees of freedom and a scale parameter 2.5 was chosen as a prior for all regression weights. The student distribution was preferred from the normal distribution because its heavy-tailedness enables substantial differences from expected value. The location was set to zero in all parameters with the exception of the intercepts in which case logits of population prevalences according to Kessler, Berglund, and colleagues (2005) and Nock and Kessler (2006) were used. The parameter estimations were computed with NUTS sampling method (Hoffman & Gelman, 2014) on 8 MCMC chains each performing 6,000 iterations (2,000 in burning phase). The e-values in favor of null hypothesis stating that odds ratio equals one were computed using fbst package (Kelter, 2020). Above mentioned priors were used as the reference functions. For details see Pereira and Stern (2020).

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domain with seven levels listed in Table 1. Dummy variable cod- ing was used with the group of athletes used as a reference group. Besides the categorical independent variable, the gender and two quantitative covariates were included in the model to hold them constant: year of birth of each subject and the length of their life. If any biography was published during the life of the subject, the age of the subject in the year of publication was used instead of age of their death, as the biography author did not have informa- tion about the subjects’ lives from that point. Both quantitative covariates were centered and scaled to the z-score format. The hypotheses about model parameters were tested with Full

Bayesian Significance test (FBST; Pereira & Stern, 1999). This pro- cedure uses e value (evidence value) as a measure of statistical signif- icance (Pereira & Stern, 2020). In its simplest form, e-value in favor of the null hypothesis stating parameter equals zero is close to the idea proposed by Thulin (2014): what is the maximal value of a resulting in 1 � a posterior credible interval not containing zero. Keeping in mind this analogy between p values/confidence intervals and e values/credible intervals, we also used value .05 for rejection of the null hypothesis. Figure 3 shows the prevalence interval estimates (95% highest

density regions) of the selected present or probable psychopatholo- gies. Each creative domain was also compared with the control group of athletes. The odds ratios of psychopathology occurrence in each group compared with the control are represented in the figures as text labels. The asterisk notation indicates e values lower than .05, .01, and .001, respectively. Dot indicates nonsignificant result with e value lower than .1. Figure 3 reports that artists were more than 2.71 times more likely to experience any mental illness over the course of their life compared with eminent athletes, whereas

scientists had approximately the same odds as athletes. Artists were most at risk for depression/bipolar (ORs = 6.28 and 9.19 for present and present/probable, respectively) compared with controls. The only disorder for which scientists were at elevated risk was the more inclusive present/probable rate for depression/bipolar (OR = 4.53). For all other disorders, scientists were either equally likely or less likely to experience them compared with athlete controls. For exam- ple, creative scientists were significantly less likely (ORs = .21 – .23) to be afflicted with substance related and addictive disorders than athletes.

In Figure 4 we present results broken down by subgroups. As is evident in Figure 4, the elevated risk of mental illness in the artist group primarily is a result of writers and visual artists. Looking at only “present” rates of specific disorders, writers and visual artists were 4.52 times more likely than athletes to suffer from any pres- ent mental illness over the course of their lifetime. In fact, no other subgroup was more or less at risk compared with athlete controls. In addition, it was primarily the writers and visual artists who were at increased risk of depression/bipolar (OR = 8.11), anxiety (OR = 7.53), and suicide/attempt (OR = 15.79).

When we expand the analysis to include “probable” or “pres- ent” rates, results were much the same except for depression and substance abuse. Musicians, actors, writers, visual artists, poets, mathematicians, and technologists were all more likely to be sus- pected of having depression and/or bipolar compared with fa- mous athletes (ORs = 3.82 – 10.86). Visual artists, writers and poets were more likely to suffer anxiety disorder (OR = 3.58) and be suicidal or attempt suicide (OR = 6.18) than athletes. Moreover, physicists and chemists were less likely than athletes to suffer substance related and addictive disorders (OR = .04).

Table 4 Sample Frequencies of Lifetime Rates of Psychopathology Across Professional Domains

Disorder Athletes (n = 26)

Biologists (n = 7)

Math. and Technol. (n = 17)

Musicians and Actors (n = 50)

Physicists and Chemists

(n = 24)

Psych. & Social Science (n = 21)

Visual Artists, Writers, and

Poets (n = 54) p

Synesthesia 0.0 (0.0) 0.0 (0.0) 0.0 (0.0) 0.0 (0.2) 0.0 (0.0) 0.0 (0.0) 18.5 (18.5) 1.00 Adjustment disorder 0.0 (0.0) 0.0 (0.0) 0.0 (17.6) 0.0 (0.4) 0.0 (4.2) 0.0 (0.0) 0.0 (7.4) .152 Alcoholism 7.7 (11.5) 0.0 (0.0) 11.8 (11.8) 20.0 (14) 0.0 (4.2) 9.5 (9.5) 27.8 (38.9) .002 Drug use/dependency 7.7 (7.7) 0.0 (0.0) 5.9 (11.8) 26.0 (16) 0.0 (0.0) 4.8 (4.8) 11.1 (11.1) .002 Depressive disorders 7.7 (7.7) 14.3 (28.6) 23.5 (41.2) 20.0 (19) 20.8 (41.7) 23.8 (42.9) 48.1 (64.8) ,.001 Bipolar disorder 7.7 (7.7) 0.0 (0.0) 5.9 (11.8) 0.0 (0.4) 4.2 (4.2) 0.0 (0.0) 18.5 (5.6) .770 Anxiety disorder 7.7 (11.5) 0.0 (0.0) 11.8 (17.6) 0.8 (24.0) 8.3 (20.8) 0.0 (14.3) 13 (38.9) .046* Obsessive compulsive 0.0 (0.0) 0.0 (0.0) 0.0 (11.8) 0.2 (0.6) 0.0 (4.2) 0.0 (0.0) 0.0 (5.6) .526 Schizophrenia 7.7 (7.7) 0.0 (0.0) 5.9 (5.9) 0.0 (0.2) 0.0 (0.0) 0.0 (4.8) 18.5 (18.5) .909 Somatic disorder 7.7 (11.5) 0.0 (0.0) 0.0 (5.9) 0.0 (0.4) 0.0 (0.0) 0.0 (4.8) 18.5 (3.7) .587 Autism spectrum disorder 0.0 (0.0) 0.0 (0.0) 0.0 (5.9) 0.0 (0.0) 0.0 (12.5) 0.0 (0.0) 0.0 (1.8) .038* Suicide/suicide attempt 0.0 (0.0) 0.0 (0.0) 0.0 (5.9) 0.0 (0.4) 4.2 (12.5) 0.0 (0.0) 7.4 (11.1) .227 Sleep disorder 7.7 (15.4) 0.0 (14.3) 0.0 (5.9) 0.4 (1.2) 0.0 (0.0) 0.0 (0.0) 3.7 (16.7) .185 Eating disorder 0.0 (0.0) 0.0 (0.0) 0.0 (5.9) 0.0 (0.6) 0.0 (0.0) 0.0 (0.0) 0.0 (0.0) .242 Personality disorder 7.7 (7.7) 0.0 (0.0) 5.9 (11.8) 0.6 (7) 8.3 (16.7) 0.0 (4.8) 0.0 (3.7) .261 Gambling disorder 15.4 (19.2) 0.0 (0.0) 0.0 (0.0) 0.2 (0.2) 0.0 (0.0) 0.0 (0.0) 3.7 (3.7) .008* Conduct disorder 7.7 (7.7) 0.0 (0.0) 0.0 (0.0) 0.2 (0.4) 4.2 (16.7) 0.0 (0.0) 3.7 (3.7) .106 Kleptomania 0.0 (0.0) 0.0 (0.0) 0.0 (0.0) 0.0 (0.0) 0.0 (0.0) 0.0 (0.0) 0.0 (18.5) 1.00 Posttraumatic stress 0.0 (0.0) 0.0 (0.0) 0.0 (0.0) 0.0 (0.2) 0.0 (0.0) 0.0 (0.0) 18.5 (3.7) .852 Paraphilia 0.0 (0.0) 0.0 (0.0) 0.0 (0.0) 0.0 (0.2) 0.0 (0.0) 0.0 (0.0) 3.7 (3.7) .852 Any psychopathology 46.1 (57.7) 14.3 (28.6) 52.9 (70.6) 52.0 (78.0) 33.3 (62.5) 33.3 (57.1) 66.7 (87.0) .003*

Note. Percentages outside brackets involve present cases of psychopathology occurrence. Percentages inside the brackets include both present and proba- ble cases. Column p contains Monte Carlo simulated p values testing null hypothesis that relative frequencies of present or probable psychopathology occurrences are uniformly distributed across compared domains. *pBonf . .05.

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There were no differences between the creative groups and ath- letes in sleep disorders.

Discussion

The intention of the current study was to examine the more com- plicated and moderated relationships between creativity and psycho- pathology by updating and replicating Ludwig’s (1992) biographical analysis of world-class creative artists and scientists. Our expectation was that artistic creative professions in general would possess higher levels of psychopathology than creative scientists. We also predicted that scientists would not differ from the base rates of psychopathol- ogy found in the U.S. population, whereas artists would. The current study controlled for researcher bias by removing

the biographical material of its subjects’ identities. The previous study conducted by Ludwig (1992) was executed with the researcher knowing the identity of each subject, and may have been biased by previous working knowledge of each professional. Certain professions that were given new classifications as the older categorizations, as designated in Ludwig (1992, 1995), may have been incorrectly assigned. For example, historians and philoso- phers were considered scientists by Ludwig. Although history and

philosophy are scholarly subjects, they are not typically considered sciences.

The current study also sought to streamline the process of finding relevant information in books by digitizing each biography into a searchable digital media. This would allow for the researchers to oper- ate at an increased pace by eliminating irrelevant text very quickly. Transforming each book into a digital format also made it possible to censor the names of each creator to limit any previous knowledge that could bias the rating group.

The results of the current study generally corroborated the findings reported in Ludwig’s and other studies, lending further support to previously established hypotheses. Despite using an entirely new set of subjects, not included in Ludwig’s (1992) sample, artists still pos- sessed higher rates of psychopathological traits than scientists, ath- letes, and the U.S. population in general. Scientists were consistently rated lower on symptoms of psychopathology than artists, despite equal eminence. These results held true in both inclusive and exclu- sive requirements for classification into the mentally ill group. How- ever, the difference between artists and athletes was not significant in the more exclusive interpretation of the data. Rates of drug abuse and anxiety also differed between artists, scientists, and athletes depend- ing on whether inclusive or exclusive criterion were used to define what constituted psychopathology. In both cases, fewer subjects

Figure 3 Prevalence of Selected Mental Disorders (Present and/or Probable) in Creative Artists and Scientists Compared With Eminent Athletes

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Figure 4 Prevalence of Selected Mental Disorders (Present and/or Probable) in Creative Domains and Athletes

Note. Text labels indicate odds ratios for psychopathology occurrence in creative domains compared to the athletes. The aster- isks indicate whether the 1-a centered highest density region for posterior density of regression weight contains zero (no effect) when a equals 5% (*), 1% (**), or 0.1% (***).

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qualified for inclusion into the mentally ill group when exclusive cri- teria were used. However, the differences between groups grew larger in the case of anxiety and smaller in the case of drug use, thus moderating the results. Artists also showed greater rates of alcoholism, drug abuse,

depression, and OCD than those found in the U.S. population. Again, statistical significance changed for a few of psychopathologies depending on the strictness of criterion for inclusion. Anxiety among artists was considered lower in the stricter assessment but still gained significance due to the high rate of anxiety reported in the U.S. popu- lation. Rates of OCD also fell for artists and scientists under stricter criterion and detectable differences were no longer found. Because we had a small comparison sample of famous but not

professionally creative athletes, we could also address the question of whether fame itself—isolated from creativity—is a contributing factor to psychopathology. Because athletes were generally less likely than artists and even scientists to develop psychopathology at some point during their lives, we can tentatively conclude that fame per SE is not the driving force behind psychopathology. There was one exception to this, namely anxiety. Athletes exhib- ited higher lifetime rates of anxiety disorders than the general pop- ulation. An interesting question therefore becomes “Do higher rates of anxiety precede or follow athletic fame?” That is, is anxi- ety a cause or effect of athletic eminence? Assuming the relationship between some forms of creativity

and some forms of pathology are robust and real, then the ques- tion becomes why might these two traits covary? Recent litera- ture from biological and evolutionary approaches have suggested biological bases and even potentially adaptive func- tions of the relationship between creative thought and behavior and psychopathology. For instance, research has reported a pol- ymorophism of a particular gene involved in psychosis that is associated with high levels of creativity and high IQ (Kéri, 2009). The gene in question is neuregulin 1, which is a candi- date gene for psychosis and affects neuroplasticity, glial func- tion, and neuronal development in general. One form of the gene, the T/T genotype, was related to both high creativity and risk for psychosis. Based on this and other evidence, Kozbalt and colleagues (2017) argued that one possible reason why a maladaptive trait may still exist in humans is its shared genetic linkage with creative behavior (cf. Akiskal & Akiskal, 2007; Greenwood, 2020; Nettle, 2001, 2006; Power et al., 2015). Sim- ilarly, other empirical and theoretical evidence supports the idea that the milder levels of mental illness, for example cyclothy- mia, confer advantages such as increase fluency of ideas that make creative thought more likely (Carson, 2011; 2014; Green- wood, 2020). Carson (2011, 2014), in fact, proposed that the “shared vulnerability” traits of openness, impulsivity, schizo- typy, cognitive disinhibition, hypomania, and cyclothymia are the traits that connect psychopathology (risk factors) and crea- tive (protective factors) behavior. In sum, there are various neu- rological, evolutionary, and adaptive factors that may undergird the associations between some forms and degrees of creativity and some forms and degrees of psychopathology.

Caveats and Limitations

A number of confounding variables limit the results of this study. One such limitation is sample bias. In the case of the current

study, writers and publishers may be more inclined to pursue biog- raphies for particularly interesting people to tell more compelling stories. Because someone with a history of psychopathology may serve as a more desirable subject for a biography than someone who is not, healthier professionals may have fewer books written about them. Indeed, the study also contained a much smaller num- ber of scientists than artists, which may be due to writers and pub- lishers favoring more artists rather than scientists since the latter may be perceived as less interesting or hold less recognition in the general public.

The level of fame could not be held constant through all three groups. Although some scientists such as Stephen Hawking and Richard Feynman are particularly well known, not all eminent sci- entists are easily recognizable to the public (e.g., Alfred Tarski, Grigori Perelman, George Beadle). Most of the actors (e.g., Mar- lon Brando, Robert DeNiro, Sophia Loren) and musicians (e.g., Ella Fitzgerald, Prince, Diana Ross, Johnny Cash) were well known to the general public. Athletes, although more recognizable than scientists, tend to dwindle in fame after retirement. Because the careers of most athletes are particularly short, their highest point of fame tends to come earlier in their lives rather than later. This is incongruent with scientists as fame for their achievements tend to come later, after their work has been recognized. Both ath- letes and scientists may also possess lower levels of fame than per- formance artists such as musicians and actors.

Another limitation of the current study is the gender imbalance in the creative sample. The biographies of men in the sample out- numbered women 164 to 35 (18% female). There are historically fewer biographies written about women than men, especially the sciences. Moreover, women have been less likely to reach the highest levels of their professions, whether they have biographies written about them or not—the famous “glass ceiling.” For exam- ple, women have historically been seriously underrepresented in mathematics and sciences. Only 8.8% 15.8% of tenure-track posi- tions among top universities are held by women in math-centric domains (Ceci & Williams, 2011), and only 20% of physics PhDs were awarded to women as recently as 2017 (Porter & Ivie, 2019). During the time that many eminent people in this sample were most active professionally—the 1950s to 1980s—the percentage of women earning PhDs in physics was between 3% to 7% (Porter & Ivie, 2019). Yet not all professions are so imbalanced. For example, our sample had five women of 68 (7%) in the STEM dis- ciplines but 29 of 104 (28%) women in the arts. In acting, the cur- rent sample had a ratio of nine of 20 (45%), and in musical performance it was eight of 26 (31%).

This finding begs the question of why are women underrepre- sented in certain fields more than others and in particular at the top of their fields? There is an extensive scientific literature on this question that goes well-beyond the scope of this article (Cheung & Halpern, 2010). Suffice it to say that social and cultural biases about marriage, child rearing, and performance play a very large role in “glass ceiling” effect (Cheung & Halpern, 2010). For example, in a nationwide study, biology, chemistry, and physics professors were found to consider men as both more hirable and competent (Moss-Racusin et al., 2012).

Similarly, the sample was skewed racially, with being of White-European ancestry (83% of our sample, compared with 60% in the U.S. population). Indeed, 100% of the Science-Tech- nology group was White. Part of this bias comes from the bias in

PSYCHOPATHOLOGY AND CREATIVITY 13

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published biographies, especially during the time frame of our study. Moreover, basing research on biographies will inherently require older samples given the delay between creative accom- plishments and publication of a biography. Future research will need to continue to determine whether these trends hold with more ethnically diverse samples. Additionally, determining how to interpret historical and bio-

graphical texts is a challenge for psychological study (Citlak, 2016; Czechowski et al., 2016). Biographies still require interpre- tation as historians of certain types of professions may differ from others in what report. Some professions may encourage exagger- ated stories, particularly of drug use, to sell their fame (Lucijani�c et al., 2010). Musicians such as rappers and rock stars may benefit from rumors of psychopathology as increased notoriety would increase exposure and thus raise the likelihood of album sales. Sci- entists do not typically benefit from fame in the same way artists do, as they typically work to discover new knowledge rather than sell products or develop a fan-base, thus there is less incentive to exaggerate claims of illness or drug use. Furthermore, we must acknowledge the fact that different disor-

ders are easier to rate from biographies than others and are more likely to show up in biographies than others. The former consists of more behaviorally expressed disorders such as drug or alcohol addiction, violence, suicide, and depression, whereas the latter con- sists of more internalized or private disorders, such as PTSD, sleep disorders or even more moderate degrees of anxiety disorders. We also need to make clear that our raters were not licensed

clinical psychologists but rather trained undergraduate research assistants. To be sure, they had to go through a reliability training process that involved learning the DSM–5 criteria for the 19 disor- ders and they could not begin rating until they obtained the .80 interrater reliability threshold. Finally, the raters were blind to the subject of the biography, and we had two independent raters code each biography. Nevertheless, these are not assessments by li- censed clinical psychologists.

Future Directions

We make little claim that this investigation settles the “debate” over the “mad-genius.” At best, it confirms one aspect of it, namely the higher rate of pathology and the different pathologies in the creative arts than other creative domains. Many questions remain. For example, as we mentioned above, the biggest question left unresolved is the gender question. Are these patterns that we found in a heavily male-dominated sample the same in famous creative women? Our dataset does not allow this question to be satisfactorily answered. Moreover, because of the restricted sam- ple size, certain analyses were not possible among smaller groups and specific professions. Additionally, no comparisons could be made for fiction writers against nonfiction writers, limiting the conclusions that could be made. Thus, more specific examinations of individual professions can be made as the dataset grows larger. Additional demographic variables that may influence professional vocation and creative output will also be collected. These variables include birth order, religious affiliation, ethnicity, and marital sta- tus of parents. Owing to time constraints, the collection of these data lay beyond the scope of the current study. In conclusion, the results of this study provide support and repli-

cation for the findings of previous biographical investigations of

highly creative people. The use of digital resources allowed for the researchers to limit bias through the use of censors to hide the identity of each creator. The classification and grouping of each profession were also reworked for further accuracy. As is true of all research, however, for each question answered, others arise and await further attention from future investigators. The topic of psy- chopathology and world-class creative achievement is a rich and complex topic and will provide material for researchers for years to come.

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Accepted August 13, 2021 n

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Clinical Medicine Insights: Psychiatry Volume 13: 1–5 © The Author(s) 2022 Article reuse guidelines: sagepub.com/journals-permissions DOI: 10.1177/11795573211069912

Does fear mediate the neuroticism-psychopathology link for adults living through the COVID-19 pandemic?

Sherman A. Lee1 and Mary C. Jobe2 1Christopher Newport University, Newport News, VA, USA. 2The George Washington University, Washington, DC, USA.

ABSTRACT

BACKGROUND: COVID-19 has globally increased psychological distress. Although research has shown a clear link between neuroticism and psychopathology, pandemic fears—manifesting as fear of death and coronavirus anxiety, have not been examined as mediating factors for explaining this connection during the pandemic.

METHODS: Therefore, to fill this void in the literature, this study examined 259 U.S. MTurk adult workers in May 2020 using an online questionnaire. The study used the Patient Health Questionnaire, the 8-item Big Five Inventory neuroticism subscale, a single-item fear of death measure, and the Coronavirus Anxiety Scale as well as collected demographic information to perform correlational and meditation analyses.

RESULTS: The results showed that both coronavirus anxiety and fear of death partially mediated the relationship between neuroticism and symptoms of depression and generalized anxiety. The results also found that those high in trait neuroticism who were fearful of death or had coronavirus anxiety showed heightened levels of depression and general anxiety.

CONCLUSION: This study’s findings were consistent with previous research and current work on pandemic-related distress. In addition, the results of these findings can help bring to light the connectedness of these psychopathological constructs with fears surrounding the pandemic—which can be useful to both researchers and mental health professionals alike.

KEYWORDS: Neuroticism, COVID-19, fear of death, coronavirus, anxiety, depression

RECEIVED: February 7, 2021. ACCEPTED: December 10, 2021.

TYPE: Original Research

DECLARATION OF CONFLICTING INTERESTS: The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

FUNDING: The author(s) received no financial support for the research, authorship, and/or publication of this article.

ETHICAL APPROVAL: All procedures performed in this study were in accordance with the ethical standards of Christopher Newport University’s ethics and IRB approval committee. In addition, the procedures are in accordance with the Declaration of Helsinki or ethical equivalent. In addition, informed consent was obtained from all individual adult participants included in the study.

CORRESPONDING AUTHOR: Mary C. Jobe, The George Washington University, 2125 G Street NW, Washington, DC, 20052, USA. Email: [email protected]

Introduction As the pandemic persists, so does the worsening of people’s

mental health and well-being.1 For example, during the first

months of the pandemic, 24.4% of Americans reported clinical

levels of depression, while 29.8% reported clinical levels of

anxiety.2 One factor that has been found to be strongly associated

with depression and generalized anxiety during the COVID-19

pandemic is neuroticism.3 According to the Five-Factor model,

neuroticism describes a broad dimension of personality concerned

with tendencies to experience negative affect, and disturbed

thoughts and behaviors that accompany emotional distress.4 The

finding that neuroticism is associated with adjustment difficulties

during the COVID-19 pandemic should not be surprising given

that individuals high in this personality trait have long been

known to suffer from a wide-range of mental and physical health

conditions5 as well as psychological distress during previous

pandemics.6,7 However, what is not clear is what the psycho-

logical mechanisms are that explain why individuals high in this

trait are experiencing heightened levels of psychological distress

during this particular global health crisis.

The COVID-19 pandemic has been shrouded by fear and

anxiety with millions of people dead from this highly infectious

disease. Consequently, many people living in this pandemic fear

for their lives and the coronavirus itself, as the virus can lead to

the death and suffering of oneself and their loved ones. Ac-

cordingly, research during this pandemic has shown that both

death anxiety and coronavirus anxiety are both positively cor-

related with depression and generalized anxiety.8,9 Moreover,

past7 and current research3,10 has shown that neuroticism is

strongly tied to pandemic-related fears and psychopathology.

That said, although research has shown a clear link between

neuroticism and psychopathology (i.e., anxiety and depression),

pandemic fears—such as fear of death and coronavirus anxiety,

have not been examined as mediating factors for explaining this

connection during the pandemic. Thus, this study will aim to

address this; we anticipate that fear of death and coronavirus

anxiety will mediate the relationship between neuroticism and

psychopathology in a sample of adults during the COVID-19

pandemic. These causal implications can enlighten the rela-

tionships these constructs hold—helping researchers better

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https://orcid.org/0000-0001-7106-7120

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understand COVID-19’s psychological impacts and possible

avenues for treatment.

Method Participants and procedures

Data from 259 adult MTurk 11

workers in the U.S. who

completed an online survey on May 15 and 16, 2020 were used

in this IRB approved study. The sample consisted of 116

women and 143 men, with a median age of 33.00 years (ranging

from 18 to 65). Most of the participants were White (n = 165;

63.7%), had earned at least a Bachelor’s degree (n = 190; 73.4%),

had not tested positive for COVID-19 (n = 227; 87.6%), and

did not know someone with COVID-19 (n = 147; 56.8%). The

participants provided consent and received payment ($0.50) for

their involvement in this study.

Measures

Background information. Participants were asked to report their

age, gender, race, level of education, diagnosis of COVID-19,

and personal knowledge of someone with COVID-19.

Psychopathology. Symptoms of psychopathology were mea-

sured using the four-item Patient Health Questionnaire-4.12

Participants indicated how frequently they experienced symp-

toms of depression (e.g., feeling down, depressed, or hopeless; α = .80) and generalized anxiety (e.g., feeling nervous, anxious, or on

edge; α = .78) over the last 2 weeks using a 4-point scale. Neuroticism. The generalized tendency to experience negative

emotions was measured using the 8-item neuroticism subscale of

the Big Five Inventory. 13

Participants indicated how much they

agreed or disagreed with descriptions of neuroticism (e.g., I see

myself as someone who worries a lot) using a 4-point scale (α = .81). Fear of Death. Fear of death was measured using a single-item

Fear of Death measure.14 Although a single-item, it has been

found to reliably assess fear of death and moderately be associated

with multi-item death anxiety scales.14 For the item, participants

indicated how much they agreed or disagreed with the statement,

“I am afraid of death” using a 4-point scale. Most of the par-

ticipants reported that they agree a little (28.2%), followed by

neither agree nor disagree (19.7%), strongly agree (18.9%), disagree

a little (17.8%), and strongly disagree (15.4%) to the item.

Coronavirus anxiety. Dysfunctional anxiety over the coro-

navirus was measured using the 5-item Coronavirus Anxiety

Scale.15 Participants indicated how frequently they experienced

physiologically based symptoms of fear and anxiety over the

coronavirus (e.g., I felt dizzy, lightheaded, or faint, when I read or

listened to news about the coronavirus) over the last 2 weeks using

a 4-point scale (α = .94).

Statistical procedures

Statistical analyses were calculated using SPSS version 26.0,

except for the mediation analyses, which were run using AMOS

version 25.0. We tested mediators one at a time to determine

independent effects16 and employed bias-corrected bootstrap

procedures using 2,000 resamples to the models.17 We chose a

bootstrap resampling method because its calculation of confi-

dence intervals is not biased by sample size, effect size, or level of

statistical significance.18

Results Correlations

Zero-order correlations were run to examine the bivariate asso-

ciations between the measures of psychopathology, neuroticism,

and the proposed mediators of fear of death and coronavirus

anxiety (see Table 1). The results revealed that depression was

correlated with neuroticism (r = .64), fear of death (r = .40),

coronavirus anxiety (r = .66), and generalized anxiety (r = .76).

Generalized anxiety was also correlated with neuroticism (r =

.68), fear of death (r = .47), and coronavirus anxiety (r = .62).

Neuroticism was correlated with fear of death (r = .40), and

coronavirus anxiety (r = .42). Fear of death was correlated with

coronavirus anxiety (r = .33), supporting their related but

distinct expressions of pandemic fear. These intercorrelation

patterns support the inclusion of the variables in the mediation

analyses.

Mediation analyses

Four mediation analyses were conducted to examine the sep-

arate influences of proposed mediators on the association be-

tween neuroticism and psychopathology (i.e., depression and

generalized anxiety). The first model tested coronavirus anxi-

ety’s mediating influence on the relationship between neurot-

icism and depression (see Figure 1). The bootstrap results

showed that the standardized indirect (mediated) effect of

neuroticism on depression was significantly different from zero

(P = .001, 95% CI [.15, .27]). Therefore, this model demon-

strated that coronavirus anxiety partially mediated the

neuroticism-depression link (β from .64 to .44) with a stan- dardized indirect effect of .20.

The second model tested coronavirus anxiety’s mediating

influence on the relationship between neuroticism and gener-

alized anxiety (see Figure 2). The bootstrap results showed that

the standardized indirect (mediated) effect of neuroticism on

generalized anxiety was significantly different from zero (P =

.001, 95% CI [.12, .23]). Therefore, this model demonstrated

that coronavirus anxiety partially mediated the neuroticism-

generalized anxiety link (β from .68 to .51) with a standardized indirect effect of .17.

The third model tested death anxiety’s mediating influence

on the relationship between neuroticism and depression (see

Figure 3). The bootstrap results showed that the standardized

indirect (mediated) effect of neuroticism on depression was

significantly different from zero (P = .001, 95% CI [.03, .12]).

Therefore, this model demonstrated that fear of death partially

2 Clinical Medicine Insights: Psychiatry n n

T a b le

1 . D e sc ri p tiv e st a tis tic s a n d ze

ro -o rd e r co

rr e la tio

n s.

M S D

1 2

3 4

5 6

7 8

9 1 0

1 D e p re ss

io n

2 .6 1

1 .9 2

—

2 G e n e ra liz e d

a n xi e ty

2 .4 7

1 .7 7

.7 6 ** *

—

3 N e u ro tic is m

2 3 .3 7

6 .1 5

.6 4 ** *

.6 8 ** *

—

4 F e a r o f d e a th

3 .1 7

1 .3 5

.4 0 ** *

.4 7 ** *

.4 0 ** *

—

5 C o ro n a vi ru s

a n xi e ty

6 .0 4

5 .9 2

.6 6 ** *

.6 2 ** *

.4 2 ** *

.3 3 ** *

—

6 A g e

3 5 .4 6

1 1 .3 0

�. 1 0

�. 1 2

�. 2 1 **

�. 0 9

.0 1

—

7 G e n d e r

.5 5

.5 0

.0 3

�. 0 3

�. 2 1 **

.0 2

.1 4 *

.0 1

—

8 R a ce

.6 4

.4 8

.0 0

.0 5

.0 0

�. 1 2 *

�. 0 5

.1 8 **

�. 0 2

—

9 E d u ca

tio n

.7 3

.4 4

.1 4 *

.2 2 ** *

.0 4

.1 5 *

.2 8 ** *

.0 4

.1 4 *

.0 7

—

1 0

D ia g n o si s

.1 2

.3 3

.2 0 **

.1 9 **

.1 1

.1 0

.3 4 ** *

.0 1

.0 8

�. 0 1

.0 9

—

1 1

K n o w le d g e

.4 3

.5 0

.1 1

.1 4 *

.0 4

.0 8

.2 0 **

�. 1 0

.0 7

�. 0 2

.2 6 ** *

N o te . N = 2 5 9 ; G e n d e r (0

= m a le ; 1 = fe m a le ); R a ce

(0 = n o n -W

h ite

; 1 = W h ite

); E d u ca

tio n (0

= L e ss

th a n a B a ch

e lo r’ s d e g re e ; 1 = B a ch

e lo r’ s d e g re e a n d h ig h e r) ; D ia g n o si s (0

= n o t d ia g n o se

d w ith

C O V ID -1 9 ; 1 = d ia g n o se

d w ith

C O V ID -1 9 ); K n o w le d g e (0

= d o e s n o t p e rs o n a lly

kn o w

so m e o n e w ith

C O V ID -1 9 ; 1 = p e rs o n a lly

kn o w s so

m e o n e w ith

C O V ID -1 9 ).

*P < .0 5 ; tw o -t a ile d , ** P < .0 1 ; tw o -t a ile d , ** *P

< .0 0 1 ; tw o -t a ile d .

3Lee and Jobe n n

mediated the neuroticism-depression anxiety link (β from .64 to .57) with a standardized indirect effect of .07. The last

model tested fear of death’s mediating influence on the re-

lationship between neuroticism and generalized anxiety (see

Figure 4). The bootstrap results showed that the standardized

indirect (mediated) effect of neuroticism on generalized

anxiety was significantly different from zero (P = .001, 95%

CI [.05, .15]). Therefore, this model demonstrated that fear

of death partially mediated the neuroticism-generalized

anxiety link (β from .68 to .59) with a standardized indi- rect effect of .09.

Discussion Overall, the COVID-19 pandemic has had an impact on mental

health. In addition, past literature has demonstrated that in

general and during pandemic times, neuroticism may play a role

in who may be more likely to experience such psychopathology

(i.e., anxiety and depression).5,19-21 Our study aimed to assess

what other mechanisms may help to explain this neuroticism-

psychopathology relationship—by exploring pandemic fears,

specifically fear of death and coronavirus anxiety. In sum, the

results demonstrated that the potential mediators explained

some of the reason as to why individuals high in trait neu-

roticism experienced elevated psychopathology symptoms

during the COVID-19 crisis. Our findings are consistent with

Nikčević and colleagues’ (2021) predicted model for COVID-19

anxiety as a mediator in the neuroticism-generalized anxiety and

neuroticism-depression relationships; however, the results of their

study did not yield significant findings between these variables.22

Moreover, our study’s findings support past literature and provide

further analysis, for using mediations to explain the fear rela-

tionships, within the pandemic context, between these commonly

associated variables: neuroticism and psychopathology. In addition,

the results demonstrate that those high in trait neuroticism, in

particular, who are fearful of death or have coronavirus anxiety may

also show these heightened levels of depression and general

anxiety. Literature has shown such psychopathology has been

increasing during COVID-1923,24 and that those high in trait

neuroticism are a vulnerable population during pandemics.7,25 This

study synthesizes these relationships, supporting Lee and Crunk

(2020)3 in showing how fears can explain these associations. After

accounting for pandemic specific fears, researchers and mental

health professionals are able to understand the bigger picture as to

why individuals high in trait neuroticism may be especially sus-

ceptible to such psychopathology, using these findings.

There are many possible approaches to treating people with

depression, generalized anxiety, and issues associated with

neuroticism during the COVID-19 pandemic. One method that

has been shown to successfully treat individuals suffering from

psychological distress and high in neuroticism, while considering

pandemic spatial distancing practices, has been the use of

Figure 4. Mediating effect of fear of death on the association between neuroticism and generalized anxiety. Note. Two-sided bias-corrected

bootstrap procedure (95% confidence intervals; 2,000 samples). Above

values reflect standardized regression coefficients. *** P < .001.

Figure 3. Mediating effect of fear of death on the association between neuroticism and depression. Note. Two-sided bias-corrected bootstrap

procedure (95% confidence intervals; 2,000 samples). Above values reflect

standardized regression coefficients. *** P < .001.

Figure 2. Mediating effect of coronavirus anxiety on the association between neuroticism and generalized anxiety. Note. Two-sided bias-corrected

bootstrap procedure (95% confidence intervals; 2,000 samples). Above

values reflect standardized regression coefficients. *** P < .001.

Figure 1. Mediating effect of coronavirus anxiety on the association between neuroticism and depression. Note. Two-sided bias-corrected bootstrap

procedure (95% confidence intervals; 2,000 samples). Above values reflect

standardized regression coefficients. *** P < .001.

4 Clinical Medicine Insights: Psychiatry n n

telehealth. Hedman et al (2014)26 found that using internet-

based cognitive behavior therapy, especially for individuals high

in neuroticism, has shown to be effective in and even lessened

both psychological distress and tendencies of those high in trait

neuroticism. Adopting this method of therapy to address pan-

demic fears and psychopathology for individuals high in trait

neuroticism may be both practical and beneficial, especially as the

pandemic persists and mental health issues rise.

This research has a major limitation worth noting. Specif-

ically, this study was constrained by a relatively small conve-

nience sample. Future research would benefit from a probability

sampling approach that would result in obtaining a large,

representative sample where more sophisticated mediation

analyses that examines both independent and simultaneous

effects could be applied. In addition, fear of death was only

assessed using a single item; further research could examine this

construct using longer measures. Further this research was

conducted using self-report measures, which could be subject to

possible social desirability. Notwithstanding these limitations,

our research reports important data that contribute to our

understanding of the mental health consequences of the pan-

demic. By understanding the causal implications of this study’s

findings, researchers can further explore COVID-19’s psy-

chological effects in relation to psychopathology and pandemic

fears; and mental health professionals can examine the effects of

neuroticism when adopting telehealth therapy and other ef-

fective approaches to help address these fears.(26)

Acknowledgements The authors would like to thank those who participated.

ORCID iD Mary C. Jobe  https://orcid.org/0000-0001-7106-7120

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https://orcid.org/0000-0001-7106-7120

https://www.kff.org/coronavirus-covid-19/issue-brief/the-implications-of-covid-19-for-mental-health-and-substance-use/

https://www.cdc.gov/nchs/covid19/pulse/mental-health.htm

https://doi.org/10.1177/0030222820949350

https://doi.org/10.1037/0022-3514.52.1.81

https://doi.org/10.1037/a0015309

https://doi.org/10.1016/j.janxdis.2020.102268

https://doi.org/10.1016/j.paid.2020.110347

https://doi.org/10.1017/S1754470X20000215

https://doi.org/10.1177/1745691617706516

https://doi.org/10.1080/074811898201254

https://doi.org/10.1080/07481187.2020.1748481

http://davidakenny.net/cm/mediate.htm

https://doi.org/10.1037/1082-989X.7.4.422

https://doi.org/10.1037/0022-0167.53.3.372

https://doi.org/10.3390/ijerph18020794

https://doi.org/10.1016/j.paid.2007.09.019

https://doi.org/10.3390/ijerph17103740

https://doi.org/10.1001/jamanetworkopen.2020.19686

https://doi.org/10.1186/s12992-020-00589-w

https://doi.org/10.30773/pi.2020.0199

https://doi.org/10.1371/journal.pone.0113871

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Does fear mediate the neuroticism-psychopathology link for adults living through the COVID-19 pandemic?

Introduction
Method

Participants and procedures
Measures
Statistical procedures

Results

Correlations
Mediation analyses

Discussion
Acknowledgements
ORCID iD
References

A Dyadic Perspective on Psychopathology and Young Adult Physical Dating Aggression

Ann Lantagne and Wyndol Furman Department of Psychology, University of Denver

Objective: Although psychopathology has been broadly implicated as a risk factor for dating aggression, very little work has examined the externalizing and internalizing symptoms of both romantic partners to more fully understand associations between psychopathology and physical dating aggression among young adult couples. The present study examined the effects of each partner’s psychopathology on physical dating aggression, the conjoint influence of both partners’ psychopathology, and whether the effects of psycho- pathology on aggression depended upon the nature of the relationship. Method: Actor Partner Interdepen- dence Models were used to examine associations between psychopathology and physical dating aggression among 127 young adult couples (M age = 22.04 years). Actor Partner Interdependence Moderation Models (APIMoMs) were then tested to determine whether negative relationship characteristics exacerbated the effects of psychopathology on aggression. Results: Both males’ and females’ externalizing and internaliz- ing symptoms were associated with dating aggression. Evidence of homophily was found, and actor partner interactions revealed that couples in which both partners had high externalizing symptoms were at greater risk, whereas when either partner had low symptoms, the risk was mitigated. Relationship risk factors interacted with externalizing symptoms to predict female physical dating aggression, and with internalizing symptoms to predict partner aggression. Conclusion: Findings lend support to the merits of using a dyadic approach to examine individual risk factors and combinations of individual and relationship risk factors in predicting young adult physical dating aggression. Results could potentially inform clinical work on patterns and combinations of risk factors characteristic of high-risk young adult couples.

Keywords: dating aggression, dating violence, intimate partner violence, romantic relationships, dating

Supplemental materials: https://doi.org/10.1037/vio0000386.supp

Rates of physical dating aggression peak among young adult couples; in fact, more than half of individuals ages 18–24 report that they have experienced violence in a relationship (Halpern et al., 2001; O’Leary, 1999). Psychopathology is a known risk factor for such aggression (Devries et al., 2013). Indeed, elevated externaliz- ing symptoms, such as conduct problems and delinquency, and internalizing symptoms, such as depression and anxiety, are associ- ated with dating aggression during young adulthood (Vezina & Hebert, 2007). Existing work, however, has primarily focused on only one individual’s psychopathology and links with aggression (Capaldi et al., 2012). Notably, each partner’s characteristics shape the relationship: among young adult couples, both partners’ antiso- cial behaviors and depressive symptoms are uniquely associated with male and female physical dating aggression (Kim & Capaldi, 2004). Young adults also tend to select partners with similar levels

of psychopathology, suggesting that certain combinations of part- ners may be at greater risk (Kim & Capaldi, 2004). By examining risk among couples, physical dating aggression can be predicted above and beyond a single individual’s risk, yet limited work has taken such a dyadic approach during young adulthood.

One of the primary purposes of the present study was to supple- ment the limited dyadic work examining both partners’ psychopa- thology and physical dating aggression during this time. By including both partners’ risk factors, the present study sought to further our understanding of whether individual risk factors for dating aggression can be conceptualized as a dyadic process; specifically, we examined whether partner psychopathology contributed above and beyond the association between an individual’s psychopathology and their own dating aggression. We also examined whether partner similarity (homophily) occurred for psychopathology and explored the conjoint influence of both romantic partners’ psychopathology on the risk for aggression. Finally, the present study extended existing research by testing a dyadic moderation model to investigate whether relationship risk factors exacerbated associations between psychopathology and aggression. Results have the potential to further our understanding of psychopathology as a risk factor for physical dating aggression among young adult couples.

A Dyadic Approach to Dating Aggression

The dynamic developmental systems perspective (DDS; Capaldi et al., 2005) provides a dyadic conceptualization of young adult physical dating aggression across multiple levels of risk factors.

This article was published Online First April 29, 2021.

Ann Lantagne https://orcid.org/0000-0002-9435-7080 Preparation of this manuscript was supported by Grant 050106 from the

National Institute of Mental Health (Wyndol Furman, P.I.) and Grant 049080 from the National Institute of Child Health and Human Development (Wyndol Furman, P.I.). Appreciation is expressed to the Project Star staff for their assistance in collecting the data, and to the Project Star participants and their partners, friends and families. Correspondence concerning this article should be addressed to Ann

Lantagne, Department of Psychology, University of Denver, Denver, CO 80209, United States. Email: [email protected]

Psychology of Violence

569

T h is d o cu m en t is co p y ri g ht ed

b y th e A m er ic an

P sy ch o lo g ic al

A ss o ci at io n o r o n e o f it s al li ed

p u b li sh er s.

T h is ar ti cl e is in te nd ed

so le ly

fo r th e p er so n al

u se

o f th e in di v id u al

u se r an d is n o t to

b e d is se m in at ed

b ro ad ly .

https://doi.org/10.1037/vio0000386.supp

https://orcid.org/0000-0002-9435-7080

https://doi.org/10.1037/vio0000386

At the core level of the perspective are the individual characteristics and behaviors each partner brings to the relationship, such as psychopathology or personality traits. The next level incorporates the relationship risk factors associated with aggression, including characteristics such as conflict, jealousy, attachment styles, and satisfaction (Capaldi et al., 2012). The DDS perspective emphasizes that to understand the risk for dating aggression, the effect of both partners’ risk factors on their own and their partner’s aggression must be examined. The perspective also posits that interactions between the individual and relationship levels can occur (Capaldi et al., 2012; Kim & Capaldi, 2004; Whitaker et al., 2010). One statistical approach that allows researchers to examine both

partners’ risk factors and the associations with dating aggression is the Actor Partner Interdependence Model (APIM; Kenny, 1996). In APIM, actor effects determine how much each individual’s psycho- pathology influences their own physical dating aggression, and partner effects reflect associations between an individual’s psycho- pathology and the partner’s physical dating aggression. Actor effects are measured while controlling for partner effects, and vice versa. Actor partner interactions take into account the interplay between the two romantic partners’ risk and assess whether combi- nations of partners’ risk factors result in a greater risk (Figure 1). Finally, additional moderators can be incorporated into APIM as well (Garcia et al., 2015).

Psychopathology as a Risk Factor

Two domains of psychopathology associated with physical dating aggression are externalizing and internalizing symptoms. First, a number of externalizing symptoms, including delinquency, antiso- cial behaviors, conduct problems, and general aggression are known risk factors for young adult dating aggression (Andrews et al., 2000; Ehrensaft et al., 2003). Across dyadic studies, discrepant patterns have been found. Among adult cohabiting couples, male and female antisocial behaviors predict female physical aggression but not male aggression (Marshall et al., 2011). In contrast, among young adult

couples in which male partners were at high risk for delinquency, male and female antisocial behaviors predict male physical aggres- sion, whereas only female antisocial behaviors predict female aggression (Kim & Capaldi, 2004). Second, internalizing symptoms are associated with greater reactivity, irritability, withdrawal, nega- tivity, and perceived alienation, which may underlie an increased risk for aggression (McCabe & Gotlib, 1993). Dyadic studies including adult couples highlight significant partner effects, such that males’ depressive symptoms predict female aggression and females’ depressive symptoms predict male aggression (Marshall et al., 2011). Among young adult couples, only females’ depres- sive symptoms predict male and female aggression concurrently (Kim & Capaldi, 2004).

Moreover, young adults and their partners tend to have similar levels of psychopathology, a phenomenon known as homophily (Kim & Capaldi, 2004; Merikangas, 1982). Homophily can occur by either assortative mating, in which individuals select partners with similar levels of psychopathology, or socialization, in which part- ners exert an influence on one another. Such pairing can increase the number of couples composed of two individuals who each have a higher risk for dating aggression. Furthermore, interactions between the partners’ psychopathology can occur, resulting in higher risk for aggression. Existing work among young adults has found additive effects of each partner’s psychopathology on aggression but may have been underpowered to find interactions between partners (Kim & Capaldi, 2004).

To date, dyadic studies have focused on psychopathology and physical dating aggression exclusively among adult couples that were cohabiting or among high-risk young adult couples that had lasting relationships (Kim & Capaldi, 2004; Marshall et al., 2011). During young adulthood, dating aggression often culminates in breakups, on-again-off-again dynamics, and relationship instability (Halpern-Meekin et al., 2013; Rhoades et al., 2011). It will there- fore be informative to supplement existing work by examining patterns across a range of young adult relationships. Additionally, by testing the conjoint influence of both partners’ psychopathology in an adequately powered sample, the field will have a better understanding of whether certain young adult couples may be at greater risk.

Relationship Characteristics as Moderators

Although psychopathology is a relatively stable characteristic (Ferdinand et al., 1995), aggression fluctuates within relationships. Fifteen percent of individuals who did not initially engage in physical dating aggression became aggressive a year and a half later within that relationship, whereas around half of individuals who were aggressive remained aggressive over time (O’Leary et al., 1989). As such, psychopathology’s associations with dating aggres- sion may be exacerbated by the presence of contextual variables such as relationship characteristics, which vary in young adult relationships (Ferdinand et al., 1995; Karney & Bradbury, 1995).

Notably, the Vulnerability Stress Adaptation model posits that individuals with vulnerabilities such as psychopathology who also experience stressful relationships are most likely to have poor relationship outcomes (Karney & Bradbury, 1995; Marshall et al., 2011). The intersection of multiple risk factors could cause a tipping point in which aggression becomes more likely (Foran & O’Leary, 2008). To the best of our knowledge, only one study has examined

Figure 1 The Actor-Partner Interdependence Model (APIM)

Note. Paths labeled a indicate actor effects and paths labeled p indicate partner effects. Paths label axp reflect actor partner interactions. Double- headed arrows represented correlated variables. e1 and e2 represent residual (explained) portion of perpetration score.

570 LANTAGNE AND FURMAN

T h is d o cu m en t is co p y ri g ht ed

b y th e A m er ic an

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both individual and relationship risk factors. Woodin et al. (2013) found that lower perceived relationship bond interacted with depres- sion to predict dating aggression among college couples; however, existing work has not examined additional relationship risk factors, explored the interaction with both internalizing and externalizing symptoms, or used a dyadic approach. By examining the moderating effect of relationship characteristics, the field can obtain a better understanding of the roles of both individual and relationship risk factors and identify potential targets for prevention and intervention.

The Present Study

Existing work has typically examined risk factors for physical dating aggression by focusing on only one partner; about 5% of studies have examined risk factors among couples (Capaldi et al., 2012). In a prior study (Lantagne & Furman, 2020), we used a dyadic approach to examine the relationship level risk factors from the Dynamic Developmental Systems theory and found that rela- tionship characteristics had main effects on dating aggression. Specifically, our findings demonstrated that both partners’ anxious relational styles and jealousy predicted male and female aggression; female satisfaction and female negative interactions predicted male and female aggression, and each individual’s avoidant style pre- dicted their partner’s aggression. The present study used this same dyadic sample as our prior study

to further contribute to the limited dyadic work on risk factors for dating aggression by first examining a separate level of risk factors from the Dynamic Developmental Systems theory—the individual level. We used APIMs to determine associations between each romantic partner’s externalizing and internalizing symptoms, as well as interactions between partners’ psychopathology, in predict- ing young adult physical dating aggression. We then applied an innovative statistical technique, the Actor Partner Interdependence Moderation Model (APIMoM) to determine whether interactions can occur across levels of risk factors. Specifically, we examined the moderating effect of relationship characteristics on the links between psychopathology and aggression within couples. The present study extends our prior work and other existing work

in several important directions. First, a dyadic approach furthers our understanding of a known risk factor by determining the unique and conjoint influence of both partners’ psychopathology on young adult dating aggression. The present study also extends existing work on psychopathology by examining whether homophily occurs and whether there are interactions between both partners’ psycho- pathology, which could place some couples at particularly high risk. Additionally, by using a dyadic approach to examine individual risk factors for dating aggression, we determine the utility, and therefore the generalizability, of such an approach across a variety of risk factors and multiple levels of risk. Finally, the present study extends existing dyadic models by incorporating additional variables as moderators for risk factors for dating aggression. An examination of such moderation enables us to obtain a more nuanced conceptu- alization of the role of psychopathology as a risk factor by helping us to understand whether the effects of psychopathology on dating aggression have a differing association depending upon the presence of relationship risk factors. This could lend support to existing theories that posit that there can be an interplay between levels of risk factors for aggression.

Hypotheses

Hypotheses included that homophily would occur, such that individuals would pair with partners who had similar levels of psychopathology (Hypothesis 1). We hypothesized that higher physical dating aggression would be associated with higher levels of an individual’s externalizing symptoms (Hypothesis 2; “a” or actor path in Figure 1) and their partner’s externalizing symptoms Hypothesis 3; “p”or partner path in Figure 1). Parallel hypotheses were posited for internalizing symptoms (Hypothesis 4 & Hypoth- esis 5). We anticipated female and male psychopathology would interact to predict physical dating aggression above and beyond the main effects of each individual’s psychopathology (Hypothesis 6; “axp” or actor partner interaction path in Figure 1). Moderation effects were also expected, such that associations between psycho- pathology and aggression would be strongest when partners expe- rienced both elevated psychopathology and stressful relationship characteristics (Hypothesis 7, high psychopathology × high nega- tive interactions; Hypothesis 8, high psychopathology × high jealousy; Hypothesis 9, high psychopathology × high anxious styles; Hypothesis 10, high psychopathology × high avoidant styles; Hypothesis 11, high psychopathology × low satisfaction, “X1M1” and “X2M2” paths in Figure 2).

Method

Participants

The participants included in this study and our prior dyadic study (Lantagne & Furman, 2020) were a dyadic subsample drawn from a larger longitudinal study examining the role of adolescent and young adult interpersonal relationships on psychosocial adjustment (Project STAR; see Furman et al., 2009). Two hundred 10th graders (100 females) were recruited from a Western metropolitan area in the United States. To obtain a diverse sample, letters were sent to families across 36 zip codes of ethnically diverse neighborhoods and brochures were distributed to students enrolled in three high schools Interested families were contacted and compensated $25 to hear a description of the project, with the goal of selecting a quota sample with a distribution of racial and ethnic groups that approximated that of the U.S. and had equal rates of males and females. As many families were contacted who did not have a 10th grader, an ascertainment rate could not be determined. 85.5% of the families that heard a description of the project expressed interest and participated in the Wave 1 assessment. In Wave 1, scores for the overall sample were compared to comparable national norms of representative samples for eleven measures of adjustment. Our sample was more likely to have tried marijuana (54% vs. 40%); otherwise, sample scores did not differ from national scores on the other 11 measures, including frequency of marijuana usage (see Furman et al., 2009).

Procedure and Selection of Dyadic Sample

The dyadic sample from Lantagne & Furman (2020) was used in the present study. Participants were eligible to invite their romantic partners to participate in our study if the romantic relationship was currently three months or longer. 75.7% of the eligible partners participated (N = 293 of 387). Independent samples t tests were used to assess for differences between the participants whose partner

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participated and those whose partner did not. Those whose partner participated reported more committed relationships, t(387) = 4.37, p = .01 and more dating aggression perpetration and victimization, t(387) = 2.14, p = .01 & t(387) = 2.90, p = .01, respectively. There were no differences in internalizing and externalizing symptoms. The dyadic sample was drawn from the first wave during young

adulthood (Waves 5–8) in which the participant had a romantic partner complete questionnaires. Data were reorganized into scores for males and females and only heterosexual dating couples were included to allow APIM analyses of distinguishable dyads. Ten LGBQ couples were excluded; additionally, seven married couples were excluded. The resulting sample consisted of 127 couples (participants’ M age = 22.04 yrs., range = 19.54—26.87 yrs; average relationship length = 17.77 months, SD = 16.42); 31.5% of the dyads were cohabiting/engaged. 74% were White, non- Hispanic, 7.7% African American, 1.85% Asian American, 12.1% Hispanic,0.7% Native American, and 3.65% biracial. The local Institutional Review Board approved the study. U.S. Department of Health and Human Services Certificates of Confidentiality pro- tected the confidentiality of the data.

Measure

Psychopathology

Each partner completed 35 externalizing and 39 internalizing items from the Adult Self-Report (Achenbach, 1997); the external- izing scale included items about aggressive behavior, rule-breaking, and intrusiveness, whereas the internalizing scale included items about anxiety/depression, withdrawal, and somatic complaints.

Participants rated how descriptive each item was on a 3-point scale ranging from 0 = not true of me to 2 = very true or often true of me. Higher scores indicated greater symptomatology. The ASR has acceptable internal reliability and construct validity (mean Cron- bach’s α= .82 for externalizing & α = .88 for internalizing).

Relationship Characteristics

The following relationship characteristics were included in the present study as moderators. These characteristics were selected from the prior dyadic study by Lantagne & Furman (2020) because they were the theoretically driven measures in our data set that allowed us to examine the constructs of interest and to permit comparisons across the two studies.

Negative Interactions. Each partner completed the Network of Relationships Inventory: Behavioral Systems Version (NRI; Furman & Buhrmester, 2009). Six items assessed negative inter- actions in the romantic relationship, including conflict, criticism, and antagonism (e.g., “How much do you and this person get on each other’s nerves?”). Ratings were made on a 5-point Likert scale ranging from 1 = Strongly Disagree to 5 = Strongly Agree. Items were averaged to create a total score; higher scores represented greater negative interactions; M Cronbach’s α = .91. Validational evidence is presented in Furman & Buhrmester (2009).

Relationship Satisfaction. A version of Norton’s (1983) Qual- ity of Marriage Index was adapted to assess young adult relationship satisfaction. A sample item was “My romantic partner and I have a good relationship.” The measure consists of five 7-point Likert items (1 = Strongly Disagree/Not at all true to 7 = Strongly Agree/Very true), and one 10-point Likert item that assessed overall satisfaction

Figure 2 Actor Partner Interdependence Moderation Model (APIMoMs) for Interaction Between Externalizing Symptoms and Relationship Satisfaction on Dating Aggression

Male Physical Dating Aggression (Y1)

Female Physical Dating Aggression (Y2)

Male Externalizing Symptoms (X1)

Female Externalizing Symptoms (X2)

Male Relationship Satisfaction (M1)

Female Relationship Satisfaction (M2)

Female Externalizing x Female Satisfaction (X2M2)

Male Externalizing x Male Satisfaction (X1M1)

Note. Double-headed arrows represent correlations; e1 and e2 represent residual portion of dating aggression.

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with relationship (1 = Extremely Unhappy, 10 = Extremely Happy). Scores were transformed to a 5-point scale so all items had the same range and averaged to derive a total score, with higher scores indicating greater satisfaction; M Cronbach’s α = .95. The measure has acceptable internal reliability and construct validity (Baxter & Bullis, 1986). Jealousy. Pfeiffer and Wong’s (1989) Multidimensional Jeal-

ousy Scale assessed emotional, cognitive, and behavioral jealousy. Each partner used a 5-point Likert scale (1 = Never to 5 = All the time) to rate 24 items; a sample item was “I suspect my romantic partner may be attracted to someone else”; M Cronbach’s α = .89. The scale has good convergent and discriminant validity (Pfeiffer & Wong, 1989). Relational Styles. The Behavioral Systems Questionnaire as-

sessed romantic relational styles (BSQ; Furman & Wehner, 1999). Each partner used a 5-point Likert scale to rate agreement with 27 statements ranging from 1 = Strongly Disagree to 5 = Strongly Agree. Two scores were calculated based on previous factor analy- ses (see Jones & Furman, 2011): (a) an avoidant score, consisting of the average of 9 dismissing items (e.g., I do not ask my romantic partner to comfort me) and 9 secure items (reverse scored) and (b) an anxious score, consisting of the average of 9 preoccupied items (e.g., I am afraid that my romantic partner thinks I am too dependent). The scales have acceptable internal reliability (M Cronbach’s α = .89 for avoidant & .84 for anxious styles) and validity (Furman et al., 2002).

Physical Dating Aggression

Participants reported on their own and their partner’s use of physical aggression using Simon and Furman’s (2010) adaptation of Kurdeck’s Conflict Resolution Style Inventory (Kurdeck, 1994). Four items assessed physical aggression (Forcefully pushing or shoving, Slapping or hitting, Throwing items that could hurt, and Kicking, biting or hair pulling). The items were similar in content to items on the Conflict Tactics Scale (Straus et al., 1996), but used the CRSI’s 7-point format (ranging from 1=never; 7= always) to assess how often each partner engaged in such aggression in arguments during the past year (M α = .82 for perpetration & .91 for victimi- zation). Higher scores indicated greater frequency of dating aggres- sion. Both partners’ reports were used to yield male physical dating aggression (male self-report & partner report of females, r = .56, p = .001) and female aggression (female self-report & partner report of males, r = .35, p = .001). This measure has demonstrated construct validity over several studies (Collibee et al., 2018; Collibee & Furman, 2016; Novak & Furman, 2016; Simon & Furman, 2010) and finds similar rates of dating aggression as other measures (e.g., 46% of adolescents experienced victimization and 52% perpetration; see Novak & Furman, 2016).

Data Analysis Plan

All variables were examined to ensure acceptable skew and kurtosis (Behrens, 1997), and outliers were Winsorized. Hypotheses were tested using MPlus 8.0 (Muthén & Muthén, 2012). Per guidelines around standardizing dyadic data in SEM (Kenny et al., 2006), predictor and outcome variables were standardized by grand mean centering across the entire sample and dividing by the standard deviation across entire sample. APIMoMs were

conducted to determine whether the effects of an individual’s psychopathology on their own and their partner’s physical dating aggression is stronger depending on the nature of the relationship.

Power was assessed using APIM Power R (Ackerman & Kenny, 2016). Given medium-size effects (β = .30) and an alpha of .05, the power for internalizing and externalizing with 127 dyads is .95 and .96. Power exceeded .80 for β’s of .25 or greater. APIM Power R does not assess interaction effects, but Kenny & Cook (1999) noted that the sample size requirements for multiple regression analyses apply to APIMs estimated via SEM. Thus, we examined the power of interaction effects using Cohen’s (1988) calculations for multiple regression. The estimates of power for the interactions were virtually identical to those for the main effects.

Results

Descriptive statistics and bivariate correlations are presented in Table 1. 24.4% of couples endorsed male physical perpetration and 34.6% endorsed female perpetration. Rates of female and male physical dating aggression were highly correlated, r = .75, p < .001. Regarding clinical cutoffs, 11.8% of our sample were in the clinical range for internalizing symptoms and 9.3% were in the clinical range for externalizing symptoms. Males reported higher levels of externalizing symptoms than females, t(123) = 1.99, p = .04; females reported higher levels of internalizing symptoms than males, t(123) = −3.05, p = .003. Evidence of homophily was found (Hypothesis 1): male and female externalizing symptoms were correlated (r = .28, p < .01) and male and female internaliz- ing symptoms were also correlated (r = .23, p = .02).

Psychopathology

Overall, higher psychopathology was associated with higher physical dating aggression. Female externalizing symptoms had an actor effect on female aggression, and male externalizing symp- toms had an actor effect on male aggression (Hypothesis 2; β = .25, p < .01 & β = .33, p = .001, respectively). Male externalizing symptoms had a partner effect on female aggression as well (Hypothesis 3; β = .40, p < .001). Additionally, male internalizing symptoms had an actor effect on male aggression, and female internalizing symptoms had an actor effect on female aggression (Hypothesis 4; β = .28, p = .001 & β = .21, p = .03, respectively). Both male and female internalizing symptoms had partner effects (Hypothesis 5; β = .39, p < .001 & β = .16, p = .05, respectively).

Regarding actor partner interactions, the product terms of male by female externalizing or internalizing symptoms were then exam- ined. Significant interactions were interpreted using Preacher et al.’s (2006) computational tools. The estimated effect of one individual’s psychopathology on their dating aggression was plotted at three levels of their partner’s psychopathology: low levels (one standard deviation below the mean), average levels (at the mean), and high levels (one standard deviation above the mean). Consistent with our hypothesis (Hypothesis 6), male and female externalizing symptoms interacted to predict both male (β = .14, p = .04) and female aggression (β = .25, p < .001; Figure 3). For couples in which females had average or high externalizing symptoms, male aggres- sion increased as male externalizing symptoms increased, t(121) = 2.94, p < .01 for average female externalizing; t(121) = 3.81, p < .001 for high). Similarly, for couples in which males had average

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or high externalizing symptoms, female aggression increased as female externalizing symptoms increased, t(121) = 3.21, p = .002 for aver- age male externalizing; t(121) = 4.46, p < .001 for high male exter- nalizing). Contrary to hypotheses, there were no interactions between male and female internalizing symptoms.

Relationship Characteristics as Moderators

Relationship characteristics were then examined as moderators of associations between psychopathology and dating aggression.

Product interaction terms were created as follows: (1) female externalizing (or internalizing) symptoms by female relationship characteristic and (2) male externalizing (or internalizing) symp- toms by male relationship characteristic (Figure 2). All product interaction terms were entered after main effects to avoid the limitations of interpreting conditional main effects (Cohen et al., 2003; Little, 2013). Main effects of relationship characteristics were reported in Lantagne and Furman (2020) and thus not presented here. Due to the number of interaction effects found, only significant simple slopes are reported in the text; however, nonsignificant simple slopes are presented as supplemental material.

Female Externalizing Symptoms

Female satisfaction interacted with female externalizing symp- toms to predict female aggression (see Figure 2, β = −.18, p = .02; Hypothesis 11), and female jealousy interacted with female exter- nalizing symptoms to predict female aggression (β = .22, p = .01; Hypothesis 8). As female externalizing symptoms increased, female aggression increased for females with low satisfaction, t(115) = 2.76, p = .01. As female externalizing symptoms increased, female aggression increased for females with high jealousy, t(115) = 2.69, p = .01.

Male Externalizing Symptoms

Male satisfaction interacted with male externalizing symptoms to predict female aggression (see Figure 2, β = −.22, p = .002; Hypothesis 11), and male jealousy interacted with male externaliz- ing symptoms to predict female aggression (β = .18, p = .003; Hypothesis 8). Male anxious styles and negative interactions inter- acted with male externalizing symptoms to predict female and male aggression (β = .16, p = .03 for male anxious styles to male aggression; β = .26, p = .001 for male anxious styles to female aggression; β = .17, p = .007 for male negative interactions

Table 1 Means and Standard Deviations of Psychopathology, and Bivariate Correlations of Psychopathology With Relationship Characteristics and Dating Aggression

Variables 1 2 3 4

Male internalizing symptoms (1) — Female internalizing symptoms (2) .23* — Male externalizing symptoms (3) .63** .24** — Female externalizing symptoms (4) .25** .72** .28** — Male negative interactions (5) .29** .25** .37** .40** Female negative interactions (6) .25** .51** .31** .58** Male satisfaction (7) −.33** −.30** −.27** −.35** Female satisfaction (8) −.29** −.38** −.21* −.40** Male jealousy (9) .37** .11 .31** .21* Female jealousy (10) .18* .44** .26** .49** Male anxious styles (11) .46** .23* .50** .32** Female anxious styles (12) .26** .52** .23* .41** Male avoidant styles (13) .23** .18* .28** .14 Female avoidant styles (14) .11 .15 .14 .15 Male dating aggression (15) .34** .25** .33** .22* Female dating aggression (16) .38** .27** .46** .37** Mean (SD in parentheses) 0.28 (0.24) 0.38 (0.26) 0.33 (0.22) 0.28 (0.22)

Note. The correlations were conducted on the measures prior to standardizing them for the APIM analyses. Please see Lantagne and Furman (2020) for correlations among relationship characteristics and dating aggression. † p < .10. * p < .05. ** p < .01. *** p < .001.

Figure 3 Actor by Partner Interactions Between Male and Female External- izing Symptoms on Male Physical Dating Aggression

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to male aggression; β = .25, p < .001 for male negative inter- actions to female aggression; Hypothesis 9 & Hypothesis 7, respectively). First, as male externalizing symptoms increased, female aggres-

sion increased for males with low or average satisfaction (low t(115) = 5.25, p < .0001 & average t(115) = 4.24, p < .0001). Next, as male externalizing symptoms increased, female aggression increased for males with high or average levels of jealousy (high t(115) = 5.28, p = .0001 & average t(115) = 4.14, p < .0001). For anxious styles, as male externalizing symptoms increased,

female aggression increased for males with high or average anxious styles, t(115) = 4.21, p = .0001 for high & t(115) = 2.58, p = .01 for average. Similar patterns were found for predicting male aggres- sion: as male externalizing symptoms increased, male aggression increased for males with high anxious styles, t(115) = 2.63, p = .01. Finally, as males’ externalizing symptoms increased, female aggression also increased for males with high or average negative interactions, t(115) = 4.95, p <.001 for high & t(115) = 3.30, p < .001 for average. Regarding male physical dating aggres- sion, as males’ externalizing symptoms increased, male aggression increased for males with high negative interactions, t(115) = 2.92, p = .004.

Female Internalizing Symptoms

Female satisfaction and avoidant relational styles interacted with female internalizing symptoms to predict male dating aggression (β = −0.17, p = .008 for satisfaction & β = .23, p = .004 for avoidant styles; Hypothesis 11 & Hypothesis 10 respectively). As female internalizing symptoms increased, male aggression increased for females with low satisfaction, t(115) = 2.47, p = .02. Next, as female internalizing symptoms increased, male aggression increased for females with high or average avoidant styles, t(115) = 4.20, p < .001 for high & t(115) = 2.33, p =.02 for average.

Male Internalizing Symptoms

Male satisfaction and anxious relational styles interacted with male internalizing symptoms to predict female aggression (β = −.30, p = .001 for satisfaction & β = .20, p = .01 for anxious relational styles; Hypothesis 11 & Hypothesis 9 respectively). Male negative interactions interacted with male internalizing symp- toms to predict female and male aggression (β = .30, p < .001 for female aggression & β = .16, p = .01 for male aggression; Hypothesis 7). First, as female internalizing symptoms increased, female

aggression increased for males with low or average satisfaction, t(115) = 3.86, p = .001 for low & t(115) = 2.25, p = .03 for average. Next, as male internalizing symptoms increased, female aggression increased for males with high anxious styles, t(115) = 2.34, p = .02. Finally, as male internalizing symptoms increased, female aggression increased for males with high or average negative interactions, t(115) = 4.71, p = .001 for high & t(115) = 2.29, p < .02 for average. Similarly, as male internalizing symptoms increased, male aggression increased for males with high reports of negative interactions, t(115) = 3.12, p = .002.

Discussion

The present study contributes to the limited work examining associations between psychopathology and dating aggression in young adult couples. Each partner’s psychopathology was associ- ated with their own and their partner’s aggression. Males and females externalizing symptoms interacted to predict both partners’ aggression, placing certain couples at greater risk. Additionally, relationship characteristics interacted with externalizing symptoms to predict female aggression, and with internalizing symptoms to predict partner aggression. Present findings add merit to conceptu- alizing the risk for young adult dating aggression as dyadic, depending on both partners’ psychopathology and the nature of the relationship.

Main Effects of Psychopathology and Actor by Partner Interactions

One goal of the present study was to extend the limited dyadic work examining young adult psychopathology and physical dating aggression. Present findings are largely consistent with existing work on externalizing symptoms (Kim & Capaldi, 2004) and with our second and third hypotheses: males’ externalizing symptoms predicted male aggression and both partners’ externalizing symp- toms predicted female aggression. Whereas existing work has shown that only females’ depressive symptoms predict male aggres- sion (Kim & Capaldi, 2004), present findings were also consistent with our fourth and fifth hypotheses and indicated that both partners’ internalizing symptoms are associated with male and female aggres- sion. Prior research has focused on relationships of high-risk young adult males; the present study may have found different patterns due to greater variability in psychopathology within our community sample. Despite differences, overall findings demonstrate that both partners’ psychopathology are risk factors for male and female physical dating aggression.

Regarding gender, past work has also found that male internaliz- ing symptoms are less influential in predicting dating aggression (Kim & Capaldi, 2004). Notably, the present study demonstrated that both male and female internalizing symptoms predict each partner’s aggression. In fact, both partners’ externalizing symptoms also uniquely predicted male and female aggression, highlighting the importance of a dyadic approach. The present study may have uncovered effects for both males’ and females’ psychopathology because we examined each individual’s risk factor on aggression while controlling for the partner’s effect.

Moreover, consistent with our sixth hypothesis regarding actor partner interactions, rates of aggression were highest when homo- phily occurred and both partners had high levels of externalizing symptoms. Hostile and aggressive patterns of interacting may be more prevalent and prolonged for these couples, as both partners could have lower impulse control and emotion regulation abilities (Capaldi & Kim, 2007; Keenan-Miller et al., 2007). In contrast, when one partner had low levels of externalizing symptoms, the other partner’s level of symptoms was not predictive of aggression. For such couples, the effects of the partner’s externalizing symp- toms on aggression were mitigated. Findings are consistent with existing work, which has found that if an individual pair with a normative partner, adaptive functioning improves, whereas if an

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individual couple with a deviant partner, maladaptive functioning continues (Pickles & Rutter, 1991; Quinton et al., 1993).

Interactions Between Psychopathology and Relationship Characteristics

The present study then examined relationship characteristics as moderators. Male satisfaction and negative interactions interacted with externalizing symptoms to predict male aggression. Female satisfaction and jealousy interacted with externalizing symptoms to predict female aggression. The risk for aggression is high for those with externalizing symptoms; when combined with low satisfaction, high conflict, or high jealousy, it may reach a tipping point where the impulse exceeds inhibition (Reyes et al., 2015). Additionally, con- sistent with our hypotheses on the moderating role of relationship characteristics, male negative interactions, jealousy, anxious styles, and satisfaction interacted with externalizing symptoms to predict female aggression (Hypothesis 7, Hypothesis 8, Hypothesis 9, & Hypothesis 1, respectively). As discussed in our prior dyadic study of this sample (Lantagne & Furman, 2020), such characteristics may be indices of relationship insecurity. Relationships in which males experience both higher insecurity and externalizing behaviors may cultivate a particularly taxing interpersonal context. Such relation- ship dynamics may also challenge the use of effective communica- tion strategies within the dyad (Capaldi et al., 2005). Females have reported that one of the most pervasive explanations for their own aggression is to show anger, which may be salient in such relation- ships (O’Keefe, 1997). Findings for internalizing symptoms were consistent with exist-

ing literature (Longmore et al., 2014), and showed that internalizing symptoms predicted partner aggression, an association that was most pronounced in the presence of negative relationship character- istics. Female avoidant styles and low satisfaction interacted with internalizing symptoms to predict male aggression (Hypothesis 10 & Hypothesis 11, respectively). Male negative interactions, jealousy, anxious styles, and low levels of satisfaction interacted with internalizing symptoms to predict female aggression (Hypothesis 7, Hypothesis 8, Hypothesis 9, & Hypothesis 11, respectively). Inter- nalizing symptoms may impede an individual’s sense of self- efficacy and self-worth, increasing the odds of entering or remaining in an unhealthy relationship (Cleveland et al., 2003; Vezina & Hebert, 2007). Studies suggest that individuals who feel depressed often stay in poor relationships to avoid losing an interpersonal connection (Vicary et al., 1995). Additionally, internalizing symp- toms can impair interpersonal competence (Longmore et al., 2014; Stroud et al., 2008). Indeed, individuals with high internalizing symptoms often demonstrate poor problem-solving in romantic relationships (Vujeva & Furman, 2011). Individuals with poor communication skills or problem-solving abilities, who are also in a romantic relationship with negative characteristics may also experience greater escalation in conflict, resulting in dating aggres- sion (Riggs & O’Leary, 1989). Globally, for couples in which one partner has high internalizing symptoms, romantic interactions are rated by objective outsiders as displaying greater hostility, irritabil- ity, negative affect, and negative communication (McCabe & Gotlib, 1993). Thus, the impact of psychopathology on relationship interactions, when combined with the presence of a negative relationship may result in greater risk.

Across internalizing and externalizing symptoms, seven signifi- cant interactions between relationship characteristics and psycho- pathology were found for males and four for females. Disinhibitory psychopathology has been found to be a unique risk factor for males (Ehrensaft et al., 2003), whereas other factors were uniquely pre- dictive for females. It may be that for males, the combination of psychopathology and relationship characteristics culminates in dis- inhibition, whereas other processes are at play for females. Notably, across genders, the interplay between characteristics and psychopa- thology suggests that not all individuals who experience psychopa- thology are involved in aggressive relationships. Rather, consistent with a theory of multifinality (Cicchetti & Rogosch, 1996), complex combinations of male and female psychopathology and relationship characteristics culminate in both partners’ aggression.

In sum, the interactions between individual and relationship risk factors highlight the interplay across multiple levels of the dynamic developmental systems theory (Capaldi et al., 2012). In a previous study of this same sample (Lantagne & Furman, 2020), we identified a number of relationship characteristics that were dyadic risk factors; here we found internalizing and externalizing symptoms were additional dyadic risk factors. However, the risk for dating aggres- sion is not simply a linear or additive risk: relationship character- istics appear to work synergistically with psychopathology (Moffitt et al., 2001) such that individuals who have high levels of psycho- pathology and who are in stressful relationships are at greater risk for aggression. Present findings are consistent with theories on multiple risk factors, which posit that the presence of any single risk factor for dating aggression can be exacerbated by the presence of additional risk factors (Kim & Capaldi, 2004). Finally, our findings also add merit to conceptualizing risk for dating aggression as dynamic (Collibee & Furman, 2016). The majority of existing studies have examined the risk for dating aggression as an invariant and static factor rather than as a risk that changes over time and across partners. Notably, the degree of current psychopathology and relationship characteristics can vary between and within young adult relationships, underscoring the dynamic nature of risk.

Limitations

The present study had several limitations. First, it was cross- sectional; longitudinal research examining dyadic models of dating aggression over time is needed to test the temporal order of the associations between psychopathology and aggression. Externaliz- ing and internalizing symptoms also tend to co-occur, and indivi- duals who experience both often have the poorest overall adjustment (Capaldi & Stoolmiller, 1999). While participant and partner reports of dating aggression were included, we only incorporated self- reports of predictors. Additionally, our measure of dating aggression assesses a range of conflict tactics but has been used less often in studies of dating aggression. It will be important to replicate the actor and partner effects with other measures such as the Conflict Tactics Scale 2 (Straus et al., 1996).

We conducted a number of statistical analyses and thus, it is likely that some Type I errors may have occurred. Statisticians have persuasively argued that corrections for Type I error do not solve the problem and, in fact, present other problems (Garamszegi, 2006; Nakagawa, 2004; Rothman, 1990; Saville, 1990). Thomas (1998) argues that simply describing which tests of significance have been performed and why is the best way to manage multiple comparisons.

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In that respect, 24 of our 52 tests of actor, partner, and interaction effects were significant. Finally, because the present study drew from a community

sample, there is greater generalizability of our findings than much existing work. However, our sample consisted of early adult couples, and it will be important to replicate findings across adolescence and adulthood to determine developmental differences in associations. Additionally, our study exclusively included het- erosexual couples. Dating aggression is also prevalent among LGBQ couples and it will be imperative to extend dyadic ap- proaches to LGBQ couples.

Research Implications

Findings from the present study lend additional support to the utility of using a dyadic approach to more fully understand the complex relationship among risk factors and dating aggression in young adult couples. Not only were actor and partner effects found, but actor partner interactions were found. The effects of high levels of externalizing symptoms were mitigated when the partner had low levels. Results also demonstrated that the combination of psycho- pathology and poor relationship characteristics substantially increased the likelihood of dating aggression. Our findings under- score that dating aggression should be conceptualized as a multi- determined behavior (Capaldi et al., 2012; Foran & O’Leary, 2008); future studies should expand analyses to include an array of pre- dictors for both male and female dating aggression, as well as the interplay among variables, to further our understanding of this complex phenomenon.

Clinical Implications

Present findings imply that there are several critical points of intervention. One point would be to focus on decreasing psychopa- thology; studies indicate that individuals with lower levels of depression are less likely to be victimized (Halpern et al., 2009). Alternatively, as different patterns of relationship characteristics moderated internalizing and externalizing symptoms, relationship prevention programs that target multiple risk factors may be most effective (Longmore et al., 2014). Finally, findings could shift the focus of existing prevention programs from individuals to young couples (Capaldi & Kim, 2007). Programs may be most effective if targeting both partners’ externalizing symptoms, as present findings indicate risk for dating aggression is higher for couples in which both partners have elevated symptoms.

Conclusion

Taken together, the current study makes several notable con- tributions to the field on young adult physical dating aggression. Findings highlight that both partners’ psychopathology is risk factor. The interplay between partners’ externalizing symptoms underscores that when couples consist of two individuals with high externalizing symptoms, the risk for dating aggression in- creases. Results also demonstrate that psychopathology does not inevitably lead to dating aggression; rather, the co-occurrence of individual and relationship characteristics shapes risk. In sum, by considering combinations of risk factors among couples, researchers may be better able to predict who is at greatest risk for physical

dating aggression, with which partners, and in which relationships (Collibee & Furman, 2016; Reese-Weber & Johnson, 2013).

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Received October 27, 2019 Revision received February 20, 2021

Accepted March 8, 2021 ▪

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https://doi.org/10.1177/019251396017003001

https://doi.org/10.1037/0021-843X.117.1.206

https://doi.org/10.1136/bmj.316.7139.1236

https://doi.org/10.1177/1524838006297029

https://doi.org/10.1006/jado.1995.1020

https://doi.org/10.1177/0886260509334402

https://doi.org/10.1521/jscp.2013.32.6.619

A Dyadic Perspective on Psychopathology and Young Adult Physical Dating Aggression

Outline placeholder

A Dyadic Approach to Dating Aggression
Psychopathology as a Risk Factor
Relationship Characteristics as Moderators
The Present Study
Hypotheses

Method

Participants
Procedure and Selection of Dyadic Sample
Measure

Psychopathology
Relationship Characteristics

Negative Interactions
Relationship Satisfaction
Jealousy
Relational Styles

Physical Dating Aggression
Data Analysis Plan

Results

Psychopathology
Relationship Characteristics as Moderators

Female Externalizing Symptoms
Male Externalizing Symptoms
Female Internalizing Symptoms
Male Internalizing Symptoms

Discussion

Main Effects of Psychopathology and Actor by Partner Interactions
Interactions Between Psychopathology and Relationship Characteristics
Limitations
Research Implications
Clinical Implications
Conclusion

References

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On the transience or stability of subthreshold psychopathology Marieke J. Schreuder*, Johanna T. W. Wigman, Robin N. Groen, Marieke Wichers & Catharina A. Hartman

Symptoms of psychopathology lie on a continuum ranging from mental health to psychiatric disorders. Although much research has focused on progression along this continuum, for most individuals, subthreshold symptoms do not escalate into full-blown disorders. This study investigated how the stability of psychopathological symptoms (attractor strength) varies across severity levels (homebase). Data were retrieved from the TRAILS TRANS-ID study, where 122 at-risk young adults (mean age 23.6 years old, 57% males) monitored their mental states daily for a period of six months (± 183 observations per participant). We estimated each individual’s homebase and attractor strength using generalized additive mixed models. Regression analyses showed no association between homebases and attractor strengths (linear model: B = 0.02, p = 0.47, R2 < 0.01; polynomial model: B < 0.01, p = 0.61, R2 < 0.01). Sensitivity analyses where we (1) weighed estimates according to their uncertainty and (2) removed individuals with a DSM-5 diagnosis from the analyses did not change this finding. This suggests that stability is similar across severity levels, implying that subthreshold psychopathology may resemble a stable state rather than a transient intermediate between mental health and psychiatric disorder. Our study thus provides additional support for a dimensional view on psychopathology, which implies that symptoms differ in degree rather than kind.

Psychopathology is increasingly recognized as a dimensional phenomenon1–5. From such a dimensional perspec- tive, psychiatric disorders reflect the extreme end of a severity continuum ranging from the absence of symptoms to the presence of severe symptoms. Along this continuum lie subthreshold symptoms, which fall short of the diagnostic criteria for a clinical disorder but may still cause burden and functional impairments3,6,7.

A dimensional view on psychopathology implies that the differences between subthreshold symptoms and their full-threshold counterparts are quantitative rather than qualitative. This is supported by studies showing that subthreshold symptoms and full-blown psychiatric disorders have a similar etiology, structure (based on symptom interrelations8), and treatment response (i.e., phenomenological continuity9). For instance, mild psy- chiatric traits and disorders share similar genetic risk factors, illustrated by the finding that 80% of the covariance between subthreshold symptoms and psychiatric disorders is attributable to genetic overlap10. Similarly, the brain regions associated with subthreshold and clinical manifestations of psychopathology are largely overlapping11. Environmental risk factors, such as childhood abuse and stressful life events, have also been related to both sub- and full-threshold expressions of psychopathology6,12 Finally, like psychiatric disorders, subthreshold symp- toms are associated with distress and declined functioning6,7,12,13, which can improve following psychological treatment14. In sum, there is substantive evidence that the distinction between subthreshold symptoms and psychiatric disorders seems to be a matter of degree—e.g., reflected in the number of symptoms and affected individuals—rather than kind15,16.

Subthreshold symptoms are commonly considered clinically relevant not only because of the above-men- tioned similarities to psychiatric disorders, but also because of their prognostic significance1. That is, individuals with subthreshold symptoms are two to five times more likely to develop a psychiatric disorder compared to individuals without such symptoms1,17,18. This implies that, for some individuals, subthreshold symptoms reflect a temporary phase between having no symptoms and having a psychiatric disorder. Yet, longitudinal cohort studies have shown that for the majority of individuals, subthreshold symptoms do not escalate into full-blown disorders. Specifically, the proportion of individuals with subthreshold symptoms that meet the criteria for a psychiatric disorder when assessed several years later ranges between 14 and 35% (depression1,2,19), 14–15% (anxiety1,20), 32% (bipolar disorder21), 25% (psychosis22), and 36–38% (substance abuse1). For other individuals, subthresh- old symptoms may either remit or persist. Such persistence contradicts the common notion that subthreshold symptoms are transient. Instead, subthreshold symptoms could—at least for some individuals—reflect stable

OPEN

Interdisciplinary Center for Psychopathology and Emotion regulation, Department of Psychiatry, University Medical Center Groningen, University of Groningen, Hanzeplein, 19713 GZ Groningen, The Netherlands. *email: [email protected]

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states rather than transient transitionary phenomena. This introduces the possibility of yet another qualitative similarity between subthreshold symptoms and psychiatric disorders: both might be stable phenotypes.

So far, the stability of psychopathological symptoms has mostly been investigated across very short timescales (e.g., hour-to-hour) and relatively long timescales (e.g., year-to-year). The present study aims to investigate the day-to-day stability of psychopathological symptoms across six months using a complex systems perspective23–26. According to this perspective, symptoms might manifest as stable states, for instance labelled as mental health, subthreshold psychopathology, or psychiatric disorder27–29. These stable states—commonly referred to as attrac- tors—can be thought of as the set point to which systems tend to return again and again upon perturbations (i.e., stressful or pleasant events). In healthy individuals, for instance, events may lead to temporary dips or uplifts in mood, but eventually, a state of mental health (i.e., their attractor) is restored. Attractors result from regulatory processes, reflected in interactions between elements of the system (e.g., feedback loops between mental states24). In the presence of strong regulatory processes, systems are resistant to change. This translates to a strong tendency to remain in an attractor (e.g., one with low symptom severity). As regulatory processes weaken, transitions from one attractor to another become more likely. Hence, the stability of an attractor can be inferred from regulatory processes, known as attractor strength30. Strong attractors (or, attractors with high attractor strength) can be considered stable and persistent. Weaker attractors, in contrast, are less stable and may therefore quickly disap- pear. It follows that strong attractors without symptoms of psychopathology can be considered favorable, as they reflect stable mental health. Strong attractors featured by severe symptoms of psychopathology, in contrast, may be unfavorable, as they reflect persistent mental ill-health. Finally, weak attractors can be considered transient conditions that easily disappear.

If subthreshold symptoms indeed reflect a stable attractor that behaves similar to the attractors with low and high symptom severity, the strengths of these attractors should be similar. This would mean that there is no clear association between the symptom severity of attractors (referred to as homebases) and attractor strengths (Fig. 1a). If, on the other hand, subthreshold symptoms reflect more transient phenomena (i.e., temporary states between low and severe symptoms), there should be a quadratic relation between homebases and attractor strengths (Fig. 1b). We investigated this hypothesis in an intensive longitudinal study where 122 at-risk young adults monitored transdiagnostic (subthreshold) symptoms daily for a period of six months. Since subthreshold symptoms are considered diffuse, representing a mix of symptoms from different psychopathological domains, we focused on attractors of overall symptom severity, rather than attractors of specific symptom domains31.

Materials and methods Participants. Participants were recruited from the clinical cohort of an ongoing study, named TRacking Adolescents’ Individual Lives Survey (TRAILS32). At the time of inclusion in the clinical cohort of TRAILS (TRAILS-CC), participants were between 10 and 12 years old and had been referred to mental health care services. Because of this history, they were considered at increased risk to develop mental health problems. Since their inclusion, participants completed bi- or tri-annual follow-up assessments. When TRAILS-CC par- ticipants were approximately 23.6 years old (range 21–24), they were invited to take part in an add-on diary

Figure 1. Illustration of the association between homebases and attractor strengths under two different scenarios. The homebase corresponds to the severity of symptoms that characterize an attractor. (A) If the subthreshold attractor is comparable to the healthy and disordered attractors in strength, there is no clear association between homebases and attractor strengths. (B) If the subthreshold attractor is transient, there is a quadratic relation between homebases and attractor strengths.

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study (TRAILS TRANS-ID). Of the 443 eligible participants, 134 (30.2%) were included in TRAILS TRANS-ID. The present study included the 122 individuals who completed the diary period. A more elaborate description of these participants, as well as other methodological details, has been published elsewhere33. All participants provided written informed consent. This study was approved by the medical ethics committee of the University Medical Center Groningen (reference no. 2017/203). All procedures contributing to this work comply with the ethical standards of the relevant national and institutional committees on human experimentation and with the Helsinki Declaration of 1975, as revised in 2008.

Procedure. Participants completed daily questionnaires every evening for a period of six consecutive months. Each questionnaire consisted of 58 items pertaining to the past day (e.g., ‘Today, I felt tired’) that were rated on a visual analogue scale (VAS) ranging from 0 to 100. These questionnaires, or diaries, were sent via a text messages to participants’ mobile phones. Prior to and immediately after the diary period (i.e., at baseline and post), a semi-structured diagnostic interview was orally administered (mini-SCAN). This interview was used to assess whether individuals met the diagnostic criteria for a DSM-5 disorder (for details on the procedure, please see33). The post assessment covered the entire diary period, and therefore, this assessment was used for sensitiv- ity analyses (see “Data analysis” and Supplement).

Data analysis. The diary procedure yielded a maximum of 183 measurements of 58 mental states per indi- vidual, for 122 individuals (i.e., > 1.2 million observations in total). The data pertaining to the 35 negative mental states assessed in our study—listed in the Supplement—were selected for analyses. Together, these mental states were considered reflective of individuals’ overall symptom severity. We estimated overall symptom severity (sx) for individual i at time t by computing the mean rating across the individual’s negative mental states (ms) at time t, so that sxi,t = Σmsi,t/35. Subsequently, a generalized additive mixed model (GAMM) was fitted34,35. Specifically, symptom severity of individual i at time t was predicted by this individual’s (1) intercept, (2) autoregressive parameter, and (3) non-linear trend in symptom severity over time (for details, see supplementSupplement). This model yielded an estimated homebase and attractor strength for each individual separately, while taking into account each individual’s change in symptoms over time. The homebase is given by the person-specific intercept (which is conceptually similar, but not equal to, the person’s mean), and reflects the symptom sever- ity that characterizes an individual’s attractor36. As such, relatively low homebases can be considered adaptive, while higher homebases may be maladaptive. The attractor strength reflects the regulatory forces that maintain the attractor, and is given by person-specific estimates of the inversed autoregressive parameter (i.e., the effect of symptom severity at t-1 on symptom severity at t)36. This operationalization of homebases and attractor strengths has also been adopted in earlier studies36,37, and can be considered a discrete-time translation of the parameters described in the DynAffect model30 and the PersDyn model38, which are formalized in continuous time.

The relation between homebases and attractor strengths was tested with regression analyses. Specifically, we compared models where attractor strength was predicted by homebase vs. squared homebase (i.e., polynomial regression). This allowed for differentiating between the scenarios displayed in Fig. 1. We repeated these regres- sion analyses in two sensitivity analyses. First, we fitted weighted regressions to account for the uncertainty in the estimates and attractor strengths. The weights in these models were proportional to the sum of the range of the confidence intervals around the homebases and attractor strengths. Second, we checked the effect of (co- morbid) full-blown disorders by omitting individuals who met the criteria for at least one DSM-5 diagnosis from the analyses. This was done to allow for the possibility that mental states, and the stability thereof, might have a different meaning for individuals with versus without psychiatric disorders39. By re-running analyses in individuals without disorders, we could verify whether findings followed from between-individual differences in e.g., the “threshold” for reporting a certain mental state. Individuals with a DSM-5 diagnosis were selected based on the mini-SCAN assessed at post, which covered the presence of psychiatric disorders during the entire diary period. All analyses were performed in R (version 4.0.2) using the package mgcv (version 1.8.33).

Results Participants (N = 122, 56.6% male) were on average 23.64 years old (SD = 0.67, range = 22.26–24.81) and had on average completed 163.39 diary assessments (88.6%, SD = 17.12, range = 116–190). At baseline, 37 individuals (30.33%) met the criteria for at least one DSM-5 diagnosis. After the diary period, 34 individuals (27.87%) had a DSM-5 disorder, of whom 23 (67.65%) were also diagnosed at baseline. Most prevalent were mood disorders (n = 24 and 23 at baseline and post, respectively), followed by anxiety disorders (n = 6 and 12) and ADHD (n = 6 and 8).

The fitted values and the distribution of residuals indicated that assumptions of the GAMM were not violated (see Supplement for details). The GAMM had an adjusted R2 of 77% and yielded homebases that varied between 2.85 and 46.51, with a mean of 17.81 (SD = 9.80). Attractor strengths varied between 1.52 and 28.83 (mean = 4.16, SD = 3.35). Neither homebases nor attractor attractor strengths were related to the within-person variability in observations (Supplement 2, GAMM details). Individuals who met criteria for a DSM-5 diagnosis at post had a higher homebase (mean = 21.57) compared to non-diagnosed individuals (mean = 16.36, t(120) = 2.70, P < 0.01, Cohen’s d = 0.55), but did not differ in terms of attractor strength (mean = 4.26 vs. 4.12, respectively; t(120) = 0.21, P = 0.84, Cohen’s d = 0.04).

Regression analyses indicated that there was no clear association between homebase and attractor strength (linear model: B = 0.02, P = 0.47, R2 < 0.01; polynomial model: B < 0.01, P = 0.61, R2 < 0.01; Fig. 2). This finding did not change after taking into account the uncertainty in the estimates nor after removing individuals with a DSM-5 diagnosis from the analyses (see Supplement).

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Discussion Symptoms of psychopathology have been proposed to lie on a severity continuum, where the absence of symp- toms and psychiatric disorders mark the extreme ends. This has been supported by the notion that subthreshold and full-threshold psychopathological symptoms show a comparable etiology6,9–12 and treatment outcome14. This study investigated the stability of psychopathological symptoms, i.e., their attraction strength, along the severity continuum. We found that the stability of symptoms assessed daily over a period of six months is independent of the severity of symptoms. This provides additional support for a dimensional view on psychopathology, which implies that subthreshold and full-threshold psychopathological symptoms differ in degree (i.e., severity) rather than in kind (e.g., stability). In conclusion, just like some individuals may experience constant mental health or psychopathology, others may get stuck in subthreshold psychopathology. Subthreshold symptoms may thus resemble stable states, rather than transient conditions that mark the progression from relatively healthy towards disordered states (or vice versa).

A dimensional view on psychopathology does not necessarily preclude the existence of discrete, stable states along the severity continuum15,40. Present findings show that such states not only lie on the extreme ends of the continuum—reflecting mental health and mental disorder—but may just as well occupy the regions in between these extremes—reflecting subthreshold psychopathology. It follows that the clinical relevance of sub- threshold symptoms does not just lie in their associated burden3,6,7 and their tendency to precede full-threshold symptoms1,17,18 (their prognostic significance), but also in their stability. Stability here refers to a property of an attractor in a complex dynamic system, namely attractor strength. In the context of psychopathology, an attractor can be considered a set of mental states to which a system tends to return upon perturbations (e.g., pleasant/stressful events23,27,29). An attractor has a certain homebase, which may describe mild vs. more severe psychopathological symptoms, and strength, which reflects the regulatory processes that maintain the attractor. Relatively strong (stable) attractors with low homebase can be considered adaptive, as they illustrate a healthy system that is resilient to external perturbations. In contrast, attractors with higher symptom severity may be maladaptive, illustrated by the current finding that individuals with a DSM-5 disorder had higher homebases than those without a disorder.

We have shown that maladaptive attractors do not differ from more adaptive attractors in terms of strength. Yet, previous work has reported that individuals with a psychiatric disorder may have weaker attractors compared to healthy controls, implying a negative association between attractor strengths and homebases36,37. Similarly, studies that used alternative measures of stability (i.e., adjusted square of successive differences41–43 and prob- ability of acute change42,43) found higher instability in patients compared to controls. However, this difference was likely driven by the standard deviation, meaning that patients and controls may differ primarily in the dispersion of mental states as opposed to the stability of mental states41,44. An explanation for the discrepancy between earlier

Figure 2. Association between the homebase and attractor strength of symptoms of psychopathology. Homebases and attractor strengths were estimated from a generalized additive mixed model using six months of daily diary data from 122 young adults. Individuals who received any DSM-5 diagnosis after the diary period are printed in blue. The black line shows the association between homebases and attractor strengths based on a linear model; the grey line shows the fit of a polynomial model. Neither model indicated an association between homebases and attractor strengths. For illustrative purposes, four outliers (individuals with an attractor strength of > 10) were omitted from this figure. Including these individuals did not change the results (see the Supplemented Figure).

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and present findings could be that the at-risk youth in the present study are more impaired than the healthy controls and/or less impaired than the patient samples in former studies36,37, which in turn may have restricted the ranges in attractor strengths and homebases in the current study. However, the large variability in symptom severity in the present sample suggests that a restricted range of psychopathological symptom severity is unlikely to underlie current findings. Instead, the differences across studies concerning attractor strengths potentially follow from considerable differences in sampling frequency (i.e., assessments with a 1-day interval vs. 15-min/1- h interval) and duration (i.e., 6 months vs. one to two days): while individuals with psychiatric disorders may have a lower hour-to-hour stability of emotions compared to non-affected individuals36,37, their day-to-day stability of mental states may be, as indicated by the current findings, similar. Hence, while stability on a short timescale could be adaptive—for instance because it signals adequate emotional responsivity to environmental cues45—the meaning of stability on a longer timescale depends on the homebase that is maintained. Specifically, stability on a longer timescale can be either adaptive (when it maintains mental health) or maladaptive (when it maintains sub- or full-threshold psychopathological symptoms). In conclusion, the meaning of psychological dynamics—such as the stability of mental states—crucially depends on the timescale under consideration. An important goal for further research is therefore to investigate the timescale at which dynamics such as attractor strengths are informative of psychopathology.

Besides the timescale of assessments, the dynamics of psychopathological symptoms might be affected by the type of symptoms under consideration. It could for instance be hypothesized that certain symptom domains (e.g., anxiety) are more stable than others (e.g., psychosis, mania46). At present, little is known about such between- domain differences: it has been reported that panic disorder and major depression show higher homebases (but similar attractor strengths) compared to borderline, post-traumatic stress and eating disorders37,47, while nega- tive psychotic symptoms may have a stronger attraction (but similar homebase) compared to positive symptoms of psychosis48. However, small sample sizes and methodological heterogeneity preclude firm conclusions. To investigate dissociations between homebases and attractor strengths across clinical stages and psychopathological domains, future studies should aim to include individuals with a wide range of symptoms of varying severity. The current study did so by including youth who experienced a widely varying degree of (mental health) problems and a wide variety of mental states.

It should be noted that although we collected intensive longitudinal data—which allows for addressing within- individual processes, including changes in homebases or attractor strengths over time within individuals—we investigated differences in homebases and attractor strengths between individuals. Our approach fits the notion that the boundaries between mental health, subthreshold psychopathology, and full-threshold psychopathology are based on differences between rather than within individuals. This can be illustrated as follows: if an individual consistently experiences more mental health problems than others (i.e., between-person difference), without ever deviating from their own homebase (i.e., without within-person differences), they can still meet the criteria for a mental disorder. Conversely, another individual who substantially differs from their own homebase (i.e., within-person difference), but not from mentally healthy individuals (i.e., without between-person differences), will not qualify for a mental disorder. Hence, it makes sense to study subthreshold psychopathology at a between- individual level, while adjusting for within-person fluctuations in symptoms over time. Nevertheless, it would be interesting to extend the current work by investigating the within-person association between the severity and stability of psychopathological symptoms. A second consideration is that, unlike the majority of earlier studies on subthreshold symptoms, the present study considered attractors on a continuum of symptom sever- ity, and did not classify individuals into subgroups based on pre-set cut-offs. This is particularly advantageous given the considerable heterogeneity in definitions of “subthreshold” psychopathology that plagues research on this topic7,13,49. Arguably, our decision to not categorize came at the cost of an unclear clinical significance of the homebase estimates, which were based on daily ratings of negative mental states. However, the fact that individuals with a DSM-5 diagnosis had significantly higher homebases than those without a diagnosis sup- ports our inferences. Another potential limitation of the current study is that the aggregation of symptoms into global psychopathology might have obscured domain-specific associations between the homebase and strength of attractors. However, our operationalization was in line with the notion that subthreshold psychopathology may not be domain-specific31, and therefore, fitted with our aim to study the dynamics of symptoms of varying severity. Finally, our estimates of attractor strengths require that the timescale of assessments (daily) matches the timescale of the process of interest (i.e., strength of attraction, or the speed with which a homebase is restored). This issue is not specific to the current study, but rather applicable to all intensive longitudinal studies: within- person dynamics (including homebases and attractor strengths) can only be estimated with sufficient sampling frequency50. Although the present timescale (daily) is in line with our interest in long-term stability of symp- toms—as opposed to momentary fluctuations in emotions41,44—further work on the role of timescales in studies on symptom dynamics is hopefully awaited (for a recent example, see Sperry and Kwapil42).

The lack of an association between homebases and attractor strengths found in the present study implies that individuals can get stuck anywhere on the severity continuum. Attractors do not, however, eternally persist: they may change over time, and such changes may involve a shift from subthreshold to full-threshold psycho- pathological symptoms or vice versa. Future research is needed to establish what triggers such shifts. After a shift towards a maladaptive attractor (one with a high homebase) has occurred, it is imperative to understand what maintains the attractor. A complex systems perspective on psychopathology implies that attractors emerge from interactions between mental states—meaning that individuals with stronger attractors would be expected to show greater connectivity between mental states24. An alternative avenue for further research concerns the comparison of attractors of different domains of psychopathology, which could expose how specific domains progress and persist, and may inform treatment.

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Received: 14 July 2021; Accepted: 18 November 2021

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Acknowledgements We thank everyone who contributed to this study.

Author contributions M.J.S. and R.N.G. collected data. M.J.S. performed analyses and interpreted results together with J.T.W.W. and C.A.H. M.J.S. drafted the manuscript. M.W. collected funding. All authors revised the manuscript and approved of the final version.

Funding The infrastructure for the TRacking Adolescents’ Individual Lives Survey (TRAILS) is funded by the Nether- lands Organization for Scientific Research (NWO), ZonMW, GB-MaGW, the Dutch Ministry of Justice, the European Science Foundation, the European Research Council, BBMRI-NL, and the participating universities. Additionally, this research was supported by the Netherlands Organization for Scientifc Research (NWO) (R.N. Groen, research talent Grant Number 406.16.507 and J.T.W. Wigman Veni Grant Number 016.156.019), and the European Research Council (ERC) under the European Union’s Horizon 2020 research and innovative program (M. Wichers, Grant Number 681466).

Competing interests The authors declare no competing interests.

Additional information Supplementary Information The online version contains supplementary material available at https:// doi. org/ 10. 1038/ s41598- 021- 02711-3.

Correspondence and requests for materials should be addressed to M.J.S.

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On the transience or stability of subthreshold psychopathology

Materials and methods

Participants.
Procedure.
Data analysis.

Results
Discussion
References
Acknowledgements

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Describing disorder: The importance and advancement of compositional explanations in psychopathology

Hannah Hawkins-Elder and Tony Ward Victoria University of Wellington

Abstract Understanding the makeup of mental disorders has great value for both research and practice in psychopathology. The richer and more detailed our compositional explanations of mental disorder—that is, comprehensive accounts of client signs and symptoms—the more information we have to inform etiological explanations, classification schemes, clinical assessment, and treatment. However, at present, no explicit compositional explanations of psychopathology have been developed and the existing descriptive accounts that could conceivably fill this role— DSM/ICD syndromes, transdiagnostic and dimensional approaches, symptom network models, historical accounts, case narratives, and the Research Domain Criteria (RDoC)—fall short in critical ways. In this article, we discuss what compositional explanations are, their role in scientific inquiry, and their importance for psychopathology research and practice. We then explain why current descriptive accounts of mental disorder fall short of providing such an explanation and demonstrate how effective compositional explanations could be constructed.

Keywords composition, description, explanation, symptoms, theory

Mental disorder represents a serious and expanding global health problem; demonstrat- ing high prevalence internationally (Steel et al., 2014) and accounting for a considerable proportion of global disease burden (Whiteford et al., 2015). Being able to assess and treat these problems effectively is therefore critically important. Researchers and clini- cians also have an ethical obligation to seek accurate understandings of mental disorders, so as not to provide mistaken accounts of people’s genuine concerns. Both goals rely

Corresponding author: Hannah Hawkins-Elder, Victoria University of Wellington, Kelburn Parade, Wellington, 6140, New Zealand. Email: [email protected]

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heavily on the explanations we have for mental disorders: our theoretical accounts of how they originated and why they persist.

Explanations are invaluable: they tell us what to look for in assessment, what to target in treatment, and how to do so successfully. At present, however, psychopathological explanations are often unsound: constructed in idiosyncratic ways and containing numer- ous conceptual flaws (see Hawkins-Elder & Ward, 2020a, 2020b,). The comprehensive description of explanatory targets—known as compositional explanation—is signifi- cantly underemphasized, and often neglected, in psychopathology (Gillett, in press). Describing the nature of psychopathological symptoms and signs holds significant value for explanation, classification, research, and practice (Wilshire et al., in press). Despite this, no explicit compositional explanations of psychopathological phenomena have been created and existing descriptive accounts present relatively poor alternatives; lack- ing sufficient depth, theoretical structure, or evidence base.

Current diagnostic syndromes provide only a short list of vaguely defined “core” features (e.g., DSM-5, American Psychiatric Association, 2013; ICD-11, World Health Organization, 2019), thereby limiting the richness of information theorists possess about the disorder. Alternative classificatory perspectives, such as transdiagnostic, dimensional, and symptom network models, although in some cases providing greater taxonomic validity, still fail to richly describe psychopathological problems at all the relevant levels. In contrast, more “clinical” descriptions, such as historical accounts (i.e., the first identification or early scientific conceptualizations of a disorder) and clinical case narratives (e.g., case studies) tend to describe disorders in more depth, but lack detail and theoretical organization and are often empirically outdated. The Research Domain Criteria (RDoC; Cuthbert & Insel, 2013) is perhaps the current option that most closely approximates a compositional explanation. However, criti- cally, this framework is not geared towards the theoretical conceptualization of psy- chopathological phenomena and therefore, although excellent at guiding empirical investigation into psychopathology, is unable to provide coherent compositional expla- nations—at least, not on its own.

Our intentions with this article are therefore threefold. First, to highlight the impor- tance of compositional explanations of psychopathology by outlining their role in scien- tific inquiry and clinical practice. Second, to demonstrate that none of our current descriptive accounts (i.e., DSM/ICD syndromes, transdiagnostic and dimensional classi- fications, symptom network models, historical accounts, case narratives, and the RDoC) are capable of successfully acting as compositional explanations. Finally, based on this discussion, to suggest how we could construct effective compositional explanations of psychopathology.

Compositional explanations: What they are and what they do

In this section, we discuss the nature of compositional explanations and their role in scientific inquiry and clinical practice. However, we first must clarify what we mean by “explanation.”

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What is an “explanation”?

There is some disagreement in science over what exactly constitutes an explanation, as well as how exactly explanations relate to models and theories. Trout (2016) provides a simple and helpful definition of explanation: “an explanation is the description of under- lying causal factors that bring about an effect” (p. 18). More specifically, an explanation is an account that provides an understanding of a phenomenon’s causes, composition, context, or consequences (Faye, 2014; Ruphy, 2016). Models and theories, in contrast, are conceptual representations of phenomena in the world: tools that can be put to the task of explanation (Mantzavinos, 2016; Savulescu et al., 2020).

For our purposes, a theory is an integrated system of concepts and ideas that can be used to explain why some phenomena occur and persist. Theories are more general than models, usually detailing more abstract phenomena (e.g., “human behaviour” in general vs. specific types or instances) and able to explain different subsets of phenomena (Bailer-Jones, 2003). Models, in contrast, represent more concrete empirical phenomena (i.e., identified factors, systems, or processes such as “clinical depression” or “binge eat- ing”); typically, in idealized and simplified ways (Bailer-Jones, 2003; Haig, 2014). Theories may inform the development of models, and models may represent localized applications of theories (Bailer-Jones, 2003). For example, the coercion cycle model represents the localized application of operant conditioning theory to the phenomenon of child conduct problems (Dishion & Patterson, 2015).

We define an explanation herein as the entire bank of explanatory knowledge about a phenomenon—that is, the most complete explanatory account (Craver & Kaplan, 2020). A model or theory may serve as an explanation if it represents the entire bank of knowl- edge about a phenomenon: when it adequately represents all aspects of the phenomenon without being overly complicated or sacrificing critical detail. However, this is rarely the case. More often, models and theories represent partial explanations (Bailer-Jones, 2003). When the phenomenon of interest is more complex, multiple theories and models will typically be needed to fully explain it (Kendler et al., 2020).

What are compositional explanations?

Philosophers of science make a distinction between causal and compositional explana- tions (e.g., Craver, 2007; Kaiser & Krickel, 2016). A causal explanation depicts the fac- tors that result in a subsequent effect—for example, heating water (a cause) until it boils (an effect). A psychopathological example is the proposition that traumatic experience can cause individuals to experience intrusive memories, elevated arousal, and avoidance behaviour (i.e., a “posttraumatic stress” syndrome). Causal explanations in psychopa- thology may also include accounts of relations that maintain the disorder, such as mutual reinforcement between symptoms (e.g., insomnia and low mood; Konjarski et al., 2018) or behavioural reinforcement “cycles” (e.g., the coercion cycle; Dishion & Patterson, 2015).

In contrast, a compositional explanation describes underlying structures and interac- tions that make up a phenomenon; viewed as part of it rather than “causing” it (Craver, 2007; Gillett, in press; Kendler et al., 2020). For example, the symptom “low mood” is

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likely to be composed of processes at the phenomenological, subpersonal, neurobiologi- cal, and physiological levels (Ward & Clack, 2019). It is important to note that composi- tional explanations may, in some cases, contain causal relations, depending on the phenomenon being explained. For example, a compositional explanation of a syndrome, like clinical depression, would necessarily include description of causal relations between symptoms (e.g., low mood and insomnia), as these relationships are part of the constitu- tion of that syndrome (although arguably do not cause it). However, these same relations could form part of an etiological explanation depending on the focus of inquiry. For instance, if, instead of describing the composition of depression, we were trying to explain the development and persistence of low mood in depressed individuals, we might ascribe causal or etiological significance to insomnia somewhere within that explana- tion, but we would not say that insomnia in any way constituted low mood. Hence, the role of factors and processes within an explanation varies depending on the question being asked.

What is the role of compositional explanation in theory, research, and practice?

Compositional explanations play a critical role in all aspects of clinical inquiry. First, they hold significant value for etiological explanation. The more detailed our composi- tional understanding of a phenomenon, the more information we have to provide clues about its etiology (Hawkins-Elder & Ward, 2020b). For example, if we were trying to explain the existence of a cake—knowing only that it was a cake—we could reason that its etiology probably involved components and processes common to most cakes (e.g., flour, sugar, being baked). However, with further detail about how it is composed—for example, chocolate sponge, cream-filled—we have additional clues to help refine our etiological reasoning; strengthening ideas about the involvement of some factors and processes (e.g., flour, being baked) and suggesting new ones (e.g., whipping cream, cocoa). When our compositional understandings are “thin” (less detailed) it can promote errors in causal reasoning: relevant causal factors and processes may be neglected or deliberately omitted, and flawed or irrelevant ones may be included. For example, we could develop multiple etiological theories about our cake, hypothesizing various baking processes, when all the while we were dealing with an ice cream cake—a type of cake indeed, but one involving none of our postulated causal processes.

Compositional explanations also hold value for research and practice. Their primary value for research is via classification. Although compositional explanations are attempts to describe disorder phenomena, they do not claim to know the best method of classify- ing the psychopathological phenomena with which they are concerned. However, because of their informational value, compositional explanations are highly useful for those aiming to develop taxonomies of mental disorder (Wilshire et al., in press): their rich descriptions may help to signal connections between syndromes or symptoms, and thereby suggest novel and improved ways of organizing them. Compositional explana- tions lay out the psychopathological landscape in comprehensive detail, allowing it to be thoroughly surveyed by those who wish to classify it.

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In clinical practice, compositional explanations hold value for both assessment and treatment. For one, their value for etiological explanations and classification systems has flow-on effects for assessment and treatment. Improvement of classification systems will likely be beneficial for diagnosis and the prescription of appropriate clinical interven- tions. Likewise, better etiological explanations will likely improve clinical formulations and intervention strategies based on them. Compositional explanations also hold inde- pendent value for clinical practice. Possessing more information about a psychopatho- logical problem provides us with more features to look for in assessment. It may also help identify potential therapeutic issues. For example, knowing that a particular disor- der often involves cognitive inflexibility or poor attentional control might contraindicate interventions requiring high levels of cognitive effort. Likewise, knowing that a particu- lar symptom involves difficulty sensing physical sensations may influence how an inter- vention is administered (e.g., devoting extra time during a mindfulness intervention to helping the client identify physical sensations).

Current “approximate” compositional explanations

There are several types of account within the psychopathology space that, due to their descriptive nature, could potentially serve as compositional explanations: namely, (a) DSM-5/ICD-11, (b) transdiagnostic and dimensional approaches, (c) symptom network models, (d) historical accounts, (e) clinical case narratives, and (f) the Research Domain Criteria (RDoC) framework. We will now address each in turn and explain why, on our view, none effectively serve as compositional explanations.

Diagnostic syndromes: DSM-5 and ICD-11. The DSM-5 (American Psychiatric Associa- tion, 2013) and ICD-11 (World Health Organization, 2019) are perhaps the most promi- nent attempts to conceptualize and describe mental disorders. Both group disorders into discrete syndromes (collections of symptoms and signs) comprising a set of diagnostic criteria (e.g., borderline personality disorder, anorexia nervosa). They are frequently used as compositional explanations in research and theory: empirical inquiry is often oriented around DSM-5 categories and etiological models commonly use them as the foundation for explanation. However, these syndromes fall short of providing a compo- sitional explanation in two important ways.

First, DSM/ICD syndromes lack explanatory scope. Each is characterized by a rela- tively small number of descriptively “thin” criteria spanning but a few levels of analysis (e.g., behavioural, cognitive, emotional). For example, the criteria for anorexia nervosa (listed in Table 1) describe only a few features, despite research identifying many others common to these individuals, such as alexithymia (Nowakowski et al., 2013; Westwood et al., 2017), interoceptive deficits (Stinson, 2019), cognitive deficits (Hedges et al., 2019), and autistic traits (Westwood et al., 2016). Furthermore, both the DSM and ICD outline only those features that are most clinically salient—that is, those most readily observable in practice or perceived as “most central” to the disorder’s pathology. Although appropriate and often useful in practice, this omits other relevant features that may be harder to identify (e.g., emotional comprehension, executive functioning,

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interoceptive ability) or have less apparent relevance (e.g., attentional bias, central coher- ence), but are nonetheless characteristic of the disorder.

Second, DSM/ICD syndromes lack explanatory depth, as the features/symptoms listed by them are typically thinly described. For instance, “disturbance in the way in which one’s body weight or shape is experienced” (American Psychiatric Association, 2013, p. 339) is a necessary criterion for anorexia nervosa (see Table 1), however there is no detail about the exact nature of this “disturbance.” For example, is it a distortion in sensory perception or cognitive evaluation (Mölbert et al., 2017)? Does it encompass the body in general or does it tend to be focused on specific areas (Cash & Deagle, 1997)? Body image is recognized to be a “multi-faceted construct consisting of a variety of measured dimensions” (Thompson, 2004, p. 8), including perceptual, conceptual, and

Table 1. DSM-5 diagnostic criteria for anorexia nervosa and bulimia nervosa.

DSM criteria: Anorexia Nervosa

A. Restriction of energy intake relative to requirements, leading to a significantly low body weight in the context of age, sex, developmental trajectory, and physical health. Significantly low weight is defined as a weight that is less than minimally normal or, for children and adolescents, less than that minimally expected.

B. Intense fear of gaining weight or of becoming fat, or persistent behaviour that interferes with weight gain, even though at a significantly low weight.

C. Disturbance in the way in which one’s body weight or shape is experienced, undue influence of body weight or shape on self-evaluation, or persistent lack of recognition of the seriousness of the current low body weight.

Specifiers: Restricting type: during the last 3 months, the individual has not engaged in recurrent episodes of binge eating or purging behaviour (i.e., self-induced vomiting or the misuse of laxatives, diuretics, or enemas). This subtype describes presentations in which weight loss is accomplished primarily through dieting, fasting, and/or excessive exercise. Binge-eating/purging type: during the last 3 months, the individual has engaged in recurrent episodes of binge eating or purging behaviour (i.e., self-induced vomiting or the misuse of laxatives, diuretics, or enemas). DSM criteria: Bulimia Nervosa A. Recurrent episodes of binge eating. An episode of binge eating is characterized by both of

the following: 1. Eating, in a discrete period of time (e.g., within any 2-hour period), an amount of food that

is definitely larger than what most individuals would eat in a similar period of time under similar circumstances.

2. A sense of lack of control over eating during the episode (e.g., a feeling that one cannot stop eating or control what or how much one is eating).

B. Recurrent inappropriate compensatory behaviours in order to prevent weight gain, such as self-induced vomiting; misuse of laxatives, diuretics, or other medications; fasting; or excessive exercise.

C. The binge eating and inappropriate compensatory behaviours both occur, on average, at least once a week for 3 months.

D. Self-evaluation is unduly influenced by body shape and weight. E. The disturbance does not occur exclusively during episodes of anorexia nervosa.

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emotional (Stinson, 2019). Therefore, the precise nature of any proposed “disturbance” would need to be more specifically detailed.

Transdiagnostic approaches and dimensional approaches. Transdiagnostic approaches advocate dispensing with existing diagnostic syndromes in favour of broader classifica- tions based on shared characteristics. In some cases, this involves collapsing said syn- dromes into a broader disorder category (e.g., anxiety disorders), in others basing classification on some common factor (e.g., the internalizing/externalizing model; Krue- ger & Eaton, 2015). Dimensional approaches are based around spectra or “scales” rather than discrete categories, such as the Five Factor Model of personality disorders (Widiger & Costa, 2013). Approaches may be both dimensional and transdiagnostic, such as the Hierarchical Taxonomy of Psychopathology (HiTOP) model: a hierarchical organization of mental disorder, consisting of transdiagnostic spectra at the top (e.g., general psycho- pathology, internalizing/externalizing) and syndromal subfactors (e.g., eating problems), shared symptoms/signs, and traits at progressively lower levels (see Kotov et al., 2017).

Although transdiagnostic and dimensional approaches may provide useful alternative means for classifying psychological problems, they do not necessarily describe psycho- pathological phenomena any more fully than diagnostic syndromes. In some cases, they even provide weaker descriptions. For example, the internalizing/externalizing model, although highlighting links between diagnostic categories and thus traversing arbitrary diagnostic boundaries, provides even less information about mental disorders. Describing a problem as an “internalizing disorder,” although useful for some purposes, gives very little information about its precise nature (e.g., whether it involves anxiety, mood, eating, etc.), or the minutiae of its presentation (i.e., the factors and mechanisms that comprise the problem). The HiTOP model provides somewhat more information than diagnostic syndromes thanks to its hierarchical structure, which conceptualizes psychopathological problems at both more general levels (e.g., spectra levels) and more specific levels (e.g., symptoms, signs, and traits). However, this model still lacks the richness of information necessary for a compositional explanation: symptoms, signs, and traits are not broken down into lower level factors or mechanisms, nor are any relevant relationships between them modelled. Furthermore, although disorders are conceptualized at broader, transdi- agnostic scales, they are not described contextually at higher levels of analysis (e.g., sociocultural, interpersonal, political); layers of meaning necessary to fully comprehend any psychopathological problem.

Symptom network models. The network theory of mental disorder proposes that psycho- pathological symptoms should be conceptualized as causing each other (e.g., persecu- tory delusions resulting in paranoia, subsequently leading to social withdrawal) rather than caused by an underlying “disease” process (e.g., delusions, paranoia, and social withdrawal as arising from a common cause, such as a neurobiological dysfunction or genetic mutation; Borsboom, 2017). Symptom network models (SNMs) apply this the- ory to specific syndrome clusters—often, but not always, DSM/ICD syndromes. A net- work structure is generated by depicting the causal links between symptoms of that condition, including their strength and direction (Borsboom, 2017). SNMs can also model the relationships between symptoms across disorders (e.g., eating disorders and

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depression/anxiety; Smith et al., 2018), which makes them particularly useful in account- ing for comorbidity (Fried et al., 2017). However, although SNMs provide a useful and interesting description of psychopathological symptom relationships, they still fail to provide effective compositional explanations.

SNMs, like DSM/ICD syndromes, lack explanatory scope and depth. Although the relationships between symptoms are elaborated within these models, the nature of the symptoms themselves is not fully explained: each is represented largely at the phenom- enological level, rather than at each level of analysis (e.g., molecular, neural, physiologi- cal, cognitive/psychological, interpersonal, sociocultural). For example, anhedonia, a key symptom of depression, can be represented at the phenomenological level as involv- ing both decreased “liking” and decreased “wanting,” at the cognitive level as a reduced hedonic capacity, reduced reward motivation, and errors in reward learning, at the neural level as dysfunction in the “hedonic network” and mesolimbic pathways, and at the molecular level as reductions in opioid and dopaminergic activity (see Clack & Ward, 2020). Compared to a full analysis such as this, the descriptions of symptoms given in SNMs are significantly underpowered. They may act as partial compositional explana- tions, certainly—as models depicting the relationships between psychopathological symptoms—but lack the depth of detail required to fully explain the constitution of the disorders with which they are concerned.

Historical accounts. We refer here to descriptions of disorder states that accompanied the first identification of a psychiatric syndrome or were developed around the time of the DSM-III (published in 1980), which represented a paradigm shift towards our current conceptualization of mental disorders (Mayes & Horwitz, 2005). Examples include Rus- sell’s (1979) initial characterization of bulimia nervosa and Bruch’s (1973, 1978/1982) early descriptive accounts of anorexia nervosa,1 considered the first “modern descrip- tion” of the disorder (Marks, 2019). These sorts of accounts typically consist of a set of clinical case studies from which the author draws broader conclusions. For example, Russell’s (1979) initial characterization of bulimia nervosa involved 30 patients, three of whom were presented as illustrative case studies, from which he drew conclusions about the disorder’s typical features, such as demographics, symptomology, medical complica- tions, and psychopathological correlates. These accounts are often more descriptively comprehensive than the classificatory approaches above. However, they are nevertheless unsuitable to serve as compositional explanations.

Most problematic is that their explanatory scope extends beyond composition. Although they do describe the presentation of a disorder—as a compositional explana- tion should—they often branch into hypothesizing its etiology as well. For example, as well as describing the disorder’s presentation, Bruch’s (1978/1982) account of anorexia nervosa makes numerous etiological claims—for example, “the child’s inability for con- structive self-assertion and the associated deficits in personality development are the outcome of interactional patterns that began early in life” (p. 37)—including several chapters highlighting precipitating factors and speculating on the causal role of family dynamics (e.g., chapters “The Perfect Childhood” and “How It Starts”). Although this information may hold relevance in a clinical context, theoretically it conflates the theo- retical tasks of compositional and etiological explanation. Although these tasks are

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related—each informing the other—they are conceptually distinct, requiring different modes of theoretical reasoning: causal versus compositional (see above). Attempting to achieve both within a single account is therefore likely to create convolution and pro- mote logical errors, thereby impairing the integrity of each task.

Historical accounts also tend to lack empirical foundation: being either the first or one of the earliest descriptions of a disorder, there was typically little empirical research to inform their construction. They are therefore most often based on a small number of case studies which, although potentially the best option available at the time, falls short of modern scientific standards. For example, there is typically extensive sampling bias: samples are generally comprised solely of the author’s existing patients, and therefore (due to reduced access to psychiatric treatment at the time; Mechanic, 2007) likely to be skewed towards those of higher socioeconomic status and European descent. Furthermore, cases are often aggregated in pseudoscientific or anecdotal ways to illustrate the author’s points, rather than analysed in a valid statistical manner.

There has been little structured effort to update or expand such accounts in line with contemporary research, despite many still being used to inform it. Although some aspects of historical accounts can now be empirically verified, there are still many claims that current research fails to support or actively refutes. For example, Bruch’s (1978/1982) account of anorexia nervosa describes the disorder as affecting “the daughters of well-to- do, educated, and successful families, not only in the United States but in many other affluent countries” (p. vii), implying that anorexia nervosa exclusively affects WEIRD populations (i.e., Western Educated Industrialized Rich Democratic; Henrich et al., 2010). However, research now indicates anorexia nervosa is not a culture-bound syn- drome (Keel & Klump, 2003; Pike et al., 2014), and shows no reliable association with ethnicity or socioeconomic status (Hadassah Cheng et al., 2018; Schaumberg et al., 2017).

Finally, as with DSM/ICD syndromes, historical accounts tend to refer to only the most salient features of a disorder (i.e., the phenomenological level) and therefore neglect those that are more deep-seated and less easily observed (e.g., neural network dysfunc- tion, alterations in hormone or neurotransmitter systems), though nonetheless relevant.

Case narratives. Case narratives are often provided to students and clinicians in text- books or treatment manuals to demonstrate how a disorder typically presents. Their descriptions usually include information about the characteristic symptoms and signs, demographics (e.g., age, gender), relevant history (e.g., familial, medical, psychiatric), and triggers for that disorder. For example:

Anna, a 15-year old girl of European descent, presented with extreme weight loss and low appetite. Her BMI had fallen from 19 (healthy for her age group) to 16 within the last six months, such that she was substantially underweight. A recent check-up revealed no underlying medical explanations for her weight-loss. Anna’s mother reported she had been refusing to join family meals, confining herself often to her bedroom, and eating a drastically reduced diet. She had also stopped spending as much time with friends and increased her exercise regime significantly—running for 1–2 hours every day, in addition to competitive swimming training. When her parents expressed their concerns to Anna, she tended to either burst into tears or

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shout at them. Anna was unconcerned about her weight-loss and denied that her eating or exercise behaviour was a problem. She expressed significant body dissatisfaction and drive for thinness, complaining she was “too fat” and wishing she were thinner. According to her mother, Anna had had many challenges throughout her development and had previously seen a child psychologist for anxiety.

As with both diagnostic syndromes and historical accounts, case narratives tend to refer only to features of the disorder that are most clinically salient. For example, the exemplar above refers largely to the phenomenological experience of the client, Anna, and neglects to include information about any physiological, neural, or molecular pro- cesses. This makes sense given that such accounts are intended as prototypical examples of clinical presentation, and in practice one would not routinely engage in the methods of investigation required to identify more deep-seated structural phenomena (e.g., fMRI, CSF sampling). However, as previously discussed, it significantly limits their explana- tory value.

Furthermore, although case narratives refer to significantly more features of the dis- order than most classificatory approaches, they still lack depth in their descriptions. They fail to go into any features in detail—relying on brief, superficial descriptions despite the fact that these constructs are often multidimensional (e.g., body image; see above)—and continue to refer to the thinly defined constructs entrenched within psychopathological research (e.g., “drive for thinness,” “body image dissatisfaction”). Case examples are also just that: examples. Each presents a specific instance of a disorder. Hence, although many features may be represented, it is unlikely that all features relevant to the disorder will be included, as real-life cases seldom (if ever) present with every feature associated with the condition.

The Research Domain Criteria (RDoC). The RDoC is a clinically independent research framework intended to guide empirical investigation into psychological mechanisms (Cuthbert & Insel, 2013). It was developed as a reaction to the publication of the DSM-5, which many perceived as being a conservative development on the previous edition (DSM-IV) that retained many of the problems originally identified (e.g., reification;2 Whooley, 2014). The RDoC presents an “alternative nosological framework” (Whooley, 2014, p. 100) that seeks to advance psychopathology research—specifically, neurobio- logical investigation (Cuthbert & Insel, 2013; Whooley, 2014). The RDoC assumes that mental disorders are “brain disorders” born out of dysfunctions in neural circuitry, and therefore aims to build a nosology of mental disorder from the “bottom-up” using current neuroscience research (Cuthbert & Insel, 2013; Whooley, 2014). The hope is that by doing so we will develop more valid diagnostic categories, anchored in neurobiology (Lilienfeld, 2014; Whooley, 2014).

The RDoC framework provides a two-dimensional “matrix” to guide psychopathol- ogy research, consisting of six psychological “domains” of investigation—(a) negative valance systems (e.g., threat, loss), (b) positive valence systems (e.g., approach motiva- tion, reward learning), (c) cognitive systems (e.g., attention, working memory), (d) sys- tems for social processes (e.g., attachment, social communication), (e) sensorimotor systems (e.g., action selection, initiation, execution, habit development), and (f) arousal/

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modulatory systems (e.g., sleep-wake, arousal)—as well as seven “units of analysis”— (a) genes, (b) molecules, (c) cells, (d) neural circuits, (e) physiology, (f) behaviour, and (g) self-report (Cuthbert & Insel, 2013; Lilienfeld, 2014). The RDoC assumes that men- tal disorders result from disruptions in the normal-range functioning of these processes and thus applies basic understandings of psychology and neuroscience to psychopatho- logical problems (Lilienfeld, 2014).

It is important that the role of the RDoC within the scientific inquiry process be accu- rately understood. The RDoC is a research framework intended to scaffold investigation into psychological processes—both their function and dysfunction—in order to obtain insight into psychopathology and thereby “inform future classification schemes [empha- sis added]” (Insel et al., 2010, p. 748). Hence, although able to generate substantial data about psychological and psychopathological processes, the RDoC does not work to con- ceptualize these theoretically—that is, to create a coherent compositional account that links these findings together in relevant and meaningful ways. It therefore does not directly produce compositional explanations.

Even if it did include such a synthesis, the RDoC matrix is not directly geared towards studying psychopathological processes. Although intended to provide insight into mental disorder, one of the core philosophies of the RDoC is that investigation should be directed towards broader psychological processes (e.g., positive valence systems, cognitive sys- tems)—how they both function and malfunction, and thereby may contribute to the development and maintenance of mental disorder—rather than specific psychopatho- logical problems (Cuthbert & Insel, 2013). Hence, the picture developed by the RDoC framework is more likely to be a comprehensive understanding of these systems— including their role in psychopathology—rather than synthesized descriptions of particu- lar mental disorders. This is not to say the RDoC cannot contribute valuably to the development of compositional explanations—the wealth of compositional data the framework has the power to generate would have great value for their construction. However, it is critical to note that the RDoC also encompasses etiological investigation (e.g., genetic research), and does not clearly distinguish between these two processes. As previously discussed, this conflates two distinct theoretical tasks (i.e., causal vs. compo- sitional explanation) and may lead to problems farther along in the explanatory process.

The RDoC is also significantly neurocentric; asserting that mental disorders be con- sidered “brain disorders” born out of dysfunctions in neurocircuitry (Cuthbert & Insel, 2013; Lilienfeld, 2014; Whooley, 2014). Although this approach has some benefits—for example, highlighting the role of neurobiological processes in mental disorder (at times discounted or neglected) and providing a platform for investigating neurobiological aspects of psychopathology—it largely sidelines other levels of explanation (e.g., phe- nomenological, sociocultural) despite their equal relevance to mental disorder. Of the seven “units of analysis” prescribed by the RDoC, five are biologically based—genes, molecules, cells, neurocircuitry, physiology—implying that neurobiological factors hold far greater explanatory weight (Lilienfeld, 2014).

Furthermore, even though one of the investigative domains concerns social/interper- sonal phenomena (i.e., systems for social processes), broader sociocultural structures and influences are not addressed within the framework. Cultural factors are well-evidenced

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as playing a significant role in multiple aspects of psychopathology (e.g., etiology, main- tenance, symptom expression) and we would argue that mental disorders cannot be understood independently of their social and cultural context. For example, some symp- toms associated with posttraumatic stress disorder can be viewed as adaptive when viewed within specific contexts, including the precipitating trauma event (e.g., hyper- vigilance, physical hyperarousal, and emotional detachment may be useful in combat situations). Hence, even though the RDoC might lead to richer neurobiological under- standings of psychopathology, it also risks decontextualizing mental distress such that lower levels of analysis (e.g., cellular, neural) are not considered within the broader context of the problem and higher levels (e.g., psychological, phenomenological, socio- cultural, etc.) end up significantly underspecified despite their explanatory relevance (Whooley, 2014).

Building better descriptions

As we have seen, current options for compositional explanation are insufficient; failing to demonstrate the necessary empirical adequacy, depth, and scope. In this section there- fore, we demonstrate how we believe effective compositional explanations could be con- structed. To begin, we first outline the theoretical framework used to guide these ideas: the Phenomena Detection Method (PDM; Ward & Clack, 2019).

Guiding framework: The phenomena detection method

The PDM (Ward & Clack, 2019) is a metatheoretical framework for the detection and modelling of “clinical phenomena” (e.g., symptoms) which is not dependent on existing classification systems such as the DSM-5 or ICD (discussed above). Critically, it empha- sizes the importance of developing compositional explanations of symptoms, making it highly relevant to the current problem. It has four phases: (1) formulating client com- plaints and/or accompanying signs, (2) discerning and analysing patterns in data related to these symptoms (i.e., detecting clinical phenomena), (3) constructing multiple models of the phenomenon using different levels or units of analysis, and (4) linking in etiologi- cal factors to develop causal explanations. Phases 1–3 are relevant to the construction of compositional explanations and thus inform our reasoning in this section.

Another important aspect of the PDM is its promotion of, and adherence to, a plural- istic account of scientific explanation, which states that scientific explanations should involve a collection of theoretical models that represent the constitution or causes of a symptom at and across different spatial and temporal scales, instead of trying to repre- sent everything using a single model. This approach is known as model pluralism and has been widely recognized as a promising way forward in both the biological and social sciences, in which the phenomena of interest are of a high level of complexity (Hochstein, 2016; Mitchell & Dietrich, 2006; Potochnik, 2010; Ruphy, 2016). The PDM endorses this by prescribing the construction of multiple compositional or causal models of the explanatory target at a range of spatial scales and levels of abstraction.

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From syndromes to symptoms

A key impediment to current descriptive accounts acting as compositional explanations is the fact that most are built around DSM/ICD syndromes, which are widely acknowl- edged to possess numerous conceptual flaws, such as symptomatic heterogeneity and rampant comorbidity (e.g., Nielsen & Ward, 2020; Whooley, 2014). Building composi- tional explanations using these constructs is therefore problematic: any resultant descrip- tion, no matter how rich or detailed, will lack a certain amount of validity as the very construct being described is conceptually flawed. Continuing to use these constructs theoretically also further entrenches them in research and practice, thereby impeding the development of better classificatory approaches. Hence, on our view, the first step towards building better compositional explanations is to transition away from these syn- dromes as the foci of explanation.

Several theorists argue that, to move forward, psychological explanation should, at least for now, focus on symptoms rather than syndromes (Berrios, 2013; Borsboom, 2017; Ward & Clack, 2019; Wilshire et al., in press). For instance, instead of trying to describe and explain the syndrome bulimia nervosa, which comprises a cluster of diverse symptoms, one would instead focus on a single symptom of that pathology, such as binge eating. This approach makes sense conceptually, as symptoms and signs have greater validity than DSM/ICD syndromes; arguably representing genuine phenomena as opposed to artificial categories. Compared to these syndromes, symptoms have more defined boundaries, less heterogeneity, and greater stability. For example, the symptom binge eating is more obviously distinct from other symptoms (e.g., self-starvation, purg- ing) than the syndrome bulimia nervosa is from other eating disorder diagnoses (e.g., anorexia nervosa). A client shifting from this symptom presentation to an alternative presentation (e.g., self-starvation) or to a state of recovery is also likely to be much more psychologically meaningful than a transition from one eating disorder diagnosis to another, which can currently be accomplished by changes in arbitrary factors like BMI. Practically, it is also useful to reduce the scope of our explanatory focus: it is much easier to detail the composition of a single symptom than a large and diverse collection of them (i.e., a syndrome).

Symptoms and signs also make for more appropriate foci at an ethical level, as they represent the actual concerns of clients: each is a valid and important aspect of the cli- ent’s difficulties that we should aim to understand. At the coarser grain size of syn- dromes, although we are getting a concise and practical account, we may neglect the description and explanation of some symptoms in favour of providing a brief and uncomplicated overall account. At finer grain sizes, such as the neurobiological (e.g., the RDoC), although generating useful and detailed information that can be used to inform theoretical conceptualization of clinical phenomena, we are no longer centring our accounts on client problems—which arguably should be our paramount concern as clinicians—and risk decontextualizing their distress (Whooley, 2014). Although to fully describe symptoms we no doubt need to investigate and describe phenomena at smaller scales (e.g., neurobiological, molecular) and consider their relationship to other symptoms (e.g., syndromes, symptom networks), we argue that the appropriate

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starting point for compositional explanations should, at least for now, be psychopatho- logical symptoms.

Starting with data

Compositional explanations should be constructed using empirical evidence: reasoning abductively from data to identify constructs and processes relevant to the phenomenon in question (Haig, 2014). This begins with an unbiased gathering of relevant data—for example, cross-sectional research from a variety of disciplines involving those present- ing with that symptom/sign—that is of high methodological quality—for example, RCTs, meta-analyses, systematic reviews, methodologically rigorous single studies— which is then mined for patterns that might represent compositional constructs or pro- cesses (Hawkins-Elder & Ward, 2020b).

For instance, within the symptom binge eating, we may theorize the existence of the phenomenon impaired inhibitory control based on meta-analyses and systematic reviews showing that individuals who exhibit binge eating demonstrate poorer performance on planning (e.g., Farstad et al., 2016), decision-making (e.g., Guillaume et al., 2015; Wu et al., 2016), and set-shifting tasks (e.g., Wu et al., 2016), higher self-reported impulsiv- ity (e.g., Farstad et al., 2016; Steward et al., 2017), and frequent engagement in other impulsive or reckless behaviours (e.g., self-harm, substance abuse; Peebles et al., 2011). Having a range of different, and methodologically robust, data all pointing to the exist- ence of impaired inhibitory control means we can be more confident that this phenome- non is genuinely present, rather than the false product of biased reasoning or methodological error. A full model constructed in this manner will therefore be a more accurate representation of the phenomenon of interest.

Multilevel explanation

Compositional explanations should describe their phenomenon at all relevant levels of analysis—for example, molecular, neurological, cognitive, phenomenological, interper- sonal, contextual/sociocultural, and so forth. Indeed, Zachar (2008) describes psycho- pathological phenomena as structures with “many overlapping levels” and argues that “having alternative models better reflects the domain of psychiatric disorders” (pp. 339– 340). Compositional explanations should therefore be similarly multilevel in order to adequately reflect this.

To accomplish this, we recommend building models in a “stacked” format, beginning with the phenomenological level (at which the symptom/sign is reported/observed) and moving outwards, considering each level of analysis in turn, to identify factors and pro- cesses that might be constitutionally relevant. This is useful because factors and pro- cesses at one level may partially constitute or be otherwise related to those at another and building outwards in this manner may help the researcher to make these connections.

Consider the symptom binge eating: at the phenomenological level, we can recount how this symptom is experienced by the client based on self-report data from empirical research: privacy is important (secretive eating; Lydecker & Grilo, 2019), emotion is often involved (emotional eating; e.g., Leehr et al., 2015; Ricca et al., 2012), individuals

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typically perceive a lack of control over their eating (e.g., Colles et al., 2008), and may experience strong physical hunger and hedonic craving for food (e.g., Ng & Davis, 2013; Witt & Lowe, 2014; see Figure 1). From this level, we can then consider factors and processes suggested by empirical research at lower levels that may comprise this symp- tom. For example, at a cognitive level, the reported hunger and craving could be repre- sented as a heightening of appetite3 (see Figure 1). This may be partially constituted at the physiological level by an impaired appetite feedback system (e.g., imbalances in hunger and satiety hormones, Culbert et al., 2016; altered vagal nerve transmission, Peschel et al., 2016) and at the neurological level by interoceptive network deficits (e.g., insular dysfunction, Gasquoine, 2014; Klabunde et al., 2017) and alterations in reward pathways (e.g., Avena & Bocarsly, 2012; Frank, 2013; Wierenga et al., 2014). Further down at the molecular level, serotonin dysregulation (e.g., Compan et al., 2012) may be partially responsible for the experience of hunger surrounding a binge (due to its role in appetite regulation; e.g., Lam et al., 2010), and the experience of intense craving may be influenced by dysregulation in opioid and dopaminergic systems implicated in reward and addiction (e.g., Berridge, 2009; Majuri et al., 2017). At a higher level, it is also worth considering how sociocultural factors may influence how the symptom is experienced (e.g., enabling or inhibiting certain behaviours, altering symptom content). For instance, overeating, for metabolic or hedonic reasons, is somewhat dependent on socioeconomic food security (e.g., Anderson-Fye, 2018), as food must be available in reasonable abun- dance for it to be overconsumed. Similarly, the content of cravings is likely to be influ- enced by the individual’s cultural environment (e.g., Osman & Sobal, 2006).

We can conduct the same process for each aspect of a symptom to build a multilevel explanation of its constitution (see Figure 1). Such an explanation provides a rich descrip- tion of the symptom, as it details the relevant factors and processes at all levels and considers how these may comprise or influence each other.

Detailing domains

An adequate compositional explanation should describe all aspects of the phenomenon in a high level of detail. One way of doing this is to build smaller compositional models of constructs “nested” within the larger account. This helps to avoid overcomplicating the broader model with specifics, allowing it to present a streamlined overview, but ensures that all constructs are sufficiently outlined and the overall explanation is descrip- tively rich.

Consider the multilevel model of binge eating previously sketched out: although this model provides a good overview of constitutional factors and processes at each level, the constructs referred to within each domain are still in need of further definition. By con- structing nested “submodels” of these phenomena, we can more clearly define the factors and processes invoked and thereby enrich the overall account. For example, consider heightened appetite (identified at the cognitive level). Based on the literature, we can construct a more detailed compositional submodel of this construct (see Figure 2).

Individuals who binge eat are more sensitive to the effects of reward (e.g., Harrison et al., 2010; Wierenga et al., 2014), including reward from food (e.g., Schag et al., 2013). They are therefore likely to have greater hedonic hunger (e.g., Witt & Lowe, 2014) than

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nonbinge-eating individuals. Binge eaters also demonstrate impaired satiety (e.g., Sysko et al., 2007). Their metabolic hunger is therefore also likely greater, as they have less indication when they are full. Finally, binge eaters reliably demonstrate poorer interocep- tion—ability to sense and interpret internal sensations—than nonbinge eaters (e.g., Jenkinson et al., 2018; Klabunde et al., 2017). They may therefore struggle to detect physical cues, including appetitive signals, and accurately interpret them, sometimes misattributing physical sensations as hunger or satiety. This may make it harder for them to appropriately modulate eating behaviour according to their body’s metabolic needs (e.g., Herbert & Pollatos, 2018).

Submodels at one level can also be linked to submodels at other levels to further enrich the explanation. For example, we might construct a physiological submodel of the impaired appetite feedback system (see Figure 3), involving alterations in the baseline levels and responses of appetitive hormones (e.g., Culbert et al., 2016; Prince et al., 2009), increased gastric capacity and delayed gastric emptying (e.g., Klein & Walsh,

Figure 1. Illustration of a multilevel approach to compositional explanation, using the symptom binge eating.

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2004), and decreased ascending vagal nerve transmission (e.g., Simmons & DeVille, 2017). This can then be linked to the cognitive model by relating the lower level physi- ological processes to those at the higher level. For example, the impaired satiety described at the cognitive level is likely partially constituted by these hormonal and gastric differ- ences (see Figure 3; e.g., Berthoud, 2008; Zanchi et al., 2017). Aberrant hormonal func- tioning could also partially comprise the increased sensitivity to food-related reward due to the influence of some hormones on dopaminergic networks (e.g., leptin; Cassioli et al., 2020). Vagal nerve dysregulation may likewise play a part in impaired interoception, as it plays a key role in transmitting sensory information from the body to the brain (Craig, 2002). This kind of intermodel linking further enriches the overall compositional picture, contributing to a more in-depth account of the symptom’s composition.

Conclusion

In this article, we suggested how better compositional explanations could be constructed by focusing on symptoms rather than syndromes, using empirical research, and creating detail-rich models spanning all levels of analysis. At present, we lack theoretically ori- ented and descriptively rich accounts of how psychopathological problems are consti- tuted. The absence of these compositional explanations is of significant concern, as they hold genuine value for both research and practice. The kind of nested modelling outlined above is a good example of how originally conceptually thin phenomena can be elabo- rated into rich, multilayered compositional accounts. Developing a network of composi- tional models at different levels of analysis may yield insight into the structures and processes constituting disorders that could, ultimately, result in stronger etiological explanations, more accurate taxonomies, and more precisely targeted treatment. In our view, greater attention to the compositional explanation of psychopathological symp- toms is a crucial step towards ameliorating the social costs and personal suffering of mental illness.

Figure 2. Example of a compositional submodel within the symptom binge eating, detailing the nested cognitive phenomenon heightened appetite.

Hawkins-Elder and Ward 859

Acknowledgements

The authors would like to thank the EPC Lab at Victoria, as well as Alexander Moses for his assis- tance in designing the figures for the paper.

Declaration of Conflicting Interests

The authors declare that there is no conflict of interest.

Funding

The authors received no financial support for the research, authorship, and/or publication of this article.

ORCID iDs

Hannah Hawkins-Elder https://orcid.org/0000-0002-3511-3908 Tony Ward https://orcid.org/0000-0002-6292-2364

Figure 3. Example model linking cognitive (heightened appetite) and physiological (impaired appetite feedback system) submodels within the symptom binge eating.

https://orcid.org/0000-0002-3511-3908

https://orcid.org/0000-0002-6292-2364

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Notes

1. The most well-known of these being her book The Golden Cage: The Enigma of Anorexia Nervosa (Bruch, 1978/1982), first published in 1978.

2. Reification refers to the process of considering or representing an abstract concept or idea as a material or concrete entity (Hyman, 2010).

3. “Appetite” refers to an individual’s drive to eat, for either hedonic or metabolic purposes (Booth, 2003).

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Author biographies

Hannah Hawkins-Elder, BSc (Hons), is a PhD and clinical psychology student in the school of psychology at Victoria University of Wellington. Her thesis focuses on the explanation of disor- dered eating; specifically, taking a metatheoretical approach to how explanations of eating disor- der phenomena are constructed and utilized in practice. Her recent publications include “The Explanation of Eating Disorders: A Critical Analysis” in Behaviour Change (2020) and (with T. Ward) “From Competition to Co-Operation: Shifting the ‘One Best Model’ Perspective” in Theory & Psychology (2021).

Tony Ward, DipClinPsyc, PhD, is a professor of clinical psychology in the school of psychology at Victoria University of Wellington, New Zealand. He has over 430 research publications and his current research focuses on the development of explanatory models in psychopathology and foren- sic psychology. His recent publications include “Why Theoretical Literacy is Essential for Forensic Research and Practice” in Criminal Behaviour and Mental Health (2020), “The Classification of Crime: Towards Pluralism” in Aggression and Violent Behavior (2020), and “Modeling the Symptoms of Psychopathology: A Pluralistic Approach” in New Ideas in Psychology (2020).

Professional Psychology: Research and Practice Examining Cognitive Performance and Psychopathology in Individuals Undergoing Parental Competency Evaluations Christian Terry and Len Lecci Online First Publication, December 23, 2021. http://dx.doi.org/10.1037/pro0000436

CITATION Terry, C., & Lecci, L. (2021, December 23). Examining Cognitive Performance and Psychopathology in Individuals Undergoing Parental Competency Evaluations. Professional Psychology: Research and Practice. Advance online publication. http://dx.doi.org/10.1037/pro0000436

Examining Cognitive Performance and Psychopathology in Individuals Undergoing Parental Competency Evaluations

Christian Terry and Len Lecci Department of Psychology, University of North Carolina Wilmington

In the determination of parental fitness, or competency of an individual to care for a child, psychological assessments are often utilized. Moreover, research suggests that parental competency examinees are distinct from child custody examinees with respect to psychopathology and should be studied as a separate group. To that end, the present study examined the cognitive functioning of 136 parental competency examinees who were undergoing court-ordered evaluations, as well as examined the relationship between cognitive functioning (as assessed by the Wechsler Adult Intelligence Scale-IV [WAIS-IV]) and psychopathology (as assessed by the Minnesota Multiphasic Personality Inventory-2 [MMPI-2]). Overall, the parental compe- tency sample had lower education and lower cognitive functioning (particularly Full Scale Intelligence Quotient [FSIQ] and Working Memory Index [WMI]) than the normative sample. MMPI-2 scores paralleled those of previous findings for parental competency examinees, and MMPI-2 Scales 8, 0, and 7 were significantly related to WAIS-IV performance, with lower cognitive scores associated with greater psychopathology. Implications include recognition of the role that cognitive functioning may play in parents being referred for parental competency evaluations, the interaction of comorbid psychopathology and lower cognitive functioning, as well as informing treatment recommendations for individuals with co-occurring psychopathology and cognitive deficits.

Public Significance Statement Parental competency examinees appear to have significantly lower scores in overall intellectual functioning and working memory on the Wechsler Adult Intelligence Scale-IV (WAIS-IV) relative to normative values, and lower cognitive functioning was found to be associated with higher psychopathology on Minnesota Multiphasic Personality Inventory-2 (MMPI-2) scales related to unusual thoughts/attitudes, social isolation, and anxiety. These findings indicate co-occurring psychopathology and cognitive deficits in those referred for parental competency evaluations and this can inform treatment recommendations.

Keywords: parental competency evaluation, psychopathology, cognition, MMPI-2, WAIS-IV

In evaluating parental fitness, or competency of an individual to care for a child, psychological assessments are often utilized to aid in this determination (Budd, 2001; Conley, 2004). Two formal assess- ments that may be included as part of a parental competency test battery are the Minnesota Multiphasic Personality Inventory-2 (MMPI-2; Butcher, 2010) and the Wechsler Adult Intelligence Scale-IV (WAIS-IV; Wechsler, 2008). Despite the MMPI-2 and WAIS-IV being among the most commonly administered psycho- logical assessment instruments in the United States (Ball et al., 1994), there has been limited research on their relationship with one

another. Indeed, although it has been shown that psychopathology predicts executive functioning (Snyder et al., 2015), it is unclear whether MMPI-2 scores meaningfully relate to WAIS-IV perfor- mance and how this may manifest specifically for parental compe- tency examinees. Moreover, little is known regarding cognition in individuals referred for parental competency evaluations. The pres- ent study seeks to examine the following three issues in a parental competency sample: (a) levels of cognitive functioning as assessed by the WAIS-IV, (b) psychopathology as assessed by the MMPI-2, and (c) the potential overlap among these constructs. Thus, the

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Christian Terry https://orcid.org/0000-0002-3904-0371 CHRISTIAN TERRY received his MA in psychology from the University of

North Carolina Wilmington (UNCW). He is presently completing his internship at Larned State Hospital in Larned, Kansas to attain his PhD in clinical psychology from UNCW. His areas of professional interest include clinical neuropsychological assessment, psychological assessment, and mindfulness-based interventions. LEN LECCI received his PhD in clinical psychology from Arizona State

University. He is presently a professor of psychology at the University of

North Carolina Wilmington and director of clinical services at MARS Memory-Health Network. His research and clinical work focuses on assess- ment, memory disorders, concussion, health anxiety, and bias. The authors have no known conflicts of interest to disclose. Anonymous data used in this study are available at the following link:

https://osf.io/7j6rx/?view_only=baae7d98065a4c47b996c14d34b1b5b1. CORRESPONDENCE CONCERNING THIS ARTICLE should be addressed to Len

Lecci, Department of Psychology, University of North Carolina Wilmington, P.O. Box 5612, 601 S College Road, Wilmington, NC 28403, United States. Email: [email protected]

Professional Psychology: Research and Practice

https://orcid.org/0000-0002-3904-0371

https://osf.io/7j6rx/?view_only=baae7d98065a4c47b996c14d34b1b5b1

https://doi.org/10.1037/pro0000436

purpose of this investigation is to highlight the value of a broader psychological assessment that includes cognitive testing for parental competency evaluations, as both cognitive difficulties and their comorbidity with psychopathology can otherwise be overlooked (Meyer, 2002).

Parental Competency Evaluations and Intellectual Functioning

The process of evaluating competency of an individual to parent is complex. As McGaw et al. (2010) outline, it is typically the case that parents undergo a competency evaluation secondary to con- cerns related to neglect rather than intentional abuse. The neglect often co-occurs with and/or stems from substance use or other mental health disorders (Resendes & Lecci, 2012), and the latter can include intellectual limitations. Although ranges for Intellectual Quotients (IQ) were previously

used to categorize individuals into mild, moderate, and severe levels of intellectual disabilities using the fourth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV; American Psychiatric Association, 1994), the most recent edition of the DSM removes IQ ranges as a criterion and instead emphasizes the consideration of other aspects of client functioning in relation to their objective cognitive performance to aid in diagnoses (American Psychiatric Association, 2013). Using the new criteria, the severity of an individual’s intellectual disability is determined based on their cognitive performance (Criterion A), evidence that these cognitive deficits are impairing the individuals’ ability to function (Criterion B), and onset of these deficits within the developmental period (Criterion C). Thus, while IQ testing can aid in documenting impaired cognitive performance (Criterion A), identifying that an individual’s intellectual functioning is such that they may be unable to care for a child may also contribute to meeting Criterion B. Of course, this interpretation is made only when comparing multi- ple sources of evidence, as IQ testing alone is insufficient to determine high-risk versus low-risk parents (McGaw et al., 2010). Moreover, given the potential comorbidity of cognitive limitations and psychopathology, it is imperative to elucidate the relation between psychopathology and cognition in parental com- petency examinees. Unpacking this relationship may aid any psychological assessor in considering the intersection of cognition and psychopathology in their patients and making appropriate recommendations for needed interventions and prognosis for change. Originally, it was argued that parental competency and custody

examinees are functionally equivalent (Stredny et al., 2006). How- ever, more recent research has determined that there are fundamental differences at least in regard to psychopathology as measured by the MMPI-2 (Resendes & Lecci, 2012). Specifically, competency ex- aminees relative to child custody examinees tend to exhibit a different pattern of defensiveness (elevated L, but lower K), more inconsistent responding (elevated variable response inconsis- tency [VRIN]; true response inconsistency [TRIN]), more unusual responses (elevated F and Fb), and psychopathology related to social introversion, depressive symptoms, difficulty incorporating and accepting societal standards, and unusual thoughts or attitudes (i.e., elevated MMPI-2 Scales 0, 2, 4, and 8, respectively, with differences reflecting large effect sizes ranging from Cohen’s d values of 1.01–1.21).

According to Resendes and Lecci (2012),

parental competency evaluations typically involve a legal intervention by a government agency in order to protect the child (e.g., allegations of abuse, neglect, etc.), and criminal charges may co-occur. In contrast, child custody evaluations are civil cases that largely involve parental disagreement about legal and/or physical custody, without necessarily involving problems with the basic parenting abilities of either par- ent. (p. 1055)

In the former, the utilization of both cognitive and psychopatho- logical assessment is necessary to answer referral questions, such as those related to neglect that may occur secondary to cognitive limitations (e.g., WAIS-IV) and psychological/substance use dis- orders (e.g., MMPI-2).

Cognitive Functioning and Psychopathology

With respect to the overlap between psychopathology and cog- nitive abilities, poorer cognitive functioning is often a specific symptom of a psychological disorder (e.g., diminished concentra- tion in major depressive disorder [MDD], disorganized speech and behavior in schizophrenia). Further, the literature consistently shows that greater psychopathology is associated with lower exec- utive functioning. For instance, Stordal et al. (2005) determined that those experiencing more depressive or schizophrenia-related symp- toms as measured by the Brief Psychiatric Rating Scale-Expanded (Overall & Gorham, 1962) and the General Psychopathology Subscale of the Positive and Negative Syndrome Scale (Kay et al., 1987) exhibited poorer executive function skills as measured by the Wisconsin Card Sorting Test (Heaton et al., 1991), Stroop Color Word Test (Stroop, 1992), Paced Auditory Serial Addition Test (Gronwall, 1977), Digits Backwards subscale of the WAIS-IV (Wechsler, 2008), and Controlled Oral Word Association Test (Benton et al., 1994). Gass (1991) found that anxiety, as measured by MMPI Scale 7, significantly predicted poorer performance on the Speech Perception Test of the Halstead–Reitan (Broshek & Barth, 2000) above and beyond age and education. In all though, other MMPI clinical scales were generally not associated with cognitive performance in their sample of veterans.

Snyder et al. (2015) performed a comprehensive literature review of studies assessing the relationship between various psychopathol- ogies and executive functioning, including inhibition, attentional shifting, updating, and working memory. They identified that the diagnosis of schizophrenia was the strongest predictor of diminished performance for each of these constructs of executive functioning, and that bipolar and MDD inversely predicted executive function, albeit to a lesser degree. Findings were mixed on the relationship between anxiety and executive functioning (Snyder et al., 2015), and for MDD, the findings corroborate research explicitly focusing on the WAIS-IV (Wechsler, 2008). Finally, the initial validation of the WAIS-IV included investigating the cognitive abilities of “special groups” (Wechsler, 2008), one of which was individuals diagnosed with MDD. Results indicated that those with MDD scored lower than matched controls on the Processing Speed Index (PSI; Cohen’s d = .26), and these findings align with prior research (Gorlyn et al., 2006).

Only one known study has directly assessed WAIS profiles of parental competency examinees (McCartan & Gudjonsson, 2016). Researchers analyzed 144 individuals who were evaluated for

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parental competency in the U.K. (i.e., Child Care Proceedings) and who were administered the WAIS-III. Results indicated that their parental competency sample had Full Scale Intelligence Quotient (FSIQ) scores just over 1 SD (M = 83.64) below the normative sample (M = 100, SD = 15). The study also assessed gender differences in personality and psychopathology as measured by the Millon Clinical Multiaxial Inventory, 3rd Edition (MCMI-III) but did not assess the association between cognition and psychopa- thology. This review turns now to the only known studies to directly evaluate the relationship between psychopathology assessed with the MMPI and cognitive performance as measured by the WAIS. Gass and Gutierrez (2017) sought to compare the MMPI-2 with

the WAIS-IV in male veterans using the content scales of the MMPI-2. Inclusion criteria for the MMPI-2 were that they com- pleted at least 557 of the 567 items, did not respond randomly or display a response bias (i.e., VRIN and TRIN < 80 T), did not exaggerate symptoms (i.e., F < 90 T, Fb < 100 T), and did not respond defensively (i.e., K < 60 T). Because the researchers performed correlation analyses between the WAIS-IV indices and MMPI-2 content scales, they condensed the 15 MMPI-2 content scales into three factors of Internalized Emotional Dysfunction (IED; e.g., low self-esteem, low energy, depression), Externalized Emotional Dysfunction (EED; e.g., antisocial attitudes, aggres- siveness, poor anger control), and Fear (i.e., physical health worries, paranoia, and intense fearfulness). None of the WAIS-IV indices correlated with IED and EED, however the Fear factor was signifi- cantly inversely correlated with Perceptual Reasoning Index (PRI), Verbal Comprehension Index (VCI), and FSIQ. The authors also found that those with T-scores greater than 64 on the MMPI-2 Fear factor scales performed more poorly on the VCI and FSIQ indices relative to those with T-scores below 56. It was noted that the Fear factor correlated most strongly with clinical Scales 8, 7, and 3 (Gass & Gutierrez, 2017). Contrary to Gass and Gutierrez’s (2017) findings, Morasco et al.

(2006) found no significant relationships among WAIS-III indices and MMPI-2 clinical scales in a sample of young adults receiving psychoeducational evaluations. Thus, it appears that there is limited and inconsistent evidence of any association between these two frequently employed measures, and the findings may be specific to the population under investigation.

The Present Study

Although research has established connections between specific disorders and executive function abilities, limited research has assessed whether degree of psychopathology (as opposed to the dichotomous presence/absence of a disorder) may influence cogni- tion more broadly. Further, explorations of the relationship between psychopathology and cognition have been very limited in parental competency samples, and past research examining the association between WAIS and MMPI scores (e.g., Gass & Gutierrez, 2017) may have been limited by employing stringent validity cutoff scores. The latter issue may be especially relevant for parental competency evaluations, as some degree of defensiveness has been documented in such samples (e.g., Resendes & Lecci, 2012). Moreover, average L scale scores for child custody examinees have also been shown to be as high as 60 (Bagby et al., 1999, as cited in Graham, 1990). Given the high comorbidity of psychopathology in those with lower cognitive functioning (Peña-Salazar et al., 2018), it is critical to

examine the interaction of comorbities in psychological examinees, especially given that psychopthology and cognitive difficulties can both individually and in combination undermine functional abilities, including with respect to parenting. Further, the effect of these comorbidites on treatment outcomes should be considered when providing treatment recommendations. Thus, the present study seeks to document the cognitive (WAIS-IV) scores of parental competency examinees, their level of psychopathology as assessed by the MMPI-2, and overlap thereof by making the following predictions:

1. Given that cognitive limitations are sometimes noted among the referral questions from Child Protective Services, average WAIS-IV performance for the competency sample is predicted to be below that of the normative sample across all WAIS-IV indices and subscales. Lower WAIS scores (by approximately 1 SD) would replicate the findings from a similar U.K. sample (McCartan & Gudjonsson, 2016).

2. To evaluate representativeness with respect to psychopa- thology, the present competency sample will be compared to scores obtained in previous parental competency samples (Resendes & Lecci, 2012; Stredny et al., 2006). It is predicted that (a) the present sample will generally align with prior samples and (b) that the present competency sample will be significantly different from Bathurst et al.’s (1997) custody sample across all MMPI-2 validity and clinical scales, reinforcing the argument that competency and cus- tody examinees require separate interpretive considerations with respect to psychopathology.

3. We will explore correlations among WAIS-IV indices and MMPI-2 clinical scale scores. Based on prior findings regarding MDD and diminished PSI performance, it is predicted that greater scores on MMPI-2 clinical Scale 2 will predict poorer performance on the WAIS-IV PSI beyond age and education (Gorlyn et al., 2006). Further, the relationship between MMPI-2 Scale 8 and WAIS-IV performance will be explored, given prior findings indicating a negative relationship between thought disorders (e.g., schizophrenia) and cognitive functioning (Snyder et al., 2015; Stordal et al., 2005).

Method

Participants and Procedure

Participants were 136 individuals aged 19–67 (Mage = 31.93, SD = 8.93) whom the court system required to complete a psycho- logical evaluation to aid in the determination of parental compe- tency. The majority already had their child(ren) removed from the home due to concerns from Child Protective Services that one or more problematic circumstances may be present which limit the individual’s ability to parent. These circumstances included sus- pected domestic violence (41.9%), substance use (56.6%), child neglect (37.5%), physical abuse (14%), sexual abuse (6.6%), psy- chiatric instability (44.9%), and cognitive incompetence (14.7%). (Note: These reflect nonmutually exclusive concerns, as 73% of individuals had more than one listed problem). Participants were predominantly female (70.6%) and Caucasian (53.7%), followed by

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PARENTAL COMPETENCY WAIS-IV AND MMPI-2 SCORES 3

African American (37.5%) and Native American (1.5%). Average education was 11.65 years (SD = 1.89) and ranged from 6 to 16 years. The psychological evaluations were completed by a licensed clinical psychologist over the course of approximately 5 hr, reflecting consecutive evaluations occurring from 2012 to 2019. Data were archivally extracted and analyzed using SPSS Statistics software, and the study was approved by the University of North Carolina Wil- mington’s Institutional Review Board (IRB; #20-0110). Anonymous data used in this study are available at the following link: https://osf .io/7j6rx/?view_only=baae7d98065a4c47b996c14d34b1b5b1

Measures

Wechsler Adult Intelligence Scale-IV

The fourth edition of the WAIS-IV (Wechsler, 2008) is one of the most widely used measures of cognitive performance/intelligence and includes the administration of 10 standard scales which take approximately 1.5–2 hr to complete. These 10 scales load onto four broader indices: VCI, PRI, Working Memory Index (WMI), and PSI. These four indices load onto a primary factor called the FSIQ (Wechsler, 2008).

Minnesota Multiphasic Personality Inventory-2

The second edition of the MMPI (i.e., MMPI-2) is a 567-item measure of personality and psychopathology which takes approxi- mately 1–2 hr to complete (Graham, 1990). It contains embedded validity measures to defensive responding (e.g., K, S, and L scales), possible exaggeration (e.g., F, Fp, FBS scales), or indiscriminate responding (e.g., VRIN, TRIN scales). Additionally, 10 clinical scales are related to a range of psychological tendencies and possible psychopathology (e.g., hypochondriasis, depression, somatization in response to stress, antisocial traits, traditional masculine/feminine roles, paranoia, psychological turmoil, thought disturbances, hypoma- nia, and social introversion). The present study focuses on the validity and primary clinical scales. Typically, a T-score of 65 (1.5 SDs > average) is the clinical cutoff for clinical interpretation (Graham, 1990), but scores below 65 can indicate meaningful variability. Although not presented here, participants also completed semi-

structured clinical and parenting interviews and a mental status exam, and records were available from other providers.

Results

Because the present research focuses on the cognitive functioning of a parental competency sample, and because cognitive functioning is related to educational attainment (Kaufman et al., 2009), it is important to examine the educational background of the present sample relative to the normative sample for the WAIS-IV to rule this out as a confounding variable. To determine whether our sample matched the normative sample in terms of average education, we first aggregated the percentages of those within each age and education group reported in the WAIS-IV technical manual. We then compared these percentages for our sample. Level of education in the present competency sample is much

lower than in the WAIS-IV normative sample. Specifically, 18.5% of the competency sample had less than 9 years of education, compared to only 4.6% of the normative sample. About 14.9% of the competency sample had 9–11 years of education, compared to

8.7% of the normative sample. While most of the competency (65.9%) and normative (60.1%) samples had between 12 and 15 years of education, less than 1% of the competency sample had greater than 15 years of education, compared to 26.6% of the normative sample. A chi-square analysis was conducted among the percentage of individuals in the normative versus competency sample across each educational category and this was significant, χ2 (3, N = 136) = 56.03, p < .001. These differences suggest that the present competency sample has a significantly greater number of individuals with less than 12 years of education than the normative WAIS-IV sample.

Also, 12.5% of the competency sample scored in the extremely low range of cognitive functioning (i.e., FSIQ < 70), whereas approximately 2% of the normative sample had FSIQ scores in this range. The 12.5% extremely low FSIQ percentage aligns with the fact that cognitive concerns were noted in the Child Protective Services referrals for 14.7% of the sample. Given that cognitive concerns are a common issue in competency evaluations (identified in 12.5% of the referred cases), this subset of individuals is a contributing factor to the overall competency sample’s WAIS-IV index scores being lower than the normative sample.

Because educational attainment has consistently been shown to positively predict cognition, we first examined this relationship in our competency sample. A bivariate correlation was performed between total years of education and WAIS-IV indices and revealed significant positive correlations between education and VCI: r(134) = .23, p = .008; PRI: r(134) = .20, p = .018; WMI: r(134) = .32, p < .001; PSI: r(134) = .24, p = .005; and FSIQ: r(134) = .29, p < .001. Considering the significant correlation between education and all WAIS-IV indices, and that the education of the competency sample is markedly lower than that of the normative sample, we controlled for education in later analyses that included WAIS-IV scores as a variable.

Hypothesis 1

To compare the WAIS-IV scores of the competency sample with normative values, single-sample t-tests were conducted. All WAIS-IV index scores and FSIQ were significantly lower in the competency sample compared to the normative sample (i.e., stan- dard score of 100; see Table 1). The lowest index scores were the WMI, M = 88.30, t(135) = −9.30, p < .001, Cohen’s d = −0.80, and FSIQ, M = 87.79, t(135) = −9.65, p < .001, Cohen’s d = −0.83. Across WAIS-IV indices, our competency sample performs between the 21st and 28th percentile on average. Single-sample t-tests were also conducted between subscale scores and normative (i.e., 10) scaled scores. Again, all subscale scores were significantly lower than the normative scores, with the lowest being Arithmetic and Coding (see Table 1). This indicates that the parental compe- tency sample shows consistently lower cognitive functioning rela- tive to normative standards. These findings persisted after controlling for education.1

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1 Single-sample t-tests performed in Hypothesis 1 were also conducted using education-adjusted means obtained from an analysis of covariance (ANCOVA). However, education-adjusted means were minimally different than nonadjusted means (i.e., changes were less than one standard point), and results were minimally different. Thus, these findings are not explicated here.

4 TERRY AND LECCI

https://osf.io/7j6rx/?view_only=baae7d98065a4c47b996c14d34b1b5b1

Hypothesis 2

MMPI-2 validity and clinical scale scores for the present sample were compared with those from two prior parental competency samples (Resendes & Lecci, 2012; Stredny et al., 2006). The hypothesis that scores would be the same between these samples was largely supported (see Table 2), except that when comparing the present sample to Stredny et al.’s (2006) competency sample, Scale 8 is significantly higher and Scale 7 is marginally higher for the present sample. Thus, while slight elevations are seen on two MMPI-2 scaled scores related to anxiety and unusual thoughts/ attitudes, scores for the present sample are largely the same as those from two previous parental competency samples, suggesting that this is a representative sample with respect to MMPI-2-assessed psychopathology. The second portion of this hypothesis, that the present compe-

tency sample will be significantly different from Bathurst et al.’s (1997) custody sample across all MMPI-2 validity and clinical scale scores, was also supported. Moreover, the observed differences resulted in at least medium and in most cases large effect sizes. This finding reinforces the argument that competency and custody ex- aminees are markedly different (i.e., 12 of 14 comparisons resulted in statistically significant and substantial differences) and thus likely require separate interpretive considerations.

Hypothesis 3

As Gass and Gutierrez (2017) have emphasized, obtaining an accurate analysis of the relationship between psychopathology and cognitive performance may only be done when examinees are as effortful as possible when taking the test. In the case of parental competency evaluations, it is quite typical for examinees to exhibit

full effort on the WAIS-IV while also exhibiting a degree of defensiveness evidenced by elevations on MMPI-2 validity scales L and to a lesser degree K. Therefore, inclusion criteria for Hypoth- esis 3 based on the MMPI-2 are that participants completed at least 557 of the 567 items, did not respond randomly or display a response bias (i.e., VRIN and TRIN < 80), did not exaggerate symptoms (i.e., F < 90, Fb < 100; which would be extremely rare for such court- ordered parental competency evaluations), and did not respond in a highly defensive manner (i.e., L and K < 80). Three participants (2.9%2) were excluded due to VRIN T-scores greater than or equal to 80, 11 (10.7%) for TRIN T-scores greater than or equal to 80, 12 (8.8%) for F T-scores greater than or equal to 90, eight (6.5%) for Fb T-scores greater than or equal to 100, 24 (17.6%) for L T-scores greater than or equal to 80, and one (0.7%) for a K T-score greater than or equal to 80. These exclusions were not mutually exclusive and after applying the above criteria, 92 of the 136 participants were left for the exploratory correlations.

A partial correlation, controlling for education, was conducted (see Table 3). The most prominent finding was that Scale 8 (unusual thoughts/attitudes) was significantly negatively correlated with all WAIS-IV indices, with the strongest correlation occurring with WMI, r(90) = −.40, p < .01. This correlation was explored further via hierarchical regression, entering education into Block 1 and Scale 8 into Block 2 to predict WMI. Assumptions for performing the analysis were met. Scatterplots indicated linearity, no skew or kurtosis was detected on p-p and q-q plots, data were homoscedastic, and no violations of independence were noted (e.g., Durbin– Watson = 1.66). Moreover, multicollinearity was not detected. The regression indicated that both education (7.1%, β = 2.53, p < .01, power = .99) and MMPI-2 Scale 8 (13.6%, β = −.48, p < .001, power = .99) significantly explained 20.7% of the variance in WMI performance, R2 = .207, F(2, 89) = 12.85, p < .001. This indicates that after controlling for premorbid cognitive achievement (education), at least one form of MMPI-2-assessed psychopathology predicts poorer cognitive efficiency (working memory) as assessed by the WAIS-IV.

The second most noteworthy finding was the consistently nega- tive correlations between Scale 0 (social introversion) and all WAIS-IV indices, that is, r(90) = −.30 to −.33, p < .01, except for PSI, r(90) = −.18, p > .05. The final MMPI-2 scale to significantly correlate with a majority of WAIS-IV indices was Scale 7 (psychasthenia), which negatively correlated with PRI, r(90) = −.27, p < .05; WMI, r(90) = −.28, p < .01; and FSIQ, r(90) = −.24, p < .05. The latter two findings indicate that social introversion and anxiety are both associated with decreased cogni- tive performance. Four other modest correlations emerged between MMPI-2 scales and WAIS-IV indices. Specifically, Scale 9 (hypo- manic activation) was negatively correlated with VCI and FSIQ, Scale 1 (hypochondriasis) was negatively correlated with PSI, and Scale 3 (hysteria) was positively correlated with VCI (this was the only significant positive correlation to emerge).

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Table 1 Independent Samples t-Tests Between WAIS-IV Normative and Competency Sample Means

WAIS-IV df Competency sample

M (SD) Independent samples t-test

(Cohen’s d)

VCI 135 90.63 (14.91) −7.33* (−0.63) PRI 135 90.22 (14.95) −7.63* (−0.65) WMI 135 88.30 (14.68) −9.30* (−0.80) PSI 135 90.10 (14.25) −8.10* (−0.69) FSIQ 135 87.79 (14.75) −9.65* (−0.83) BD 135 7.99 (2.96) −7.92* (−0.68) SI 135 8.17 (2.86) −7.48* (−0.64) DS 135 8.18 (2.85) −7.45* (−0.64) MR 135 9.00 (3.24) −3.60* (−0.31) VC 135 8.07 (2.83) −7.97* (−0.68) AR 106 7.10 (2.42) −12.37* (−1.20) SS 131 8.45 (3.23) −5.53* (−0.48) CD 133 7.81 (2.66) −9.52* (−0.82) CO 131 8.83 (3.22) −4.17* (−0.36)

Note. Independent samples t-tests were conducted between normative scores and competency samples’ scores. WAIS-IV = Wechsler Adult Intelligence Scale-IV; df = degrees of freedom; VCI = Verbal Comprehension Index; PRI = Perceptual Reasoning Index; WMI = Working Memory Index; PSI = Processing Speed Index; FSIQ = Full Scale Intelligence Quotient; BD = Block Design; SI = Similarities; DS = Digit Span; MR = Matrix Reasoning; VC = Vocabulary; AR = Arithmetic; SS = Symbol Search; CD = Coding; CO = Comprehension. * p < .01.

2 Percentages of excluded cases were based on the total (i.e., n = 136) sample for F, L, and K but were based on a smaller subset of individuals for VRIN (n = 103), TRIN (n = 103), and Fb (n = 124) due to unavailability of T-scores for the remaining participants as they only completed the first 370 items of the MMPI-2. For these latter three scales, those with missing data were still included in the exploratory correlations as long as F, L, and K were valid.

PARENTAL COMPETENCY WAIS-IV AND MMPI-2 SCORES 5

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C o m p a ri n g th e M M P I- 2 S ca le s fo r C u st o d y a n d C o m p et en cy

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A v er su s C

A v er su s D

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1 .8 4 (. 2 2 )

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F 6 0. 6 8 (1 7 .8 2 )

4 4 .6 7 (6 .8 2 )

5 8 .9

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5 8 .5 9 (1 9 .1 2)

1 6. 3 0 * (1 .5 7 )

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.9 3 (. 1 1 )

K 5 2. 9 7 (1 2 .8 0 )

5 8 .6 8 (8 .6 1 )

5 2 .6

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5 1 .5 0 (1 2 .2 7)

− 6 .1 3*

(− .5 9 )

.2 6 (. 0 3 )

.9 7 (. 1 2 )

F b

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4 4 .1 2 (4 .1 7 )

5 6 .1

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5 9 .1 7 (1 7 .9 3)

1 4. 8 6 * (1 .4 9 )

.6 2 (. 0 8 )

− .8 0 (− .1 0 )

1 (H

s) 5 7. 3 4 (1 2 .0 1 )

4 8 .3 9 (7 .1 0 )

5 6 .6

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5 4 .2 5 (1 1 .6 1)

1 1. 0 7 * (1 .0 7 )

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2 .1 6 (. 2 6 )

2 (D

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4 6 .6 2 (7 .1 1 )

5 7 .2

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5 5 .8 1 (1 1 .0 8)

1 4. 2 6 * (1 .3 8 )

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5 3. 7 9 (1 2 .4 2 )

5 2 .3 1 (7 .8 9 )

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5 2 .7 4 (1 2 .3 2)

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4 (P d)

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5 0 .8 7 (7 .3 5 )

6 3 .3

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6 0 .2 6 (1 2 .8 9)

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− .8 7 (− .1 1)

1 .2 0 (. 1 5 )

5 (M

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5 0 .5 6 (8 .8 3 )

5 2 .8

(1 0 .5 )

5 8 .4 6 (1 6 .0 9)

2 .5 0 (. 2 4 )

− .0 2 (− .0 03 )

− 3 .4 7*

(− .4 2 )

6 (P a)

6 0. 3 0 (1 5 .7 4 )

5 2 .4 4 (8 .9 6 )

5 9 .4

(1 3 .7 )

5 8 .4 6 (1 3 .7 2)

7 .5 8*

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1 .0 3 (. 1 2 )

7 (P t)

5 5. 3 6 (1 1 .8 5 )

4 7 .1 8 (6 .7 7 )

5 4 .3

(1 1 .2 )

5 0 .9 1 (1 4 .5 7)

1 0. 4 5 * (1 .0 1 )

.7 6 (. 0 9 )

2 .7 6* * (. 3 4 )

8 (S c)

5 9. 4 0 (1 3 .7 9 )

4 6 .8 7 (6 .6 2 )

5 6 .9

(1 1 .9 )

5 4 .6 2 (1 0 .6 6)

1 5. 0 3 * (1 .4 5 )

1 .6 0 (. 1 9 )

3 .2 0*

(. 3 9 )

9 (M

a) 5 5. 5 6 (9 .5 3 )

4 8 .3 5 (7 .5 7 )

5 4 .3

(1 0 .3 )

5 4 .8 7 (1 1 .6 7)

9 .3 1*

(. 9 0 )

1 .0 5 (. 1 3 )

.5 3 (. 0 7 )

0 (S i)

5 1. 1 6 (1 0 .0 3 )

4 2 .6 9 (7 .1 )

5 1 .7

(1 0 .4 )

5 1 .6 8 (9 .4 5 )

1 1. 2 4 * (1 .0 8 )

− .4 4 (− .0 5)

− .4 4 (− .0 5 )

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6 TERRY AND LECCI

Contrary to the previous literature and our prediction, no corre- lation was found between Scale 2 (depressive symptoms) and PSI. This effect also failed to emerge when dichotomizing MMPI-2 Scale 2 scores into high and low, to be more commensurate with the previous literature (Gass & Gutierrez, 2017). Thus, depressive symptoms and processing speed were unrelated.

Discussion

The rationale for examining the cognitive abilities of those undergoing parental competency evaluations is that limited cogni- tive functioning has been raised as a concern by Child Protective Services. Moreover, when evaluating parental competency more broadly, cognitive functioning is often at the forefront. For example, court cases pertaining to termination of parental rights cite low IQ on behalf of the parent as a barrier to parenting in the majority of cases (Callow et al., 2017). Despite this reliance on intellectual abilities, cognition alone is a poor predictor of parental competency (McGaw et al., 2010). Instead, a combination of low intellectual functioning with co-occurring risk factors (e.g., increased psychopathology) and lack of protective factors (e.g., low social support) is more predictive of child outcome and, hence, parental competency (Feldman et al., 2012). Thus, the present study sought to examine (a) levels of cognitive functioning as assessed by the WAIS-IV, (b) psychopa- thology as assessed by the MMPI-2, and (c) the potential overlap among these constructs, as it presents in parental competency evaluations. As expected, the parental competency sample had lower educa-

tion than the normative WAIS-IV sample and had a greater inci- dence of individuals with extremely low cognitive functioning (i.e., 12.5%) compared to the normative sample (i.e., 2%). Moreover, our sample’s WAIS-IV performance was over half a standard deviation below that of the normative sample. This finding indicates that parental competency examinees score on average in the 21st to 28th percentile of cognition. The fact that our sample’s cognitive perfor- mance aligns with another (i.e., McCartan & Gudjonsson, 2016) parental competency sample’s performance, and that a notable (i.e., 12.5%) portion of this sample exhibited extremely low cognitive

function, suggests that similar rates may exist in other parental competency samples elsewhere. Though prior findings suggest that parental competency assessors are including standardized cog- nitive measures in their test batteries (Conley, 2004), assessment of cognitive functioning is not an explicit recommendation found in parental competency assessment guidelines (American Psychological Association [APA], 2013; Steinhauer, 1983) and therefore these areas of potentially problematic functioning may be overlooked. Such an oversight may lead to attributing problem- atic parenting behaviors (e.g., neglect) to more nefarious explana- tions (i.e., intentional neglect), when in fact the provision of parenting classes and/or supportive services could remedy such behaviors. Notably, when examining our sample, 35% of those with FSIQ scores less than 70 were referred due to concerns of neglect.

Aside from the FSIQ, the WMI was normatively the lowest index and was 0.80 SDs below average. Given that the WMI was strongly associated with MMPI-2 Scales 7, 8, and 0, it is possible that the WMI difficulties tend to manifest in the context of mood and thought disturbances (Snyder et al., 2015; Stordal et al., 2005). Moreover, it is also reasonable to assume that the more problems that a parent has (i.e., difficulties affecting multiple domains, such as cognition and psychopathology) the more likely they will experience dysfunction in general and come to the attention of Child Protective Services (e.g., recall that 14.7% of examinees in our sample were referred for cognitive concerns, and 12.5% scored in the extremely low range of cognitive functioning). Thus, although diminished cogni- tion and psychopathology are each factors that may prompt or contribute to Child Protective Services intervention, they likely have a compounding effect on one another. This effect highlights the importance of considering the interaction of cognition with psychopathology.

The underperformance on WAIS-IV subscales, particularly Arithmetic and Vocabulary, aligns with prior findings indicating that lower education corresponds to underperformance on these WAIS subscales (Shuttleworth-Edwards et al., 2004). In our sample, 34.6% of participants performed more than 1 SD below the norma- tive average on Vocabulary, and 45.8% for Arithmetic. This under- performance suggests that both reading literacy and numerical literacy issues may also be common in parental competency cases. Thus, careful consideration should be made regarding a client’s educational attainment and literacy and the effect that it may have in suppressing cognitive performance, especially in evaluations as consequential as those pertaining to parental competency. Adapta- tions may be necessary when illiteracy is of concern (e.g., reading aloud questionnaires to the examinee instead of having them read for themselves when dealing with surveys, etc.). Moreover, limitations associated with literacy may be more amenable to interventions as compared to cognitive limitations that may be associated with congenital or developmental disorders.

The present sample’s scores on the MMPI-2 were largely similar to those of two prior parental competency samples (Resendes & Lecci, 2012; Stredny et al., 2006) with the exception that, when compared to Stredny et al.’s (2006) competency sample, Scale 8 is significantly higher in the present sample. This difference is likely attributable to the present sample having more individuals with disturbances in thinking than in Stredny et al.’s (2006) sample, particularly given the lack of difference on Scale 8 between the present sample and Resendes and Lecci’s (2012) sample. Significant elevations on Scale 8 (i.e., T > 75) raises the possibility of a

T h is d o cu m en t is co p y ri g ht ed

b y th e A m er ic an

P sy ch o lo g ic al

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T h is ar ti cl e is in te nd ed

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b e d is se m in at ed

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Table 3 Partial Correlation Between WAIS-IV Indices and MMPI-2 Clinical Scale Scores, Controlling for Education

MMPI-2 VCI PRI WMI PSI FSIQ

1 (Hs) −.03 −.06 −.15 −.25* −.12 2 (D) 0.0 −.11 −.06 −.10 −.08 3 (Hy) .25* .16 .08 .09 .18 4 (Pd) .17 .12 .04 .14 .15 5 (Mf) −.05 −.16 −.02 −.01 −.08 6 (Pa) −.07 −.11 −.18 −.16 −.13 7 (Pt) −.15 −.27* −.28** −.11 −.24* 8 (Sc) −.23* −.28** −.40** −.29** −.33** 9 (Ma) −.25* −.12 −.21 −.19 −.21* 0 (Si) −.31** −.31** −.30** −.18 −.33**

Note. WAIS-IV =Wechsler Adult Intelligence Scale-IV;MMPI-2 = Minnesota Multiphasic Personality Inventory-2; VCI = Verbal Comprehension Index; PRI = Perceptual Reasoning Index; WMI = Working Memory Index; PSI = Processing Speed Index; FSIQ = Full Scale Intelligence Quotient. Scales 1–0 correspond to MMPI-2 clinical scale T-scores. * p < .05. ** p < .01.

PARENTAL COMPETENCY WAIS-IV AND MMPI-2 SCORES 7

psychotic disorder (Graham, 1990) or at least disturbances in thinking about oneself or others. Schizophrenia and other psychotic disorders are usually characterized as maintaining a chronic course, high comorbidity with substance use and other psychiatric disorders, and frequently necessitate formal and/or informal assistance with daily living activities (American Psychiatric Association, 2013). The impact of these disorders on daily functioning likely increases the chance of a parent with such a disorder, especially when undiagnosed and/or untreated, to come to the attention of Child Protective Services and thereby may account for the greater inci- dence of Scale 8 elevations in parental competency samples. The replication of Resendes and Lecci’s (2012) findings regarding the substantial difference between parental competency and custody samples further highlights that parental competency examiners should not use parental custody data as a means of comparison, and vice versa. Following the precautions recommended by Gass and Gutierrez

(2017), we excluded participants who exhibited invalid response sets on the MMPI-2 prior to conducting the exploratory correlations in Hypothesis 3. It is noteworthy that upwards of 17% of respon- dents had invalid protocols, though this aligns with a previous competency sample (Resendes & Lecci, 2012). As a follow-up exploratory analysis, we sought to examine whether intellectual functioning (i.e., WAIS-IV FSIQ) is related to MMPI-2 invalidity. Independent samples t-tests were conducted separately between those who were and were not excluded due to L, TRIN, and F invalidity. FSIQ scores were significantly lower for those excluded based on elevated TRIN and F T-scores, with the differences reflecting large effect sizes (Cohen’s d values of 1.3 and 1.1, respectfully). Though nonsignificant, those who were excluded due to elevated L T-scores had lower FSIQ scores (M = 83.67) than those who were not excluded (M = 88.68). Despite causality being unclear, these findings implicate low intellectual functioning as a potential source of MMPI-2 invalidity regarding TRIN, atypical responding (F), and possibly defensiveness (L). Clinicians should therefore be mindful to not assume that an invalid MMPI-2 profile indicates a blatant attempt by the examinee to subvert the assessment. The relationship between Scale 8, 0, and 7 and WAIS-IV indices

has important implications for assessing parental competency ex- aminees. For instance, Scale 8 is consistently negatively correlated with WAIS-IV indices suggesting that diminished cognition may be an accompanying factor for individuals with a greater propensity to experience unusual thinking/attitudes. Importantly, only six parti- cipants scored at a level on Scale 8 which would more strongly suggest the presence of a thought disorder (T-score > 75) and a relatively wide range of T-scores (32–93) was obtained. Thus, the relationship between Scale 8 and WAIS-IV indices was likely not solely (or at all) attributable to individuals with thought disorders. Although we considered cognition to be the dependent variable in

our analyses (e.g., Scale 8 predicted WMI), the directionality of the relationship between psychopathology and cognition is unclear. For example, working memory deficits are a common feature of schizo- phrenia (Eryilmaz et al., 2016), yet whether these deficits are a consequence of or comorbid with schizophrenia is not established. Despite nebulous causality, our findings support previous literature indicating that impaired working memory on the WAIS-IV is seen in individuals with disturbances of thinking, as measured by MMPI-2 Scale 8 (Snyder et al., 2015; Stordal et al., 2005). Our findings even

partially support those of Gass and Gutierrez (2017) regarding the impact of fear-related MMPI-2 content scales (which includes Bizarre Mentation, a scale strongly correlated with clinical Scale 8) on the WAIS-IV PRI, VCI, and FSIQ. However, the fact that their Fear factor did not correlate with WMI is less consistent with present findings.

The broad negative correlation between social introversion (Scale 0) and all WAIS-IV indices except for PSI is consistent with the fact that diminished social engagement has been found to occur in individuals with significant psychopathology, such as those with schizophrenia spectrum disorders (Green et al., 2018). Further, it may also be the case that those with lower cognitive functioning have lower social support and, thus, are more socially isolated (Graham, 1990). Regardless of causality, the co-occurrence of low cognition and social introversion implicates the need to provide supportive services (e.g., support groups and other tangible inter- personal help) to individuals with lower cognition and elevated psychopathology.

A significant negative relationship also emerged between MMPI-2 Scale 7 and perceptual reasoning, working memory, and FSIQ. As a measure of psychological turmoil and anxiety, it is reasonable that individuals elevated on this scale would exhibit impaired cognitive performance; particularly given consistent find- ings that anxiety can impact performance on tasks of working memory and attention (Dorenkamp & Vik, 2018). Though some additional, small correlations emerged, these findings must be interpreted with caution given the exploratory nature of the analysis, and future studies can better determine whether these relationships are robust.

Finally, the prediction that MMPI-2 Scale 2 would negatively correlate with PSI was not supported despite depressive symptoms commonly predicting low processing speed in the literature (Gorlyn et al., 2006; Snyder et al., 2015; Wechsler, 2008). One explanation that may account for this is in the measurement of depression. While prior studies utilized the diagnosis of MDD as a predictor for PSI, we used a continuous measure of depressive symptoms. It may be the case that no relationship emerged because MMPI-2 Scale 2 linearly measures depressive symptoms, rather than as a clinically significant diagnosis (e.g., does not include a measure of significant impairment in daily functioning). Other factors related to undergo- ing parental competency examinations may have also contributed to the lack of a relationship between Scale 2 and PSI, such as greater effort typically seen in parental competency examinees, whereas amotivation is a common symptom of depression and may manifest more readily in other assessment contexts. The relationship between MMPI-2 Scale 2 and PSI performance should be assessed in more diverse samples to account for sampling bias.

We argue that the above findings underscore the need to consider comorbidities and the interactions thereof that may be present in psychological assessments of parental competency examinees. The present study specifically highlights the cross section between cognition and psychopathology, but there are countless other comorbid factors that examiners must consider, including most notably substance use disorders.

Limitations

Several limitations should be noted. First, our sample was a parental competency sample with a majority of females, and thus our

T h is d o cu m en t is co p y ri g ht ed

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A ss o ci at io n o r o n e o f it s al li ed

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8 TERRY AND LECCI

findings regarding cognition and psychopathology have limited generalizability beyond this population. However, the fact that some relationships align with findings in other populations, such as the relationship between Scale 8 and WMI, indicates this may be a robust finding. It should also be noted that the majority of the sample being female is likely due to the greater tendency of females to take a primary role in caring for the child, rather than females being more likely to have compromised parenting. Further, our sample was obtained archivally and, thus, we were unable to collect other information which may have informed these analyses, such as stand-alone validity tests or psychiatric diagnoses. Comparing cognitive performance with both continuous measures of psycho- pathology (e.g., MMPI-2) in addition to discrete diagnoses would provide important insight into the relationship between psychopa- thology and cognition. That is, identifying thresholds at which psychopathology impacts cognition may inform decisions for when and to what extent to provide interventions. Finally, the newest (third) edition of the MMPI has recently been released, and development of the fifth edition of the WAIS is underway. We utilized the MMPI-2 instead of the MMPI-2-Restructured Form or MMPI-3 because the data collection began in 2012, which predated the newer versions. However, the findings of the present study should be replicated with the MMPI-3 and WAIS-V, when avail- able, to determine whether these relationships persist despite revi- sions to the instruments.

Implications and Applications

Evaluations and research of parental competency should be done with adherence to the Ethics Code (American Psychological Association, 2017) and to guidelines laid out for conducting psy- chological evaluations related to child protection (APA, 2013). These guidelines include, but are not limited to, maintaining impar- tiality, practicing with competence, using multiple data-gathering approaches, and basing conclusions on actuarial data. The present study provides additional actuarial data specific to parental compe- tency evaluations when the WAIS-IV and MMPI-2 are used. These data may inform such assessments and facilitate adherence to ethical guidelines. It should also be noted that, although there is a clear rationale for

the use of tests like the WAIS-IV in parental competency evalua- tions, as cognitive limitations can contribute to less than optimal functioning and coping, there are also clear limitations in using such tests, especially for child custody evaluations (e.g., Brodzinsky, 1993). Measures such as the WAIS-IV and MMPI-2 are by them- selves insufficient to inform whether an individual should be considered to have low parental competence (McGaw et al., 2010). Rather, assessors must integrate multiple sources of data (e.g., social support, occupation) and consider the interaction of the examinee’s risk and protective factors when highlighting possible areas of strengths and weaknesses for parental competency examinees (Callow et al., 2017; Feldman et al., 2012). This study represents the first attempt to identify relationships

between psychopathology as measured by the MMPI-2 and cogni- tion as measured by the WAIS-IV for parental competency exam- inees. Additionally, we have made WAIS-IV index and subscale data of parental competency examinees available for the first time, which may aid evaluators in future parental competency assess- ments as a point of comparison. The data may also be used to

determine a client’s intellectual abilities relative to the average parental competency examinee and whether this may predict paren- tal fitness, in conjunction with MMPI-2 performance.

Of clinical relevance is the co-occurrence of diminished cognition in those with psychopathology, which suggests that the effective- ness of interventions for individuals with disturbances in thinking and/or mood is inversely related to cognitive scores. The presence of borderline intellectual functioning in those who may evidence symptoms of a thought disorder does not bar an individual from being able to effectively participate in treatment (Pitschel-Walz et al., 2009). Rather, the provision of interventions to those with greater psychopathology and/or lower intellectual abilities may be most effective when it is conveyed in a concrete and easily under- stood manner, focuses on skills-based techniques (e.g., dialectical behavior therapy), and minimizes interventions requiring high cognitive demand (e.g., cognitive or insight-oriented therapies). Unsurprisingly, decreased functioning has been observed in higher-severity psychotic disorders with comorbid intellectual dys- function compared to those with similar psychotic disorders without intellectual impairment (Bouras et al., 2004). Thus, a good under- standing of cognitive functioning is critical to parental competency assessments to inform prognosis and treatment recommendations.

Importantly, noncompliance or poor treatment outcome may be perceived as a volitional behavior on the part of the patient to not engage in treatment. However, our findings suggest that comorbid conditions may contribute to this noncompliance. For example, a common treatment recommendation for parental competency ex- aminees is to participate in parenting classes. However, if borderline or impaired intellectual functioning is present (and especially if it goes undetected), then the ability of that individual to understand and engage in the course material may be jeopardized. In the very least, lower cognitive functioning can undermine the informational benefit that can be derived from such classes. As such, a recom- mendation for one-on-one parent training, as opposed to a group format, may be more appropriate. Such an understanding may additionally foster a more compassionate approach to treatment on behalf of the individual administering the intervention when they encounter treatment barriers with the patient. In all, clinicians should consider all risk (e.g., cognitive impairment, psychopathology, lack of employment/housing) and protective (e.g., social support, dis- ability/other assistive services) factors in evaluations of parental competency, and treatment recommendations should likewise be guided by such factors.

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10 TERRY AND LECCI

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Accepted September 28, 2021 ▪

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PARENTAL COMPETENCY WAIS-IV AND MMPI-2 SCORES 11

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https://doi.org/10.1037/t15169-000

Perspectives

Structural developmental psychology and health

promotion in the third age

Lars Bauger1,* and Rob Bongaardt2

1Department of Nursing and Health Sciences and 2Department of Health, Social and Welfare Studies,

Faculty of Health and Social Sciences, University College of Southeast Norway, Porsgrunn, Norway

*Corresponding author. E-mail: [email protected]

Summary

In response to the ever-increasing longevity in Western societies, old age has been divided into two

different periods, labelled the third and fourth age. Where the third age, with its onset at retirement,

mostly involves positive aspects of growing old, the fourth age involves functional decline and in-

creased morbidity. This article focuses on the entry to the third age and its potential for health promo-

tion initiatives. Well-being is an important factor to emphasize in such health promotion, and this arti-

cle views the lifestyle of third agers as essential for their well-being. The structural developmental

theory of Robert Kegan delineates how a person’s way of knowing develops throughout the life

course. This theory is an untapped and salient perspective for health promotion initiatives in the third

age. This article outlines Kegan’s approach as a tool for developing psychologically spacious health

promotion, and suggests future directions for research on the topic.

Key words: health promotion programs, quality of life, qualitative methods, older people

INTRODUCTION

Retiring from work is a major transition in life and in

many countries. It is the social marker of entering into

old age (Kloep and Hendry, 2006). The conception of

old age altered dramatically during the late 20th century

as people lived increasingly longer. As one consequence

of this, researchers now distinguish between the ‘third

age’ and ‘fourth age’ (Baltes, 1997; Baltes and Smith,

2003; Laslett, 1996). In gerontology the last stage of a

person’s life is often called the fourth age (Koss and

Ekerdt, 2016), which is a period characterized by func-

tional decline and an increased dependency. The third

age, with its onset in retirement, is seen as a period of

relatively good health with the potential of active social

engagement forming a solid base for healthy ageing

(Robinson, 2013). Even though the third age has a posi-

tive ring to it, it may come with some challenges that are

specific for this period of life. Retirement itself, whether

it comes voluntarily or, as may happen, involuntarily,

may be experienced as troubling (Daatland and Solem,

1995) and can have a negative effect on the well-being

of the retiree (Wang, 2007). Studies of retirement effects

on the person’s well-being have demonstrated that be-

tween 9-25% experience negative effects to their well-

being after retirement (Wang, 2007; Pinquart and

Schindler, 2007). In their recent review, Wang and Shi

(2014) highlighted different factors pre, during and post

VC The Author 2017. Published by Oxford University Press.

This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/4.0/),

which permits unrestricted reuse, distribution, and reproduction in any medium, provided the original work is properly cited.

Health Promotion International, 2018;33:686–694

doi: 10.1093/heapro/daw104

Advance Access Publication Date: 11 January 2017

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retirement that affected the well-being of the retiree.

The negative factors were ill health, involuntary retire-

ment, a concern with the maintenance of social status

and contacts, and strongly identifying with one’s work

role (Wang and Shi, 2014). Health promotion may help

retirees to find a suitable place in society and improve

well-being in spite of these negative factors. In addition,

health promotion will prolong this third age period and

as a consequence likely compress morbidity during the

fourth age period (Whitehead, 2011). Whitehead (2011)

also suggests that during the fourth age, persons may

draw on existential forces to overcome adversity, forces

that are built up during earlier stages of life, including

the third age. Health promotion is apt to endorse such

existential forces. In other words, health promotion dur-

ing the third age may postpone the onset of the fourth

age, make it shorter and more endurable once the person

faces adversity.

Health promotion typically targets large populations

and may be unable to address individual differences.

The third age population, however, is characterized by

an immense heterogeneity (George, 2011; Wang, 2007),

and many third agers have acquired a unique profes-

sional competence, a specific way of living, and a net-

work that intertwines two or three generations of family

and friends. Ideally, health promotion should be individ-

ually tailored to the needs of each third ager. However,

the group’s heterogeneity renders that unfeasible. In this

article we outline a feasible approach to shaping health

promotion, directed at the intermediate range between a

large population and the unique individual. We do so by

introducing the structural developmental theory to the

healthy ageing discourse and linking this to the policy

making and practice of healthy lifestyle promotion. The

specific purpose of this article, then, is to outline a struc-

tural developmental approach to the field of health pro-

motion that targets the well-being of third agers. Before

presenting the structure of the rest of this article, we will

first delineate some central concepts.

The structural developmental theory focuses on con-

secutive stages of mental structures in a person’s life.

Such a theory is perhaps best introduced by contrasting

it to phase theories of life course development that

emphasize normative phases of life, such as birth, child-

hood, education, young adulthood, marriage, parent-

hood, working life and retirement (e.g. Erikson, 1980).

Whereas the phase developmental theory focuses on the

content of age-dependent periods of life, structural de-

velopmental stage theory underscores how this content

is put into perspective by the person – i.e. the extent to

which one takes responsibility for the unfolding of

events, and, ultimately, how the story of one’s life is told

at any particular moment in time. The development of

these perspectives is referred to as the development or

growth of complexity of mind (Kegan, 1994).

The field of health promotion often refers to the life

style concept. However, definitions of the lifestyle con-

cept abound. We assume that lifestyle is made of the fab-

ric of a person’s attitudes, manners, behaviours and

practices, which are all woven into a Gestalt

(Cockerham, 2005; Elstad, 2000). In our view, a per-

son’s complexity of mind underpins his or her lifestyle.

We thereby emphasize coherence in what are often pre-

sented as separate lifestyle ‘factors’, such as smoking,

diet, exercise, etc. (cf. Veal, 1993). Furthermore, lifestyle

and well-being can be seen as reciprocally related – well-

being is embedded in lifestyle and takes shape through

it. Well-being is a heavily debated topic within health

psychology and we are not advocating for any of its

schools of thought. In this article, we take a broad per-

spective and focus on the subjective experience of the

phenomenon. Nevertheless, our use of well-being is in

line with how Huppert (2009 p.137) defines psychologi-

cal well-being, i.e. ‘the combination of feeling good and

functioning effectively’. Feeling good, then, is not just

concerned with happiness and contentment but addi-

tional emotions such as ‘interest, engagement, confi-

dence and affection’ (2009, p. 138), whereas functioning

effectively captures ‘the development of one’s potential,

having some control over one’s life, having a sense of

purpose (e.g. working towards valued goals), and

experiencing positive relationships’ (2009, p. 138).

The structure of this article is as follows. We first re-

view and present the key concepts of our article; the

third age, health promotion and lifestyle. Then we sum-

marize Kegan’s theory of structural development of the

mind. After that, we present the design of a study that

addresses the experience of well-being premised on com-

plexity of mind, and, finally, discuss the logical implica-

tions of a psychological developmental approach to

tailoring health promotion for third agers.

HEALTH PROMOTION AT THE ONSET OF THE THIRD AGE

A positive perspective on the third age is well captured

by the gerontology term ‘successful ageing’. The term

gained popularity during the last decades of the 20th

century (Baltes and Smith, 2003). It was introduced by

Rowe and Kahn (1987) who reacted to the tendency in

gerontology to distinguish only between older people

with disease or disability and those without such condi-

tions. They introduced successful ageing as a positive

concept in order to address high cognitive and physical

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functioning and an active engagement with life, in addi-

tion to a low probability of disease and disability. In the

newfound optimism in the field of gerontology, the per-

ception of ageing changed from a passive experience to a

process of active engagement and participation (Baltes

and Baltes, 1990).

This more optimistic perspective on ageing has influ-

enced political discourse (Villar, 2012), as witnessed by

the introduction of the term ‘active ageing’ by the World

Health Organization (2002). The WHO defines active

ageing as ‘the process of optimizing opportunities for

health, participation and security in order to enhance

quality of life as people age’ (2002, p. 6). The WHO pol-

icy is to promote active ageing as a way to address socie-

tal and economic challenges stemming from an ageing

population as well as individual challenges associated

with getting older (World Health Organization, 2002).

Here the focus is on adding ‘more life to years, not just

years to life’ (Vaillant, 2004, p. 561), which is a hallmark

of health promotion in the third age. Wilson and Palha

(2007) argue that health promotion during this transi-

tional period will not only assist in maintaining existing

health but could also improve health and well-being sim-

ply because this is a period when one has more time to at-

tend to health-related needs than when one was working.

The third age is a period where one is left more to one’s

own devices with few established social structures and so-

cially defined roles (Freund et al., 2009). People are often

more free to do what they want, but those who do not

know or have not planned for what to do with this new

freedom could easily become ‘passive and couch ridden’

(Solem, 2012, p. 88; our translation).

It is evident that retirement is seen as an important

period for health promotion efforts. However,

retirement-specific research on health promotion is still

in its early stages. Reviewing the research, Wilson and

Palha (2007) identified 20 studies on the topic. Their

content analysis of these studies revealed four major

themes in the research on health promotion at the onset

of the third age, i.e. retirement: (1) the considerable ef-

fect of retirement and the need to support positive retire-

ment, (2) the identification and overcoming of barriers

to health promotion at retirement, (3) the best methods

to promote and sustain healthy lifestyle changes among

retirees and (4) the short and long-term benefits of

health promotion at retirement (Wilson and Palha,

2007). Given the aim of the present article, we will elab-

orate on theme (3), which links successful ageing to the

promotion of healthy lifestyles.

We emphasized above that the Gestalt of a person’s

attitudes, manners, behaviours and practices can be seen

as his or her lifestyle. A lifestyle approach to health

promotion builds on the assumption that the individual

can amend this lifestyle (Elstad, 2000; Nutbeam, 1998).

Although studies show that adopting a healthy lifestyle

may be beneficial for healthy ageing, the literature re-

ports some difficulty in promoting a healthy lifestyle

through interventions (Zhang et al., 2013). The main fo-

cus has been restricted to financial planning (Osborne,

2011), whereas psychological or social changes that

might occur after retirement have received hardly any

attention (Kloep and Hendry, 2006). Health promotion

initiatives usually communicate messages about healthy

lifestyles to a large target population through health ed-

ucation booklets or pamphlets. Kreuter et al. (1999)

have criticized this way of promoting health for its ‘one-

size-fits-all’ approach, with little consideration of indi-

vidual needs and personal relevance. In response to this

criticism, there has been a growing interest in tailoring

interventions to different individual users and user

groups (Davis, 2008; Orji and Mandryk, 2014). We

share this interest and wish to contribute. Our contribu-

tion to the development of tailor-made methods to pro-

mote and sustain healthy lifestyle changes among

retirees is based on structural developmental theory,

which we describe in the following section.

STRUCTURAL DEVELOPMENTAL THEORY

Neo-Piagetian psychologist Robert Kegan developed a

structural developmental theory (1982, 1994) which

proposes that individuals interpret and make meaning of

their world in qualitatively different ways. These ways

of meaning-making develop throughout the life course

along an invariant path whereby more complex ways of

meaning-making build upon and transform earlier ways

of meaning-making. The ways of meaning-making are

termed structures or orders of mind. Kegan (1982) has

described three orders of mind that capture most of the

adult population. He refers to these orders as the social-

ized, the self-authoring, and the self-transforming mind

(Kegan, 1994). Each order captures what an individual

can take as an object – can see ‘in front of’ him or her –

and what an individual is subject to – is part of and

thereby lacks a perspective on.

Individuals who have developed a socialized order of

mind can think in abstract terms and have the capacity

to internalize the meaning systems of others, such as

family values, social values, professional culture, etc.

They have the ability to subordinate their own desires

and be guided by the norms and standards in the ideolo-

gies, institutions or people that are most important to

them (Fitzgerald and Berger, 2002). At this order of

mind, one easily sees beyond one’s own needs and can

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adopt a larger picture, in which one is part of a socially

defined reality. Even though one has the capacity to in-

ternalize others’ points of view, one is embedded in these

points of view and is essentially dependent on them.

That is to say, the individual’s experience of being a per-

son or ‘self’ is entangled with ‘the quality of . . . internal

experiences of others’ experiences of them’ (Lewis,

2011, location 692). This means that at this order of

mind one does not ‘have the capacity to stand apart

from the values, beliefs, expectations, or definitions of

one’s tribe, community, or culture and make indepen-

dent judgments about them’ (Kegan, 1998, p. 201).

Individuals who make meaning with a self-authoring

mind have distanced themselves from the sense of being

entangled in others’ feelings and ideas about themselves.

They now have the capacity to be in charge of their own

feelings and generate an internal personal meaning sys-

tem, theory or ideology. Thus, one is able to take as an

object the values, beliefs and expectations of others

(one’s ‘tribe’, local community, or culture) that one was

subject to earlier. Individuals making meaning with this

order of mind perceive others as independent entities,

with their own integrity, distinct from themselves.

Unlike individuals at the socialized order of mind who

may struggle heavily with conflicting internalized views,

the self-authoring mind tolerates such conflicts or re-

solves these by invoking a system of self-authored values

and knowledge. This system has typically developed

over a period of years, gradually integrating the experi-

ences and reflections of personal encounters with a wide

variety of other knowledge and value systems (Kegan,

1994). This system of ‘self’ requires strong boundaries,

which may prevent the person from recognizing the con-

structed nature of the system itself. When meeting this

construction of self, others may experience it as a some-

what distant way of being, an obstacle to gaining direct

contact. However, ‘[t]his greater psychological indepen-

dence does not mean that [the person is] any less com-

mitted to you and to . . . other close relationships’

(Lewis, 2011, location 1111).

Those individuals who make meaning according to

the self-transforming mind have gained a perspective of

their own identity construction, and are no longer

‘blind’ to their self-authored identity. At this order, the

construction of identity is object to them. This implies

that they are now hesitant to see personhood as coincid-

ing with ‘a single system or form’ (Kegan, 1994, p. 313),

but rather see their system of self as incomplete and in

continuous development. At this order, individuals view

the ‘other as part of oneself’ (Souvaine et al., 1990, p.

253) and they are characterized by their embeddedness

in a multisystem perspective (Rosen, 1991). These

individuals are less likely to view the world in dichoto-

mies, and ‘suspicious of their own tendency to feel

wholly identified with one side of any opposite and to

identify the other with the other side of that opposite’

(Kegan, 1994, pp. 311-312). Meaning-making with this

order of mind concerns the reflections on the process of

making meaning itself more than the outcomes of this

process. The individual reflects on his or her own need

for meaning while acknowledging that knowledge is al-

ways partial, and he or she thrives on ‘rending every

new veil that comes into awareness, because . . . closure

and fixed boundaries [are] restrictive’ (Cook-Greuter,

1999, p. 107).

In his book In over our heads: The mental demands

of modern life, Kegan (1994) asks whether people make

meaning in accordance with society’s demands. In other

words, he asks what order of mind is required to suc-

cessfully parent, partner, work, learn, heal, and collabo-

rate as modern society frames these life tasks. He shows

that society implicitly demands a self-authoring mind

for all these tasks. In a composite study sample of adults

(Kegan, 1994, p. 195), about half of the persons did not

construct their experiences as complexly as the self-

authoring mind.

What are the mental demands on ageing in our mod-

ern Western society? Does the ageing population meet

these demands? Currently, hardly any empirical research

exists that answers these questions. Newhouse (as refer-

enced in Kegan, 1998) suggests a number of tasks and

expectations typical of the third age: giving up a central

identity formed around work and a career, changing

from a highly structured to a less structured everyday

life, needing to create new friendships after the loss of a

ready-made social network, and remaining relatively in-

dependent of the care-taking resources of family or soci-

ety. Kegan infers from Newhouse’s list that it is ‘the self-

authoring mind that constitutes the implicit mental

threshold for successfully handling this curriculum, a

threshold many adults will not yet have reached in old

age, and not having done so, will be ‘at risk’ for poorer

outcomes thereby’ (1998, p. 209; italics in original).

Therefore, he argues that it may be ‘an absolutely crucial

educational or mental health goal serving as a protective

factor against decline and depression in old age’ (Kegan,

1998, p. 212) to develop a self-authoring mind since it is

with this order of mind that one can meet the demands

of ageing. Moreover, if it is true that more people

make meaning with a self-authoring mind, then the so-

cial institutions relevant to the third age are challenged

to provide the space for the personal paths and demands

that are so typical for individuals with this order of

mind.

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It is against the backdrop of Kegan’s theory and its

possible implications for the third age that we now turn

to outlining the research we envision. In the following

section, we juxtapose the promotion of healthy lifestyles

during the third age with Kegan’s psychological develop-

ment theory.

DEVELOPING HEALTH PROMOTION FOR THIRD AGERS

Structural developmental theory has informed classroom

practice in educational psychology, where developmen-

tally conscious teachers are teaching in ways that en-

courage students to make meaning in an increasingly

complex way, while also meeting students at their stage

of development (Helsing et al., 2004). In the context of

business coaching and counselling, Berger (2012) refers

to this practice as keeping conversations ‘psychologi-

cally spacious’. Inspired by such thinking, we envision

health promotion initiatives to be psychologically spa-

cious and tailored to a person’s order of mind. Neither

our aim nor our interest is in highlighting or facilitating

the development towards one specific order of mind

(e.g. self-authoring). Our contribution is rather to raise

awareness of the qualitatively different ways of making

meaning in the world, and, where possible, outline how

health promotion can be formulated in developmentally

spacious ways, to enable more people to be reached and

feel included.

In order to do so, we require a knowledge base that

links a person’s lifestyle to his or her stage of structural

development. Our research will hopefully help to estab-

lish this knowledge base. The rationale for our research

is that much information can be gained from the experi-

ences of individuals who report that they have recently

transitioned successfully into the third age. In other

words, our preferred starting point is narratives concern-

ing a successful lifestyle during retirement, i.e. one that

leads to an experience of well-being. True to this

experience-oriented bottom-up approach, we employ no

specific definition of well-being. The next logical step in

our rationale is to relate these situation-specific experi-

ences to a person’s order of mind. Kegan’s measure of

order of mind indicates in general terms how a person

structures his or her life in terms of responsibility alloca-

tion and perspective taking, that is, how a person under-

stands him- or herself to play a role in his or her own

life. The assumption is that persons with different orders

of mind structure retirement-specific experiences in dif-

ferent ways, because lifestyle and the ensuing experience

of well-being are dependent upon order of mind.

More concretely, our research will unfold as follows.

We will recruit participants recently retired from work-

ing life and reporting having done so satisfactorily ac-

cording to their own expectations and standards. To

assess the participants’ orders of mind, we will conduct

subject-object interviews (SOI) (Lahey et al., 1988/

2011) with all our participants. During the SOI, ten

emotionally laden probes (e.g. ‘Can you tell me of a re-

cent experience of being quite angry about something?’)

are presented to a participant, and he or she is asked to

write down recent experiences brought to mind by the

probes. The participant then selects some of the experi-

ences to elaborate on. During the interview, the inter-

viewer listens sympathetically and confirms the content

of the participant’s experience, while also probing for

the structuring of the experience. The combination of

the emotionally laden probes and the why-questions in-

vites the participants to describe their experiences at the

borderline between what is and is not explicitly reflected

upon. An analysis of transcripts from the interview al-

lows the researcher to score where participants are on

their developmental journey according to Kegan’s devel-

opmental theory (1982, 1994). This score indicates

whether the participants are currently at one order of

mind or in transition between two orders of mind,

where four sub-stages can be distinguished. The inter-

rater reliability for the SOI ranges between 0.82 to 1.00

for agreement within one discrimination unit (Kegan,

1994; Lahey et al., 1988/2011). We have completed

training in subject-object interviewing, are experienced

and reliable scorers, and we will establish and report on

our inter-rater reliability within this study. If a partici-

pant scores at a transitional order of mind, we will allo-

cate him or her according to the dominant order. We are

interested to include all adult orders of mind in this

study, preferably three participants within each order.

However, we are aware of the difficulty of recruiting

persons who make meaning at the self-transforming

mind as they are few and far between (Kegan, 1994).

Knowing this, and given the resources necessary to con-

duct and analyse such SOIs, it is unlikely that we will be

able to recruit enough participants at the self-

transforming mind. It is likely that we can include at

least three persons at the socialized mind and three at

the self-authoring mind, as these are the two orders

where most of the adult population makes meaning

(Kegan, 1994).

We will conduct an in-depth phenomenological inter-

view with each of the participants. This form of the

open qualitative interview will allow us to reveal the

phenomenon of well-being as it emerges in the partici-

pants’ descriptions of their experiences of the

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phenomenon (Giorgi, 2009). We have found that three

such interviews suffice to make valid inferences about

the participants’ experiences with the phenomenon un-

der investigation. That is mainly because a descriptive

phenomenological analysis makes use of all data mate-

rial and is not guided by themes that are established be-

forehand. We will analyse the descriptions separately for

each of the orders of mind, resulting in so-called general

meaning structures. Such a general meaning structure re-

veals the shared meaning across many variations of how

participants experience the phenomenon in their daily

life (Giorgi, 2009). In a final analysis, we will compare

and discuss differences and similarities in the general

meaning structure of the phenomenon between the or-

ders of mind. The results of this will feed into the next

stage of the project.

SHAPING STRUCTURAL DEVELOPMENTAL HEALTH PROMOTION

We referred earlier to a quote that a hallmark of health

promotion is the aim to bring ‘more life to years, not

just years to life’ (Vaillant, 2004, p. 561). One way to

bring more life to years is to facilitate experiences of

well-being through the promotion of a lifestyle pervaded

by such experiences. We will endeavour to make our re-

search results accessible to retirees as well as to the

policy-makers and welfare and health promotion profes-

sionals who are engaged in their well-being. What do we

expect to be able to tell them? What does our research

underscore or explicate? In the following, we present a

preliminary sketch along three lines of the contribution

value of the rationale presented above.

First, both forms of interview will most likely pro-

vide information about the shift from working life to re-

tirement. The phenomenological interview aims to

capture the general meaning structure of well-being dur-

ing early retirement. The SOI explores how the individ-

ual structures some of his or her recent experiences with

change, success, feeling torn, etc. A change of lifestyle

that comes with a major shift (such as retiring) appears

in the light of a structural developmental approach as ei-

ther solving a technical problem or overcoming an adap-

tive challenge (Heifetz and Linsky, 2002). The latter

implies a change in order of mind, whereas the former

means that the person maintains the same order of mind

while incorporating new activities in his or her daily life.

For instance, the third age could be lived so that time is

increasingly spent on previously well-established activi-

ties, or it could incorporate new activities that facilitate

or emerge with the structural development of mind. An

awareness of the differences between these changes

assists the retiree, welfare professional and policy-maker

alike in choosing or recommending one activity in fa-

vour of another.

Second, both types of interview will provide informa-

tion about how well-being takes shape in different orders

of mind. Following Labouvie-Vief et al. (1989), Noam,

Young, and Jilnina (2006) have argued that people at var-

ious levels of mental complexity may experience and un-

derstand their well-being in qualitatively different ways.

Bauer (2011) researched the content of the growth stories

told by persons with late stages of mental growth (with

what he refers to as ‘postconventional selves’). He found

that, on average, later stages of development do not nec-

essarily make a person more happy as measured by estab-

lished quantitative measures of well-being (Diener et al.,

1985), which is consistent with Kegan’s theoretical as-

sumptions. One finding, however, stands out, namely

that the individuals with the highest score of mental com-

plexity had indeed higher levels of well-being on average

when compared to the other stages (Bauer et al., 2011).

However, Bauer et al. (2011) findings are preliminary,

given the relatively small number of participants who

scored in the highest stage. Mental complexity, Bauer and

colleagues confirm, taps into different aspects of well-

being, but their research is inconclusive as to how the

first-person experience of well-being relates to mental

growth, especially concerning individuals who have not

reached the very late stages of development, i.e. the ma-

jority of the population.

Kegan (1982, pp. 267-268) has looked into what can

be called psychological ‘ill-being’ and its relation to

mental complexity. He analysed patient journals at a

psychiatric hospital and inferred three different kinds of

depression, characterized by three types of loss, respec-

tively: a loss of one’s own needs or the increasing costs

of trying to satisfy these needs, a loss of an interpersonal

relationship leading to loneliness or even a loss of parts

of oneself, and loss of control over meeting one’s own

standards. Upon first measuring mental complexity and

then relating it to these three types of depression, a

strong association between type of depression and men-

tal complexity was observed.

We aim to follow up on the interest of Noam et al.

(2006) and Bauer et al. in the link between mental com-

plexity and well-being, and use a research design in-

spired by Kegan’s study of depression. Here we will first

divide our participants up into groups according to their

SOI score, and then interview them to discover how they

experience well-being.

Third, the combination of both interviews will pro-

vide essential information to suggest new opportunities

for tailoring interventions to the intermediate range

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Deleted Text: Shaping structural developmental health promotion

between the unique individual and larger cohorts of the

population. Tailored interventions have been defined as

follows: ‘Any combination of information or change

strategies intended to reach one specific person, based

on characteristics that are unique to that person, related

to the outcome of interest, and have been derived from

an individual assessment’ (Kreuter and Skinner, 2000,

p. 1; italics in original). For our purposes, this may be an

unattainable ideal considering the amount of resources

required. At the other end of the continuum, health pro-

motion that is specific to cohorts, though economically

more manageable, may risk not reaching all the mem-

bers of the targeted population. Consequently, we prefer

an intermediate range at which to target the population

of retirees. In other words, understanding how individ-

uals with different orders of mind experience well-being

differently allows programme developers to tailor psy-

chologically spacious programmes while avoiding indi-

vidual time-consuming assessments. Moreover, health

care and welfare professionals will benefit from an

awareness of structural development, lest they under- or

overshoot their communication with the target popula-

tion concerning health promotion activities. Therefore,

our research may also help to provide these profes-

sionals with knowledge of lifelong development and

learning as well as active ageing.

CONCLUSION

In this article we have outlined perspectives which have

as yet not been combined. We have emphasized the no-

tion of adding more life to years as well as the potential

for structural developmental thinking in health promo-

tion initiatives. This is an area largely untouched in the

health promotion literature, and we see its inclusion as a

contribution to extending the positive period of the third

age while also aiding the compression of the fourth age.

We have underscored the reciprocity of well-being

and lifestyle and have argued that the experience of

well-being may have quite different manifestations for

different persons when seen through the lenses of a

structural development approach. We have sketched a

feasible mid-range approach to tailoring health promo-

tion initiatives. This approach attends to the orders of

the mind within the target group and has the potential

to overcome the practical difficulties of developing

unique individual health promotion initiatives.

We have presented one structural developmental the-

ory within the neo-Piagetian tradition as a contrasting

view to the current phase theories employed in ageing

research, but there are many others which we have not

discussed. Notable examples of others in this tradition

are Kohlberg (1969), Fowler (1981), Commons et al.

(1998), Gilligan (1982), Basseches and Mascolo (2009),

Cook-Greuter (1999) and Loevinger and Blasi (1976).

Kegan’s theory of adult development in health promo-

tion serves our purpose well, which is why we have not

focused on other potentially appropriate theories of

adult development or mental growth. We conclude that

a sensitivity towards the complexity of mind with re-

spect to the experience of well-being will provide health-

care professionals and policy-makers with a powerful

tool in their health promotion toolbox.

ACKNOWLEDGEMENTS

We wish to thank the two reviewers for their insightful com-

ments and specific points of improvements for the article.

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Linked Articles: Bjorklund; doi: 10.1111/cdev.13019 Bjorklund; doi: 10.1111/cdev.13020 Frankenhuis and Tiokhin; doi: 10.1111/cdev.13021

Evolutionary Developmental Psychology: 2017 Redux

Cristine H. Legare The University of Texas at Austin

Jennifer M. Clegg Texas State University

Nicole J. Wen The University of Texas at Austin

Bjorklund is a pioneer in bringing evolutionary theory to developmental psychology. In doing so, he has made major contributions to the field, including publishing a widely adopted and influ- ential textbook (Bjorklund & Causey, 2017). We commend him for his groundbreaking research and strongly agree that it is “undeniable that evolu- tionary thinking has seeped into the minds of many cognitive developmental psychologists” (Bjorklund, 2018, p. 14).

We suggest that evolutionary theory has impacted developmental psychology even more strongly than Bjorklund suggests. Many of the most influential recent programs of research in the field of developmental psychology, cognitive and other- wise, take an evolutionary approach to understand- ing the ontogeny of cognition and behavior (as just a few recent examples: Barrett et al., 2013; Blake et al., 2015; Broesch, Rochat, Olah, Broesch, & Hen- rich, 2016; Clay & Tennie, 2017; Gopnik et al., 2017; Hamlin, 2014; Henrich, 2015a; Heyes, in press; House et al., 2013; Nielsen & Haun, 2016; Rosati & Warneken, 2016; Santos & Rosati, 2015; van Leeu- wen, Call, & Haun, 2014; Warneken & Tomasello, 2017; Wertz & Wynn, 2014). Additional evidence of impact can be found in recent programs at major conferences in the field. The Society for Research in Child Development, the Cognitive Development Society, and the International Congress for Infant

Studies have all featured evolutionary research in preconferences and invited addresses in recent years. In fact, evolution has been so successful as a metatheory within developmental psychology, many doing research within this tradition do not use this label to identify their area of expertise or theoretical approach.

Perhaps as a result of developmental psycholo- gists conducting research that is increasingly guided by evolutionary theory, but not explicitly labeled as such, there is a large body of recent literature not reviewed by Bjorklund. To give one example, the best research on cognitive obstacles to understand- ing evolution and recommendations for how to teach it comes from research programs in cognitive and developmental psychology that draw on evolu- tionary theory. This research demonstrates that intu- itive cognitive bias such as essentialism and teleological reasoning impede understanding of evo- lutionary concepts (e.g., Emmons, Smith, & Kele- men, 2016; Evans, in press; Heddy & Sinatra, 2013; Legare, Lane, & Evans, 2013; Lombrozo, 2013; Short & Hawley, 2015; Shtulman, Neal, & Lindquist, 2016).

Another increasingly influential trend within developmental, cognitive, and comparative research guided by evolutionary theory, not covered in Bjorklund’s review, is to examine the origins of complexity and variability in human culture. Tack- ling interdisciplinary questions of this kind requires understanding the differences between human and

Commentary on Bjorklund (2017). Child Development. Correspondence concerning this article should be addressed to

Cristine H. Legare, The University of Texas at Austin, Depart- ment of Psychology, 1 University Station #A8000, Austin, TX, 78712. Electronic mail may be sent to [email protected].

Child Development, November/December 2018, Volume 89, Number 6, Pages 2282–2287

info:doi/10.1111/cdev.13019

info:doi/10.1111/cdev.13020

info:doi/10.1111/cdev.13021

http://orcid.org/0000-0001-5655-9899

http://orcid.org/0000-0001-8471-4876

nonhuman social learning capacities, the ontogeny of those capacities, and their expression across diverse human populations. We propose that only the combination of these perspectives will enable us to fully understand the roots of human culture. We and others advocate for a triadic approach to understanding the evolution and ontogeny of cul- tural learning by integrating comparative, cross- cultural, and developmental psychological research, with all of these lines drawing heavily on evolu- tionary theory (Legare, 2017; Nielsen & Haun, 2016).

Our research differs from Bjorklund’s not because we disagree about the importance and impact of evo- lutionary theory within developmental psychology, but instead is based on the relative emphasis we place on the scientific importance of understanding cultural transmission and variation. Examining cul- tural variation would enrich Bjorklund’s discussion of developmental cognitive neuroscience and cogni- tive development. Claims about the universality and ontogeny of cognitive mechanisms without data on global diversity are unwarranted (Nielsen, Haun, Kaertner, & Legare, 2017). Prioritizing studying cul- tural diversity in programs of research would also encourage researchers to utilize cutting-edge and state-of-the-art methodologies and tools, elevating evolutionary developmental science programs. Below we describe an example of a comparative, cross-cultural, and developmental program of research on cultural learning and social group cogni- tion and behavior, all based on evolutionary theory.

Comparative Perspectives on Cultural Learning

Cultural variation in humans is unique among ani- mals and differs dramatically even from our closest primate relatives (Boyette & Hewlett, 2017; Henrich, 2015b; Lew-Levy, Reckin, Lavi, Crist�obal-Azkarate, & Ellis-Davies, 2017; Mesoudi, Chang, Murray, & Lu, 2015; Terashima & Hewlett, 2016). Here culture is defined as “group-typical behaviors shared by members of a community that rely on socially learned and transmitted information” (Laland & Hoppitt, 2003). Although nonhuman animals may have the ability to learn social information (Aplin, 2015; Leadbeater, 2015; Perry et al., 2003; Plotnik, Lair, Suphachoksahakun, & de Waal, 2011; White- head & Rendell, 2015) and to transmit group-speci- fic behavior (Cantor et al., 2015; Garland et al., 2013; Laland & Galef, 2009), humans display a much wider repertoire of socially acquired and transmitted behaviors that vary more across groups

than nonhuman animals (Dean, Vale, Laland, Flynn, & Kendal, 2014; Johnson-Pynn, Fragaszy, & Cummins-Sebree, 2003).

How does human cognition differ from non- human primate cognition? One potential candidate is cross-species variation in social cognition (van Schaik & Burkart, 2011). Our prolonged early development also sets humans aside from other primates. As Bjorklund and others suggest, natural selection favored an extended childhood to allow for increased flexibility in cognitive development (Bjorklund, 2018; Bjorklund & Ellis, 2014). During this extended juve- nile period, our offspring are dependent on adults for survival, and in turn, this dependency increases opportunities for interaction with caregivers and enables social learning (Hublin, 2005).

The technological and social complexity of human populations is due to our ability for cumu- lative cultural transmission, a process by which the discoveries and inventions of others are built upon to create increasingly complex reserves of socially heritable knowledge (Henrich, 2015b). Human psy- chological flexibility allows us to build upon estab- lished behaviors by relinquishing old solutions and flexibly switching to more productive or efficient ones (Davis, Vale, Schapiro, Lambeth, & Whiten, 2016). Evidence for culture in nonhuman species continues to grow, but there is little evidence for the accumulation of cultural innovation in nonhu- man animals. Recent comparative research has examined the development of social learning and imitative flexibility across hominin evolutionary his- tory (Whiten, 2017). Comparative research on this topic will increase our knowledge of how cognitive capacity may constrain young children’s and chim- panzees’ learning potential and technological skill, as well as elucidating the diverse learning heuristics that children and chimpanzees employ. Although largely absent from Bjorklund’s commentary, re- search contrasting children’s and other primates’ social cognition adds to our understanding of the origins of cumulative culture in humans and evolu- tionary theory more broadly.

Development and Diversity of Cultural Learning

Young children are adept at acquiring the beliefs and practices of whatever group they are born into, a cognitive capacity that requires substantial flexi- bility. We agree with Bjorklund that the sociocogni- tive mechanisms that children display are not the “derivatives of ‘hard’ cognition” but a set of critical psychological adaptations in their own right

Evolutionary Developmental Psychology 2283

(Bjorklund, 2018, p. 15). For example, children have a number of cognitive biases that aid in the acquisi- tion of their specific cultural practices. These biases include preferences for learning from those who are from similar social groups (Kinzler, Dupoux, & Spelke, 2007), those who conform (Haun & Over, 2014) and display behavioral or cognitive consensus with others (Claidi�ere & Whiten, 2012; Corriveau, Fusaro, & Harris, 2009; Herrmann, Legare, Harris, & Whitehouse, 2013), and those who display prestige (Chudek, Heller, Birch, & Henrich, 2012; Henrich, 2009).

Missing from Bjorklund’s commentary on the development of the sociocognitive brain and the social brain hypothesis (Bjorklund, 2018, p. 15) is a discussion of the flexibility and diversity of chil- dren’s social learning. We argue that studying the flexibility and diversity of children’s sociocognitive development provides insight into the evolution and ontogeny of human culture. This same flexibil- ity and diversity provides an interesting evolution- ary problem—if children’s capacity for social learning explains cultural transmission, the psycho- logical mechanisms should be universal, but these psychological mechanisms must also be respon- sive to diverse ontogenetic contexts and cultural ecologies (Apicella & Barrett, 2016; Hrdy, 2009; Legare & Harris, 2016; Nielsen et al., 2017). To address this problem, we must first ask: H is cul- ture acquired?

Children possess cognitive and communication systems that evolved to acquire the complicated technical and social skills characteristic of human cultures. They are attentive to social input and learn important skills and information through observa- tion. Another way that children acquire cultural knowledge and practices is through imitation. As Bjorklund mentions, we know that children are also precocious imitators and “overimitation” may be an adaptive learning strategy to promote the high-fide- lity acquisition and transmission of behavior. Is high fidelity copying an adaptation that provides the psychological foundation of human cultural transmission? What is the function of imitation? We have developed an integrated cognitive psychologi- cal and ontogenetic account of how imitation and innovation work in tandem to drive cultural learn- ing and facilitate our capacity for cumulative cul- ture. We propose that the unique demands of acquiring instrumental skills (based on physical causation) and rituals (based on social convention) provide insight into when children imitate, when they innovate, and to what degree. For instrumental learning, with an increase in experience, high-fidelity

imitation decreases and innovation increases. In con- trast, for conventional learning, imitative fidelity stays high, regardless of experience, and innovation stays low (Legare & Nielsen, 2015).

What distinguishes instrumental from ritual prac- tices is a matter of interpretation based on contextual information and social cues. We have used both quantitative and qualitative methodologies to exam- ine the kind of information children use to determine when an event provides an opportunity for learning instrumental skills versus learning cultural conven- tions (Clegg & Legare, 2016b; Legare, Wen, Her- rmann, & Whitehouse, 2015), the implications of learning instrumental skills versus learning cultural conventions for social group behavior (Watson-Jones & Legare, 2016; Watson-Jones, Legare, Whitehouse, & Clegg, 2014; Wen, Herrmann, & Legare, 2016), and socialization of instrumental skills versus cultural conventions in early childrearing environments (Clegg & Legare, 2017; Clegg, Wen, & Legare, 2017). Data from cross-cultural research have demonstrated that children use imitation flexibly to acquire the specific practices, beliefs, and values of their groups (Clegg & Legare, 2016a).

To understand the ontogeny of human social learning, we must examine how it changes over the life span and how it varies in a strategically selected set of cultural contexts that differ along theoretically relevant variables. How do caregiver socialization practices and the development of social learning capacities enable and structure cumulative cultural transmission? We are addressing the question by studying the impact of diverse childrearing environ- ments, practices, and social dynamics on the devel- opment of cultural learning. For example, we conduct research in educational settings and home environments in both the United States (Austin, Texas) and Vanuatu (Tanna; Clegg & Legare, 2016a). Vanuatu, a Melanesian island nation in the South Pacific, is one of the most remote, culturally and linguistically diverse, and understudied coun- tries in the world. Vanuatu provides a unique opportunity to explore the development of cultural learning in populations that vary in extent of Wes- tern influence. Conducting this research cross-cultu- rally in Vanuatu and the United States allows us to examine the imitative foundations of cultural learn- ing in contexts that represent key aspects of the diversity of human childrearing practices.

Humans are uniquely able to accumulate and build upon the cultural innovations of previous generations (Kurzban & Barrett, 2012; Pagel, 2012; Pradhan, Tennie, & van Schaik, 2012; Whiten & Erdal, 2012). Teaching and imitation work in tandem

2284 Legare, Clegg, and Wen

to conserve and transmit group-specific cultural knowledge, increasing the likelihood for modifica- tions and innovations, thus enhancing cultural com- plexity (Enquist, Strimling, Eriksson, Laland, & Sjostrand, 2010). Developing a comprehensive understanding of teaching and imitation requires the systematic study of cultural variation in childrearing practices (Nielsen et al., 2017). We can enrich our understanding of the developmental origins of cumulative cultural transmission by conducting cross-cultural research on cognitive and social devel- opment (Legare & Harris, 2016).

In sum, comparative, developmental, and cross- cultural research guided by evolutionary theory provides insight into the evolution and ontogeny of human cognition and behavior. Evolutionary theory has made a profound and permanent impact on the field of developmental psychology, shaping our own research programs, as well as those of many others. Bjorklund deserves substantial credit for this striking scientific success story and should be feel- ing very well indeed.

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Maslow’s Unacknowledged Contributions to Developmental Psychology

Andrew M. Bland1 and Eugene M. DeRobertis2,3

Abstract Few readily identify Maslow as a developmental psychologist. On the other hand, Maslow’s call for holistic/systemic, phenomenological, and dynamic/ relational developmental perspectives in psychology (all being alternatives to the limitations of the dominant natural science paradigm) anticipated what emerged both as and in the subdiscipline of developmental psychology. In this article, we propose that Maslow’s dynamic systems approach to healthy human development served as a forerunner for classic and contemporary theory and research on parallel constructs in developmental psychology that provide empirical support for his ideas—particularly those affiliated with characteristics of psychological health (i.e., self-actualization) and the conditions that promote or inhibit it. We also explore Maslow’s adaptation of Goldstein’s concept of self-actualization, in which he simultaneously: (a) explicated a theory of safety versus growth that accounts for the two-steps- forward-one-step-back contiguous dynamic that realistically characterizes the ongoing processes of being-in-becoming and psychological integration in human development/maturity and (b) emphasized being-in-the-world-with- others with the intent of facilitating the development of an ideal society

1Millersville University, Millersville, PA, USA 2Brookdale College, Lincroft, NJ, USA 3Rutgers University–Newark, Newark, NJ, USA

Corresponding Author: Eugene M. DeRobertis, Department of Psychology, Brookdale College, MAN 126c, Lincroft, NJ 07738, USA. E-mail: [email protected]

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by promoting protective factors that illustrate Maslow’s safety, belonging, and esteem needs. Finally, we dialogue with the extant literature to clarify common misgivings about Maslow’s ideas.

Keywords Maslow, self-actualization, developmental psychology, dynamic systems

Few readily identify Maslow as a developmental psychologist. Both he and the humanistic movement are almost always excluded from developmental textbooks (DeRobertis, 2008), and an EBSCO search in February 2017 yielded a dearth of relevant articles. In the rare instances in which Maslow is included, his ideas are typically misrepresented. On the other hand, as we have previously suggested (Bland & DeRobertis, 2017; DeRobertis, 2012), Maslow and other founding humanistic psychologists’ calls for holistic/sys- temic, phenomenological, and dynamic/relational developmental perspec- tives in psychology (as alternatives to the dominant natural science paradigm) anticipated what emerged both as and in the subdiscipline of developmental psychology. Accordingly, herein, we propose that classic and contemporary theory and research in developmental psychology provide empirical support for Maslow’s ideas, particularly those affiliated with characteristics of psy- chological health (i.e., self-actualization) and the factors that promote or inhibit it.

Maslow (1999) observed that “from a developmental point of view,” self- actualizing individuals “are more fully evolved” insofar as they are “not fix- ated at immature or incomplete levels of growth” (p. 172). They strive toward “unity of personality” and “spontaneous expressiveness” as well as “seeing the truth rather than being blind,” “being creative,” and demonstrating “seren- ity, kindness, courage, honesty, love, unselfishness, and goodness” (Maslow, 1999, p. 171). Using growth and health as his baseline, Maslow helped usher in a focus on normative and transformative developmental processes in psy- chology. At the same time, he acknowledged the role of regressive forces and the potential for stagnation, often as the outcome of inadequate environmen- tal conditions.

Maslow’s Developmentally Oriented Adaptation of Goldstein’s Self-Actualization

Maslow (1987) adapted the construct of self-actualization from Goldstein, an organismic-oriented neurologist–psychiatrist. According to Whitehead (2017),

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Goldstein’s construct was built on three axioms. First, self-actualization refers to a process of individuation (i.e., the ongoing emergence and regeneration of a self as an active, creative authority distinct from other biochemical systems) that, second, must be conceptualized holistically and not in isolation (i.e., it is only through the organism–environment relationship that the meaning behind behavior, pathology, personality, motivation, emotion, etc., can be under- stood). Third, Goldstein proposed that behavior is invariantly motivated in terms of self-actualization (i.e., is not synonymous with tension reduction or mere self-preservation or survival).

Whereas Goldstein (1934/1995, 1963) primarily focused on self-actual- ization vis-à-vis the resilient reorganization of a person’s capacities in response to brain injury or psychopathology, Maslow further included over- coming obstacles (real and perceived) and living authentically despite one’s personal, environmental, and historical shortcomings as functions of healthy development. Maslow (1999) explicated a theory of safety versus growth that accounts for the two-steps-forward-one-step-back contiguous dynamic that realistically characterizes the ongoing process of being-in-becoming and of graded experiential awareness and psychological integration in human maturity. Beginning in childhood and continuing throughout the lifespan, individuals negotiate a dialectic between homeostasis (i.e., defen- sively clinging to the familiar and predictable, irrespective of how stagnant, disappointing, or precarious the outcome) and morphogenic enactment “of all [their] capacities, toward confidence in the face of the external world at the same time that [they] can accept [their] deepest, real, unconscious Self” (Maslow, 1999, p. 55).

Maslow challenged the classical Freudian assumption of homeostasis as an end state. Instead, like Erikson (1959/1994), he argued that “healthy chil- dren enjoy growing and moving forward, gaining new skills, capacities and powers” that evolve into “authentic selfhood, [i.e., knowing] what one really wants and doesn’t want, what one is fit for and what one is not fit for” (Maslow, 1999, pp. 30, 213). Taken together, Maslow’s focus on the dialecti- cal relationship between a process of continuous improvement and ongoing integration, organization, and self-consistency (see Frick, 1971) reflects Goldstein’s aforementioned first axiom.

In addition, Maslow emphasized that self-actualization entails a sense of being-in-the-world-with-others, interindividuality, community feeling, and interest in making changes for an ideal society. These points are synonymous with Adler’s (1931/1998) social interest and parallel Erikson’s (1959/1994) emphasis on participating in (rather than struggling against) society as both conducive to and reflective of healthy social and emotional development. Maslow distinguished between uniqueness and distinctiveness in relation to

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others (Koydemir, Şimşek, & Demir, 2014), drawing from and making best use of one’s potentials to benefit the collective:

Authentic or healthy [individuals] may be defined not . . . by [their] own intrapsychic and non-environmental laws, not as different from the environment, independent of it or opposed to it, but rather in environment- centered terms. . . . Self-actualization . . . paradoxically makes more possible the transcendence of . . . self-consciousness and of selfishness. It makes it easier for [one] . . . to merge as a part in a larger whole. (Maslow, 1999, pp. 199, 231, italics added in first sentence)

This relational viewpoint is commensurate with Goldstein’s second axiom. With regard to Goldstein’s third axiom, Maslow (1987) eschewed reduc-

tionistic explanations of behavior and emphasized that behavior is “overde- termined or multimotivated,” reflecting combinations of needs in striving toward self-actualization. As an organizing principle, Maslow (1987, 1999) proposed a hierarchical structure from physiological to security to belonging to self-esteem. Each set of needs is gratified on a continuum from more exter- nalized (lower, more basic needs) to more intrinsic (higher, more idiosyn- cratic needs). Furthermore, Maslow (1999) emphasized that one’s essential “core” involves “potentialities, not final actualizations” that are “weak, sub- tle, and delicate, very easily drowned out by learning, by cultural expecta- tions, by fear, by disapproval, etc.” and can therefore become “forgotten, [i.e.,] neglected, unused, overlooked, unverbalized, or suppressed” (pp. 212- 213). To illustrate:

[Children] who [are] insecure, basically thwarted, or threatened in [their] needs for safety, love, belongingness, and self-esteem . . . will show more selfishness, hatred, aggression, and destructiveness. . . . This implies a reactive, instrumental, or defensive interpretation of hostility rather than an instinctive one. (Maslow, 1987, p. 86)

Maslow (1987) emphasized that fulfillment of the basic needs is neither a lockstep progression nor confined to specific ages/phases of life, but rather is a holistic process:

[The statement that] if one need is satisfied, then another emerges . . . might give the false impression that a need must be satisfied 100% before the next need emerges. In actual fact, most [individuals] are partially satisfied in all their basic needs and partially unsatisfied in all their basic needs at the same time. A more realistic description of the hierarchy would be in terms of decreasing percentages of satisfaction as we go up the hierarchy of prepotency.

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. . . The emergence [of a new need] is not a sudden, saltatory phenomenon, but rather a gradual emergence by slow degrees. (pp. 27-28, italics added)

Thus, Rowan (1999) used the analogy of Russian nesting dolls to illustrate the idea that the lower needs are transcended but also included within the higher ones, that is, they are never lost.

Dynamic Systems Developmental Orientation

Perhaps one reason that Maslow is not typically included in developmental textbooks and research articles is that his quotidian vision of psychology as a human science was not fully congruent with either discontinuous stage mod- els or the continuous, quantitatively driven perspectives that constituted the majority of the traditional developmental psychology literature during the second half of the 20th century. Meantime, taken out of context, his emphasis on self-actualization reeks of Western individualism and therefore generally has been dismissed (or, at best, overlooked) by most sociocultural theorists in the new millennium. On the other hand, during the past decade, dynamic systems models—the paradigm with which Maslow’s (1987) “holistic- dynamic” thinking aligned (p. 15)—have gained legitimacy in psychology (see Bland & Roberts-Pittman, 2014; DeRobertis, 2011b; Gelo & Salvatore, 2016), and they were included as a theoretical category in Bergen’s (2008) textbook on human development.

Dynamic systems models incorporate concepts of complexity, plasticity, and recursive nested features (Bergen, 2008). Maslow (1971) emphasized that self-actualizing should be conceptualized iteratively (i.e., as a verb) and not as an achievement or trait (i.e., as a noun). Moreover, dynamic systems models are built on the assumptions that (a) complex, chaotic systems (e.g., human beings) have the ability to self-organize into purposeful behaviors and that (b) sensitive dependence on initial conditions—in which a small input in a system may yield disparate results—can explain developmental change (Bergen, 2008). Maslow (1987) accounted for the possibility of quantum leaps in development, in which significant changes at one need level can incite substantive changes at the subsequent levels.

Congruent with Maslow’s aforementioned safety versus growth principle (two-steps-forward-one-step-back), Skalski and Hardy (2013) noted that such quantum transformation is typically propagated by individuals’ under- standings of themselves and the world becoming disintegrated by stress, rela- tional difficulties, hopelessness, losing control/holding on, and psychological turmoil and then enhanced by the presence of a trusted other who provides corrective experiences (see Bland, 2014; Castonguay & Hill, 2012). To

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illustrate, DeRobertis’ (2016) study on children’s education implied that quality teachers can serve not only as extensions of attachment relationships (when they already exist) but also as surrogates thereof (when they do not). In addition, whereas Graber, Turner, and Madill (2015) hypothesized that during adolescence family support would moderate the significance of friend- ships as a risk or protective mechanism, they discovered instead that, irre- spective of family, having just one fulfilling friendship prevents relational, emotional, and behavior problems.

Furthermore, dynamic systems models can be characterized as prototheo- retical rather than fully developed, falsifiable theories and are supported by research methods that involve collecting minute process data (Bergen, 2008). Maslow’s aforementioned initial study on the characteristics of self-actualiz- ing people (included in Maslow, 1987) and his research on peak experiences (included in Maslow, 1999) employed iterative qualitative analyses (see Wertz et al., 2011). These involved him extracting themes from biographies and interviews with purposive samples to critically catalog and describe their common attributes which he then triangulated with extant theory and empiri- cal research in conjunction with quantitative and qualitative studies he had conducted during his early career (see Hoffman, 1988; Maslow, 1973). Maslow’s emphases on self-actualization and on values in psychology set the stage for psychologists acknowledging the realities of plasticity and of multi- dimensional, multidirectional developmental principles that value the whole person in context and that are now underscored in developmental textbooks (e.g., Capuzzi & Stauffer, 2016; Music, 2017). It is crucial to note that Maslow’s theories were built as an outcome of his research (not the other way around), that he was flexible, open to criticism, and constantly expanding and revising his ideas, and that he emphasized the need for them to be empirically tested and reworked as appropriate (see Frick, 1971; Maslow, 1971, 1999).

Finally, Maslow’s nonexclusive vision also paved the way for develop- mental psychology’s resolution of long-held (stereotypically Western) con- ceptual bifurcations (see Music, 2017). For example, with regard to nature versus nurture, Maslow (1987) remarked as follows:

How can it be said that a complex set of reactions is either all determined by heredity or not at all determined by heredity? There is no structure, however, simple . . . that has genetic components alone. At the other extreme it is also obvious that nothing is completely free of the influence of heredity, for humans are a biological species. (p. 48)

Maslow (1966, 1971, 1987, 1999) also emphasized moving beyond the antin- omies of free will versus determinism, continuity versus change, universality

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versus cultural specificity, and experimentalism versus experientialism in understanding human development.

Classic and Contemporary Empirical Support

Physiological

Maslow’s working class upbringing as the eldest son of Russian Jewish immigrants influenced his lifelong focus on social justice (Hoffman, 1988). According to Anne Richards (personal communication, 2003), in his classes during the 1960s, Maslow advocated for the development of reduced-price meals in schools (now a given in most communities in the United States) as a means of minimizing obstacles to impoverished children’s growth and empowerment. Maslow’s suggestion brought awareness of how issues of social policy and both availability and quality of resources at Bronfenbrenner’s (1994) exosystemic, macrosystemic, and chronosystemic levels influence individuals’ development, whereas the principal focus of psychology at mid- 20th century was almost exclusively at the individual and microsystemic levels.

Accordingly, since Maslow’s day, developmental researchers have come to emphasize the connections between malnutrition and children’s: (a) ability to sustain attention (which in turn affects cognitive development and aca- demic performance); (b) levels of irritability and self-regulation (which affect social development); and (c) propensity to diagnosable mental health condi- tions as well as susceptibility to infectious disease, obesity, and eventual dia- betes and heart issues (as summarized in Arnett, 2016; Broderick & Blewitt, 2015). Congruent with the dynamic systems assumption that a small change can spawn sustentative outcomes, Broderick and Blewitt (2015) commented, “When we intervene to reduce one risk factor, such as malnutrition, we may actually [also] reduce the impact of other negative influences” (p. 56). In addition, Prince and Howard (2002) extended Maslow’s thinking on the developmental implications of physiological needs to include access to ade- quate health care, insurance, and living environments safe from toxicity (e.g., exposure to lead). Furthermore, Desmond’s (2016) ethnographic research addressed the systemic challenges in tenants’, landlords’, and social service agencies’ abilities to uphold sustainable living environments and the devel- opmental impacts for both children and adults.

Maslow (1987; Maslow & Mittelmann, 1951) also noted that healthy growth and development involves not only gratification of the basic needs but also the ability to withstand reasonable deprivation. “Increased frustra- tion tolerance through early gratification” enables individuals to “withstand

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food deprivation” because they “have been made secure and strong in the earliest years,” which reciprocates into them remaining secure and strong thereafter (Maslow, 1987, p. 27). As applied to the physiological needs, Erikson (1959/1994) suggested that a developmental task of infancy is to establish confidence in one’s caregivers to eventually attend to one’s needs even if caregivers are unable to drop what they are doing the moment one expresses a need. Accordingly, secure interactions between parent and child moderate the relationship between low socioeconomic status and develop- mental outcomes (Bronfenbrenner, 1994).

Safety

Maslow (1987) defined the safety needs as “security; stability; dependency; protection; freedom from fear, anxiety, and chaos [and] need for structure, order, law, and limits” (p. 18). In contrast with conventional wisdom in (par- ticularly) American parenting practices that emphasize independence as quickly as possible, models such as attachment parenting (Miller & Commons, 2010) promote the value of strong bonding early in life, congruent with less ruggedly individualistic cultures around the globe (see Maté, 2011; Morelli & Rauthbaum, as cited in Arnett, 2016). Researchers have noted that such highly responsive caregiving practices: (a) mitigate potentially overwhelm- ing negative emotional states (e.g., preventable fear, anger, distress) and therefore propagate appropriate emotional regulation; (b) reduce exposure to stressors that adversely affect brain development and self-regulation and that contribute to eventual mental health problems; (c) are associated with fewer expressions of distress; and (d) promote empathy, perspective-taking, social competence, cooperative behavior, and engagement in school life (see Broderick & Blewitt, 2015; Campa, 2013; Miller & Commons, 2010). In contrast, executive functioning becomes impaired “when young children are exposed to chronically stressful situations” insofar as:

the brain development of the lower portions of the brain, responsible for “fight or flight” reactions, are strengthened while the development in the cortex regions of the brain, which are responsible for functions such as abstract and rational thinking, are weakened. (Prince & Howard, 2002, pp. 29-30)

Thus, paradoxically, a strong sense of attachment early on facilitates appropriate levels of differentiation of self (Bowen, 1978; Firestone, Firestone, & Catlett, 2013) and autonomy (Erikson, 1959/1994)—all of which include mindful self-regulation and approaching unfamiliar situations with curiosity and interest rather than as threatening. Accordingly, they are

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conducive to self-sufficiency (comfort in one’s skin and with one’s own beliefs, attitudes, and preferences) and assertiveness (vs. aggression, passiv- ity, or passive-aggression).

Attachment. Secure attachment (Ainsworth, as summarized and updated in Siegel, 2012; also see Music, 2017), marked by caregivers’ sensitivity and responsiveness to infants’ cues, is associated with curiosity and differentia- tion of self by early childhood (i.e., preschool and kindergarten age), with positive social interactions and stronger academic performance during school age, and with appropriate self-esteem and a strong sense of identity as adults (all prerequisites for, though not necessarily characteristics of, self-actualiz- ing, Maslow, 1987). On the other hand, with respect to insecure attachment, Maslow observed that when safety needs are not met, behavior and motiva- tion are disposed to stagnation or regression:

Since others are so important and vital for the helpless baby and child, fear of losing them (as providers of safety, food, love, respect, etc.) is a primal, terrifying danger. Therefore [children], faced with a difficult choice between [their] own delight experiences and the experience of approval from others, must generally choose approval from others, and then handle [their] delight by repression or letting it die, or not noticing it or controlling it by willpower. In general, along with this will develop a disapproval of the delight experience, or shame and embarrassment and secretiveness about it, with finally, the inability to even experience it. (Maslow, 1999, pp. 59-60)

This can lend itself to rigidity; to efforts to distract oneself from inner experi- ence (Frankl, 1978; Harris, 2006); to engagement in addictive and/or compul- sive behaviors as surrogates for meaningful interaction (Maté, 2010); and/or to involvement in (sometimes precarious) relationships (Campa, 2013) and/or institutional affiliations (May, 1967) that offer the illusion of security.

Parenting Styles. Maccoby and Martin (1983) noted that authoritative parent- ing (see Gordon, 1975; Shapiro & White, 2014)—characterized by a balance of emotional warmth and high expectations (demandingness); associated with secure attachment and, later, identity achievement (Erikson, 1959/1994; Marcia, 1966)—promotes the development of assertiveness, competence and self-confidence, social responsibility, healthy achievement orientation, adapt- ability, and so on (all qualities of Maslovian self-actualizing people). In con- trast, children of authoritarian parents (high demandingness, low warmth; associated with avoidant attachment and, later, identity foreclosure) are prone to conformity, dependency, perfectionism, resentful anxiety, and susceptibil- ity to bullying. Children of permissive/indulgent parents (high warmth, low

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demandingness; associated with ambivalent attachment and, later, chronic moratorium) are at risk for becoming impulsive, egocentric, low in self-reli- ant decision making, underachieving, and easily frustrated by authority (being unaccustomed to structure). Neglectful/uninvolved parenting (low warmth and low demandingness; associated with disorganized attachment and, later, identity diffusion) is predictive of delinquency and children devel- oping a symptomatic presentation consisting of both externalizing (impulsiv- ity, aggression) and internalizing (moodiness, low self-esteem) qualities.

Maslow (1999) alluded to authoritative parenting by saying that children should “be directed . . . both toward cultivation of controls and cultivation of spontaneity and expression” (p. 219) and noted that “youngsters need a world that is just, fair, orderly, and predictable” and that “only strong parents can supply these important qualities” (Maslow, 1996, p. 46). Maslow also cau- tioned against both excessively authoritative and permissive parenting styles. With regard to the former, Maslow (1999) suggested as follows:

It is necessary in order for children to grow well that adults have enough trust in them and in the natural processes of growth, i.e., [to] not interfere too much, not make them grow, or force them into predetermined designs, but rather let them grow and help them grow in a Taoistic rather than an authoritarian way. (p. 219)

With regard to the dangers of permissive parenting:

Children, especially younger ones, essentially need, want, and desire external controls, decisiveness, discipline, and firmness . . . to avoid the anxiety of being on their own and of being expected to be adultlike because they actually mistrust their own immature powers. (Maslow, 1996, p. 45)

Maslow (1971) continued that this anxiety eventually manifests into the defense mechanism of desacrilizing (i.e., mistrusting the possibility of values and virtues associated with self-actualization) based on having felt “swindled or thwarted in their lives” and therefore coming to “despise their elders” (p. 48). Similarly, Horney (1945) proposed that to deal with this anxiety, based on their particular formative experiences, individual children develop means of coping via moving toward others (compliance), against them (aggression), or away from them (withdrawal).

Love and Belonging

Maslow (1987) conceptualized the love needs as “giving and receiving affec- tion” without which one “will hunger for relations with people in general—for

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a place in the group or family—[because] the pangs of loneliness, ostracism, rejection, friendlessness, and rootlessness are preeminent” (pp. 20-21). He (Maslow & Mittelmann, 1951) continued that love needs include the abilities to form sustainable emotional ties; to empathize, enjoy oneself, and laugh with (vs. at) others; and to express resentment without losing control (i.e., one can love others and be angry with them at the same time), as well as having valid reasons for being unhappy (vs. harboring resentment). Concerning the place- ment of love and belonging at the same hierarchical level, he stated, “It is clear that, other things being equal, a person who is safe and belongs and is loved will be healthier . . . than one who is safe and belongs, but who is rejected and unloved” (Maslow, 1987, p. 38). For an example of the latter, consider gang or cult membership.

Sociometric Status. Coie and Dodge (1988) and subsequent researchers explored the relationship between how children are perceived by their peers (i.e., liked vs. disliked) and their behavior. Popular children, most often rated as liked by their peers, tend to be cooperative, friendly, sociable, and interpersonally sensi- tive. Rejected children, typically boys, are most often rated as disliked and rarely as liked by peers. They fall into one of two groups: (a) rejected-aggres- sive children (most typical), who have reputations for bullying and disruptive- ness and (b) rejected-withdrawn children (about 10% to 20% of cases), who are perceived by others as depressed. Neglected children, typically girls, are rated neither as liked nor disliked; however, their peers typically misremember them. Average children are not rated at either extreme (they are neither popular nor unpopular) but they are known for being socially skilled. Finally, controversial children are rated as liked by some and disliked by others; they have reputa- tions as class clowns and as leaders with disregard for social rules.

Ollendick, Weist, Borden, and Greene (1992) noted that teachers tend to rate rejected children at highest risk of engaging in problematic behaviors during ninth grade based on their sociometric status at fourth grade, followed by, in order, controversial, neglected, and popular children—and average children at minimal risk. With regard to actual engagement in behaviors that led to suspension or legal issues, rejected children were highest. Perhaps more notably, 20% of average children dropped out, whereas none of the neglected children dropped out. Arguably, teachers’ reaching out to children who had been neglected by their peers may have contributed to a sense of belonging. In contrast, the average children, being overlooked by both teach- ers and peers, were less likely to “identify with the establishments of schools” and therefore drop out due to feeling “out of place” (Prince & Howard, 2002, p. 30). Furthermore, Prinstein (2017) differentiated between popularity and likability; Maslow would have regarded the former as deficiency (D-) love/

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belonging, and the latter as indicative of appropriately fulfilled (being, B-) love/belonging.

Identity, Intimacy, and Generativity. Maslow’s love and belonging needs also are implicated in Erikson’s (1959/1994) developmental tasks of adolescence and adulthood. The mission of adolescence is to search for and settle on a sense of stability and continuity in individuals’ personality amid confusion, change, and uncertainty. One dimension of identity development is clarification of their values and vocation—not only to earn money but also to strive for an honest sense of accomplishment within the lens of their culture. Like Maslow (1971, 1999), Erikson cautioned that American society’s overemphasis on standardization and conformity places adolescents at risk of helplessness and foreclosure, while its oversaturation of choices begets stagnation and avoid- ance of responsibility. On the other hand, when the process goes well, adoles- cents arrive at a sense of belonging and of congruence between their actual self and the contributions they make to their society by employing their potentials and abilities. Also, they become more at ease in multiple roles across several life domains (e.g., work, family, community, etc.). Cordeiro, Paixão, Lens, Lacante, and Luyckx (2016) noted that Portuguese adolescents’ perceived parental support (Maslow’s love/belonging) is a protective factor in career decision making, while parental thwarting is a risk factor. Both are mediated by adolescents’ subjective feelings of having their love/belonging needs met, which result in either confidence in proactive exploration and commitment making or in endless rumination over identity options.

As individuals enter adulthood, the development during childhood and adolescence of a strong sense of self is necessary to merge identities with another in a loving adult relationship without fear of losing their own identity, autonomy, and integrity. Erikson (1959/1994) noted that disconnection and repeated failed marriages arise out of failure to establish an intimate connec- tion. On the other hand, when the process goes well, individuals are able to engage in authentic relationships (vs. overly formal or stereotyped ones and/ or isolation). By middle adulthood, healthy development involves an increased shift in focus from self toward other and toward guiding the next generation as an expression of their belief in the species (not just their immediate social network). On the other hand, if Maslow’s security and love/belonging needs have not been adequately satisfied, Erikson (1959/1994) noted that people fall into self-absorption and mechanical, unfulfilling routines.

Self-Esteem

“If . . . the person wins respect and admiration and because of this develops self-respect, then he or she is still more healthy, self-actualizing, or fully

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human,” Maslow (1987) wrote; thus, “satisfaction of the self-esteem need leads to feelings of self-confidence, worth, strength, capability, and adequacy, of being useful and necessary in the world” (pp. 38, 21). Maslow (1987; Maslow & Mittelmann, 1951) conceptualized self-esteem as a multifaceted construct that includes (a) some originality, individuality, and independence from group opinions—that is, real self instead of idealized pseudo-self (Horney, Rogers, Winnicott, as cited in DeRobertis, 2008), differentiated self instead of emotional cutoff (Bowen, 1978); (b) having achievable, realistic, and compatible goals which involve some good to society as well as reason- able persistence of effort to achieve them; (c) absence of excessive need for reassurance and approval; (d) desire for adequacy, mastery, competence, and achievement; (e) a sense of confidence in the face of the world—which, like Adler (1927/2010; see also DeRobertis, 2011a), Maslow (1987) distinguished from sheer willpower and determination; (f) positive (vs. negative) freedom; (g) desire for dignity, appreciation, and deserved respect from others—which Maslow distinguished from external fame, celebrity, and unwarranted adula- tion; (h) appreciation of cultural differences; and (i) realistic appraisal of per- sonal strengths, limitations, motivations, desires, goals, ambitions, inhibitions, defenses, compensations, and so on.

With regard to acceptance of one’s imperfections and defenses as well as one’s strengths, Neff (2011) proposed the construct of self-compassion as an alternative to both the hubristic and fleeting images of self-esteem propa- gated by American culture and psychology in the interest of self-enhance- ment—which Maslow would have classified as D-esteem. Rather, self-compassion emphasizes nonjudgmental, mindful self-awareness as a means of overcoming self-consciousness and improving self-efficacy and well-being. Maslow (1999) noted that “fear of knowledge of oneself is very often isomorphic with, and parallel with, fear of . . . any knowledge that could cause us to despise ourselves or to make us feel inferior, weak, worthless, evil, shameful” (p. 71). Cultivating self-compassion can result in lower self- condemnation and higher self-forgiveness (Cornish & Wade, 2015) as well as in decreased maladaptive dependency and increased sense of connectedness (Chui, Zilcha-Mano, Dinger, Barrett, & Barber, 2016).

Self-Actualization

When conditions are favorable and the intrinsic self is heeded, the possibility of self-actualizing comes into focus for the developing person. Maslow (1971) noted that “self-actualization means experiencing fully, vividly, self- lessly, with full concentration and total absorption” and therefore “being more easily [oneself]” and “expressing rather than coping,” that is, directing one’s energies toward the best uses of one’s potentials and abilities and

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feeling discontent and restless when one is not doing what one was uniquely fitted for (pp. 44, 290). Maslow (1999) identified several interrelated quali- ties of self-actualizing people:

Clearer, more efficient perception of reality; more openness to experience; increased integration, wholeness, and unity of the person; increased spontaneity, expressiveness, full functioning, aliveness; a real self, firm identity, autonomy, uniqueness; increased objectivity, detachment, transcendence of self; recovery of creativeness; ability to fuse concreteness and abstractness; democratic character structure; ability to love, etc. (pp. 172-173; see also Maslow, 1987)

Maslow’s description of self-actualizing people is consistent with R. Walsh’s (2015) conceptualization of wisdom, which involves the following: (a) peo- ple’s abilities to “more deeply and accurately . . . see into themselves, reality, and [their] existential challenges and limitations” and to embrace “ethicality and benevolence [as] appropriate ways to live”; (b) the motivation to benefit others; and (c) operating on the awareness that “the deeper the kind of bene- fits they can offer, . . . the more skillfully they may offer them” (p. 289).

Propriate Striving. As noted earlier, self-actualizing is an outcome of healthy personality development, which entails an ongoing process of striving for still greater improvement and growth as opposed to an end state, as synony- mous with Allport’s (1955) propriate striving. Self-actualizing people assume the courage and freedom to create/recreate aspects of their personality based on new life experiences and interactions with others—especially those that test their ordinary ways of thinking, being, and relating and which liberate and integrate their intellect, emotions, and body—rather than remain homeo- statically fixated in their comfort zones. This paves the way for self-transcen- dence (Maslow, 1971). Likewise, McAdams (2015) proposed that personality development involves a tripartite emerging process of social actor (disposi- tional traits, temperament), motivated agent (personal goals, projects, plans, values), and autobiographical author (narrative identity).

Social Interest. Self-actualizing involves a greater sense of identification with humanity and therefore compassion and altruism, devoting one’s “energies and thoughts to socially meaningful interests and problems” beyond one’s own self-interest and/or need gratification (Maslow, 1999, p. 22). Because healthier people “need less to receive love [and] are more capable to give love, [they] are more loving people” (Maslow, 1999, p. 47). Therefore, they demonstrate increased comfort being alone and enhanced self-discipline ver- sus gregariously exuberant disposition (Maslow, 1987). At the same time,

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they are more democratic, interdependent, and problem focused; have better interpersonal relations; are more accepting and forgiving of others; and are able to extend these capacities to a variety of relationships (Maslow, 1999; Maslow & Mittelmann, 1951). Toumbourou (2016) outlined a framework for identifying and evaluating beneficial action (i.e., altruistic and prosocial behavior) based on developmental and contextual influences that resemble Maslow’s needs theory.

Resilience. Maslow (1999) wrote, “Self-actualization does not mean a tran- scendence of all human problems. Conflict, anxiety, frustration, sadness, hurt, and guilt all can be found in healthy human beings”; on the other hand, “with increasing maturity,” one’s focus shifts “from neurotic pseudo-prob- lems to the real, unavoidable existential problems” (p. 230). Maslow (Maslow & Mittelmann, 1951) emphasized the abilities to constructively adapt to cir- cumstances beyond one’s control, to sustainably and nondefensively remain collected in the face of crisis, and to withstand setbacks as opportunities for growth (instead of as threatening). “The child with a good basis of safety, love, and respect-need-gratification is able to profit from . . . frustrations and become stronger thereby” (Maslow, 1999, p. 220). Maslow (1996) also accentuated that tragedy is conducive to growth insofar as it “confronts [indi- viduals] with the ultimate values, questions, and problems that [they] ordi- narily forget about in everyday existence” (p. 56). Likewise, F. Walsh (2016) defined resilience as follows:

“Struggling well,” experiencing both suffering and courage, effectively working through difficulties both internally and interpersonally, . . . [striving] to integrate the fullness of the experience of . . . life challenges into the fabric of [one’s] individual and collective identity, influencing how we go on with our lives. (p. 5)

Aldwin (2007) cited cognitive skills (insight, creativity, humor, morality), temperament (independence and initiative), and social integration (all remi- niscent of self-actualizing people) as factors that characterize resilient chil- dren irrespective of social class or ethnicity. Furthermore, Masten (2014) identified attributes and outcomes of a supportive, accepting, and enriching but also appropriately challenging family, school, and community environ- ment (i.e., Maslow’s safety, belonging, and esteem needs) as protective fac- tors that promote resilience.

Postconventional Morality. In self-actualizing people, locus of control shifts from externalized to intrinsic, and both motivation and ethics follow suit. They are

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“not only or merely [their institutional and/or national affiliation] but also mem- bers at large of the human species” and “[looking] within for the guiding values and rules to live by” (Maslow, 1999, p. 201). Being strongly focused on prob- lems outside themselves, their focus broadens to include matters reflecting a desire for truth, justice, beauty, and so on. In addition, being comfortable in their skin, they are inclined to do what is right versus what is easy even if it goes against the tide (i.e., resistance to enculturation and transcendence of one’s envi- ronment). Using Kohlberg’s (1984) model of moral development, postconven- tional morality is characterized first by right action based on compromise and reciprocity. The letter of the law is considered insufficient to uphold a society; rather, rules are broken and/or revised when one is faced with situations in which the rules interfere with human rights or needs. Second, right/wrong is based on universal ethical principles of fairness and equality, and individuals turn to their inner conscience with respect for diversity, dignity, and human welfare and for balancing individual and social concerns. Similarly, Gilligan (1982) proposed a parallel concept, a morality of nonviolence (i.e., preventing harm to self and oth- ers), as the telos of her feminist moral development model.

Postformal Cognition and Psychological Flexibility. Maslow (1999) emphasized that cognition associated with self-actualizing people is marked by “[sharpened] awareness of the limitations of purely abstract thinking, of verbal thinking, and of analytic thinking” and by “dichotomies [becoming] resolved, opposites . . . seen to be unities, and the whole dichotomous way of thinking . . . recognized to be immature” (pp. 227-228). Post-Piagetian psychologists (e.g., Basseches, Kitchener, Labouvie-Vief, Perry, Sinnot, etc., as cited in Arnett, 2016; Broder- ick & Blewitt, 2015) emphasized that, when conditions are favorable, the for- mal operational thought of adolescence gives way to more flexible, complex, and integrated postformal cognition characterized by pragmatism (adapting idealistic, logical thinking to the practical constraints of real-life situations), dialectical thought (awareness that problems often have no clear solution), and reflective judgment, relativism, and postskeptical rationalism. Decisions are based on situational circumstances, and emotion is integrated with logic to form context-dependent principles. Accordingly, the legitimacy of competing points of view and of psychological flexibility (Wilson, Bordieri, & Whiteman, 2012) is recognized and favored over making arguments for the justification of only one true/accurate perspective at the exclusion of others (Schneider, 2013). Maslow (1966) discussed how these principles could be applied to develop a more humanistic approach to science.

Emotional Intelligence. Maslow (1999) observed that “the ability to be aggres- sive and angry is found in all self-actualizing people, who are able to let it

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flow forth freely when the external situation ‘calls for’ it” (p. 216). They are accepting of the full range of human impulses without rejecting them in the interest of reducing tension. Like postformal cognition, Goleman’s (1995; see also Dalai Lama, 2012) emotional intelligence theory emphasizes mov- ing away from Western dualistic assumptions about emotions as inherently positive (approach, pleasant) or negative (withdrawal, unpleasant) and instead recognizing that each emotion has both beneficial (constructive) and afflictive (destructive) elements. For example, fear can signal legitimate threats and promote survival, and righteous anger is necessary and appropri- ate for confronting injustice. The ability to accept emotions as they are rather than deny, repress, or project them also promotes empathy and compassion (toward both self and others), consistent with Maslow’s simultaneous focus on propriate striving and social interest.

Creativity. Maslow (1999) recognized creativity as the dialectic integration of primary (childlike, Dionysian) and secondary (rational, Apollonian) pro- cesses, a conceptualization that was elaborated by Arieti (1976) and explored in a qualitative inquiry by Bland (2003). Specifically, Maslow focused on the nonduality between young and old (i.e., a sense of playfulness and the ability to integrate imagination with practical wisdom). In addition, he emphasized that creativity (a) is not limited to production of products (i.e., art, music, literature, scientific work) but also includes the propriate process of individu- als’ growth and development and (b) serves to benefit society by providing alternatives to the limitations of convention. Sternberg (2016) proposed a triangular theory of creativity that involves defying the crowd (i.e., the beliefs, values, and practices of one’s field despite the short-term interpersonal risks), defying oneself (self-challenging and self-transcending by moving beyond one’s own earlier values, practices, and beliefs), and defying the zeitgeist (i.e., the unconsciously accepted presuppositions and paradigms in a field). In addition, consistent with Maslow’s suggestions for social conditions that are conducive to self-actualization (i.e., a consistent and nurturing environment that enables one to express oneself rather than cope and conform), Ren, Li, and Zhang (2017) noted that while Chinese adolescents’ creativity is enhanced by behavioral control from their parents, it is stifled by parents’ psychologi- cal control over them.

Dialogue With the Extant Literature

Maslow’s work has been met with ongoing criticism and confusion since he initially introduced his ideas at mid-20th century. His association with the worst of 1960s counterculture (about which he publicly expressed

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frustration; see Maslow, 1964/1970; 1984; 1987) arguably contributed to his work being dismissed (or at best ignored) today by many conventional psy- chologists as a historical relic. In addition, since Maslow’s death in 1970, the more complex and nuanced aspects of his thinking have become distorted or lost due to oversimplified and/or inaccurate portrayals of his work in second- ary sources that resemble an academic game of “telephone” (Bland & DeRobertis, 2017).

Applied to this article, perhaps the most troubling misrepresentation of Maslow’s work has been the attempt by developmentally oriented research- ers to reformulate his dynamic systems approach as a discontinuous stage model with clearly defined categorical phases. For example, some have attempted to equate each level of his needs hierarchy with specific stages in extant models (e.g., Bauer, Schwab, & McAdams, 2011; D’Souza & Gurin, 2016; Harrigan & Commons, 2015), and others with factors on assessment measures (e.g., Reiss & Haverkamp, 2005). We find these efforts problem- atic, as they fail to uphold Maslow’s emphasis on holistic conceptualization and his cautioning against misunderstanding fulfillment of the basic needs as a simplistic, lockstep progression (“not a sudden, saltatory phenomenon,” Maslow, 1987, p. 27) but rather as a dynamic process in which fulfillment of the higher needs is proportional to fulfillment of the lower needs. Accordingly, we agree with Rowan’s (1998) call to “[do] away with the triangle!” (p. 88). First, Maslow never actually represented his theory with a pyramid (Eaton, 2012)—at least in the way that it is commonly presented in textbooks (see Bland, 2013). More important, while such a visual image is convenient for instructional purposes, it implies that maturation has an end point, which belies Maslow’s foci on propriate striving and on self-transcendence (Rowan, 1998). As an alternative, we propose the aforementioned image of Russian nesting dolls, an expanding spiral or helix, or a lightning bolt, all of which better convey the two-steps-forward-one-step-back, contiguous dynamic of maturation as an ongoing process (see Kegan, 1982).

Another criticism leveled at Maslow (e.g., see Hanley & Abell, 2002) is his emphasis on hedonistic values and on culture-biased notions of self- esteem and self-actualization. However, numerous international studies have directly (e.g., Koydemir et al., 2014; Winston, Maher, & Easvaradoss, 2017) or indirectly (see citations throughout the previous section of this article) demonstrated the cross-cultural validity of Maslow’s theorizing.

Furthermore, others have (a) made pleas for a more dynamic interactional self as an alternative to Maslow’s proposition of an instinctoid self in his adaptation of Goldstein (Frick, 1982; Morley, 1995) and (b) accused Maslow of “[emphasizing] the importance of maintaining a unified, coherent self,” whereas “the self-concept differentiates with maturity, [incorporating] both

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the private and the more public sides of our nature, accommodating our abil- ity to keep our own counsel and still be known to others by virtue of our interactions with them” (Broderick & Blewitt, 2015, pp. 169-170). These cri- tiques tend to focus on the individuating aspects of self-actualization (i.e., Goldstein’s first and third axioms) without adequately acknowledging Maslow’s emphasis on maturity within a social–environmental context (Goldstein’s second axiom), which has been more properly acknowledged by Sassoon (2015). Maslow (1987, 1999) accentuated that the difference between merely healthy individuals and self-actualizing ones who genuinely embody social interest is mediated in part by adequate cultural–societal con- ditions. Likewise, he insinuated that, paradoxically, individuals are simulta- neously both more externalized and ego-centered at the lower end of his needs hierarchy, whereas at the higher end they are guided by more idiosyn- cratic/intrinsic aims while also becoming more self-transcendent.

Conclusion

In this article, we have employed Maslow’s needs hierarchy as a dynamic systems process framework for situating parallel developmental constructs that serve as empirical support for his ideas at multiple ages and in various contexts, and we have sought to clarify common misgivings about his ideas on psychological health (i.e., self-actualization) and the factors that promote or inhibit it. Our intent has been to legitimize Maslow’s unacknowledged contri- butions to developmental psychology in an effort to overcome the “recurrent Maslow bashing that one finds in the literature” (Winston et al., 2017, p. 309). We further reach the conclusion that Maslow ought to be counted as a forerun- ner of contemporary existential–humanistic developmental thought (see DeRobertis, 2008, 2012, 2015; DeRobertis & McIntyre, 2016).

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publi- cation of this article.

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Author Biographies

Andrew M. Bland is a member of the graduate clinical psy- chology faculty at Millersville University in Lancaster County, PA. He received a master’s degree from the University of West Georgia’s humanistic-existential-transpersonal psychology pro- gram in 2003 and a PhD in counseling psychology from Indiana State University in 2013. He is a licensed psychologist; since 2004, he has provided therapeutic services in a variety of set- tings in four states, currently at Samaritan Counseling Center in Lancaster, PA. His research interests include the practical appli- cation of themes from contemporary existential-humanistic

psychology in the domains of love, work, social justice, the processes of therapy and education, creativity, spirituality, and human development. His passions include lis- tening to and creating music, gardening, traveling, and spending time with his wife and their two young children.

Eugene M. DeRobertis is a professor of psychology at Brookdale College and a Lecturer at Rutgers University– Newark in New Jersey. He holds a BA in philosophy from St. Peter’s University and a PhD in psychology from Duquesne University. He is the author of Humanizing Child Developmental Theory: A Holistic Approach (2008), The Whole Child: Selected Papers on Existential-Humanistic Child Psychology (2012), Existential-Phenomenological Psychology: A Brief Introduction (2012), Profiles of Personality: An Approach-Based Companion (2013), and The Phenomenology of Learning and Becoming: Enthusiasm, Creativity, and Self-Development (2017).

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REVIEW published: 19 October 2018

doi: 10.3389/fpsyg.2018.01992

Edited by: Jill Popp,

The LEGO Foundation, Denmark

Reviewed by: Nicolas Cuperlier,

Université de Cergy-Pontoise, France Gautier Durantin,

The University of Queensland, Australia

Eiji Uchibe, Advanced Telecommunications

Research Institute International (ATR), Japan

*Correspondence: Hélène Cochet

[email protected]

Specialty section: This article was submitted to Developmental Psychology,

a section of the journal Frontiers in Psychology

Received: 13 October 2017 Accepted: 28 September 2018

Published: 19 October 2018

Citation: Cochet H and Guidetti M (2018)

Contribution of Developmental Psychology to the Study of Social

Interactions: Some Factors in Play, Joint Attention and Joint Action

and Implications for Robotics. Front. Psychol. 9:1992.

doi: 10.3389/fpsyg.2018.01992

Contribution of Developmental Psychology to the Study of Social Interactions: Some Factors in Play, Joint Attention and Joint Action and Implications for Robotics Hélène Cochet* and Michèle Guidetti

CLLE, Université de Toulouse, CNRS, UT2J, Toulouse, France

Children exchange information through multiple modalities, including verbal communication, gestures and social gaze and they gradually learn to plan their behavior and coordinate successfully with their partners. The development of joint attention and joint action, especially in the context of social play, provides rich opportunities for describing the characteristics of interactions that can lead to shared outcomes. In the present work, we argue that human–robot interactions (HRI) can benefit from these developmental studies, through influencing the human’s perception and interpretation of the robot’s behavior. We thus endeavor to describe some components that could be implemented in the robot to strengthen the feeling of dealing with a social agent, and therefore improve the success of collaborative tasks. Focusing in particular on motor precision, coordination, and anticipatory planning, we discuss the question of complexity in HRI. In the context of joint activities, we highlight the necessity of (1) considering multiple speech acts involving multimodal communication (both verbal and non-verbal signals), and (2) analyzing separately the forms and functions of communication. Finally, we examine some challenges related to robot competencies, such as the issue of language and symbol grounding, which might be tackled by bringing together expertise of researchers in developmental psychology and robotics.

Keywords: human–robot interaction, human development, joint attention, joint action, coordination, complexity, gestures

INTRODUCTION

Developmental psychologists aim at describing and explaining changes across the life span in a wide range of areas such as social, emotional, and cognitive abilities. Focusing on childhood is a way of grasping numerous changes, especially in terms of communication: infants gradually learn to identify the common ground they have with others and engage in social interactions. The development of such abilities relies on the personal experiences shared between partners in specific contexts (Liebal et al., 2013), among which social play may offer particularly rich opportunities for children to acquire joint action and joint attention skills. Studying the different forms and functions of communication in this context paves the way for identifying the necessary ingredients

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for effective joint activities and therefore better understanding the architecture of human–social interactions. Even though the concept of effectiveness may cover different theoretical frameworks, the latter objectives have several applications, for example in supporting children with atypical development, especially when they have difficulty communicating both verbally and non-verbally (e.g., children with autism spectrum disorders, ASD), but also in the field of artificial intelligence. The role of robots in society raises indeed a lot of debates and challenges, as they share more and more space and tasks with humans, for instance in service robotics to assist elderly people. The robots’ ability to initiate and respond to social interactions is one of the key factors that will shape their integration in our everyday life in the future. Researchers in social robotics have been working on the question of joint action for over two decades now, sometimes in collaboration with developmental psychologists (e.g., Scassellati, 2000), in order to improve robots’ motor and communicative skills. Developmental models of human communicative behavior can indeed help define the components to implement in human–robot interactions (HRI), so as to build rich and natural joint activities (Breazeal et al., 2004; Lemaignan et al., 2017).

The objective of this paper is twofold. First, we intend to present the point of view and some research perspectives of developmental psychologists on joint attention and joint action, in particular in the context of social play. To this end, we will also define, starting from studies on non-human primates, what can be regarded as complex (or rich) and natural (or effective) interactions in both human communication and HRI. Second, we aim to show the extent to which the above-mentioned issues may be of interest to roboticists, in helping conceptualize and implement some variables associated with joint attention and joint action in the context of HRI. Collaborative tasks involving robot and human partners, regarded as tantamount to children’s social play, will thus be considered through the prism of pragmatic communication, allowing researchers to dissociate the forms and the functions of communication.

HOW DOES COMMUNICATION DEVELOP IN THE CONTEXT OF SOCIAL PLAY?

The definitions of play include a wide range of activities, which makes it difficult to determine where play begins and where it ends, even though it is traditionally associated with positive affective valence (Garvey, 1990). Play, which occurs in several animal species (most notably in mammals), has been argued to allow “practice of real-world skills in a relatively safe environment” (Byrne, 2015). We will focus here on social play in human children, which may also enable them, as highlighted by Bruner (1973), to “learn by doing” as they interact with one or several partners. At the individual level, children can indeed explore and enhance specific skills like motor control and creativity, while developing for example cooperation abilities at the social level. The concepts of artifact-mediated and object- oriented action, originally formulated by Vygotsky (1999), are

particularly relevant to describe these situations: the relationship between the child and the surrounding objects is indeed mediated by cultural means, tools, and signs. Studying the development of play can therefore reveal how children come to represent and think about their environment.

Social attention is a crucial capacity for the emergence of these play situations, allowing children to focus on some of the other’s characteristics such as the facial expressions, gaze direction, gestures, and vocalizations. When the direction of another’s attention has been identified (for example through gaze following or point following), we can shift our own attention to focus at the same time on the same external object or event as our partner. This process of joint attention is usually inferred from behavioral cues, including mainly gaze alternation between one’s partner and a specific referent (Bourjade, 2017). Joint attention seems therefore necessary for individuals to perform joint action, i.e., to coordinate their actions in space and time to produce a joint outcome, whether it involves here symbolic play (with or without objects), construction toys, board games or any other forms of play.

Joint attention and joint action begin to appear at the end of the first year in human development (Carpenter et al., 1998), gradually allowing children to integrate the notion of common ground and engage in social interactions. The development of gaze understanding, which has been widely studied, plays a key role in this regard. It was for example shown in a study using habituation-of-looking-time procedure that infants start to understand ecologically valid instances of social gaze between two adults interacting, and to have expectations concerning gaze target at 10 months of age (Beier and Spelke, 2012). Besides, responsive joint attention skills (e.g., gaze following and point following) have been reported to emerge before initiative joint attention skills, from 8 months of age (Corkum and Moore, 1998; Beuker et al., 2013).

However, depending on the authors, the definitions of these social-cognitive skills can be more or less demanding, the main difference lying in whether or not individuals have mutual understanding of their shared focus of attention. The ability to “know together” that we are attending to the same thing as our partner has sometimes been referred to as shared attention (Emery, 2000; Shteynberg, 2015), which would develop in parallel with shared intentionality (Tomasello and Carpenter, 2007). The latter involves the motivation to share goals and intentions with the other, as well as forms of cognitive representation for doing so. This ability has been argued to constitute a hallmark of the human species (Tomasello et al., 2005), even though it is particularly difficult to assess when verbal language is not available as a clue to these representations (in pre-linguistic children or non-human primates). Similarly, joint action may rely solely on the learning of the cues that appear significant (e.g., gestures and eye contact) to coordinate actions in space and time with a partner, or it may also involve, in a more demanding perspective, the common and explicit knowledge of the objectives of the activity and of the way to achieve them (Tomasello and Carpenter, 2007).

Joint attention and joint action, whether they are accompanied or not with shared and explicit intentions, thus allow children

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to participate with others in collaborative activities in which each partner benefits from the joint outcome and/or from the interaction in itself. In a series of experiments, the ability to coordinate with a partner in social games was shown to significantly improve between 18 and 24 months of age, whether the games involved complementary or similar roles (Warneken et al., 2006). In the first game of this study, one person had to send a wooden block down one of a tube mounted on a box on a 20 degrees incline, while the other person had to catch it at the other end with a tin can that made a rattling sound. Two tubes were mounted in parallel so that individuals could perform in turn the different roles. In the second game, two persons had to make a wooden block jump on a small trampoline (67 cm diameter ring covered with cloth) by holding the rim on opposite sides. The trampoline collapsed when being held on only one side. Children successfully participated in both games, although the 24 month-olds were more proficient than the 18 month-olds, and they all produced at least one communicative attempt to reengage the adult partner when the latter stopped participating in the activity. Children for example pointed at the object, and/or vocalized while looking at the adult, which was regarded as evidence for a uniquely human form of cooperation, involving shared intentionality (Warneken et al., 2006). A less “mentalistic” interpretation could be proposed (D’Entremont and Seamans, 2007), but these results nevertheless highlight children’s motivation for reinstating joint action toward a shared goal. The development of this capacity has received much attention from researchers, as the initiation of joint attention appears to be strongly related to language comprehension and production in the second and third year of life (Colonnesi et al., 2010; Cochet and Byrne, 2016), as well as to theory of mind ability (e.g., Charman et al., 2000; Milward et al., 2017) in both typical and atypical development (e.g., Adamson et al., 2017).

In addition, the observation of children’s behavior during collaborative activities may lead to a thorough description of multimodal communication (e.g., gaze, facial expressions, gestures, and verbal language) and of the way its components become coordinated. For example, the production of gestures gradually coordinates with gaze in the course of development. Children start to produce pointing gestures to orient the attention of another person around 12 months of age; an object, a person or an event can become the shared focus of attention but then children do not usually look at their partner while they point (Franco and Butterworth, 1996). A couple of months later, they are able to alternate their gaze between their partner and the object of interest, which represents a key feature of intentional triadic interactions (Cochet and Vauclair, 2010). At 16 months of age, gaze toward the adult can precede the production of pointing (Franco and Butterworth, 1996), suggesting that children may thus take into account the partner’s attentional state before initiating communication (Lamaury et al., 2017).

Children also gradually learn to take account of their partner’s facial expressions to infer their emotional state and adjust their response accordingly. Infants are sensitive to the characteristics of faces from very early on; newborns look for example significantly longer at happy expressions than at fearful ones, demonstrating some discrimination skills (Farroni et al., 2007).

The still-face paradigm, initially designed by Tronick et al. (1978) also suggests that infants have expectations about interactional reciprocity from a few months of age, partly relying on emotional expression. This sensitivity manifests itself in specific behavioral and physiological responses (e.g., reduced positive affect and gazing at the parent, increased negative affect, rise in facial skin temperature) when the mother puts on a neutral and unresponsive face, after a period of spontaneous play with his/her infant (Aureli et al., 2015). The ability to recognize and identify facial expressions of basic emotions further develops in preschool children, before they can understand a few months later the external causes of emotions and then, around 5 years of age, the role of other’s desires or beliefs in emotional expression (Pons et al., 2004).

During play interactions, being attentive to the other’s facial expressions allows each partner to consider the emotional nature of the signals (e.g., joy, surprise, and frustration) and to possibly modify his/her own behavior to change or maintain this emotional state. The development of facial expression perception thus plays a key role in the emergence of joint actions, in coordination with other communicative modalities. Facial expressions are indeed usually synchronized with vocalizations and/or gestures, and this from infancy.

The vocal and the gestural modalities also become more and more coordinated as children grow older, which represents a key feature of human communication as we use gestures as we speak throughout our life. Communicative gestures are first complemented by vocalizations, whose prosodic patterns may already code for semantic and pragmatic functions (Leroy et al., 2009). In the second year of life, children then produce their first gesture-word combinations, which have an important role in the transition to the two-word stage (e.g., Butcher and Goldin-Meadow, 2000). Pointing and conventional gestures (e.g., waving goodbye, gestural agreement, and refusal: Guidetti, 2002, 2005) remain in the child repertory after the two-word stage, but other forms of gestural-vocal coordination are observed from 3 years of age with the emergence of co-speech gestures. Although we are usually not aware of producing or perceiving them, co-speech gestures can lend rhythm, emphasize speech and sometimes serve deictic or iconic functions. The deictic presentation of pointing gesture can for example be combined with vocal pointing, performed through syntactic or prosodic means (Lœvenbruck et al., 2008). Such coordination between the vocal and gestural modalities is omnipresent in adults and play a crucial role in face-to-face communication for both speaker and listener (e.g., McNeill, 2000; Kendon, 2004).

Moreover, the characteristics of gaze, gestures, and vocalizations and their coordination may vary according to the communicative function of the signal. A gesture can indeed serve different purposes, starting with the traditional distinction between imperative and declarative functions (Bates et al., 1975). Imperative gestures are used to request a specific object or action from a partner whereas declarative gestures are used to share interest with the other about some referent or provide him/her with information that might be useful. Imperative and declarative pointing, which both represent powerful means of establishing joint attention, have been extensively studied and compared:

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hand shape and body posture were shown to differ according to the communicative function of the pointing gesture (Cochet et al., 2014), as well as the frequency of gaze alternation between the partner and the referent and the frequency of vocalizations (Cochet and Vauclair, 2010). These comparisons (see section “Pragmatics in HRI: Which Ingredients Are Necessary for Effective Interactions?” for more detailed results) thus highlight the strong relationship between the form of the gestures (in the broad sense, i.e., including visual and vocal behavior in addition to movement kinematics and hand shapes) and pragmatic features in children, even semantic ones in adults (Cochet and Vauclair, 2014).

To sum up, when two children are playing together or when a child is playing with an adult, they do so in the framework of joint action; they attend to a common situation and use multimodal communication to initiate, maintain, or respond to the interaction. These three different roles in the interaction can be assessed with the Early Social Communication Scales, in particular with the French version (Guidetti and Tourrette, 2017). In an evaluation situation, giving the child the opportunity to initiate the interaction is particularly crucial in atypical development, for example in children with ASD. The initiation of shared attention is a key ability in this context as it allows joint action coordination (Vesper et al., 2016) and has also significant consequences on the development of cognitive and emotional processes (Shteynberg, 2015). Whether this coordination relies on the representation and the understanding of the other’s intentions or only on behavioral cues is a challenging question, as we do not have any direct access to the other’s subjectivity. In the field of HRI, an objective that appears sufficiently ambitious for now, or at least the one we chose to focus on in the present review, is to design robots able to identify the observable changes in the human’s behavior, in order to make the right inferences and thus the appropriate decisions in the interaction. This appears as an essential condition for a successful exchange between a robot and a human, which can depend on the joint outcome (has the common goal been reached?), but also on the way the interaction has been perceived by each individual, for example in terms of coordination between gaze and gesture and fluidity of movement (Hough and Schlangen, 2016). The richness of communication here lies indeed in the ability of each partner to integrate multiple communicative cues in a way that what will seem natural to the humans, i.e., that will be close to peer interaction in everyday life.

This appears as a complex ability and probably the most challenging one to replicate in HRI. In pursuit of this objective, we now need to further describe the concept of appropriateness and propose a frame to determine the relative importance and the relative complexity of the different behaviors observed during joint activities such as social play.

TO WHAT EXTENT CAN INTERACTIONS BE CHARACTERIZED AS COMPLEX?

Smith (2015) has argued that “development, like evolution and culture, is a process that creates complexity by accumulating change.” This perspective applies to the development of

social interactions, from the emergence of joint attention to coordinated and multimodal communication that enable joint action. Several attempts have been made in developmental robotics to explore the cognitive, social, and motivational dynamics of human interactions (Oudeyer, 2017); algorithmic and robotic models can then be used to study the developmental processes involved for instance in imitation (Demiris and Meltzoff, 2008) or language (Cangelosi et al., 2010). In this context, roboticists aim at designing systems allowing for self- organized and “progressive increase in the complexity” of the robot’s behavior (Oudeyer et al., 2007).

To benefit further from their exchanges, developmentalists and roboticists may therefore need to frame the study of HRI by disambiguating the concept of complexity. Because “complicated systems will be best understood at the lowest possible level” (Smith, 2015), we aim to differentiate different levels of complexity depending on the nature of the elements to take into account for decision making. This analysis will allow us to go forward in the study of joint attention and joint action and define what is implied by the qualifying terms “complex” (or rich) and “appropriate” (or effective) when referring to interactions.

To this end, we used a categorization recently proposed in research on animal behavior, including human and non-human primates, to define the concept of complexity (Cochet and Byrne, 2015). Three dimensions have been described: motor precision, coordination, and anticipatory planning, which can relate to both individual and social activities. The authors argue that “the complexity of a given mechanism/behavior can be assessed by distinguishing which of these three dimensions are involved and to what degree,” which may “clarify our understanding of animal behavior and cognition.” Such analysis applied to joint attention and joint action, although there may be other ways of untangling the question of complexity, may here allow researchers to dissect the different factors involved in social interactions for each dimension, and thus help them assess the “manipulability” of these factors in HRI.

In order to make appropriate decisions in a collaborative task, i.e., decisions leading to the desired joint outcome and/or decisions that approach the characteristics of human interactions, the robot first needs to recognize specific patterns in his/her partners’ behavior, without asking for agreement or information for all actions. The robot can for example rely on gaze direction, manual movements or body posture to identify the human’s attentional and intentional states and thus define the most useful role it can play in the interaction. By way of illustration, if a human and a robot share the common goal of building a pile with four cubes in a definite order and putting a triangle at the top, each of them can perform different actions: they can grasp an object (a cube or a triangle) on the table, grasp an object on the pile, give an object to the partner, support the pile while the partner places a cube on it, etc. Other actions can emerge, for example if the pile collapses or if one agent does not pile the cubes in the correct order (Clodic et al., 2014). Individuals can then blame each other, or give each other some instructions. In addition to the perception of its own environment, the robot thus has to observe the activity of the human and take his/her perspective

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(e.g., to determine whether an object is reachable for the other).

Motor precision is therefore necessary in this context to obtain flexible and human-aware shared plan execution (Devin and Alami, 2016), as it enables a selective shift of attention toward aspects of the environment that will become shared knowledge, which has also been described as the accuracy of shared attention states (Shteynberg, 2015). First, the emergence of joint attention requires to properly use gaze and/or pointing gesture to localize the object or event referred to. Verbal cues also demand particularly fine motor skills through speech articulators. Second, joint action necessitates some motor control to reach the expected outcome, hence the importance of evaluating beforehand human motor skills, especially during development, as well as the technical capabilities of the robot. Following on from the previous example, children’s grasping skills in relation to the size of the cubes as well as the characteristics of robotic gripper to handle objects have to be finely described.

Moreover, recent experimental findings have shown that the execution of object-oriented actions is influenced by the social context such as the relative position of another person and the degree of familiarity with this person (Gianelli et al., 2013). Individuals perform for example more fluent reach-to- grasp movements, with lower acceleration peaks and longer reaction time when a partner is located close enough to be able to intervene on the same object than when he/she is farther away (Quesque et al., 2013). In addition, there is a significant relationship between the kinematic features of the actions and the actor’s explicit social intention: movements have longer durations, higher elevations and longer reaction times when individuals place an object on a table for another person than when they place the object for a later personal use (Quesque and Coello, 2015). These variations, although they do not seem to be intentionally produced, have been suggested to facilitate the partner’s detection of planned actions, thus enhancing potential interactions. These kinematic effects were indeed shown to influence the subsequent motor productions of an observer (Quesque et al., 2015). The motor characteristics of actions performed in a social context may therefore prime the perceiver to prepare and anticipate appropriate motor responses in the interaction.

The second dimension that can allow us to understand the complexity of joint activities pertains to the coordination between several communicative modalities and between interacting individuals. Whether joint action involves complementary or similar roles, it can be performed through several coordination processes, which can determine the efficiency of shared attention states (Shteynberg, 2015). Efficiency requires here a representational shift from the first-person singular to the first- person plural, as the partners attend to the same referent at the same time. The ability to monitor each other’s attention and action, using behavioral cues such as gaze direction, facial expressions, gestures, and speech is essential for successful coordination. The intentional production of communicative signals, representing hints for one’s partner, is also an efficient way of achieving joint outcomes.

Coordination is therefore necessary first at the individual level, so that the different communicative modalities such as gestures and gaze synchronize or follow one another in a natural order, i.e., acceptable with regard to human interaction patterns (see above). Each agent can then make decisions based on these signals, moderate their behavior accordingly and thus coordinate at the social level to reach a common objective. The ability to adjust one’s behavior to others’ actions during collaborative activities (including play) has been argued to “reach a higher degree of complexity when intentional and referential signals are directly addressed to specific individuals” (Cochet and Byrne, 2015). In order to build the pile of cubes, interacting partners can then for example point toward a specific cube or ask the other to wait before placing another cube.

In those cases, coordination processes can be enhanced by predicting the effects of each other’s actions on joint outcomes and by distributing tasks effectively (Vesper et al., 2016). This ability involves the third dimension characterizing the question of complexity, namely the dimension of anticipatory planning (Cochet and Byrne, 2015). It requires to go beyond the immediate perception of the environment and represent the relationship between a sequence of actions and a precise goal. At the individual level, planning ability implies to mentally review an action sequence in anticipation of a future need (e.g., selecting a specific cube in a first room in order to build a pile of cubes in another room). At the social level, planning ability allows individuals to predict the other’s behavior and adjust one’s own sequence of actions, leading to a better coordination. Whether the ability to make such inferences necessitates to mentalize about others’ inner states (e.g., beliefs and preferences) is still subject of debate, but again, this question may not be central in the context of joint attention and joint action between a robot and a human.

The above-described categorization can therefore provide a common ground between ethologists, psychologists, and roboticists that may clarify which dimensions need to be considered in an attempt to implement the characteristics of motor precision, coordination and anticipatory planning in human–robot joint activities (see Table 1 for an overview). The objective is to approach the complexity (or richness) of human interactions and obtain appropriate (or effective) responses from robots with regard to these different dimensions.

PRAGMATICS IN HRI: WHICH INGREDIENTS ARE NECESSARY FOR EFFECTIVE INTERACTIONS?

The increasing complexity of communicative abilities (complexity that involves the three above-mentioned dimensions) in the course of human development leads to a rich potential of interactions. Children actively go through different stages allowing them to engage successfully in joint activities, i.e., to operate within their physical environment, coordinate with other people, plan their own behavior and anticipate their partners’. Intending to model, at least partially, human developmental pathway seems a fruitful way of designing robots that can effectively initiate and respond to communicative

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TABLE 1 | Complexity in HRI: illustration of three dimensions at the individual and social levels (adapted from Cochet and Byrne, 2015).

Individual Social

(1) Motor precision Joint attention: ability to properly use gaze or pointing to identify the object or event referred to. Joint action: human motor skills/technical capabilities of the robot to reach the expected outcome

Influence of the social context (e.g., relative position of the individuals, intention of the actor: moving an object for oneself or for another person) on the kinematics features of the actions performed

(2) Coordination Coordination (including synchronization) between different modalities of one’s communicative signal (gaze, gesture, vocalizations, etc.)

Ability to take into account the multimodal behavioral cues produced by a partner to adjust one’s own behavior

(3) Anticipatory planning

Representation of a sequence of actions to anticipate a personal future need

Ability to predict the effects of the other’s actions on joint outcomes to plan one’s own behavior

situations. Such enterprise, although still recent, has given rise to a substantial amount of literature in robotics, especially from the 2000s, covering several sub-fields such as for example developmental and epigenetic robotics, cognitive systems and social robotics. Several journals, including both HRI experimental studies and computational modeling, focus entirely on these questions (e.g., IEEE Transactions on Cognitive and Developmental Systems, Journal of Human-Robot Interaction, Journal of Social Robotics), and numerous conferences also take place every year, whose proceedings are usually available online1.

The data from developmental psychology described in the first section, coupled with the framework proposed in the second section to help researchers define complex and effective HRI, may contribute to this growing body of work. To this effect, it seems necessary (1) to consider the multimodality of interactions and (2) to adopt a pragmatic perspective to be based upon an accurate representation of human communicative behaviors. Indeed, children learn to communicate through joint activities with adults who combine various forms of expressions, serving various functions. In the course of development, children gradually integrate the dissociation between the form and the function of language – they become more and more flexible in understanding that a single form can serve different functions and reciprocally, that a single function can be expressed through several forms. Language is here regarded as more than a medium to convey an information, in agreement with a proposition that was developed in the speech act theory (Austin, 1962; Searle and Vanderveken, 1985). Language would be way of acting on the environment, of “doing things with words,” independently of its structural properties. Initially aiming at describing the relationships between the forms and functions of linguistic utterances, this theory defines several speech acts, depending on whether one intends to assert, comment, warn, request, deplore,

1 For example, http://www.lucs.lu.se/epirob/

etc. This theory has later been adapted to non-verbal behavior (e.g., McNeill, 1998; Guidetti, 2002). The form still refers to the message structure, but applies to the whole body, including the posture, the structure of communicative gestures (kinematic features and hand shape), gaze and facial expressions. These non- verbal signals can be used in complementarity with speech or be used alone for example in the case of conventional gestures (see Guidetti, 2002). The function refers to the illocutionary force of the speech act (what one achieves by speaking), in other words here to the effect of these communicative acts in a specific context, thus giving some insight into the signaller’s intention. Gestures, and especially the conventional gestures produced by children during the prelinguistic period, are thus regarded as genuine communicative acts, with a propositional content that can equal the one expressed by words. For instance, agreeing and refusing can be expressed gesturally by nodding or shaking one’s head. The separate analysis of the forms and functions of communication, as well as the description of the different modalities involved during interactions, therefore provide a key framework to help define what capacities the robot should be equipped with to ensure efficient collaboration with humans.

In this perspective, Mavridis (2015) has proposed a list of “ten desiderata that human–robot systems should fulfill” to maximize communication effectiveness. One of the guiding lines relates to the importance of considering multiple speech acts, for both verbal and non-verbal communication, and not restrict the robot competencies to “motor command requests.” In the same way as imperative gestures (see section “How Does Communication Develop in the Context of Social Play?”) are generally understood and produced later than declarative gestures in human development (Camaioni et al., 2004), robotic systems initially aimed to assign the robot a servant role, with the human driving the interaction. Devising wider robots’ pragmatic abilities is a first step toward the conception of human–robot shared plans. The robot may for example comment on the pile of cubes as it is being built (see example section “To What Extent Can Interactions Be Characterized as complex?”) to support or correct the human’s action, rather than just producing a motor response to the human request. The dimension of social coordination is thus added to that of motor precision (see Table 1).

Similarly, flexibility in HRI also requires “mixed initiative dialog” (Mavridis, 2015), so that the robot can both initiate and respond to the interaction. Integrating models based on human adaptation and probabilistic decision processes, Nikolaidis et al. (2017) have indeed shown that the performance of human–robot teams in collaborative tasks is improved when the robot guides the human toward an effective strategy, compared to the common approach of having the robot strictly adapting to the human. The human’s trust in the robot was also facilitated by a greater symmetry in role distribution and adaptation between the robot and the human, which might in turn lead to greater acceptability of HRI.

Designing such “socially intelligent and cooperative robots” (Breazeal et al., 2004) requires specific temporal dynamics of the interaction, which represents a considerable challenge especially at a computational level. These dynamics convey social meanings

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to such an extent that any delay in the interaction can sometimes question its effectiveness. Researchers here face a dilemma that seem to bring into opposition interaction complexity (which requires to take account of numerous parameters) and interaction timing. The implementation of fast timescales (on the order of 100 ms) is usually considered necessary for robots to integrate (i.e., detect, interpret, and predict) and react to social stimuli in a timely manner through interactions (Durantin et al., 2017). Researchers developing a storytelling robot interacting with children aged 4–5 years have confirmed the importance of temporal features in the pragmatics of interactions. Contingent responses from the robot, in relation to the attentional and social cues signaled by the children, were indeed found to facilitate engagement of the latter (Heath et al., 2017).

The variation in some characteristics of the robot’s behaviors according to the action performed may also illustrate further the question of pragmatics in HRI, moving us one step closer toward human-like interactions. For example, the morphological differences that have been reported in young children between pointing and reaching (Cochet et al., 2014) could be applied to the robot. First, regarding body posture, we might expect robots to lean closer to a given object when they intend to grasp it than when they want to communicate about that object. Second, depending on the robot technical possibilities (e.g., two- or three-finger grippers, biomimetic anthropomorphic hands), differences in the form of manual gestures produced should be observed between imperative and declarative pointing. The former is typically characterized by whole-hand gestures (all the fingers are extended in the direction of the referent), while the latter is mostly associated with index-finger gestures (the index finger is extended toward the referent and the other fingers are curled inside the hand) (Cochet and Vauclair, 2010; Liszkowski and Tomasello, 2011). Hand shape is also influenced by precision constraints: imperative gestures are likely to shift from whole-hand pointing to index-finger pointing when the target is surrounded by distractors (Cochet et al., 2014), which can be the case when the robot has to identify a specific object among several (e.g., the human can ask the robot to give him/her the red cube). Here, the notion of iconicity, which plays a role in both oral and sign languages, may help researchers to precisely analyze the structure of gestures and better understand the interface between gestures and signs (Guidetti and Morgenstern, 2017). The importance of motor precision is here directly related to the dimensions of coordination and anticipatory planning, therefore providing a comprehensive framework to assess the complexity and effectiveness of HRI.

Moreover, the importance of implementing responsive social gaze in robots has previously been highlighted (e.g., Yoshikawa et al., 2006), but this response might also vary depending on the communicative function involved. To mirror child development, gaze alternation between the partner and the referent should indeed be more frequent in declarative situations than in imperative ones (Cochet and Vauclair, 2010). The coordination between gestures and gaze (see also section “How Does Communication Develop in the Context of Social Play?”) is also an important factor, which can help the robot to estimate the state of goals, plans, and actions from human point of

view, and allow the human to feel that he/she is involved in fluid interactions with the robot, both facilitating the emergence of joint outcomes. If a robot alternates its gaze between an object and its partner before initiating a pointing gesture, the human may for example interpret this behavior as the robot’s willingness to take into account his/her attentional state before gesturing, thus favoring the exchange of information. Broadly speaking, coordinated gaze behavior could be considered as the most fundamental modality for effective HRI, or at least as a key prerequisite in collaborative tasks.

The consideration of facial expressions may also facilitate turn-taking dynamics and limit miscommunication, by allowing some inferences about the other’s affective state. Integrating the emotional component into HRI gives each partner additional cues to decide what is the most appropriate response in a given situation. The development of methods for facial expression analysis raises several issues though (e.g., Kanade et al., 2000). Even if there have been some attempts to design facial expression mechanism in humanoid robots (e.g., Hashimoto et al., 2006; Gao et al., 2010), most of current robots’ facial features are still far from the extremely rich motor possibilities of the human face. In parallel, the development of real time coding of emotional expressions seems to be an achievable goal (Bartlett et al., 2003), allowing robots to directly perceive some changes in the human facial expressions.

In addition to visual information, the auditory modality can also play a role in influencing robots’ and humans’ decisions and coordination processes. In children at around 2 years of age, vocalizations accompany more frequently declarative gestures than imperative ones (Cochet and Vauclair, 2010). More recently, the prosody of these vocalizations was shown to gradually match the function of pointing during the second year of life (Tiziana et al., 2017), allowing to differentiate imperative from declarative gestures (Grünloh and Liszkowski, 2015). Other features such as the positioning of the object and the attentional state of the partner have also been suggested to influence the rising and falling tones in the vocal productions simultaneous to gestures (Leroy et al., 2009). Prosody can therefore serve pragmatic purposes, and changes in pitch, intensity, or duration of speech or vocalizations can in this regard be considered as a full-fledged component of multimodal communication.

Beyond prosody, language content may be the most effective way for human–robot teams to coordinate. However, the design of robots with language comprehension and production abilities that could lead to fluid conversations with humans raises several issues. Verbal language requires indeed symbolic representations, which need to be connected not only to the robot’s sensory system, but also to “mental models” of the world internalized within its cognitive system. Mavridis (2015) has highlighted here the question of “situated language and symbol grounding.” For example, the relation between the verbal label “cube” uttered by the human and the physical cube that it refers to in front of the robot can be mediated through sensory data, but the use of conventional signs should allow the robots to go beyond the here- and-now and extend symbol grounding to abstract entities in addition to objects, people, or events. To implement architecture that can be compared to human interactions, this relation should

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be bidirectional: the visual perception of a cube should activate the right symbol in the robot’s cognitive system, leading to the production of the word “cube”; reciprocally, a request addressed to the robot to give the human the cube should create a precise representation, allowing the robot to identify the right object.

Moreover, the identification of emotion labels in the verbal modality could also contribute, in addition to the recognition of emotional facial expressions and acoustic properties of speech (see Breazeal, 2004 for a complete review on emotion systems in robots), to a better coordination between each partner of the interaction. The haptic modality, playing an important role in social interactions, is also regarded as a valuable medium for expressing emotion (Yohanan and MacLean, 2012). By developing motion capturing system and tactile sensors, the robot may use its human partner’s positions and such “affective touch” to estimate human intentions (Miyashita et al., 2005). This modality, essential in human development, may be a particularly good candidate to study complexity of HRI, involving simultaneously motor precision, coordination and planning (see section “To What Extent Can Interactions Be Characterized as complex?”).

Finally, in addition to the coordination dimension, the verbal dialog between a robot and a human would ideally imply purposeful speech and planning (Mavridis, 2015), in order to avoid fixed mapping between stimuli and responses. Anticipatory planning abilities, as described in Section “To What Extent Can Interactions Be Characterized as complex?”, would enable the robot to make the most appropriate or efficient decisions in a given shared activity, in conjunction with its perspective-taking skills and the goal of the activity. If the robot can represent which information are needed by the human to perform a specific action (and therefore identify which information the human misses), it can decide to express a verbal request or comment on the situation, and/or plan a sequence of actions to coordinate with its partner.

This last example raises the question of intrinsic motivation in interactions: why is each partner engaged in this multimodal coordination, and to what extent does it influence the characteristics of the interaction? Studies in developmental robotics have shown that intrinsic motivation systems based on curiosity can directly impact learning skills and lead to autonomous mental development in robots (Oudeyer et al., 2007). Such mechanism is obviously involved in human development and in social play in particular: children discover and create new possibilities by exploring their physical and social environment. Through the development of social referencing, self-consciousness or cooperation, human social interactions may even sometimes constitute a motivated goal per se (Tomasello, 2009), which provides some perspectives to shape robots’ intrinsic motivation with a “social reward” function.

We can see here that the relationships between theories in developmental psychology and robotics offer bidirectional benefits. To put it in a nutshell, some models in developmental robotics are based on psychological theories, which are then formalized and implemented in robots, while developmental robotics allows researchers in psychology to go further in the elaboration of their theories through thorough experimentations

and hypothesis testing. This applies to a variety of questions addressed in this review, from the conditions that influence learning process during interactions (Boucenna et al., 2014) to the description of stages in language development (Morse and Cangelosi, 2017). Advances in developmental robotics may thus provide previous help in the analysis and implementation of the processes involved in interactions.

CONCLUSION AND PERSPECTIVES

The question at stake in the present work was to improve the effectiveness of human–robot interactions in collaborative tasks, first in terms of joint outcomes – has the task been completed? – but also with regard to the human’s perception and interpretation of the interaction. Is the robot’s behavior appropriate, i.e., acceptable, considering the frame of human communication? We argue here that the observation of the development and the structure of interactions between the child and the adult, especially in the context of social play, can help answer this question. To shape a shared common space between the human and the robot that could reflect the complexity of human interactions, we have also proposed to focus on three dimensions: motor precision, coordination, and anticipatory planning. The specific examples developed in Section “Pragmatics in HRI: Which Ingredients Are Necessary for Effective Interactions?” suggest that the more robots use human-like communicative modalities (e.g., facial expressions, gestures, and language) in respect to these three dimensions, the more they invite interactive behaviors that are natural to people. The interpretation of dealing with a social agent is strengthened, which facilitates in turn the interaction with robots. In this sense, and to paraphrase Cangelosi et al. (2010), the integration of action and language may constitute a roadmap to better frame and assess HRI from a developmental point of view and with a pragmatic perspective.

However, there are still numerous obstacles before achieving the level of details pictured in the present article, involving mainly technological challenges, given the motor and cognitive correlates of the above-mentioned behaviors. To put it bluntly, developmental psychologists cannot expect roboticists to implement in robots all the subtleties of multimodal communication that occur in human children. There may also be some conceptual difficulties as the attempts to approach human realism, aiming at maintaining the human’s trust in the robot, can sometimes be confronted with an uneasy feeling of viewing and/or hearing a robot that looks imperfectly human. This uncanny valley effect (Mitchell et al., 2011; Mori, 1970, 2012), which was shown to emerge in middle childhood in relation to developing expectations about humans and machines (Brink et al., 2017), may complicate the design of socially interactive robots, both in terms of appearance and behavior. Empirical evidence for the uncanny valley seems nevertheless inconsistent or restricted to specific conditions (Kätsyri et al., 2015), with the definition of human-likeness mostly involving physical realism.

By contrast, anthropomorphic behavior (see Duffy, 2003), in addition to its facilitating role in the interaction with humans (see

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above), also results in better and faster learning by the robots. For example, in a task in which they have to learn the meaning of words, the robots’ performances are enhanced when they provide humans with social cues to communicate a learning preference, as these cues influence the tutoring of the human teacher (de Greeff and Belpaeme, 2015). We observe the same phenomena when human children start to learn new concepts: according to Bruner’s constructivist theory, children need scaffolding from adults (or from children who have already acquired the concept) in the form of active support, which may represent at first a reduction in the choices a child might face. Such learning processes play obviously an important role in human development, and may also enable quick and effective application of robotic systems. Multi-level learning may indeed constitute a key line of research for HRI (Mavridis, 2015), which might again benefit from research in developmental psychology.

Reciprocally, the field of robotics provides interesting perspectives for psychologists, especially for research on atypical development. Atypical development might be a direct window on typical development and vice versa: “development is the key to understanding developmental disorders” (Karmiloff- Smith, 1998). Joint action and joint attention are for example usually impaired in children with ASD; the comparison with typical development has revealed different use of social gaze and often a lack of the declarative function, both for verbal and non-verbal communication. The exchanges between robotics and developmental psychology could help conceptualize the stages of joint attention in order to better understand how children develop joint attention and get through the whole sequence of declarative pointing. This will have an impact on elaborating intervention programs for children with neurodevelopmental disorders. Moreover, numerous intervention programs have recently been proposed

showing the added value of therapy robot for the development of communication, play, or emotional skills (e.g., Robins et al., 2009; Huijnen et al., 2016).

In conclusion, the combination of insights and methods in robotics and developmental psychology allows researchers to conceive models of HRI in which the robots can come to develop motor, social, and cognitive skills. These models may benefit fundamental research on joint attention and joint action in typical development, but also early evaluation and intervention programs for atypical development (e.g., Dautenhahn, 2007). The continuation of these interdisciplinary discussions, which may possibly integrate some of the elements proposed in the present article, will undoubtedly lead to more and more solid HRI models in the next decades.

AUTHOR CONTRIBUTIONS

HC and MG devised the conceptual ideas presented in the article. HC drafted the manuscript. MG revised it critically and gave final approval of the version to be submitted.

FUNDING

This article is part of the project JointAction4HRI, funded by the French National Agency for Research (n◦16-CE33-0017).

ACKNOWLEDGMENTS

Many ideas presented in this paper stem from fruitful discussions with R. Alami, A. Clodic, and E. Pacherie, all involved in the Joint Action for Human-Robot Interaction project funded by French National Agency for Research (Project No. 16-CE33-0017-01).

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Conflict of Interest Statement: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

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Contribution of Developmental Psychology to the Study of Social Interactions: Some Factors in Play, Joint Attention and Joint Action and Implications for Robotics

Introduction
How Does Communication Develop in the Context of Social Play?
To What Extent Can Interactions Be Characterized as Complex?
Pragmatics in Hri: Which Ingredients Are Necessary for Effective Interactions?
Conclusion and Perspectives
Author Contributions
Funding
Acknowledgments
References

EuropEan Journal of DEvElopmEntal psychology, 2017 vol. 14, no. 6, 629–646 https://doi.org/10.1080/17405629.2017.1382344

INTRODUCTION

Developmental psychology without positivistic pretentions: An introduction to the special issue on historical developmental psychology

Willem Koopsa and Frank Kesselb

autrecht university, utrecht, the netherlands; buniversity of new mexico, albuquerque, nm, usa

ABSTRACT Emphasizing the importance of understanding children and child development as ‘cultural inventions’, William Kessen urged developmental psychologists to forego ‘positivistic dreaming’. The first section of this paper summarizes Kessen’s central ideas. In the second section the pretensions of positivism (classical nineteenth century positivism as well as twentieth century neo-positivism) are analyzed. The core critique of positivism is based on Poppers falsificationism and the so- called Positivismusstreit within the Frankfurter Schule. Despite those and related fundamental critiques, anti-positivism (such as Kessen’s) does not imply anti- empiricism. One corollary – Although contemporary developmental psychology is dominated by empirical-quantitative approaches, a wider range of philosophical and methodological approaches are called for if the failings of lingering positivism are to avoided. In particular, twenty-first century developmental psychology requires critical thinking about the discipline’s foundations and history, along with deep analyses of how childhood and child development, and the field itself, are historically and culturally embedded (as Kessen asserted). Section 4 concludes with several critical notes regarding, e.g., the predominantly Western orientation of historical studies of child development and the need to recognize the unavoidable normative, moral dimension in the study of human development. The final section provides a brief overview of the papers that comprise this special issue on historical developmental psychology.

ARTICLE HISTORY received 17 september 2017; accepted 17 september 2017

KEYWORDS historical developmental psychology; positivistic psychology; analytical empirical approaches; developmental science; srcD

1. Introduction

The often-cited developmental psychologist William Kessen (1925–1999) con- sidered the American child a ‘cultural invention’ (Kessen, 1979). Inter alia, this

CONTACT Willem Koops [email protected]

mailto: [email protected]

http://www.tandfonline.com

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630 W. KOOPS AND F. KESSEL

implies that developmental psychology cannot function fruitfully without his- torical analysis. And that is what this special issue seeks to demonstrate.

The first section of this introduction focuses on Kessen’s ideas. The second section takes a closer look at the meaning of ‘positivism’, a concept and move- ment Kessen often considered. In particular, we will assert that it is possible to be an anti-positivist while simultaneously believing that theoretical conceptions must be approached systematically and assessed empirically-analytically as rig- orously as possible. In other words, while recognizing – as Kessen did later in his career – that scientific knowledge is always contingent on time and place, schol- arly concepts and claims must remain open to empirical inquiry. Conversely, section three elaborates on the view that scientific thinking not only depends on empirical-analytical research, but also requires self-reflection, in particular, critical thinking about a discipline’s foundations and history. Section four con- cludes with several critical notes as a bridge to brief descriptions of the papers that comprise this special issue.

2. Kessen’s plea

During the (only) ‘International Year of the Child’ (1979), Kessen wrote an influ- ential essay on ‘The American Child and Other Cultural Inventions’ (Kessen, 1979; also Kessel & Siegel, 1983). Among several other central observations Kessen pointed out that:

No other animal species has been cataloged by responsible scholars in so many wildly discrepant forms, forms that a perceptive extraterrestrial could never see as reflecting the same beast. (Kessen, 1983, p. 27)

Understandably scientists who study children wish to continue to pursue what Kessen referred to as a ‘positivistic dream’, in which such multiple variations in the definition of the child are considered the ‘removable [correctible] error of an [as-yet-]incomplete science’ (l.c.). Kessen’s view, however, was that develop- mental psychologists needed to finally attempt to bridge what he considered the abyss of the positivistic nightmare. This requires them to recognize that the upbringing and development of children, as well as the sciences of developmen- tal psychology and pedagogy, are culturally-historically influenced in significant ways:

For not only are American children shaped and marked by the larger cultural forces of political maneuverings, practical economics, and implicit ideological commit- ments (a new enough recognition); child psychology is itself a peculiar invention that moves with the tidal sweeps of the larger culture in ways that we understand at best dimly and often ignore. (Kessen, l.c.)

Grounding his position in historical analysis, Kessen suggested that, in the mid-nineteenth century, the United States of America was being prepared, socio-culturally, for the birth of what came to be known as child psychol- ogy. Against the background of the industrial revolution, he discussed three

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cultural-historical changes that have shaped the fundamental principles of developmental psychology through to the present. And while Kessen conse- quently spoke about American child and developmental psychology, his critique applies to Western culture as a whole, if only because of the dominant influence of North American developmental psychology in the twentieth and even twen- ty-first century. He did, therefore, delete the adjective ‘American’ (from the title ‘The American Child and Other Cultural Inventions’) in his revisited version in 1983; hence: ‘The Child and Other Cultural Inventions’ (Kessen, 1983).

In Kessen’s analysis, the first cultural-historical change that led to the inven- tion of the modern-day child was the gradual division between the domains of work and family. When women in America between 1830 and 1840 were excluded from the industrial workforce, this division, marked by the walls of the family home, became increasingly impregnable (Kessen, l.c., p. 31). Work was carried out in specialist workplaces (factories) by specialist people (men), and home became a place where one did not work.

Second, masculinity and femininity were so strongly separated that two different worlds arose: the ‘ugly aggressive, corrupting, chaotic, sinful and irre- ligious’ world of men and the ‘sweet, chaste, calm, cultured, loving, protective and godly’ world of women (Kessen, l.c.). This division made women ‘naturally’ and exclusively responsible for the upbringing of and caring for children.

A third change followed from the other two: As children no longer had access to the grown-up professional world and home ‘took on the coloration of mother, hearth and heaven’ (Kessen, l.c.), children became sentimentalized. They were seen as pure, unspoiled, and even ‘heavenly’. Wordsworth’s ‘Heaven lies about us in our infancy’ succinctly expresses this view (Stassijns & van Strijten, 2004, pp. 138, 139). Moreover, the critical importance of early childhood for lifetime development was canonized. Again, Wordsworth is (too) often quoted: ‘The Child is father of the Man’ (l.c. pp. 128, 129).

Kessen’s central message is that these cultural foundations of ‘developmental science’ are generally not recognized as such, i.e., as culturally-historically con- tingent, and are often even regarded as fundamental laws of nature. As Kessen argued, in developmental psychology the importance of a harmonious family, the significant role of mothers, and the decisive role of early experience in the development of the child are conventionally considered as principles anchored in the laws of nature, for which researchers seek and find empirical evidence. And the now commonplace use of ‘developmental science’ can be seen as a final integration of developmental psychology with ‘science’, and not with the humanities. As a key qualifying corollary, this view overlooks, or at least tends to overlook, any and all alternative conceptions of the child and of develop- ment in different historical epochs and socio-cultural contexts. To Kessen, this also means that progress in developmental psychology, i.e., seeking deeper understanding of human development, cannot be achieved by collecting more and more empirical data but, also and as important, has to entail analyzing the

632 W. KOOPS AND F. KESSEL

basic principles and processes of the field from a cultural-historical perspective (again, as the title of his essay so precisely states: ‘The [American] Child and Other Cultural Inventions’.

To provide a preview of the final sections below – Working within such a phil- osophical framework, the authors of the papers in this special issue are focused on a particular task: Providing various insightful illustrations of a critical cultur- al-historical approach to the (‘fundamentals’ of ) developmental psychology.

3. Positivistic and empirical-analytical approaches

As signaled above, in Kessen’s view the positivist program was and is funda- mentally misguided; he therefore criticized ‘positivistic dreaming’, viz., the assumption that empirical-experimental (human and social) science will yield fundamental facts and universal, timeless principles. Given that the terms positivism and positivistic have long been used by critics of ‘normal science’, examining them further is warranted. In the next subsection, the origin and meaning of the concept of positivism will be discussed, as well as a number of its characteristics that have been subject to criticism and that, therefore connect to the core of Kessen’s position.

As a prefatory note, it is important to underline that the assumptions and goals of positivism can be rejected without implying an opposition to empir- ical research (as some movements in psychology and pedagogy antithetical to empirical science have asserted). Thus neither Kessen nor we are opposed to systematic and reflective empirical research in (developmental) psychology and pedagogy. On the contrary, whenever possible, and while acknowledging limitations on the possibility of data-collection and certainty of related interpre- tation, researchers should analyze and reflect on their theoretical assumptions in the context of the most systematic available empirical data. Such a principled stance of vulnerability, or humility, regarding the limits of scientific knowledge – which can be traced back, among others, to the philosopher of science Karl Popper (1902–1994) – will be referred to as an empirical-analytical approach.

3.1. The positivist approach

Positivism is the notion that only the empirical sciences can yield valid knowl- edge. Positivism asserts that science is solely based on empirical facts and rejects all metaphysical assertions and assumptions. The classical positivism from the nineteenth century merges with the belief in the progress of the Enlightenment, i.e., progress in science will eventually provide solutions to all possible problems (Steel, 1989, p. 99). Positivism emerged from the confrontation of philosophy with the successful modern (physical) sciences and the consequential view that the certain knowledge of empirical science could not be matched by phi- losophy (or the humanities in general). Already by the end of the eighteenth

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century philosophy had begun to cede the field of nature to positivistic modern physics and chemistry. And in the nineteenth century the humanities were also gradually redefined as empirical sciences. Positivistic sociology appeared first, promoted by Auguste Comte (1798–1857), considered the ‘father of positivism’ (Bourdeau, 2011); he referred to sociology as ‘social physics’ (Steel, 1989, p. 98). Comte’s positivistic program for sociology was elaborated by his pupil Émile Durkheim (1858–1917).

In the case of psychology, the establishment of the first psychology labo- ratory by Wilhelm Wundt (1832–1920) in Leipzig (in 1879) has conventionally been identified as the beginning of positivistic, i.e., scientific, experimental psy- chology (Boring, 1950; as the canonical source). But here it is especially worth noting that critical historians have demonstrated how such accounts com- pletely neglected the other deep dimension of Wundt’s work (1900–1920), viz., his Völkerpsychologie studies of phenomena such as language, art, myths and religions, law, culture in historical perspective, and more. (See, e.g., Blumenthal, 1977; Danziger, 1979; Leary, 1979) And it is plausible to see the spirit of the ‘other Wundt’ expressed in the various, emerging-in-the-1990s and now-vibrant forms of ‘Cultural (Developmental) Psychology’, for example, in the rich, paradigm-de- fining writings and research of Michael Cole (1996), Barbara Rogoff (2003) and Richard Shweder (1994). (See also Goodnow, Miller, & Kessel, 1995).

Comte’s positivistic program of principles was described in his writing about the positive mind (Comte, 1844). That program also demonstrates the strong belief in progress that was intertwined with Comte’s positivism. He believed, for instance, that the rise of the modern sciences was a slow but inevitable process. He formulated the law of the three stages: First, a theoretical stage when the explanation for phenomena is sought in supernatural powers. This is followed by humanity entering a metaphysical stage when the world is explained by referring to abstract principles or essences. Eventually humanity enters a positive stage when it becomes clear that only empirical science can yield real knowledge. At this stage knowledge should be considered as accessible to all and relevant for all daily requirements and needs. Therefore, according to Comte, positivism is inevitable. The law of the three stages is founded on the presumed positivistic law of progress and evolution of human thinking. Delanty and Strydom (2003, p. 14) have extensively described positivism. Assuming access to their writing, we will now further concentrate here on some criticisms of positivism by way of a discussion of Popper’s ideas and the debate within the Frankfurter Schule.1

Positivists believe that scientific knowledge originates primarily via induc- tion: By systematically observing specific perceptible phenomena one induces general and abstract laws. This, however, is not how it appears to unfold in scientific reality. A fundamental criticism of such a position came in the form of

1a detailed discussion of all these ideas, and those in the previous section, is contained in Koops (2016), notably chapter 1.

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Popper’s falsificationism (Popper, 1935, 1959) and his classic ‘Even if one has seen a hundred white swans, the next one could still be black’. According to Popper, one can only falsify or refute, not ever confirm or prove a posited hypothesis. So ‘all swans are white’, can only be refuted by encountering a black swan. It follows then that one must first posit a certain assumption (hypothesis or H1) and then try to refute it by rejecting the contrary hypothesis (H0). And even if this succeeds, the basic hypothesis (H1) can only be maintained provisionally, and never be lifted to the level of absolute knowledge through observation alone. For Popper, then, there is no pure induction from observation to certain knowledge.

Popper’s description of this logical asymmetry between verification and falsification – hence Conjectures and Refutations (1963) – is a key element in his philosophy of science. It led him to choose falsifiability as the criterion to distinguish science from non- or pseudo-science: A theory can only be genu- inely scientific if it is falsifiable. Falsifiability as a demarcation criterion for the distinction between science and un-science therefore led him reject the claims to scientific status of both Marxism and psychoanalysis, given that both theories are not falsifiable.

In summary, Popper made it clear that induction from observation cannot lead to true, universal knowledge, and that all scientific knowledge is tempo- rary and provisional. This is a significant qualification of original positivist pre- tensions. Popper’s analysis also seriously undermined the notion of inevitable progress. As a consequence, those following Popper’s analysis have little reason to believe that scientific knowledge automatically advances and improves; they also do not have any reason to expect that we will ever be able to solve all social problems purely through knowledge derived via positivistic science. In addition, classical positivism’s assumption that knowledge can be exhaustive and that induction one day will have yielded all important certainties about the universe is, for Popper, an indefensible optimism.

A complementary set of ideas emerged in the 1960s, in the form of a debate in Germany that became known as the ‘Positivismusstreit’ (the Positivism bat- tle); this exchange deepened the critique on positivism. (See Adorno, Albert, & Dahrendorf, 1993; Dahms, 1994) Even though it focused primarily on the meth- odology and epistemology of sociology, the debate was particularly relevant to positivist claim that science is value-free. The discussion between Theodor Adorno (1903–1969) and Popper, in particular, focused on this topic. It is note- worthy that both agree that the scientific practitioners are always embedded in cultural history and that their minds, therefore, are pervaded or shaped by this context. According to Popper, however, the ensuing scientific research is meant precisely to determine empirical-analytically the tenability of the claims of the embedded scientific researcher.

For their part, the philosophers of the so-called Frankfurter Schule, with key representatives such as Adorno and Jürgen Habermas (born in 1929), believed

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that although society as a whole could be analyzed scientifically, value-freedom was an illusion in all respects. The members of the Frankfurter Schule built on the theories of Marx, Hegel, and Freud (as noted, all unscientific in Popper’s view). The fundamental assumption of the was that they could understand the struc- ture of society as a whole and, in principle, identify the conditions to change or entirely alter this structure consistent with certain value assumptions. This approach was thus called Critical Theory. (In the 1960s and 1970s, widespread social criticism from the democratization movements, particularly at universities, was inspired by the Frankfurter Schule publications.)

The discussions that emerged during the Positivismusstreit made it clear that the value-freedom as claimed by positivism should at least be qualified. Such an analysis underlines that scientific researchers are members of a community whose work is shaped by the wider society’s values. As a key corollary, these values play a role in their theoretical and methodological choices and com- mitments. For his part, Popper thought that falsificationism would provide the critical means to subject the tenability of theoretical claims to empirical-ana- lytical test; and that, in turn, could always lead to the refutation of the claims. And the Frankfurter Schule believed that they could understand and modify social value patterns and dynamics. However, contrary to classical positivism’s assumption that objective observations and logical induction guarantee value freedom, both did not deny – indeed, acknowledged – that values play a role in science. While Popper aimed to subject value-laden theoretical notions to scrutiny via falsificationism, the Frankfurther Schule sought to respond ‘critically’ to these values.

As a final note in this section, it is worth emphasizing that the account above is an abbreviated, selective account of the critique of positivism. Among other strands (emerging especially in the 1960s): Thomas Kuhn’s analysis of scien- tific ‘paradigms’ and ‘revolutions’, and Michael Polanyi’s discussion of ‘personal knowledge’ and ‘the tacit dimension’ (See Kessel, 1969).

3.2. The empirical-analytical approach

Whereas Adorno (1993) invented the term ‘Positivismusstreit’, Popper objected to the term as he did not want to call himself a positivist. Or, more accurately, he objected being considered (even) a neo-positivist.

Neo-positivism had originated during the period of the Wiener Kreis. The Wiener Kreis (1920–1938) referred to a group of philosophers and scientists who gathered around Moritz Schlick (1862–1936). Key figures included the econ- omist Otto Neurath (1882–1945), and the philosophers Friedrich Waismann (1896–1959) and Rudolf Carnap (1891–1970). Often present but not a formal member of the group, Popper deviated from key points of the logical positiv- ism or logical empiricism promoted by the group. Rejecting metaphysics and epistemology as useless, the Wiener Kreis sought to unify science by making

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use of a common scientific language, symbolic logic. Eschewing such a common core language, Popper described his own approach as critical rationalism. The term ‘critical’ is rather ambiguous: The Frankfurter Schule uses it to refer to social criticism; Popper wished to (critically) determine which theories were tenable and which were not.

Thus Popper criticized both classical positivism and the neo-positivism of the Wiener Kreis. Contrary to the positivistic tradition, he believed that all science is partial (and always incomplete); that scientific knowledge does not automati- cally advance but often has to take apparent detours; and that science cannot ever produce complete understanding and the solution of all social issues. He also agreed with the Frankfurter Schule that the theories and hypotheses of a scientist are can never be value-free in the sense that they are unconnected with the everyday lived environment (of the scientific community). But contrary to the Frankfurter Schule, Popper deemed it possible to refute untenable assump- tions and hypotheses via falsification, not as in the tradition of positivism via induction. In essence, his falsificationism is an empirical-analytical tool: It aims to examine and refute hypotheses and predictions by making use of empirical data.2

Conducting path-breaking empirical-analytical research on infants, Kessen in fact established his reputation in the American behaviorist tradition, a par- adigm that more than any other institutionalized positivist assumptions in mainstream psychology.3 He was thus certainly aware of the importance of the empirical-analytical tradition. Later in his scholarly career, however, and based in part on his own study of historical sources (Kessen, 1965), Kessen sought to understand how the practice of developmental psychology and of theorizing in general was linked to the cultural history in which it was, and is, embedded. For him, and us, such self-critical understanding is the only way to preclude assumptions and views about children that are, as Kessen underlined, variable across cultural space and historical time being mistakenly considered natural, universal phenomena.

In a related vein, we suggest that scientific questions can only be answered in a meaningful way at the level of organization of the phenomenon being studied. We borrow this conception of ‘level of organization’ from the Dutch psychologist, Johannes Linschoten (1964). In a distinctive way, he made clear that questions at one level of organization cannot be answered by data at a different level of organization, at least not without losing relevance and understanding. As a

2such an empirical-analytical approach remains a core element of the methodology of contemporary psy- chology. to give an example, in the second half of the twentieth century Dutch (and European) psychol- ogy was totally redefined by De groot’s classic book (1961; English translation 1969), whose prescriptive methodology was largely based on the ideas of popper. (see Busato, 2014 for a description of the effect of De groot’s work.).

3Kessen was not alone in forcefully rejecting psychology’s positivist-behaviorist paradigm in which he made his early, widely-recognized contributions. sigmund Koch serves as another compelling, still-relevant example. (see finkelman & Kessel, 1999; leary, 2001).

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corollary, Kessen’s plea for historical understanding of the child and of child development implies that gathering and analysing only quantifiable data, we will miss essential understanding of the historical and cultural embeddedness of child development. Because the complexity and the time scale of historical phe- nomena call for a different level of organization than that of the individual child in the here-and-now (to be studied exclusively via experimental approaches), the study of cultural historical embeddedness of human development requires different methods and analyses.

In a similar spirit: The anthropologically informed, ethnographically sophisti- cated developmental psychologist whose research entails making observations of and conducting conversations with children (and their families) in diverse cultures seeks to capture those in field notes that, in the best case, serve as the basis for rich, meaningful narratives about the meanings of child behavior and experience in such contexts. Such plausible stories cannot be replaced by exclusive quantitative analysis of isolated variables. This illustrates Lischoten’s caution: To gain understanding of local knowledge and dynamics at the level of cultural complexity, research calls for subtle stories and not purely quantitative analyses and models based on a certain conception of the natural sciences.

The empirical-analytically minded researcher thus tries to find the most pre- cise answer possible at the level of complexity that defines or represents the problem focus of the research. Even if that most precise answer is in the form of a verbal explanation, it is still possible and even necessary to try to test the tenability of a hypothesis by examining opposing hypotheses (as a non-numer- ical, verbal form of Popperian falsification).

What we are advocating is best considered ‘methodological liberalism’, which implies that, in adopting an empirical-analytical approach, the researcher seeks to collect and fit data at the level of the organization of the object of study, and that these data are analyzed as accurately as possible. If possible, and where appropriate, researchers derive and analyse data using numbers/statistics; but if this is not possible at the given level of organization, or meaningful in the context of the problem being studied, then the researcher should turn positively to narratives. As suggested above: At some levels of organisation mathematical models are not feasible or even desirable, so narrative accounts are preferable. But even then it is possible to profit from Popper’s falsification ideal: The goal should always be to search systematically for a convincing, possibly conclusive argument that is in conflict with the conclusion. It is, for example, acceptable within modern psychology to test statistically whether a mathematical model is ‘fitting’. Popper might have regretted this, for such an approach is the oppo- site of his falsificationism. However, even within such a ‘model-fitting’ research approach, respect could be paid to Popper’s falsificationism by systematically exploring alternative, contrasting models.

In summary, even though – humbly echoing Kessen – we are anti-positivists, we too are not opposed to empirically-oriented developmental psychology.

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Our view is that developmental psychology should be empirical-analytical in overall methodology while recognizing and accepting that empirical data cannot, indeed should not, be more exact than appropriate for the level of organization of the studied phenomenon. Among other things, this means that research methods can be qualitative or quantitative; that while data collection and analysis seek to be as exact and detailed as possible, sometimes they will – indeed should – consist of the systematic interpretation of texts and citations, other times of statistical data derived via measurements. Indeed, over the past couple of decades clear signs have emerged that qualitative methods, of various kinds, are being accepted as both legitimate and important forms of develop- mental inquiry (Jessor, Colby, & Shweder, 1996; Kessel, 2013; Weisner, 2005) and psychology more broadly (Bevan & Kessel, 1994; Josselson, 2017; Packer, 2004; Willig & Rogers, 2008).

4. Principles and history

In the previous sections, drawing on an admittedly shorthand review of some previous ideas from the philosophy of science that undermined positivism, we have attempted to delineate some of our ‘pluralistic’ methodological and epis- temological convictions. As a corollary, we suggest it is still all too simplifying and seductive to take classical, Newtonian physics as a model for the study of human and social phenomena. Given different levels of organization (that is, different levels of complexity of phenomena studied), we need to continue to develop, adapt, and accept a variety of different methodologies, i.e., many forms of descriptive-analytic narrative approaches as well as ‘conventional’ experimen- tal-statistical methods. Nor can there be a simple formula for making insightful decisions about which method is best suited to the topic, issue, and level of organization at hand. And more: A critical scientific discipline will strive to be knowledgeable about its own history and engaged in self-critical reflection on its foundations.

It is therefore of great and immediate importance that developmental psy- chology focuses on questions that deal with the foundations and history of the field. This is more urgent than gathering ever more ‘empirical’ data and adding ever more ‘empirical’ papers to myriad journals. It is particularly essential to establish understanding of the discipline’s intellectual and institutional con- text, rather than only accumulating further fragmented and complicating, or worse, simplifying knowledge. To that end, in our view critical historical analysis is essential. As the papers in this special issue make clear, past and present (and future) empirical research on child behavior and experience is intricately con- nected with the history of theories and assumptions about children and their development. Moreover, self-critical knowledge of the history of the discipline itself can help prevent the reinvention of the wheel or, to adapt another met- aphor, simply (and misleadingly) placing old wine in shiny new bottles. While

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research practice within the discipline requires defined empirical-analytical methodology (both qualitative and quantitative), study of the structure and nature of the discipline requires extended contemplation, analysis, and critical thinking, especially about its past as embedded in the present and future. (Below we address the central question of how, where, and by whom such analysis and thinking are best conducted.)

5. Concluding discussion

The fact that Kessen referred to the child as a ‘cultural invention’ might be taken to mean he was suggesting that children are not (also) biological beings. We should realize, however, that, via his title and related analysis, Kessen sought to provoke self-critical reflection. In effect, he wanted to wake up those he saw as mainstream and misguided ‘positivistic dreamers’. The child is also a cultural invention, a product of the ‘Zeitgeist’. Kessen challenges developmental psy- chologists to be critically aware of their (normative) concepts of the child, con- cepts which they absorb, reinforce, and reify in their own theories and methods, influenced by the socio-cultural zeitgeist, and which they are inclined to regard and present as empirically established, universal, value-free laws of nature.

Consider the example of the decisive role of early experience, an assumption often adhered to in the nineteenth century, consistent with the sentimentalized child image of that century. It is at least debatable how decisive early experi- ences are; but it is comforting to adhere to this view, in part because, as Kagan (1984) asserted, it dovetails with and reinforces the convictions of the wider public. He argued that developmental psychologists find it hard to consider contra-indications seriously and prefer to keep adhering to the notion of early determinism. For him, defending this absolute early determinism is as intelligent as Ptolemy ‘proving’ that the earth is the stable center of the universe (Kagan, 1984, p. XI). Of course, in light of many findings since 1984, early experience and education are undoubtedly important. But Kagan objected, in our view appro- priately, to overgeneralizing and overvaluing early development as uniquely causal in determining life course outcomes. In essence, Kagan wanted research- ers to refrain from uncritically adopting general culturally-shaped assumptions, concluding that ‘We celebrate empirical science because it corrects pleasing, but not always accurate, intuitions.’ (l.c., p. X).

It is important that the celebration of empirical science does not lapse into a positivistic tendency in the sense that we have described here. So, although this may be a primarily rhetorical point, why is it that it has recently become de rigueur to emphasize that we are engaged in developmental science? For one thing, what does that imply about the (ir)relevance of multi-dimensional disci- plines such as anthropology and history for shedding light on the complexities of human development in rich and diverse socio-cultural contexts? And on the same theme: When child developmental inquiry was institutionalized (in North

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America) in the 1920s. It was explicitly seen as a multi- or even inter-disciplinary endeavor. Only later (primarily in the post-World-War II era) did it come to be regarded and practiced as developmental psychology; moreover, one specific conception and form of the discipline, viz., ‘experimental’ and, in essence, posi- tivistic (Kessel, 2009). Is there now meaningful movement away from that restric- tive, uni-disciplinary perspective? Perhaps. (See our concluding comments.)

Our view of what empirical-analytical research should be seems to dovetail with what Kagan proposed when he wrote that ‘The Vienna philosophers went too far in their accommodation to the new discoveries in physics . . .’ (l.c., p. XIII). Consistent with what we suggested earlier about the Wiener Kreis, Kagan serves to illustrate that Kessen’s critical, post-positivist chords are being echoed and amplified by many (developmental) psychologists. (See Bronfenbrenner, Kessel, Kessen, & White, 1986; Brown & Cole, 2001; Kessel, 1983) And that includes the authors of the papers in this issue (as we hope will be evident).

An important closing question is whether Kessen’s critique and the contribu- tions in this special issue are unduly oriented towards the West, or global North. While these papers, for practical reasons of manageability, are primarily focused on trends in Europe and the United States, we suggest that the analyses and understanding emerging from the study of the history of childhood – exem- plified by the contributions here – can be generalized to other continents and regions.

Stearns’ book about Childhood in World History (2006) is an instructive example. Because, however reluctant and careful he is in generalizing Western developments to the rest of the world, Stearns nevertheless makes it clear that contemporary globalization reflects general trends regarding the changing contexts of child and family life. In particular, the transition from agricultural to modern societies – such as first occurred after the Enlightenment in Europe and North America – offers a number of discernible general patterns. For example, children who no longer contribute to the workforce but go to school to learn what is now considered relevant for their future functioning in the community or society; also, children who have fewer siblings and will die at an early age much less frequently than previously. And while the order and causal relation- ships between these dynamic changes may differ at different locations in the world and at different points in time, such patterns do indeed occur worldwide.

As another example, Stearns believes that the emphasis on the striving for children’s happiness has also become a global tendency which is subtly interlinked with these other patterns. Thus, the decrease of child mortality and increase in health care, as well as increased welfare, allows more room for con- cerns about ‘happiness’ (Stearns, 2010, 2011).

Thus, while the majority of the papers of this special issue are primarily focused on elements of Western culture, we should emphasize that this is not an unintended expression of a form of ethnocentrism but, rather, because historical trends in the West are also unfolding in other parts of the world as a function

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of modernization processes (Koops & de Winter, 2011). Moreover, as powerfully illustrated by the Keller and Vicedo papers in this issue, a reciprocal process is underway, where both historical and culturally-informed scholarship prompt a critical perspective on core, deeply-entrenched mainstream assumptions and theories. In their case, the focus is on attachment theory and research; a parallel process is now underway regarding the presumed ‘word gap’, i.e., supposed con- sequential deficiencies in the verbal environments of poor children, including those in contexts outside the North America and Europe, compared to their more affluent peers. (See Avineri & Johnson, 2015; Miller & Sperry, 2012)

The articles collected in this special issue will, we hope, encourage fur- ther (self-)critical historical research, further contributions to what might be called Historical Developmental Psychology (Koops & Elder, 1996). That, in turn, reflects two related and fundamental features of what a generative post-positivist paradigm entails: First, affirmative recognition that (develop- mental) psychology is, at root, a ‘moral science’ (White, 1983a), where normative assumptions are embedded, more or less explicitly, in both theory and practice, and most fundamentally in the very notion(s) of ‘development’ itself (White, 1983b). And second:

An historical [developmental] psychology involves, … in the first place, an aware- ness of the historicity of the very norms that are dominant in a given culture or within a given science at a given time. In the second place, an historical [develop- mental] psychology takes seriously the variety of culturally and socially operative factors that go into the very constitution of such norms, whether of childhood, or of cognitive development [or of social development], and at the same time an historical [developmental] psychology is aware or critically self-aware of the status of its own operative norms and methods of inquiry … An historical [devel- opmental] psychology is thus, necessarily, a normative psychology, not only in the descriptive sense of studying prevalent or historical norms, but also in the critical sense of rejecting and proposing norms. (Wartofsky, 1983, p. 189; see also, Bronfenbrenner et al., 1986, p. 1227)

And this follow-up passage powerfully underlines our overall theme (on the critical role of historical developmental psychology, and psychologists):

[None of this means] we can’t get started until we all agree on the norms. But it puts the determination and critique of norms right in the ballpark as a concern of actual psychological theory and psycho logical practice. [This] doesn’t mean every psychologist has to do so every day or say it as a little prayer every morning. But it means that it [the determination and critique of norms becomes an integral part of the field … and not some after-hours, cracker-barrel stuff you do when the real psychologists aren’t around … which is its usual status. That is, consideration of norms has to become integral to the field such that those who are doing it are in touch with those who aren’t, making them aware of it and so percolating the field. (op cit., p. 219)

All of which, we believe, both reinforces and honors Bill Kessen’s plea for a cul- tural-historical approach to the study of child and human development (Kessel, 1991).

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6. Brief overview of the papers in this issue

We are pleased to record that this special issue originated in Ann Arbor, Michigan on 12–14 May 2016 in a symposium on ‘Historical Perspectives on Child Development: Implications for Future Research’ organized by then-still- in-place History Committee of the Society for Research in Child Development (SRCD). In essence the following papers are the written, final versions of the symposium presentations by members of the Committee and other guests. Appreciative of the Society’s support for that event, we conclude this introduc- tion with the following Socratically-intended comments.

At least in its current stated strategic goals (Sherrod, 2016), SRCD – perhaps the most influential organization of its kind – is signaling commitments to some of the suggestions we have made here. As a noteworthy example, it has declared the goal of returning to its, and the field’s, multi/inter-disciplinary roots. Similarly, there is announced emphasis on seeking understanding of the cultural and con- textual dimensions of human development, with a presumed greater receptivity to qualitative forms of inquiry still more widely practiced in disciplines such as cultural and linguistic anthropology and history; also, a recent, loosely-re- lated focus on ‘social justice’. And there are some signs of a recognition that relationships, both institutional and intellectual, between the global north and south need to become more reciprocal, where theories, methods and findings are open to critique and fundamental revision from outside–the-mainstream perspectives. (See, e.g., Dawes, 2016; Kessel & Lukowski, 2016; Verma, 2016)

How will these commitments be institutionally enacted, most notably in the planning and review processes for both SRCD’s highly sought-after biennial meetings and its visible, high-impact journals? For a range of reasons, including the understandable inertial dynamics of large professional-scientific organi- zations, our view is that only time will tell how deep and consequential such projected philosophical and substantive shifts will be.

In particular, and again for a combination of reasons, we are skeptical – though hopeful – that the Society and the field as a widespread whole will create significant space for the kind of critical historical-developmental scholarship that these papers so persuasively represent. Such space would signal recognition, for example, that twenty-first Century ‘history’ is far from being a single, stand-alone ‘discipline’ but, instead, variously engages issues at the intersection of culture, society, politics and both epistemology and moral philosophy.

So will we get to the stage when, in Wartofsky’s perennially challenging words, ‘[the determination and critique] of norms [are] integral to the field such that those who are doing it are in touch with those who aren’t, making them aware of it and so percolating the field’? Seeing such self-critical engagement with normative and moral (and political) questions as akin to a final post-pos- itivist frontier for developmental inquiry (at least in our professional lifetimes), and inspired by these papers, we will strive to keep hope alive!

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Consistent with the main theme of this collection, Steven Mintz (Why history matters: Placing infant and child development in historical perspective) under- scores the importance of systematic knowledge about how conceptions of childhood vary across social time and space. In the process, he demonstrates how such understanding helps rebut myths, undercuts linear views of progress (and thus ‘development’), and sheds light on often misunderstood long-term trends and processes.

With a focus on changing social views and standards regarding children and emotions, Peter Stearns (Children and emotions history) provides a detailed case study of the overall themes underlined by Mintz. He examines, in socio-cul- tural context, two major changes in American approaches (around 1800 and in the 1920s), as well as possible explanations for shifts in specific emotions (e.g., happiness and shame). In a more ‘meta’ mode, he considers complexities in discussing changes or continuities in children’s emotions, and reflects on the possibilities for connections between historical and psychological approaches.

As a complement to Stearns’ paper, Paul Harris (Emotion, imagination and the world’s furniture) considers how a particular conception of emotions that emerged in the late nineteenth century was uncritically embedded in the work of subsequent generations of psychologists (at least in Europe and North America). Highlighting that conception’s heavily evolutionary-biological under- pinnings, he then examines two species-specific qualities of human emotions, where culture and imagination are central. Finally, he suggests that such a frame- work would be generative in considering connections between the history of emotions and their development in children.

Focusing on how John Bowlby’s and Mary Ainsworth’s ethological theory of attachment was received in different disciplinary communities, Marga Vicedo (Putting attachment in its place: Disciplinary and cultural contexts) makes two essen- tial points: From Margaret Mead’s 1950s anthropological-critique onwards, cultural challenges to the theory’s central assumptions (e.g., of universality) have been essentially ignored. And second, that such a (dys)functional dynamic can be best explained in terms of different disciplinary paradigms – philosophical and meth- odological, positivist and not. She thus provides an insightful illustration of some of the themes presented above, not least how fine-grained historical-archival research can shed illuminating light on major areas of ‘mainstream developmental science’.

Heidi Keller (Cultural and historical diversity in early relationship formation) complements both Vicedo’s paper and, again, parts of the ‘post-positivist’ view presented above. Drawing on the work of cultural psychologists and anthropolo- gists, as well as context-attuned developmental psychologists (herself included), she reviews how caregiving/socialization beliefs and patterns vary, consequen- tially, across changing sociocultural environments and historical time. She concludes with reflections on how the often-assumed contradiction between cultural-historical specificity and universality, e.g., in the realm of attachment and overall early relationship formation, can be overcome. As a corollary, she

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too illustrates how historical and developmental analysis can and should be two sides of the same analytic coin.

Lassonde’s focus (Authority, disciplinary intimacy & parenting in middle-class America) is on historical shifts, from the mid-19th-century through to the pres- ent, in beliefs and childcare advice regarding appropriate styles of parenting. Examining such topics as views regarding corporal punishment and its pre- sumed link to authoritarianism, his analysis emphasizes the importance of understanding changing dynamics in wider socio-cultural-political contexts, not least for critically locating the contingent views of developmental ‘experts’ (during various periods). And although the patterns he discerns are based in the United States, that sort of analytic principle and goal is no less important for work elsewhere, i.e., historical-developmental research (on ‘parenting’) that can yield a picture of differences and similarities across time and space(s).

As a broad complement to Lassonde’s paper, Sandin (The parent: A cultural invention. The politics of parenting) explores how – in Sweden in the twentieth century – beliefs, practices, and policies regarding the relative roles of parents and social institutions in fostering and protecting children were significantly shaped by the philosophy of the wider welfare state. He analyzes how govern- ment policies and (interventionist) practices both reflected and reified assump- tions, for example, about limited parental responsibility, especially in relation to children seen as competent, individual agents with adult-like rights; such assumptions were, in turn, tied to certain notions of ‘developmental well-being’ and reinforced by certain international conventions.

In the end, then, the harmonious sounding of some distinctly Bill Kessen-like themes!

Disclosure statement

No potential conflict of interest was reported by the authors.

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Abstract
1. Introduction
2. Kessen’s plea
3. Positivistic and empirical-analytical approaches

3.1. The positivist approach
3.2. The empirical-analytical approach

4. Principles and history
5. Concluding discussion
6. Brief overview of the papers in this issue
Disclosure statement
References

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rstb.royalsocietypublishing.org

Research Cite this article: Kline MA, Shamsudheen R, Broesch T. 2018 Variation is the universal:

making cultural evolution work in

developmental psychology. Phil. Trans. R. Soc.

B 373: 20170059. http://dx.doi.org/10.1098/rstb.2017.0059

Accepted: 12 December 2017

One contribution of 16 to a theme issue

‘Bridging cultural gaps: interdisciplinary studies

in human cultural evolution’.

Subject Areas: cognition, evolution, developmental biology,

behaviour

Keywords: cultural evolution, developmental psychology,

cross-cultural psychology, ethnocentrism,

evolution and human behaviour

Author for correspondence: Michelle Ann Kline

e-mail: [email protected]

†The second and third authors contributed

equally to this manuscript.

Variation is the universal: making cultural evolution work in developmental psychology

Michelle Ann Kline1,2, Rubeena Shamsudheen3,† and Tanya Broesch1,†

1Department of Psychology, Simon Fraser University, Burnaby, BC, Canada V5A 1S6 2Institute of Human Origins, Arizona State University, Tempe, AZ 85287-4101, USA 3Department of Cognitive Science, Central European University, Nador u. 9, 1051 Budapest, Hungary

MAK, 0000-0002-1998-6928

Culture is a human universal, yet it is a source of variation in human psy-

chology, behaviour and development. Developmental researchers are now

expanding the geographical scope of research to include populations beyond

relatively wealthy Western communities. However, culture and context still

play a secondary role in the theoretical grounding of developmental psychol-

ogy research, far too often. In this paper, we highlight four false assumptions

that are common in psychology, and that detract from the quality of both stan-

dard and cross-cultural research in development. These assumptions are: (i) the universality assumption, that empirical uniformity is evidence for universality, while any variation is evidence for culturally derived variation; (ii) the Western centrality assumption, that Western populations represent a normal and/or healthy standard against which development in all societies can be compared;

(iii) the deficit assumption, that population-level differences in developmental timing or outcomes are necessarily due to something lacking among non-Wes-

tern populations; and (iv) the equivalency assumption, that using identical research methods will necessarily produce equivalent and externally valid

data, across disparate cultural contexts. For each assumption, we draw on cul-

tural evolutionary theory to critique and replace the assumption with a

theoretically grounded approach to culture in development. We support

these suggestions with positive examples drawn from research in development.

Finally, we conclude with a call for researchers to take reasonable steps towards

more fully incorporating culture and context into studies of development, by

expanding their participant pools in strategic ways. This will lead to a more

inclusive and therefore more accurate description of human development.

This article is part of the theme issue ‘Bridging cultural gaps: interdisci-

plinary studies in human cultural evolution’.

1. Human development requires culture Humans stand out among other animals because we adapt to new environments

both by being clever innovators [1] and through the accumulation of cultural

knowledge across generations [2,3]. Social learning, including intensive forms

such as teaching [4 – 6], can facilitate cumulative cultural evolution. In fact, low-

cost social learning mechanisms, as well as sources of innovation, are prerequisites

for the evolution of cumulative culture. For this reason, social learning mechan-

isms are central to the understanding of cultural evolution—and cultural

evolution is key to explaining why and how human ontogeny is so very flexible.

Culture is a human universal: all societies have shared knowledge, practices,

beliefs and rituals that are transmitted socially. At the same time, culture is also a

source of psychological and behavioural variation both within and across popu-

lations. Developmental processes that are sensitive to socio-environmental

influences are one way that flexibility can evolve [7,8], and evolution can produce

developmental processes that vary in adaptive ways in terms of the degree and

nature of their flexibility [9]. Elaborating on the relationship between culture

http://crossmark.crossref.org/dialog/?doi=10.1098/rstb.2017.0059&domain=pdf&date_stamp=2018-02-12

http://dx.doi.org/10.1098/rstb/373/1743

http://orcid.org/0000-0002-1998-6928

http://orcid.org/

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and development first requires recognizing that evolution and

development are not mutually exclusive, then building on that

insight to explore how evolved developmental mechanisms

that are sensitive to cultural influence can create psychological

and behavioural variation across and within societies [8].

cietypublishing.org Phil.Trans.R.Soc.B

373:20170059

2. Developmental psychology requires a culturally diverse sample

Despite the importance of culture to development, develop-

mental psychology as a field retains a near-absolute focus on

development in relatively wealthy Western, English-speaking

populations. Henrich et al. [9] term general psychology’s par- ticipant pool ‘WEIRD:’ Western, educated, industrialized, rich

and democratic. A recent review provides evidence that this

is also the case in leading developmental psychology journals:

more than 90% of study populations represented there are from

the USA, Europe and/or are English-speaking [10]. The rest of

the world is vastly underrepresented, with only approximately

7% of participant populations coming from non-Western

human populations (the remainder are non-human animal

populations). In this context, developmental psychologists

who pursue cross-cultural research are wisely expanding

the scope of research to include participants beyond predomi-

nantly Western, upper middle class and often ethnically

white participants [9,11,12]. We applaud these efforts—

anything less would only perpetuate an incomplete and

inaccurate picture of human development.

Poor sampling, however, is not the only problem in the

field. Arnett [11], and Meadon & Spurrett [13] address a lack

of inclusivity in the broader practice of psychology: theories,

studies and publications in the American Psychological Associ-

ation journals are all overwhelmingly created, reviewed and

edited by this same subset of the world’s population. This is

one reason why the sampling problem in developmental

psychology is not likely to be solved by laboratory-based

researchers making the decision to take on cross-cultural

work unilaterally, in the short term. Dropping in on commu-

nities with unfamiliar cultures to run brief, one-off studies

without a long-term reciprocal relationship with the commu-

nity can be ethically dubious [14], especially where there is a

power differential. Further, interpreting results in isolation

from a population’s daily cultural context can produce more

confusion than answers [15]. And yet avoiding these pitfalls

requires investing what can be a prohibitive amount of time,

effort and funding to start and maintain a field site. A more

plausible way to ameliorate psychology’s WEIRD problem is

to recruit, support, include and collaborate with more scientists

from beyond the WEIRD populations that have created the bias

in the first place [11,13]. Alternatively, researchers can work

with non-university populations nearby, to explore variation

among people in their own local context [14]. More generally,

researchers who study WEIRD populations must also recog-

nize that their populations are also influenced by culture and

should consider carefully how to define the specific population

from which they recruit participants. Both these strategies fit

with a broader, theoretically motivated approach to expand

the inclusiveness of sampling in developmental psychology.

This paper aims to show why developmental psychology

needs this change, and establish some guidelines for how to

study culture’s role in development, no matter how near or

far from home the study site may be.

3. Cultural evolution can motivate a better science of developmental psychology

Cross-cultural data are expensive to get, but valuable to have.

Their rarity in developmental psychology is due to more

than a lack of interest in cross-cultural sampling, and we

cannot dissolve those very real barriers in this paper. Instead,

our goals in this paper are twofold. First, we aim to convince

researchers in the field of developmental psychology that con-

siderations of culture are relevant to their work, even if they

do not do far-flung fieldwork themselves. Second, for cross-

cultural developmental psychologists, we aim to leverage

cultural evolutionary theory to enrich the central role of

cross-cultural data to developmental psychology as a field.

To achieve these aims, we highlight four common but false

assumptions in present-day approaches to cultural variation

in developmental psychology, and critique each in turn by

drawing on cultural evolutionary theory and empirical find-

ings. This step of identifying and refuting these assumptions

will help to integrate the ‘cross-cultural’ niche within develop-

mental psychology, in general, by demonstrating how culture

and culture-based assumptions underlie some of the basic

ideas that motivate research in developmental psychology.

Those assumptions are that: (i) universality and uniformity

are equivalent: that what is universal must necessarily follow

a uniform pattern of development; (ii) Western populations

are central in human psychology; (iii) differences among

populations in development are always indicative of deficits;

(iv) methods can automatically be transported across cultural

contexts and yet maintain validity. We critique each assump-

tion in turn, by drawing both on cultural evolutionary theory

and on positive examples from the developmental psychology

literature. In our conclusion section (§8), we summarize a gen-

eral strategy for research that eschews these assumptions, and

argue that this approach can pave the way for an improved

science of developmental psychology by placing the cultural

nature of humans at its centre.

4. Problem no. 1: the universality as uniformity assumption

The universality assumption is the belief that observed uniformity is evidence for species-wide, biologically based universality. By

contrast, any variation is regarded as evidence for culturally

derived differences. By ‘universal’, we mean core mental or

behavioural attributes shared by humans everywhere [16].

This assumption sometimes takes the form of an explicit

claim that uniformity implies genetic underpinnings (often mis-

categorized as ‘biological’ or ‘evolutionary’), while variation

necessarily indicates ‘cultural’ influences [17]. In all its forms,

this assumption rests on the false nature/nurture dichotomy,

that culture and biology are separate, opposite and competing

explanations. In reality, human cultural capacities are part of

our biology [18,19]. Equating psychological or behavioural vari-

ation with cultural influence precludes a deeper understanding

of human behaviour, because a universally shared develop-

mental process can function to produce behavioural or

psychological variation. Instead, developmental flexibility and

culture are both parts of the biology of human development,

not alternative explanations—culture is a part of human

biology and development [8].

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This false dichotomy between nature and nurture pro-

duces two versions of the universality as uniformity

assumption: (a) that variation is equivalent to a lack of uni-

versality, and that (b) psychological/behavioural similarity

is equivalent to universality. For the sake of clarity, we

address each in turn.

(a) Variation equals cultural influence and lack of universality

This assumption is often implicit in data analysis and study

interpretation. For example, researchers conduct cross-site com-

parisons and conclude that any between-site difference is

‘cultural’, without explaining how culture produces differences

in psychology and behaviour. In addition, researchers often

treat whole cultures as if they are a single experimental con-

dition, without considering the influence of environmental

factors, such as resource availability, wealth or differences in

the interpretation of the method (see §6 below). For example,

directly comparing norms for anonymous sharing among

wealthy Americans with those among poor, food-insecure

Polynesian populations may result in differences—but those

differences may be due to circumstances specific to resource

scarcity, rather than some underspecified aspect of culture.

This line of reasoning is not considered sufficient for studies

of culture in other animals, and leads to energetic debates

about sources of behavioural variation even in our closest

living relatives (e.g. [20 – 22]). However, the same logic is

rarely questioned in cross-cultural comparisons of human

psychology. While cross-cultural comparisons do contribute

to our knowledge of the range of variation in human behaviour,

most fall short of understanding the sources and the scale of

variation that can emerge via developmental processes—the

real question at hand.

(b) Uniformity equals genetic roots and lack of cultural influence

The other side of the universality assumption consists of a belief

that uniformity in behaviour and psychology is indicative of

universally ‘innate’ traits that develop without cultural inputs.

When developmental psychologists ask whether a feature

is innate, and then seek to show that it emerges early and

reliably across human populations, they rely upon assump-

tions that equate sameness, universality and innateness. By

contrast, biologists have recognized notions of innateness as

useless in ecology, biology and behaviour since the early

1990s [19]. This rests on a recognition, as Barrett [8, p.157]

writes, that ‘. . .[t]here are not two kinds of things, the innate

and the non-innate, but only one, the developmental process

itself.’ Put simply, genes rely upon the environment in order

to create an organism, and vice versa. In humans, culture is

part of that ever-present environment.

describe a general human psychology in these terms, have

long been a driving philosophy in American psychology

[11,16,23]. While valuable as a first pass, documenting simi-

larities across sociocultural contexts is a subpar strategy for

data collection when the goal is to understand culture’s role

in shaping development, or vice versa. Cultural evolutionary

theory offers an alternative perspective for shaping research

questions: that genes and culture have co-evolved in humans.

Because of this ‘dual-inheritance’ system, both genetic and cul-

tural information are essential ingredients in any explanation

of human biology. Most developmental psychologists would

not argue with this stance, but putting it into action in a

research programme is still a challenge. Cultural evolutionary

theory is useful in this practical sense, because it provides a

working definition of culture that can inform quantitative

work: ‘[c]ulture is information capable of affecting individuals’

behaviour, that they acquire from other members of their

species through teaching, imitation, and other forms of social

transmission’ [19, p. 5].

Cultural evolution’s distinction of culture as socially

learned information is useful as a research tool because it

means developmental psychologists need not ask whether

any particular trait is universal, biological and innate, versus

cultural. When biology and culture are not opposites, this

either/or is a meaningless, and therefore unanswerable,

question. Instead, developmental psychology can embrace a

transformed question: what is the relative influence of environ-

mental, cultural and other contextual factors on shaping

development of specific traits, in particular population? In

other words, how variable and flexible is the development of

this trait? Answering this context-rich question through studies

that theorize about the functional role of variation will produce

a body of evidence on how human psychological development

varies. From this, researchers can build a more complete map

of human psychological development.

This view, rooted in cultural evolutionary theory, places

flexibility at the centre of understanding what is universal

about human psychological development. This provides a

theoretically motivated way to predict when and how culture

ought to impact development, rather than simply checking

Western-based work against non-Western populations and

lumping traits that are the ‘same’ as universal, and those that

are ‘different’ as cultural.

(d) Developmental research case study Studies of human language acquisition and socialization pro-

vide evidence for both variation in a cultural context, and

shared developmental processes. Geographically and culturally

disparate populations typically speak different languages, and

in some cases even show variation in the neurological under-

pinnings necessary to master and use different languages [24].

The cultural expectations for children as language learners

are shaped by their cultural contexts, and in some ways are inse-

parable from socialization more generally [25]. Language

acquisition processes illustrate that developmental processes

themselves—such as statistical learning [26]—can constitute

universal learning mechanisms, which in turn generate behav-

ioural and psychological variation. The same can be said for

children’s early learning environments: there are both shared

and variable features, cross-culturally. For example, Broesch &

Bryant [27,28] find that mothers and fathers across disparate

societies routinely modify the properties of their speech when

addressing young infants compared to when they address

adults, yet they do so in different ways [28]. Despite identifying

the existence of infant-directed speech by caregivers in North

America, Kenya, Fiji and Vanuatu, they also find that parents

vary cross-culturally in the form their infant-directed speech

takes. Mothers across diverse societies and rural Vanuatu

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fathers modified their speech by adjusting features of the per-

ceived pitch of their speech to infants. However, fathers in

North America only slowed down the rate of their speech, with-

out adjusting the perceived pitch [27]. The results of this study

demonstrate why researchers cannot simply search for univers-

ality by equating it with similarity: it is too broad a question,

and would lead us to ignore key details about the flexible

nature of developmental processes.

hing.org Phil.Trans.R.Soc.B

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5. Problem no. 2: the Western centrality assumption

The Western centrality assumption is the belief that Western populations represent a normal and/or healthy standard

against which development in all societies can and should be

compared. This assumption literally fits the original definition

of ethnocentric [29], in that it divides global populations into two rough categories, ‘the West’ and ‘the Rest,’ with Western

societies at the centre of everything. This assumption is rarely

if ever made explicit in print, but it is worked into the foun-

dation of much developmental research, including the

cognitive and medical milestones that serve as guidelines for

both Western parents and international health agencies.

(a) Improvements From a cultural evolutionary perspective, lumping Western and

non-Western societies into two broad categories of analysis is

simply throwing data away. The study of cultural evolution is

necessarily built on the study of the cultural history of societies

all over the world, because explaining cultural variation

requires a breadth of data across socioecological environments

([19]; see e.g. the range of sites included in Mace et al.’s edited volume [30]). From this perspective, every cultural context is

an equally valid study site, and the importance of a particular

site is down to its specific cultural features and their relevance

to the research question. For example, Polynesia’s history of

step-wise settlement by ocean-faring canoe and its estimable

rates of contact among societies make its cultural history an

excellent case study on how population interconnectedness

can influence the accumulation of complex material culture

[31,32]. The key message from cultural evolutionary theory

here is that these studies stand alone, and do not require a

Western comparison sample to lend them value.

(b) Developmental research case study The Western centrality assumption directly damages the accu-

racy and usefulness of developmental research. For example,

Karasik et al. [33] review how developmental textbooks and medical guidelines employ standards for motor development

that are built exclusively on American middle-class samples

as proscriptive milestones. Karasik et al.’s data, drawn from six different societies, document within- and between-

population variation in both the timing of the motor develop-

ment of sitting, as well as the social and material contexts that

contribute to those differences. This establishes a causal link

between context and developmental trajectories. Karasik et al. conclude that using American-centric guidelines as if they

are universal has ‘led to a gross misrepresentation of motor

development’ ( p. 1033). Treating Western samples as a univer-

sal measuring stick for development is, unfortunately, a

pervasive practice. Greenfield et al. [34] review evidence that

developmental trajectories derived from the study of Western

populations, with their focus on independence, are unlikely

to match how children learn and grow in sociocultural contexts

where interdependence is prioritized. This is particularly true

for social development. For example, while adolescence may

be a transition to autonomy in independence-focused societies,

in an interdependent society it is instead a relational shift that

makes sense only in the context of kinship and community [34].

Likewise, classic theories of attachment [35] presuppose

that the end goal of child development is independence and

autonomy, rather than locally appropriate integration into

kinship- and community-based interdependent relationships.

In a review, Keller [36] questions whether these theories hold

up when used to explain behaviour in cultural contexts

beyond Western societies, and argues that incorporating data

from additional populations requires revising existing theory

along lines suggested by cultural and evolutionary theories

of development.

6. Problem no. 3: the deficit assumption The deficit assumption is that population-level differences in developmental timing or outcomes are necessarily caused by

something lacking, typically in parenting or educational

systems. This line of reasoning allows for no flexibility, and

assumes a single, inflexible developmental outcome. The

assumption rides the coattails of the Western centrality assump-

tion, in that the timeline that establishes ‘normal’ development

from ‘delayed’ development is typically anchored on data from

Western populations. However, the deficit assumption can also

apply to Western populations or subpopulations therein. For

example, Lancy [37] argues that excessive levels of teaching in

Western societies may impinge on the development of a

child’s autonomy, The deficit assumption is also sometimes

applied to subpopulations within Western societies, and so

has recently become an important domain for self-critique in

the field of developmental psychology (see [38]). However,

the deficit assumption differs from the Western centrality

assumption in two important ways. First, the deficit assump-

tion carries an extra layer of interpretation in comparison

to the Western centrality assumption. By this we mean that

researchers simultaneously judge a given pattern in deve-

lopment as deviant and also attribute that difference to

something that is lacking or missing from a family’s or a popu-

lation’s way of raising children. This carries with it a value

judgement that goes beyond a scientific approach to describing

and explaining variation, and in doing so obscures the science

itself. Second, the Western centrality assumption functions

only in one direction. By contrast, the deficit assumption can

lead researchers to claim that Western children are somehow

worse off than non-Western ones. Often this takes the form

of arguing that Western children are coddled, spoiled or

excessively dependent on direct parent intervention.

In assuming that group-level developmental differences

are due to what is lacking in schooling or parenting, research-

ers frequently fail to (a) give any evidence for this mechanism

beyond handwaving that ‘culture’ is the cause, and (b) in

doing so, fail to consider the many specific axes of varia-

tion that comprise between-population differences. When

researchers fail to give a specific cultural mechanism yet attri-

bute differences to ‘culture,’ some of the variation may be due

to situation (e.g. resource insecurity) rather than culturally

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inherited differences (e.g. collective ownership norms). Where

this is the case, it is a serious challenge to the validity of cross-

cultural comparisons, in that it fails to account for potential

confounding variables. Recognizing and controlling for poten-

tial confounds are accepted as a crucial components of high-

quality research in developmental psychology, with particular

attention to detail in experimental studies. The same standard

should be applied at the level of cross-cultural comparisons.

The risk of neglecting to recognize a confounding variable

decreases with a research team’s expertise in the local context

at their study site. Finally, the deficit assumption reinforces a

deeper-seated assumption, (c) that there is one shared, correct

outcome for various stages of development, and that this does

not vary across populations or across societies.

(a) Improvements Cultural evolutionary theory instead presents a functionalist

perspective. This means that the focus is on how different

domains of development fit into both physical maturity and

context-dependent social, emotional and relational factors.

This emphasis on function in context is shared with dynamic

systems theories [39], but an evolutionary approach is further

motivated by understanding how developmental processes

have emerged over an evolutionary timespan and in compari-

son to other species. From this perspective, developmental

flexibility, including social learning, is part of what allows

human culture to evolve faster than the human gene pool

[40], and this in turn makes humans adaptable over short time-

scales [2]. (In contrast with dynamic systems theory, the term

‘adapt’ is almost never used in cultural evolutionary theory

to refer to the timescale of a single individual behaving flexibly,

but rather it is a population-level concept.) As a result, psycho-

logical development is pluralistic by design, and this evolved

because flexibility is incredibly useful for a wide-ranging, inva-

sive species like Homo sapiens. Barrett [8] has coined the term ‘designed emergence’ to capture the idea that developmental

processes are flexible as a result of evolution by natural selection.

Simply put, this means there is a range of healthy, functional

outcomes that emerge from developmental processes. Outside

of that range, pathology is still possible, especially in cases of

extreme abuse or neglect that fall outside the breadth of typical

human experience. Specific outcomes are not predetermined by

genes, but are instead shaped by the interaction between genes

and environment in ways that have been manufactured by

natural selection. For developmental psychologists, the take-

home message here is that shared processes of human dev-

elopment have a variety of outcomes, and this flexibility in outcomes is a feature rather than a bug. Developmental

researchers can leverage this insight to create and evaluate

hypotheses about how the form and developmental timing of

psychological phenomena fit in functional ways with children’s

roles in varying sociocultural contexts.

(b) Developmental case study For example, psychologists have long assumed that direct,

active teaching (often characterized by the verbal communi-

cation of abstract ideas) is the most efficient way to scaffold

learning, and that therefore it must be present in all human

societies (for review see [6]). By contrast, some anthropologists

have often conflated direct instruction with involuntary, forced

transmission, which replaces more enjoyable and (by this

account) effective forms of learning by participation

([37,41,42]; see [6] for review). For both accounts, at least

some societies have got the wrong answer to how children

learn best—and children in those societies are at a deficit.

Kline [6,43] uses cultural evolutionary theory as a foun-

dation to argue that there are many functionally distinct

types of teaching, which can be mixed and matched with learn-

ing problems. From this perspective, no single type always

provides a ‘best’ outcome for the learner, because it depends

on the learning problem at hand. This approach treats develop-

ment as an integral working part of evolutionary processes,

and prioritizes functional and causal explanations of variation.

This is in contrast with other evolutionary accounts that

explain why humans, and only humans, teach by referring to

constraints in other animals. When successful, a cultural

evolutionary approach uses the rich and culturally specific

interpretations offered by ethnographic research as insights

that can inform broader claims about the evolution and

nature of human developmental psychology. Taking a func-

tionalist, cultural evolutionary perspective offers power for

generating and testing hypotheses in developmental psychol-

ogy by incorporating the full range of human variation into

what developmental psychologists term ‘typical’ development.

7. Problem no. 4: the equivalency assumption The equivalency assumption is that using identical research methods, scales or questions will automatically produce equiv-

alent and externally valid data, even across disparate cultural

contexts. Arnett [11] elaborates on this rationale as the predo-

minant philosophy of science in experimental American

psychology: that in the laboratory, it does not matter who the

participants are, or where or how they live—it matters only

that the procedures within the experiment itself are sufficiently

controlled. The equivalency assumption is demonstrably false

when taken to the extreme: written methods must be trans-

lated, and translation inevitably brings up questions of

whether or not there are shared concepts and meanings,

across sociolinguistic contexts. Non-linguistic methods may

avoid the problem of translation, but the question of whether

methods and stimuli map to shared concepts, social context

and expected behaviour across cultural groups is still an impor-

tant one. Such comparisons are only useful when the meaning

of the protocol is comparable across societies [44 – 46]. Further,

assuming equivalency also means that researchers may fail to

account for culturally specific environmental factors in devel-

opment that are either present in WEIRD contexts but not at

their study site, or that are absent in WEIRD contexts and there-

fore may be unrecognized as important factors at their study

sites. For example, while direct verbal instruction may be rare

in many non-Western societies, ethnographic studies of devel-

opment in these contexts reveal a rich, interactive social context

in which learning happens via participant observation and

inclusion of children in everyday activities [37,41,47]. The

social learning mechanisms vary but learning and develop-

mental change happen in all cultural contexts.

(a) Improvements Cultural evolutionary theory treats the human brain, mind

and behaviour as having evolved in the context of human

interaction with the world, rich with social and cultural

context. Ignoring that this cultural context affects how parti-

cipants understand and respond to methods is particularly

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problematic when transporting methodologies across sociocul-

tural contexts that differ in broad ways [16,44,48,49]. This is a

problem even for developmental psychologists who do not

venture to do cross-cultural work, because it means their

methods and their results may be culture-bound and therefore

limited in ways they have not explored.

The equivalency assumption raises a particularly difficult

challenge for cross-cultural comparisons in developmental

psychology. The standards for experimental control are strin-

gent and technically demanding. For example, effect sizes

and statistical significance for studies with infants can

depend on looking times that differ in terms of milliseconds.

These tasks often require electricity, delicate equipment,

trained personnel and quiet laboratory space to run effec-

tively. However, even a perfectly replicated and controlled

methodology cannot guarantee that participants from two

different sociocultural contexts are interpreting the situation

in similar ways and therefore the behaviours observed may

not be comparable.

As Heine and co-workers [44,50] conclude, there is no

straightforward solution for this broad problem of context-

specific methodological validity. Instead, establishing real

comparability across populations requires more context, not less—and this means bringing ethnography into the picture

as a standard resource to inform the design and interpretation

of studies in developmental psychology. Cultural evolutionary

research may seem an unlikely resource for addressing this

methodological challenge because the field has no signature

methodology of its own: for example, its studies of learning

biases draw upon established psychological methods, and its

studies of behaviour build on human behavioural ecology

and animal behaviour. The formal mathematical models that

established the field are themselves built on established

models in epidemiology and genetics. The field is so

thoroughly interdisciplinary that some cultural evolutionists

have even proposed a division of labour within cultural evol-

utionary studies that subsumes existing disciplines [51]. We

advocate instead for a mixed-methods approach, deploying

methods in combinations that strategically compensate for

the particular shortcomings of each method, and that are

suitable for the research problem at hand. This is standard

practice in some areas of social science, including the anthropo-

logical sciences, where both qualitative and quantitative data

and analyses are used as needed [52].

(b) Developmental case study For example, researchers often treat mutual eye gaze between

infant and caretaker as a reliable and stand-alone indicator of

joint attention in the study of infant cognition. However,

Akhtar & Gernsbacher [53] point out that the social role of

eye gaze is variable across cultural contexts, and hence is not

always a reliable indicator of joint attention. North Americans

typically privilege eye contact and verbal interaction as a key

part of parenting [54], but Gusii mothers in Kenya avert their

eyes in response to mutual eye gaze with an excited infant, in

part to keep their babies calm [55]. According to LeVine &

LeVine [55], gaze avoidance by mothers is consistent with

polite behaviour by Gusii adults, where excessive eye contact

is considered rude and sometimes even aggressive. Gaze

avoidance does not mean Gusii mothers are inattentive to

their infants, but rather that they do not use mutual gaze as a

means of establishing joint attention. Instead, they may use

more physical types of interaction—a typical Gusii mother

cosleeps with her infant, breastfeeds on demand and responds

quickly to her infant’s distress. Based on Lancy’s review of the

ethnographic literature on children and childhood [54], the

Gusii approach of using more tactile contact and gestural com-

munication may be more typical around the world than the

North American approach, which emphasizes eye contact

and verbal communication. An excessive focus on eye gaze

as the key element in joint attention (e.g. [56]) may twist the

scientific understanding of joint attention by underestimating

its prevalence in societies where eye gaze is less important

than in North American contexts.

Rather than the narrowly Western-centric cue of eye gaze,

vocal and postural behaviours may represent a more culturally

generalizable set of cues for the study of infant social cognition

[53]. In fact, gestural, postural and vocal cues may play an

important role in Western contexts, but one that is de-empha-

sized in developmental psychology as a reflection of North

American culture. However, the plurality of methodological

approaches suggested by cultural evolutionary theory means

there is another option besides searching for single (or a set

of ) cues that always indicate joint attention, across sociocul-

tural contexts. Instead, researchers should use an array of

cues, designed for particular sociocultural contexts, to compare

the prevalence and behavioural form of joint attention across

human populations. Using identical methods based on cultu-

rally specific cues will produce only superficially comparable

data, and will produce a misleading picture of the ways in

which populations vary.

8. Conclusion For each assumption above, we offer a shift in perspective that

uses cultural evolutionary theory to pry those assumptions

loose from present-day developmental psychological research.

For standard developmental psychology, this means seeing the

culture-bound nature of the questions, methods and results,

and appropriately characterizing the generalizability of the

research given the limited samples. For cross-cultural develop-

mental psychology, this means guarding against some of the

assumptions that are common in psychology more generally,

and employing cultural evolutionary theory to improve how

cross-cultural research is designed, conducted and interpreted.

Using this approach, researchers can take some small steps to

remediate the sampling problem in developmental psychology.

Researchers working at institutions in WEIRD societies can step

off campus to create more inclusive study by sampling popu-

lations in their towns but beyond campus, and in doing so can

increase the inclusivity of their samples with a moderate level

of investment in community engagement. They can also collab-

orate with and learn from colleagues at institutions outside of

North America and Western Europe, to work with scholars

who are both highly trained academics as well as regional

experts in the societies in which they work and live. We do not

argue that researchers should avoid studying or drawing

comparisons between WEIRD populations and additional

populations around the world. Instead, we argue that carefully

specifying the meanings of cross-cultural studies, using cultural

evolutionary theory, may open up a rich avenue for compara-

tive research. This includes comparisons both within and

between populations, to look for robust relationships between

cultural variation and corresponding psychological, behavioural

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and developmental variation. This kind of data will allow

researchers to study just how flexible human psychological

development may be, because it allows us to ask whether the

same causal relationships hold for development across popu-

lations, or whether the relationships and processes themselves

are flexible. In essence, this approach ties the form of develop-

mental flexibility to the sociocultural and ecological contexts in

which human psychology functions over the lifespan.

Researchers before us have tackled the question of appro-

priate cross-cultural comparisons, with a similar emphasis on

the need for strategic selection of field sites and research

problems (see e.g. [9,16]). In addition to these existing rec-

ommendations, we caution against any approach that treats

entire ‘cultures’ or nations as indivisible wholes that are cultu-

rally, psychologically or behaviourally homogeneous. Rather

than comparing whole ‘cultures,’ researchers should aim to

map variation both within and across populations, along mea-

surable axes of variation. This is especially applicable to broad

cross-site surveys, which often include only coarse measures

of cultural variation (e.g. gross domestic product, Gini

coefficient or years of education), treat single sites as represen-

tative of entire countries, and further conflate those countries

with ‘cultures.’ However, it is equally applicable to studies

restricted to Western populations, where researchers can both

expand the inclusivity of their samples, and be more explicit

about the degrees of variation included in those samples.

Both these practices will lead to better science in developmen-

tal psychology. By placing cultural context—and the flexibility

that it entails—at the centre of this work, researchers will gain a

deeper understanding of the developmental processes that

build human cultural variation.

The overarching message from a cultural evolutionary

perspective is that developmental trajectories and endpoints

can vary due to the human ability to learn flexibly, acquire

information from others, and to recombine socially and

individually learned information in creative ways. Using

this as a springboard, developmental psychologists are well

positioned to explore the developmental mechanisms and

processes by which human children adapt to their local socio-

cultural and environmental contexts. Doing so will mean

shedding light on one of the broadest human universals of

all: variability.

Data accessibility. This article has no additional data. Authors’ contributions. M.A.K. conceived of and drafted the manuscript. R.S. and T.B. both made intellectual contributions prior to the manu- script’s first draft, and made edits and contributions to manuscript drafts. R.S. and T.B. contributed equally. All the authors approved the final version of this manuscript.

Competing interests. We declare we have no competing interests. Funding. This research was made possible through the support of a grant from the John Templeton Foundation to the Institute of Human Origins at Arizona State University (no. 14020515). The opinions expressed in this publication are those of the authors and do not necessarily reflect the views of the John Templeton Foundation.

Acknowledgements. We would like to thank Central European Univer- sity’s Department of Cognitive Science, for inviting the authors to a Social Mind Institute Workshop, which led to the formation of some of the early ideas for this paper.

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Variation is the universal: making cultural evolution work in developmental psychology

Human development requires culture
Developmental psychology requires a culturally diverse sample
Cultural evolution can motivate a better science of developmental psychology
Problem no. 1: the universality as uniformity assumption

Variation equals cultural influence and lack of universality
Uniformity equals genetic roots and lack of cultural influence
Improvements
Developmental research case study

Problem no. 2: the Western centrality assumption

Improvements
Developmental research case study

Problem no. 3: the deficit assumption

Improvements
Developmental case study

Problem no. 4: the equivalency assumption

Improvements
Developmental case study

Conclusion
Data accessibility
Authors’ contributions
Competing interests
Funding
Acknowledgements
References

Vol.:(0123456789)

Advances in Health Sciences Education (2020) 25:1025–1043 https://doi.org/10.1007/s10459-020-10011-0

1 3

I N V I T E D PA P E R

How cognitive psychology changed the face of medical education research

Henk G. Schmidt1 · Silvia Mamede1

Received: 12 September 2020 / Accepted: 27 October 2020 / Published online: 26 November 2020 © Springer Nature B.V. 2020

Abstract In this article, the contributions of cognitive psychology to research and development of medical education are assessed. The cognitive psychology of learning consists of activa- tion of prior knowledge while processing new information and elaboration on the resulting new knowledge to facilitate storing in long-term memory. This process is limited by the size of working memory. Six interventions based on cognitive theory that facilitate learn- ing and expertise development are discussed: (1) Fostering self-explanation, (2) elaborative discussion, and (3) distributed practice; (4) help with decreasing cognitive load, (5) pro- moting retrieval practice, and (6) supporting interleaving practice. These interventions con- tribute in different measure to various instructional methods in use in medical education: problem-based learning, team-based learning, worked examples, mixed practice, serial-cue presentation, and deliberate reflection. The article concludes that systematic research into the applicability of these ideas to the practice of medical education presently is limited and should be intensified.

Keywords Knowledge acquisition · Self-explanation · Elaborative discussion · Distributed practice · Cognitive load · Retrieval practice · Interleaving practice · Medical expertise

Introduction

Research into medical education began to attract serious attention with the publication of the Journal of Medical Education (now Academic Medicine) in 1951. Not surprisingly, from its very beginning it has been influenced by what was current in the psychology of learning and instruction and always reflected its ongoing concerns. In the fifties and sixties the language of behaviorism was dominant in the medical education literature. Learning was seen as the result of repetition and reward, with its application to so called ‘learn- ing machines’ (Owen et al. 1965, 1964), to programmed instruction (Lysaught et al. 1964; Weiss and Green 1962), and with its emphasis on ‘behavioral’ objectives (Varagunam 1971). Cognitive-psychology concepts such as ‘memory,’ ‘retention,’ and ‘reasoning’

* Henk G. Schmidt [email protected]

1 Department of Psychology, Erasmus University, P.O. Box 1738, 3000, DR, Rotterdam, the Netherlands

http://orcid.org/0000-0001-8706-0978

http://crossmark.crossref.org/dialog/?doi=10.1007/s10459-020-10011-0&domain=pdf

1026 H. G. Schmidt, S. Mamede

1 3

started to appear only in the early seventies (Elstein et al. 1972; Klachko and Reid 1975; Levine and Forman 1973), and found an early synthesis in the groundbreaking work of Elstein and colleagues on medical problem solving (Elstein et al. 1978). The purpose of the present article is to assess the role of cognitive psychology in the study of medical education (and by extension health professions education). We will focus here on how cog- nitive conceptualizations of learning and instruction have assisted in an understanding of knowledge acquisition and expertise development in medicine. Of course, these two top- ics, knowledge acquisition and expertise development, are closely intertwined. However, the study of clinical reasoning is so vital to medical education and has seized upon its own niche within the research community, that we will discuss it separately. Since this article was written to contribute to the celebration of the 25th anniversary of Advances in Health Sciences Education, references are to articles published by this journal whenever possi- ble. First however we present a crash course in the cognitive psychology of knowledge acquisition.

A brief introduction to the cognitive psychology of knowledge acquisition

When first-year medical students are confronted with information new to them from a chapter of Guyton and Hall’s textbook of medical physiology, they activate prior knowl- edge from high-school or college biology to help them interpret the new information; they use existing knowledge to construct new knowledge. This new understanding, if sufficient thorough, is stored in long-term memory to be used for subsequent learning or application (Anderson et al. 2017). What can be learned however is also dependent on limitations of working memory, the part of memory where knowledge is consciously processed (Badde- ley and Hitch 1974; Mayer 2010). Finally, knowledge needs to be biologically consolidated in memory in order to survive (Lee 2008; McGaugh 2000). This consolidation is biochemi- cal in nature first, then synaptic. These processes take several hours to stabilize. It is well- known that memory for things learned is much better after a good night sleep. A third and final process is systems consolidation in which memories are moved from the hippocampal area to the cortex and become indestructible—although not necessarily retrievable (Wino- cur and Moscovitch 2011). This process takes years. Retrievability is influenced by the extent to which students apply their knowledge in contexts of sufficient variability and the extent to which these contexts resemble the context in which it was learned initially (Eva et al. 1998; Norman 2009).

Instructional interventions that foster learning

The cognitive processes described above, delineating what the mind, engaged in learning, does naturally, can be boosted by instructional interventions. We will first describe these interventions here, focusing on the most important ones. Some of these interventions aim at strengthening the relationship between prior knowledge and new information. Others attempt to facilitate processing of information. A third category aims to strengthen long- term memory. In a subsequent section we will relate these interventions to some of the most prevalent instructional approaches to medical education developed since the early seventies.

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Interventions aimed at strengthening the relationship with prior knowledge

Encouraging self‑explanation

Self-explanation is a form of elaboration upon what is learned. The students do this by relating new information to knowledge previously acquired or repeat the information ver- bally in their own words (Chi et al. 1989, 1994). Elaboration is known to be more helpful than simple repetition of new material (Craik and Lockhart 1972). Chi et al. (1994) found that students who were asked to self-explain after reading each line of a passage on the human circulatory system had a significantly greater knowledge gain from pre- to posttest than students who read the text twice. In an experiment of van Blankenstein et al. (2011) students either listened to an explanation provided for a particular problem or had to gener- ate an explanation themselves, before studying an appropriate text. There were no immedi- ate effects on retention of the text. However, one month later, participants who had actively engaged in self-explanation remembered 25% more from the text.

Facilitating elaborative discussion

If students are allowed to discuss subject matter with peers or are being prompted by a teacher, learning improves considerably. In a meta-analysis of small-group learning in sci- ence, mathematics, engineering, and technology (Springer et al. 1999) found effects on learning considerably more sizable than those of most other educational interventions. Ver- steeg et al. (2019) studied how elaborative discussion among peers would foster under- standing of physiology concepts compared with individual self-explanation and a control condition. They found that the elaborative-discussion group outperformed the self-explana- tion group, while both outperformed the control group. Interestingly, students with initially wrong concepts profited even when discussing them with a peer who also had an initial wrong understanding.

Promoting distributed practice

If one spreads learning and retrieval activities over time, returning to the same contents a couple of times, knowledge become better consolidated. Distributed-study opportunities usually produce better memory than massed-study opportunities (Delaney et al. 2010). It turned out difficult however to find a suitable example of the effects of massed versus spaced practice in medical education. Kerfoot et al. (2007) conducted a number of studies in which they sent to residents at regular intervals emails on four urology topics. These emails consisted of a short clinically relevant question or clinical case scenario in multiple- choice question format, followed by the answer, teaching point summary, and explanations of the answers. Students were randomized to receive weekly e-mailed case scenarios in only 2 of the 4 urology topics. At the end of the academic year, residents outperformed their peers on the questions related to the emails they had received. However, this effect could also be explained by mere exposure since the residents apparently had not received the same information in massed form.

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Interventions aimed at facilitating processing of new information

Help in decreasing cognitive load

As indicated above, working memory allows for only limited information to be processed at the same time. If the cognitive load of information exceeds what can be processed, learning is hampered (van Merrienboer and Sweller 2010). Much research has gone into the ques- tion how cognitive load could be optimized by instruction. One successful strategy is the use of worked examples. Rather than require students to solve problems in a particular domain by themselves, the teacher presents worked-out examples of these problems for study (Chen et al. 2015). The assumption here is that by seeing all elements required to solve a problem, decreases cognitive load. Students with limited knowledge seem to profit from such approach, whereas students with enough knowledge are sometimes hampered (Kalyuga et al. 2001).

Interventions aimed at strengthening long‑term memory

Fostering retrieval practice

When you ask students to retrieve information previously learned from memory, for instance by providing them with regular quizzes, knowledge reactivated this way becomes more entrenched in memory. Dobson and Linderholm (2015) for instance, had students reading anatomy and physiology texts either three times, two times with the possibility of making notes, or two times interspersed by an attempt to retrieve as much information as possible. After a one-week retention interval, those who engaged in retrieval practice dem- onstrated superior performance compared to the other two groups.

Fostering interleaving practice

Offering cases with different diagnoses in a clinical reasoning exercise boosts learning because students learning to distinguish between cases that look the same but have different diagnoses, and cases that look different but have the same diagnosis. Interleaving may slow initial learning but, in the end, leads to better retention and application. An illustrative example is provided by Hatala et al. (2003). They presented students with electrocardiograms with the aim to learning to diagnose such ECGs. In one of their experiments, students were randomly allocated to one of two practice phases, either "contrastive" where examples from various categories are mixed together, or "non-contrastive" where all the examples in a single category are practiced in a single block. Students in the mixed-examples condition outperformed those in the blocked-practice condition while diagnosing a set of new ECGs. See for another example Kulasegaram et al. (2015).

To what extent are these interventions applied to the practice of medical education?

No doubt, these interventions are sometimes applied by teachers in their courses on an individual basis. Teachers allow students to discuss subject matter in small groups or pro- vide quizzes during their lectures. However, there have been attempts, most of them only

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during the last twenty years, to develop instructional models explicitly based on cognitive principles as discussed above. We will outline four of these: Problem-based learning, team- based learning, worked examples, and mixed practice.

Problem-based learning. (PBL) was actually an early innovation. It was developed at McMaster University, Canada where in 1969 a first group of 20 students entered medi- cal school. PBL has the following six defining characteristics: (i) Biomedical or clinical problems are used as a starting point for learning; (ii) students collaborate in small groups for part of the time; (iii) under the flexible guidance of a tutor. Because problems are the trigger for learning (iv) the curriculum includes only a limited number of lectures; (v) learning is student-initiated, and (vi) the curriculum includes ample time for self-study. For the founding staff PBL was merely a combination of good educational practices aimed at increasing motivation among students (Servant-Miklos 2019a). However, by the end of the seventies, and due to work done at Maastricht University, the Netherlands, PBL underwent a reinterpretation in line with cognitive psychology findings (Schmidt 1983; Servant-Mik- los 2019b). Table 1 contains the authors’ labelling of cognitive processes and interventions underlying PBL (Schmidt et al. 2011).

Team-based learning (TBL) was developed in 1997 by Larry Michaelsen at the Uni- versity of Central Missouri, US, when increasing class sizes prevented him from teaching in the Socratic fashion (Michaelsen et al. 2002). The idea emerged for the first time in the medical education literature in 2005 (Koles et al. 2005). TBL consists of three phases: (i) A preparatory phase, in which students study individually preassigned materials often con- veyed through video; (ii) an in-class readiness assurance phase, consisting of an individual test, a subsequent retest taken after discussion of the answers to the individual test are dis- cussed in a team, and teacher feedback; (iii) an in-class application phase in which stu- dents through facilitated interteam discussion solve new problems and answer new ques- tions derived from the initial learning materials. Schmidt et al. (2019) and colleagues have recently provided the cognitive account of what happens to the learner in TBL as outlined in Table 1.

Worked examples are common in text books on physics, mathematics and chemistry. It was probably Sweller and Cooper (1985) who saw their potential for reducing cognitive load while problem solving. In the previous section we have already provided a successful example of the application of cognitive load theory in the health professions field (Chen et al. 2015). However, the number of studies on worked examples reported in that litera- ture is still limited. A search into the three most-cited journals in health professions educa- tion, Academic Medicine, Medical Education, and Advances in Health Sciences Educa- tion unearthed 15 articles, the oldest being from 2002. The use of worked examples would potentially be a fruitful addition to the arsenal of methods used to teach clinical reasoning, but we definitively need more studies.

Mixed practice or interleaving has large potential for medical education, in particular because one of its important functions is the teaching of diagnostic problem solving (Rich- land et al. 2005; Rohrer 2012). Cases that superficially look the same may have different causes. Alternatively, cases demonstrating a quite different array of symptoms, may have the same underlying pathology. Training student to compare and contrast such cases would be optimal using this instructional approach. However, only six illustrative examples could be found in the extant health professions literature, interestingly most of them provided by Geoffrey Norman, and his associates from McMaster University.

Table 1 summarizes the extent to which each of the cognitive principle discussed in the previous section are actualized in these four instructional approaches.

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The study of medical expertise

Medical expertise is an attractive domain of study for cognitive psychologists. This is so not only because the quality of our care as patients depends on the performance of our physi- cians but also because of peculiar features of the medical practice. Physicians operate upon an extremely broad and complex knowledge basis, and clinical problem-solving involves a large spectrum of cognitive processes, ranging from attention and perception to decision-making. Not surprisingly, medical expertise has drawn researchers’ attention over four decades (Norman 2005). This research has focused on clinical reasoning, particularly the diagnostic process. One of major goals of medical education is to develop students’ clinical reasoning and helping stu- dents become good diagnosticians is much valued. Medical expertise research has contributed substantially to our understanding of how this goal can be achieved (or at least how it should be pursued). The following session summarizes the main contributions of this research to what we know about, first, the nature of clinical reasoning and, second, how it develops in medical stu- dents. Subsequently, we will discuss the impact of this research on medical education, particu- larly how its contributions have interacted with conceptualizations of learning and instruction discussed earlier in this article to inform the teaching of clinical reasoning.

The nature of clinical reasoning

The major findings that have shed light on the nature of clinical reasoning can be grouped into three subheadings that parallels the history of the research on the subject.

The ‘hypothetico‑deductive’ method as a general model of clinical problem‑solving

Early in a clinical encounter, physicians generate one or a few diagnostic hypotheses and subsequently gather additional information to either confirm or refute these hypotheses.

Table 1 Extent to which cognitive principles are actualized in four instructional models

+ + means that according to literature the principle is explicitly operationalized in the instructional model. + means that it can be expected to play a role although not explicitly assumed.—means that it does not play a role

Problem-based learning

Team-based learning

Worked examples

Mixed practice

Activation of prior knowledge + + + + + + Consolidation − + + − − Appropriate context + + + + + + + Self-explanation + + + + − − Elaborative discussion + + + + − − Decreasing cognitive load − − + + − Retrieval practice + + + − − Distributed practice − + − + + Interleaving practice − − − + +

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This ‘hypothetico-deductive’ method was revealed by pioneering studies conducted in the 1970s using traditional methods of cognitive psychology research, such as observing phy- sicians and students interacting with standardized patients while thinking aloud (Elstein et al. 1978, 2009). These studies attempted to uncover the reasoning process that char- acterizes experts’ reasoning, which could then be taught to students. However, although the hypothetico-deductive method provides a general representation of diagnostic reason- ing, subsequent studies soon showed that it does not explain expert performance (Elstein et al. 1978; Neufeld et al. 1981). Medical students also employed the same approach, and what differentiated expert and novice diagnosticians was not a particular reasoning process but rather the quality of their diagnostic hypotheses (Barrows et al. 1982). An additional crucial finding of the same period was that diagnostic performance on one clinical case did not predict performance on another case. The phenomenon, labeled by Elstein ‘content specificity’ (Elstein et al. 1978), was proved to happen even when the cases were within the same specialty (Eva et al. 1998; Norman et al. 1985).

How medical knowledge is structured in memory and used in diagnostic reasoning

It is not a particular process that determines expert performance, but rather the content of reasoning, i.e. knowledge itself (Norman 2005). This conclusion came from a new era of studies conducted when researchers, faced with the aforementioned findings, turned atten- tion to the kinds of medical knowledge, how knowledge is structured in memory and used to diagnose clinical problems. These studies relied heavily on methods from cognitive psy- chology research to carefully search from differences in knowledge structures of expert and non-expert diagnosticians. For example, many of these studies requested medical students at different years of training and (more or less) experienced physicians to diagnose clini- cal cases and subsequently explain the patient’s signs and symptoms or, alternatively, to solve the case while thinking-aloud. The resulting protocols were analyzed to identify the kinds and amount of knowledge used during diagnostic reasoning (Patel and Groen 1986; Schmidt et al. 1990). Several knowledge structures have been proposed, suggesting that diseases would be represented in memory, for example, as prototypes (Bordage and Zacks 1984), or as instances of previously seen patients (Norman et al. 2007), or yet as sche- mas and scripts (Schmidt et al. 1990). Some of these proposals, such as prototype models, consisted of application of representation models long existing in psychology to medical knowledge. Other authors however developed formats specifically for representing medical knowledge, such as the concept of illness scripts. Illness scripts are mental scenarios of the conditions under which a disease emerges, the disease process itself, and its consequences in terms of possible signs, symptoms, and management alternatives (Feltovich and Bar- rows 1984). Some empirical support exists for several proposals, and it is likely that (some of) these different knowledge structures coexist in physicians’ memory to be mobilized when needed (Custers et al. 1996; Schmidt and Rikers 2007).

These conceptualizations have framed our understanding of diagnostic reasoning. Notice that, despite their differences, they share the basic idea that diseases are associated in memory with a set of observable clinical manifestations. Briefly, the presence of some of these manifestations in a patient activates in the physician’s memory the mental repre- sentation of the disease, generating a diagnostic hypothesis. Search for additional informa- tion follows to verify whether other manifestations associated with the disease are actually present. When this search reveals findings that contradict the initial diagnosis and rather suggest others, new hypotheses may be activated and tested against the patient findings.

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The dual nature of diagnostic reasoning

Dual-process theories of reasoning, long studied in psychology, represent another approach to understanding and conceptualizing diagnostic reasoning. They assume that two different forms of reasoning exist, one that is associative, based on pattern-recognition, fast, effort- less and largely unconscious (usually named System 1 or Type 1) and another that depends on applying rules, is slow, effortful and takes place under conscious control (System 2 or Type 2) (Evans 2008, 2006; Kahneman 2003). While Type 1 processes accounts for intui- tive judgments, Type 2 processes have to take place when these judgments are verified. Appling this model to medical diagnosis, Type 1 reasoning would explain the generation of diagnostic hypotheses whose subsequent verification depends on Type 2 processes. Indeed, studies within the medical expertise research tradition seem in line with dual-process mod- els. There is substantial evidence that physicians use non-analytical reasoning to arrive at diagnoses (Norman and Brooks 1997). Radiologists, for example, were able to detect abnormalities in medical images with around 70% accuracy in 200 ms (Evans et al. 2013; Kundel and Nodine 1975). Studies on the role of similarity in diagnosis also provide addi- tional evidence: diagnostic accuracy increased when a dermatological case was preceded by a similar one (Brooks et al. 1991), and similarity affected the diagnosis even when what was similar in two cases was a diagnostically irrelevant feature (e.g. the patient occupation) (Hatala et al. 1999). There is also substantial evidence that physicians adopt both intuitive and analytical reasoning modes in different degrees depending on the circumstances such as the level of complexity of the case or perception of how problematic a case might be (Mamede et al. 2007, 2008).

Dual-process representations of diagnostic reasoning have become prominent in the medical literature (Croskerry 2009). A research tradition has grown triggered by increasing concerns with the problem of diagnostic error. Flaws in the physician’s cognitive processes have been detected in the majority of diagnostic errors (Graber 2005), and the sources of cognitive errors have been much discussed in the medical literature (Norman 2009; Nor- man et al. 2017). Several authors have attributed flaws in reasoning, and consequently errors, to cognitive biases induced by heuristics, shortcuts in reasoning frequent in Type 1 processes (Croskerry 2009; Redelmeier 2005). Conversely, other authors argue that heuris- tics are usually efficient and point to specific knowledge deficits rather than particular rea- soning processes as the explanation for reasoning flaws (Eva and Norman 2005; McLaugh- lin et al. 2014; Norman et al. 2017). This controversy should not be seen as a theoretical discussion only, because it has direct consequences for medical education. While the first position demands educational interventions aimed at increasing trainees’ and practicing physicians’ ability to recognize biases and counteracting them, the second points to inter- ventions that enhance knowledge acquisition and restructuring. We will return to this point when discussing the teaching of clinical reasoning. To discuss teaching, we need first to understand how clinical reasoning develops in medical students.

The development of clinical reasoning in medical students

In the course towards becoming an expert, medical students move through different stages characterized by qualitatively different knowledge structures that underlie their perfor- mance (Schmidt et al. 1990; Schmidt and Rikers 2007). This restructuring theory of medi- cal expertise development has come out of a research program focused on understanding

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how knowledge was organized in memory and used to solve clinical problems as students progress through education. In the first years of their training, students rapidly develop mental structures representing causal networks that explain the origins and consequences of diseases on the basis of their pathophysiological mechanisms (Schmidt et al. 1990; Schmidt and Rikers 2007). Studies that asked students at this stage to diagnose clinical problems showed that, because students still do not recognize patterns of connected symp- toms, they try to explain isolated symptoms based on their causal mechanisms. This pro- cessing is effortful and detailed, with much use of basic sciences knowledge. This trans- lated, for example, in the finding that students recalled more from a case than experts, which has become known as the ‘intermediate effect’ (Schmidt and Boshuizen 1993).

A first qualitative shift in knowledge structure occurs when students start to apply the knowledge that they have acquired to solve clinical problems. Gradually, the detailed knowledge of the chain of events that leads to a symptom is ‘encapsulated’ in more generic explanatory models or diagnostic labels that stands for the detailed explanation (Schmidt et al. 1990; Schmidt and Rikers 2007). Through this process, a small number of abstract, higher-order concepts, representing for example a syndrome or a simplified causal mecha- nism, ‘summarize’ a larger number of lower-levels concepts. For example, when students were requested to explain the clinical manifestations in a patient presenting with bacte- rial endocarditis and sepsis, they reasoned step-by-step through the chain of events that starts with the use of contaminated syringes until their consequences, i.e. the symptoms. Conversely, experts used the concept of ‘sepsis’ as a label that ‘encapsulates’ much of the chain of events, without the need to use this knowledge in their diagnostic reasoning (Schmidt et al. 1988). Many studies have shown experts to make much use of this type of ‘encapsulated’ concepts when reasoning through a case, leading to think aloud or recall protocols that contain less reference to basic sciences concepts or underlying mechanisms than the students’ ones (Boshuizen and Schmidt 1992; Rikers et al. 2004, 2000). However, basic sciences knowledge remains available and is indeed ‘unconsciously’ used during the diagnosis as studies with indirect measures of reasoning have shown (Schmidt and Rikers 2007).

A second shift in knowledge structures occurs as exposure to patients increases. Encap- sulated knowledge is gradually reorganized into narrative structures that ‘represent’ a patient with a particular disease (Feltovich and Barrows 1984; Schmidt et al. 1990). These ‘illness scripts’ contain little knowledge of the causal mechanisms of the disease, because of encapsulation, but are rich in clinical knowledge about the enabling conditions of the disease and its clinical manifestations (Custers et al. 1998). Knowledge of enabling condi- tions tends to increase with experience and play a crucial role in expert physicians’ reason- ing (Hobus et al. 1987). As exposure to actual patients increases, traces of previously seen patients are also stored in memory. Illness scripts exist therefore at different levels of gen- erality, ranging from representations of disease prototypes to representations of previously seen patients (Schmidt and Rikers 2007).

Successful diagnostic reasoning seems to depend critically on developing rich, coher- ent mental representations of diseases (Cheung et al. 2018). For instance, a series of stud- ies attempting to investigating the role of biomedical knowledge in diagnostic reasoning had students learning the clinical features associated with a disease either together with explanations of how they are produced or without explanation (Woods et al. 2007). Learn- ing how the clinical features are connected by causal mechanisms led to higher diagnostic accuracy when diagnosing cases of the disease after a delay. Besides bringing additional evidence of the knowledge encapsulation process, these studies suggest that understand- ing their underlying mechanisms help ‘glue’ the clinical features together, leading to more

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coherent and stable mental representations of the diseases, which make it easier to recog- nize them when diagnosing similar cases in the future.

This body of research contributed to our understanding of how students develop the ability to diagnose clinical problems in the course of medical education and to set a for the design of interventions for the teaching of clinical reasoning.

The teaching of clinical reasoning

The research described above provides substantial evidence that expert physicians do not employ any peculiar reasoning mode and there is no such thing as general reasoning skills that can be taught to students. Nevertheless, proposals for teaching students how to rea- son, common in the 1990s, are still very frequent in the literature (Schmidt and Mamede 2015). Indeed, more recently, as dual-process theories have gained attention, these propos- als have also gained the form of interventions such as courses on clinical reasoning and cognitive bias (Norman et al. 2017). Not surprisingly, whenever trainees’ actual diagnostic performance was evaluated, the effect of these process-oriented interventions has been null or minimal (Norman et al. 2017; Schmidt and Mamede 2015). Conversely, interventions directed towards acquisition and restructuring of disease knowledge, which seems more in line with what we know about the nature of clinical reasoning and how it develops, looked much more promising. For example, an intervention directed at increasing knowledge of features that discriminate between similar-looking diseases successfully ‘immunized’ phy- sicians against bias in reasoning (Mamede et al. 2020).

We try here to give a brief account of interventions that have been proposed for the teaching of clinical reasoning, focusing on those that have been empirically investigated and trying to relate them with the research discussed so far. Interventions that appear prom- ising, consistently with evidence on the knowledge structures underlying diagnostic rea- soning and the role of exposure to clinical problems in the development of such structures, share two basic features: they are directed at refinement of diseases knowledge and consist of exercises with clinical cases.

The serial-cue approach with simulation of the hypothetico-deductive model appeared in a recent review of the literature as the most prevalent intervention proposed for the teaching of clinical reasoning (Schmidt and Mamede 2015). In this approach informa- tion of the case is disclosed step-by-step, and students required in each step to generate diagnostic hypotheses and identify which additional information is needed to arrive at a diagnostic decision. The approach has rarely been investigated. While two studies showed the approach to have no effect on students’ diagnostic accuracy relative to a control group (Windish 2000; Windish et al. 2005), a recent study showed a slight advantage of using serial-cue during a learning session over employing self-explanation (Al Rumayyan et al. 2018). Its similarity to real practice may explain the widespread use of the serial cue approach, but it has been argued that it may be overwhelming for students who do not have yet developed illness scripts to guide the search for information.

Self-explanation as an instructional approach for the teaching of clinical reasoning has been tested in a series of studies conducted by Chamberland and colleagues (Chamberland et al. 2013, 2015, 2011) in recent years. Basically, these studies involved a learning ses- sion, in which students diagnosed clinical cases either with self-explanation, i.e., explain- ing aloud how the clinical features were produced, or without self-explanation, and a one- week later test. Students who used self-explanation better diagnosed similar cases in the

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test than their peers who had practiced without self-explanation. Students only benefitted from self-explanation on cases with which they were less familiar and which required them to extensively use biomedical knowledge, a finding that reaffirms the value of such knowl- edge in diagnostic reasoning. Together with deliberate reflection (see below), self-expla- nation has been adopted in a longitudinal curricular program at the Sherbrooke Medical school, an experience which has been recently reported (Chamberland et al. 2020).

Instructional interventions that, differently from self-explanation, focus on clinical rather than biomedical knowledge have also been proposed. These interventions foster retrieval of previous acquired clinical knowledge and elaboration on the information at hand during practice with clinical problems. Despite the different formats they may take, these interventions share the basic idea of providing students with guidance to compare and contrast different alternative diagnoses for the problem at hand. One example is con- cept mapping, which has been employed in various formats (Montpetit-Tourangeau et al. 2017; Torre et al. 2019) to foster students’ clinical reasoning. One of the most investigated of this type of interventions is deliberate reflection, which presents students with clinical cases that look similar but have different diagnoses (e.g. diseases that have chest pain as chief complaint) and requests students to generate, for each case, plausible diagnoses, com- paring and contrasting them in light of the case features (Mamede et al. 2019, 2012, 2014). In several studies, students who engaged in deliberate reflection during practice with clini- cal cases provided better diagnoses for new cases of the same (or related) diseases in future tests than students who adopted a more conventional approach such as making differen- tial diagnosis. An intervention that used deliberate reflection to strengthening knowledge of features that discriminate between similar-looking diseases has been recently shown to increase internal medicine residents’ ability to counteract bias in diagnostic reasoning (Mamede et al. 2020).

Interleaving practice, usually referred to in medical education as ‘mixed practice’, is a requirement for the abovementioned interventions. It is only possible to compare and contrast the features of clinical problems that may look similar but have in fact different diagnoses when problems of different diseases that look alike are presented together in the same exercise. The benefits of mixed practice relative to blocked practice, which pre- sents examples of the same diagnosis together, have been demonstrated in studies compar- ing students’ performance when interpreting EKG after being trained either with mixed or blocked practice (Ark et al. 2007; Hatala et al. 2003).

Decreasing processing through the use of worked examples in the teaching of clinical reasoning has been more scarcely investigated. Nevertheless, indication that this interven- tion deserves further attention has come from a few studies exploring the influence of using erroneous examples and different types of feedback on learning diagnostic knowledge (Kopp et al. 2008, 2009) or the benefits of studying worked examples of reflective reason- ing for diagnostic competence (Ibiapina et al. 2014).

Table 2 presents an attempt to summarize the extent to which these interventions for the teaching of clinical reasoning allows for the realization of the cognitive principles dis- cussed in the first sections of this paper.

Summing up, cognitive psychology research has provided crucial contributions to guide teaching of clinical reasoning. Many of these contributions have translated into instruc- tional interventions that have had their effectiveness empirically evaluated, with promis- ing results. Nevertheless, as a recent review of these interventions highlighted, the existing empirical research is still scarce considering the importance of clinical reasoning in medi- cal education. More interventions based on the conceptualizations of learning and instruc- tion offered by cognitive psychology and more theory-driven research are much needed.

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How often do manuscripts delineating these ideas appear in advances in health sciences education?

Twenty-five years ago, the founding editors of the journal, both cognitive psychologists, and among them the first author of this article, found it necessary to create a journal in which these new approaches to medical education would feature explicitly. To what extent did they succeed? Table 2 contains the results of a search for appropriate articles in Advances in Health Sciences Education, published between 1995 and 2020. The total num- ber of articles published in that period was 1249.

Twenty-five percent of the manuscripts published in Advances in Health Sciences Edu- cation discussed or studied the role of cognition in medical education. One could say that the initial motivation for establishing the journal has not yet entirely been fulfilled. There is clearly still room for more research into the application of these important principles of learning, expertise development, and instruction to our field.

The future of cognition in medical education: Cognitive science

New areas hitherto not so much explored will probably attract increasing attention within medical education development and research. We refer here to artificial intelligence and to the neurosciences, both incorporated with cognitive psychology under the heading cogni- tive science. We discuss two examples here. First, developments in clinical practice that have strong implications for education have brought new research demands. One of these developments is the digitalization of health care, including the incorporation of artificial intelligence (Wartman and Combs 2018). Computer-based algorithms, whether derived from expert knowledge or machine learning, are expected to dramatically improve diag- nostic and prognosis decisions (Obermeyer and Emanuel 2016). However, “side effects” have long been identified. For example, “automation bias” resulting from overreliance on automation systems tends to make clinicians less prone to review their initial impressions, eventually causing errors (Bond et al. 2018; Lyell and Coiera 2017). Future research should explore how clinicians can be better prepared to incorporate these developments in their practice, aiming also at better understanding the mechanisms underlying such biases and how to make trainees less susceptible to them. Moreover, the digitalization of health care

Table 2 Numbers of studies published in Advances in Health Sciences Education between 1995 and 2020 applying cognitive principles and instructional models

Cognitive principles No of articles Instructional models No of articles

Activation of prior knowledge 29 Problem-based learning 121 Consolidation 2 Team-based learning 4 Appropriate context 16 Worked examples 3 Self-explanation 7 Mixed practice 4 Elaborative discussion 21 Teaching of clinical reasoning 17 Decreasing cognitive load 17 Retrieval practice 4 Distributed practice 0 Clinical reasoning 62

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has brought changes to the clinical setting that affect what students can learn from their experiences there. Think, for example, of clinical decision support systems, often asso- ciated with electronic health records (EHR), now widely adopted (Keenan et al. 2006). Patient care has been substantially altered by the widespread presence of computers, with clinical encounters now involving the ‘provider-computer-patient triangulation’ and staff rooms changed into rows of students and residents staring at computer screens. On the one hand, EHRs can be powerful educational tools. Many of them offer instant access to online learning resources at point of care. Trainees can, for example, ‘pull’ clinical guidelines or recommendations about care management during the clinical encounter. This would allow for new knowledge to be learned in a context very similar to the one in which it would be used in the future, a basic principle to facilitate retrievability. EHRs also gives trainees the possibility to easily go back to review a case and facilitates keeping track of one’s clini- cal experiences (Keenan et al. 2006; Tierney et al. 2013). On the other hand, potentially adverse effects have been discussed. For example, the volume of online information may be overwhelming, and trainees’ attention may be diverted from the patient to the data- entering process. More subtly, EHRs give trainees the possibility to easily convey the raw patient data to supervisors, without being compelled to interpret findings and build a nar- rative out of them. Incentive for the student or resident to reflect upon the problem there- fore decreases, and so does the opportunity for discussion with attending physicians (Peled et al. 2009; Wald et al. 2014). How EHRs and CDDS affect trainees learning and which specific characteristics of the system itself or of its use can be optimized to foster learning are examples of areas that are likely to call attention within cognitive science research.

A second expanding research area involves the use of neurosciences tools to get insights on the processes in the brain associated with learning and expertise development. Although the complexity and cost of some of the approaches for capturing brain activity make their use less attractive, non-invasive, lower-cost tools have emerged that seem promising. Elec- troencephalography (EEG) signals arising from neural activities have been used to estimate students’ learning states, including within e-learning environments (Lin and Kao 2018). For example, a device that showed to be wearable proved EEG-based technology to accu- rately assess mental overload while surgeons performed procedures of different levels of complexity (Morales et al. 2019). Detecting mental overload in surgeons is crucial to guide the design of training programs so that situations that may bring threats to the patient or the resident can be avoided. Near Infra-Red Spectroscopy (NIRS) is another promising tool that has recently started to be employed in medical education. By measuring the level of blood oxygenation of the prefrontal cortex, NIRS provides a cost-effective alternative to other techniques such as functional Magnetic Resonance Imaging to look at the brain while students and clinicians solve problems. For example, by using NIRS in a study which trained medical students in diagnosing chest X-ray, Rotgans et al. showed that activation of the prefrontal cortex decreases with experience with a case, supporting the idea that exper- tise development is associated with a pattern-recognition based reasoning mode (Rotgans et al. 2019).

Trying to predict the future is always a risky endeavor, but these two areas have great potential to draw the attention of cognitive research in the coming years. If our bet is cor- rect, we will see the products of this attention in the anniversary issue of Advances in Health Sciences Education twenty-five years from now.

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licence, and indicate if changes were made. The images or other third party material in this article are included in the article’s Creative Commons licence, unless indicated otherwise in a credit line to the mate- rial. If material is not included in the article’s Creative Commons licence and your intended use is not per- mitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creat iveco mmons .org/licen ses/by/4.0/.

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1043How cognitive psychology changed the face of medical education…

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Publisher’s Note Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

How cognitive psychology changed the face of medical education research

Abstract
Introduction
A brief introduction to the cognitive psychology of knowledge acquisition
Instructional interventions that foster learning

Interventions aimed at strengthening the relationship with prior knowledge

Encouraging self-explanation
Facilitating elaborative discussion
Promoting distributed practice

Interventions aimed at facilitating processing of new information

Help in decreasing cognitive load

Interventions aimed at strengthening long-term memory

Fostering retrieval practice
Fostering interleaving practice

To what extent are these interventions applied to the practice of medical education?
The study of medical expertise
The nature of clinical reasoning

The ‘hypothetico-deductive’ method as a general model of clinical problem-solving
How medical knowledge is structured in memory and used in diagnostic reasoning
The dual nature of diagnostic reasoning

The development of clinical reasoning in medical students
The teaching of clinical reasoning
How often do manuscripts delineating these ideas appear in advances in health sciences education?
The future of cognition in medical education: Cognitive science
References

Scholarship of Teaching and Learning in Psychology Sometimes a Demo Is Not Just a Demo: When Demonstrating Cognitive Psychology Means Confronting Assumptions Marianne E. Lloyd Online First Publication, April 16, 2020. http://dx.doi.org/10.1037/stl0000192

CITATION Lloyd, M. E. (2020, April 16). Sometimes a Demo Is Not Just a Demo: When Demonstrating Cognitive Psychology Means Confronting Assumptions. Scholarship of Teaching and Learning in Psychology. Advance online publication. http://dx.doi.org/10.1037/stl0000192

PEDAGOGICAL POINTS TO PONDER

Sometimes a Demo Is Not Just a Demo: When Demonstrating Cognitive Psychology Means Confronting Assumptions

Marianne E. Lloyd Seton Hall University

Recent cross talk between cognitive psychology and education has yielded an onslaught of articles, books, and demonstrations to improve application of basic cognitive principles to educational settings. This essay will describe an example of how one of these demonstrations can also illustrate potentially incorrect assumptions about stu- dents. Specifically, a highly effective demonstration on the negative effects of task switching on performance also revealed assumptions about language automaticity and neurotypicality. Rather than avoiding these concerns, such demonstrations, in addition to highlighting cognitive phenomena, can also be a springboard to explicit discussions of issues of assumptions that may have implications for inclusion.

Keywords: demonstrations, assumptions, task switching

Several years ago, I started using a classroom demonstration from The Learning Scientists (Wein- stein, 2018) to demonstrate the impact of task switching on performance. In this demonstration, participants pair up and then time themselves per- forming three tasks. First, each person recites the alphabet from A to Z. Then each counts from 1 to 26. For the final task, the two previous tasks are com- bined (i.e., 1-A, 2-B, 3-C . . . 26-Z). The single tasks of reciting the alphabet and counting typically takes less than 10 s, whereas combing counting and the alphabet often takes 1–2 min. There is usually laugh- ter at people’s ability to speak with lightning pace for just letters or numbers, but there is often a very different, much quieter tone to the room for the interleaving task. During this third task, one can usually see the students using a variety of strategies to manage the difficulty of combining the two lists— closing eyes, plugging ears, using fingers as spatial markers, getting encouragement from their partner, and sometimes even giving up. In this way, it is a

very successful demonstration of the difficulties of task switching versus engaging in a single task.

I have implemented this demonstration in my one-off lectures for first-year students on im- proving college performance as an activity on the first day of many of my other classes to justify my no– cell phone policy and in faculty development events to encourage bringing cog- nitive psychology findings to pedagogy. It works beautifully every time. Although the stu- dents show some level of frustration, faculty especially groan at the task switching condition, and I remind them this can help build empathy to the difference between how we feel about material (crystal clear and fun) and a student’s experience (muddy and bleak). Students are readily able to understand that things that are easy on their own because of automaticity be- come difficult when combined. Overall, it was a perfect demonstration as far as I was concerned to show that easy is not always as such.

However, this summer, when I again pre- sented the demonstration as part of a program for boosting first-year student success in col- lege, I realized that some of my assumptions about it might not always be correct. First, I had always assumed that the first two tasks are easy because of their automaticity. As an English-

Correspondence concerning this article should be ad- dressed to X Marianne E. Lloyd, Department of Psychol- ogy, Seton Hall University, 400 South Orange Avenue, South Orange, NJ 07079. E-mail: [email protected]

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speaking monolingual person from Ohio, yes, this is true for me. However, it might not be true for students who did not grow up learning the same A-Z alphabet or counting from 1 to 26 in English. Consequently, these might not be au- tomatic tasks for all participants. Second, clas- sifying these tasks as easy or difficult assumed some level of neurotypicality among partici- pants. Presumably, this task would not be as easy for any of my students who have language or numeracy difficulties or working memory impairments. Lastly, I assumed the demo would be easy because it was a low-stakes task (i.e., done in pairs instead of in front of the entire class). However, performing for a partner could add additional difficulty to the task for a student with a lot of social anxiety or one with a speech impairment who does not feel comfortable re- citing the material under time pressure.

When the demonstration is finished and I collect the data to present to the class, we typ- ically start by discussing the main idea—that even tasks that are usually accomplished quickly can take more time when completing multiple tasks at once. I use this as a plea for keeping phones away during class. After all, what is happening in class and on the phones are both more complicated than reciting something likely already memorized, so following both lecture and one’s phone distractions at the same time should be even more difficult than com- bining numbers and letters. Once you add in that the phone is pretty much guaranteed to be of greater interest than what is happening in class, this kind of multitasking becomes an even bigger risk of becoming a barrier to learning. At least for that day, the students seemed con- vinced that task switching is not an ideal way to spend class time.

Now when I included this demonstration in my class, I follow the discussion on the main idea that switching tasks is problematic with pointing out all the assumptions that I had made about the tasks they had just performed. I am explicit that this failure to consider my own assumptions was likely not limited to this dem- onstration and asked the students to help me realize when I am making incorrect assump- tions. I also highlight that this does not, how- ever, change the key point of the demonstration that learning will be more effective with less divided attention. Despite my potentially incor- rect assumptions about the task being easy for

everyone, the demonstration does reliably yield data in which the task-switching condition has a higher total completion time by a significant margin than the total completion time of the two single tasks.

Being aware of the assumptions we make about the students in our classes is perhaps a regular part of teaching reflection for many pro- fessors. However, I must be honest that I was considering these assumptions for the first time. When I revise my courses, I take many factors into consideration—student feedback, test per- formance, difficulty of material, and insights from teaching conferences and journal articles. However, I was not trained to contemplate in- dividual differences may increase or decrease the suitability of blanket statements I make about how a demonstration works. This does not mean these helpful demonstrations should be discarded but rather that I need to be more thoughtful about how I frame them. This spring, I have continued to include the demonstration in my courses. The students enjoy it and it gives me to opportunity to nudge them toward better classroom choices.

I expect that now that I have found these assumptions inherent in this demonstration, I am only just beginning to see the way that assumptions about my students might influence my teaching. I have also begun to recognize other assumptions that I use in my lectures on increasing academic success. The demonstra- tion of the difficulty in picking out the correct penny from a set of distractors (Nickerson & Adams, 1979) and the Moses Illusion (“How many animals of each type did Moses bring on the ark?”; Erickson & Mattson, 1981) both also come with assumptions. The former assumes experience with American currency and the lat- ter expects some familiarity with characters and stories associated with Abrahamic faiths. These are still acceptable choices to demonstrate key teaching points in class, but now I try to balance their use with some context about how they work only when one has consistent background experience and that for some students in my classes this may not be the case.

As I work to improve the teaching of psy- chology, I think we need to be aware of other places in which assumptions such as these may lurk. A quick review of the ancillary materials for an introductory psychology textbook sug- gests other potentially less inclusive demos, in-

2 LLOYD

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cluding those that relied on visual materials for demonstrations of perceptual illusions or schema memory examples that presumed a level of familiarity with the stimuli. There has been some progress toward acknowledging these concerns with the recent distribution of a manual for including issues of disability in in- troductory psychology courses (Rosa, Bogart, & Dunn, 2018). This resource contains demon- strations such as a tactile version of Gestalt principles, which would be suitable for vision- impaired students in ways the more conven- tional pictorial stimuli would not. A similar resource would be a welcome addition for fac- ulty wanting to consider additional factors re- lated to diversity and inclusion. In the mean- time, I am not going to try to find only those demonstrations that are universally appropriate because this would likely be impossible. In- stead, I will model my willingness to learn by continuing to share many kinds of demonstra- tions while adding in discussions of the assump- tions about the participants that are inherent in each.

References

Erickson, T. D., & Mattson, M. E. (1981). From words to meaning: A semantic illusion. Journal of Verbal Learn- ing and Verbal Behavior, 20, 540–551. http://dx.doi .org/10.1016/S0022-5371(81)90165-1

Nickerson, R. S., & Adams, M. J. (1979). Long-term memory for a common object. Cognitive Psychol- ogy, 11, 287–307. http://dx.doi.org/10.1016/0010- 0285(79)90013-6

Rosa, N. M., Bogart, K., & Dunn, D. S. (2018). Increasing inclusiveness and awareness: Disability in introductory psychology. Retrieved from http:// teachpsych.org/resources/Documents/otrp/resources/ Disability%20in%20Intro%20Psych%20Revision %20042419%20-%20Google%20Docs.pdf

Weinstein, Y. (2018). The cost of task switching: A simple yet very powerful demonstration. Retrieved fromhttps://www.learningscientists.org/blog/2017/ 7/28-1.

Received October 10, 2019 Revision received February 19, 2020

Accepted March 14, 2020 �

3SOMETIMES A DEMO

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http://dx.doi.org/10.1016/0010-0285%2879%2990013-6

http://teachpsych.org/resources/Documents/otrp/resources/Disability%20in%20Intro%20Psych%20Revision%20042419%20-%20Google%20Docs.pdf

https://www.learningscientists.org/blog/2017/7/28-1

Sometimes a Demo Is Not Just a Demo: When Demonstrating Cognitive Psychology Means Confronting A …

References

Revista Argentina de Clínica Psicológica 2020, Vol. XXIX, N°2, 871-877 DOI: 10.24205/03276716.2020.324

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APPLICATION OF GAME ACTIVITIES IN MENTAL HEALTH EDUCATION OF KINDERGARTENS BASED ON COGNITIVE PSYCHOLOGY

Na Yao, Liping Wang*

Abstract

Game activities are the most effective means of mental health education in kindergartens. This paper mainly explores how to design game activities based on cognitive psychology, and apply them in mental health education of kindergartens. First, the psychological characteristics of young children were analyzed from the perspective of cognitive psychology. Then, game activities were designed based on these characteristics, and verified through a case study. The children’s behaviors before and after the game activities were compared in details. The results show that the game activities designed based on cognitive psychology accord with the psychological characteristics of kindergarten children of all ages, meeting their psychological needs and mental health demands; moreover, the designed game activities can correct the problematic behaviors of young children and promote the children’s cognition of behavior. The research results provide a reference for mental health education in kindergartens.

Key words: Cognitive Psychology, Game Activities, Mental Health Education, Psychological Characteristics.

Received: 18-05-19 | Accepted: 12-08-19

INTRODUCTION

When studying the psychology of criminals, Professor Li Meijin of People’s Public Security University of China divides the criminal population into “dangerous personality” type and “dangerous heart knot” type. “Dangerous personality” type criminals are mostly caused by problems in the process of mental cognitive structure and personality development in their congenital or early years. Hence, at the most important stage of the formation of psychological cognitive structure and personality in infant aged 0-6 years (Renaud & Suissa, 1989), it is mainly dependent on family education and kindergarten school education, Cognitive knowledge and experience acquired during this period lay the foundation for life -long learning (Donaldson Vollmer, Krous et al., 2011). The

Tangshan Normal University, Tangshan,063000, China. E-Mail: [email protected]

physical and mental development of infants aged 0-3 years mainly depends on family education, while the physical and mental development of infants aged 3-6 years is greatly influenced by the kindergarten environment. Their strong physique, coordinated actions, emotional self – control, good habits and independence are the main factors for judging children’s physical and mental health (Nacheret, Garcia -Sanjuan, & Jaen, 2016).

Therefore, mental health education in kindergarten aims at actively responding to the children’s inner psychological needs, setting up the corresponding mental health education curriculum according to the mental and physical cognitive characteristics of children aged 3 -6 years, and cultivating the preschool children’s mental and physical health development, so that they have positive emotional regulation, strong quality of consciousness, positive behavior and good social communication skills (Larson , Russ, Nelson et al., 2015). The quality of mental health education directly affects the development of

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children’s mental health and plays an important role in the formation of 3-6-year-old children’s personality.

China’s kindergarten education concepts and management methods are relatively backward and traditional. In addition, the shortage of kindergarten teachers and professional mental health teachers leads to the current situation of a teacher-student ratio of 1:15 in kindergarten. Compared with a teacher-student ratio of 1:5 in foreign kindergartens, kindergarten teachers in China have to undertake too many tasks in daily learning activities. In order to unify the management for time saving, early kindergarten teachers often label “problem children” on children whose personality behavior is special. At the same time, these children are classified as the focus of mental health education (Jones , Greenberg, & Crowley, 2015).

Due to the lack of professional mental health teachers, kindergarten teachers are unable to carry out mental health education from the perspective of psychology. In order to better discipline young children and highlight the effectiveness of mental health education or to cope with the supervision of higher education departments, many children who don’t really have mental problems are included in the correction scope of mental health problems. For example, slow eating, dietary bias, willfulness and cowardice, or children’s behavior characteristics that will naturally disappear in the psychological development with age are taken as children’s psychological problems to be corrected, which will only deepen the children’s impression on the so-called “problem behavior”, and even reinforces the behavior into internalized personality. For this kind of personality problem that will disappear naturally, the education focus shall be changed to correct the problem behavior by the way of guiding and encouraging (for example, game activities). Constructive mental health education is carried out from the perspective of children’s inner psychological cognition.

This study constructs game activities from the professional angle of cognitive psychology, analyzes children’s real psychological problems and behaviors, carries out psychological intervention and correction pertinently, and promotes the children to acquire the psychological self-confidence, satisfaction and security through happy game activities. At the same time, it can promote children’s

interpersonal communication ability, team cooperation ability, language expression ability, logical thinking ability and emotion regulation ability through collective game activities, so that young children develop in a better direction from the mutual coordination of physiological and psychological interaction.

RELATIONSHIP BETWEEN COGNITIVE

PSYCHOLOGY AND THE MENTAL OF KINDERGARTEN CHILDREN

Starting from the children’s cognitive psychology, it is found that children have a specific sensitivity to a certain thing at a specific period (Feshbach & Price, 1984). During this period, targeted guidance shall be conducted

(Melhuish, 2011). Children’s body and mind

are satisfied and supported with their curiosity, desire, exploration, self-confidence, satisfaction, and safe feeling, which will further st imulate deeper exploration and cognition. At the same time, they can gain the learning effect with twice the effort. First, we should understand the psychological characteristics of kindergarten children of different ages, as shown in Figure 1, which aims at constructing game activities, correcting so-called problem behaviors through game activities imperceptibly, and promoting the cognition of correct behaviors.

Figure 1. The exclusive psychological characteristics of different ages

Strong curiosity psychology

Prominent group psychology

Unconscious imitation psychology

Emotion control psychology

Attachment psychology

Lively and active love to

play psychology

Image thinking

Intentional behavior

Love to learn questions

Abstract thinking

The expression of the story

Intentional behavior increased

The initial formation of personality

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The psychological cognitive characteristics of 3-4-year-old preschool children have strong curiosity psychology, attachment psychology, prominent group psychology, unconscious imitation psychology and emotion -dominated psychology. The behavior of children in this age group is not controlled by brain rationality, and it belongs to the behavior dominated by primitive psychological needs and is greatly influenced by the external environment (Freitag , Feineis-Matthews, Valerian et a l., 2012). For example, 3-year-old children who just go to the kindergarten will cry to find their mothers when seeing other children crying to look for their mothers. This emotional control psychology will cause group cry, which is the most annoying for caregivers. Attachment psychology is the attachment to fosters. This kind of attachment psychology is obvious in the separation on the morning for 3-year-old children who just go to kindergarten. The unconscious imitation psychology, group psychology, the m utual infection of anxiety emotion of 3 -4-year-old children control the collective insecurity of the whole small-class children, which increases the workload and work intensity of kindergarten teachers. Under the condition of abnormal teacher-student ratio, kindergarten teachers may make cognitive judgment or behavior which is unfavorable to children’s mental health when they are subjectively tired.

Preschoolers aged 4-5 years, compared with the preschoolers aged 3-4 year, have changed a lot. Their inner potentials are released and their psychological cognitive characteristics are lively and active, image thinking and intentional behavior (Kraybill & Bell, 2013). Young children of this age are energetic, lively and active. Their cognition of things is no longer aimless wait-and- see, but actively participation in guiding the game process like a director to guide and practice the characters in the game. The 4 -5- year-old preschoolers have accumulated a certain amount of things cognitive experience, and the individual’s output behaviors begin to be controlled by the brain, so that they can rely on the existing mental cognitive structure of the brain to carry out image-specific thinking activities, and be able to listen to adult requests and suggestions. This is reflected in intentional behaviors in attention, memory and imagination, more intentional concentration in listening to stories and remembering the characteristics of things, and more imaginative activities and game

activities. The psychological cognitive characteristics of

preschoolers aged 5-6 years are mainly manifested in their interest in learning and asking, their abstract thinking ability and their strong desire to express their stories, increased intentional behaviors and initial personality formation (Warman & Cohen, 2000). Unlike the thirst for knowledge of 3-4-year-old children under the psychological effect of curiosity, 5 -6- year-old children are no longer satisfied with the superficial knowledge when learning and asking. They will spontaneously observe and explore related knowledge related knowledge of things at a deeper level under the joint action of active thinking (Jobe, 2003). The abstract logic thinking of 5-6-year-old children begin to develop, and they can carry out thinking activities of generalization thinking and logic abstraction. For example, they can classify objects according to their function and scope (Dijksterhuis & Aarts, 2009).

MENTAL HEALTH CURRICULUM SETTING BASED

ON THE GUIDANCE OF COGNITIVE PSYCHOLOGY

Direction of constructing game activities based on children’s cognitive psychology

According to the psychological cognitive characteristics of 3-year-old children, the game activities developing children’s cognitive ability are constructed. For example, based on the children’s curiosity about the surrounding things, the daily objects of interest are printed on the drawings and cut into two, three or four pieces. Then the children are asked to combine freely to obtain the complete puzzle, and say the name of the thing. Then we use the group psychology to construct game activities to develop the children’s interpersonal communication ability. The children are asked to exchange the puzzles or things in their hands, to name the things in their hands, or to describe and ask questions about the features of the things, or to describe the color, shape, softness, transparency of the things. Besides, we can ask heuristic questions about the function and use of the objects. Combining the unconscious imitation psychology, we can cons truct game activities of developing children’s living habits and rules by organizing children to wash hands and feed fruits for dolls, and let children imitate adults to dress dolls, wear shoes and hats, and fasten buttons for dolls.

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Table 1. Construct the game according to the psychological characteristics of 3 -4 children

Age Psychological

characteristics Game setting

3-4 years old

Strong curiosity psychology

New thing puzzles, light clay making (hand clay painting, animal clay model, etc.), leaf puzzle and other cognitive game activities

Prominent group psychology

The eagle catches the chicken (children take turns to be the eagle and the chicken, the teacher does the chicken mother)

Unconscious imitation psychology

Act out a picture book story

Table 2. Construct the game according to the psychological characteristics of 4 -5 children Age Psychological characteristics Game setting

4-5 years

old

Lively and active love to play psychology and image thinking

Go out to play in order to know nature, the garden in the campus, insects, flowers and trees things cognition

Intentional behavior Role-playing game activities (e.g., playing doctor to see a patient,

playing cook to cook, etc.)

Table 3. The exclusive psychological characteristics of different ages

Age Psychological

characteristics Game setting

5-6 years old

Knowledge discovery Books on “a hundred thousand whys”

Abstract logic Mathematical game activities such as classification of things, number

graphics game activities Expressive desire for

language Picture book story description

According to the psychological cognitive

characteristics of 4-5-year-old children, they are guided to observe their life through game activities or multiple scenes in their development stage of intentional behaviors. They can constantly get growth in insig ht in the observation and enrich psychological cognitive structure with a large number of specific images experience while developing focus, memory, thinking organization, imagination and language skills. The curiosity psychology of 4 -5-year-old children is expressed as “Hundred Thousand Whys” questions in lively and active activities. The cognitive psychology with high thirst for knowledge and imagination at this stage is utilized to construct game activities to develop the expression and creativity of chi ldren. Moderate help, spiritual encouragement and affirmation will be given to increase children’s self-confidence, satisfaction, pleasure and stimulate their desire to recreate, so as to stimulate children’s positive and healthy mental conditions.

Although the logical thinking ability of 5 -6- year-old children is relatively superficial, their thinking mode and thinking ability have undergone qualitative changes, providing important psychological cogni tive ability for

entering primary school learning activities. According to the psychological characteristics of 5-6-year-old children with a strong desire to express their stories and combining the development of logical thinking and the accumulation of language words, we can construct story-telling game activities to satisfy the children’s desire to express their stories, thereby helping them to build up self -confidence and develop ability of telling stories in a coherent language, providing the basis for entering primary school to learn written language.

In accordance with children’s cognitive psychology, we construct game activities that are easy to be accepted by children. On the one hand, the children’s advantageous behaviors such as focus and creativity are optimized. On the other hand, the children’s problem behaviors considered by the adult are improved, and children’s internal stress and anxiety are released from game activities, and they gain pleasure and self-confidence from game activities, which enables children to reconstruct the psychological cognitive structure in the game activities with autonomy and participation, and develop the output behavior in a positive direction. Figure 2 shows a flowchart of

APPLICATION OF GAME ACTIVITIES IN MENTAL HEALTH EDUCATION OF KINDERGARTENS BASED ON COGNITIVE PSYCHOLOGY

2020, Vol. XXIX, N°2, 871-877

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constructing game activities based on the children’s cognitive psychology.

Figure 2. Construct the flow chart of game activities based on children’s cognitive psychology

Psychological

characteristics

of children

Game

Behavior

advantages

Behavior

disadvantages improve

Optimize

Healthy

psychological

feelings

Normative

behavior

output

3-6-year-old preschool children own the

absorptive mind so that they can absorb a large amount of input information from the surrounding environment through the sense organs in a conscious state. Children have different physical and mental development characteristic in different age groups, that is, each age group has a specific psychological cognitive structure. We should carry out mental health education according to the specific psychological cognitive structure, and construct appropriate game activities to guide the children to explore and learn freely and stimulate the children’s internal potentials, so as to acquire self-confidence, security and concentration, creativity and good interpersonal skills.

Guide the direction of mental health

education according to the cognitive psychological model of children

Every child’s cognition of the world is based on his/her acquired knowledge structure, which constructs the world he/she sees, and guides the output of his/her own behavior. The abnormal behaviors behind the problem children depend on the knowledge structure acquired from the living environment. The purpose of mental health education curriculum in kindergarten is to reconstruct the children’s cognitive structure through game activities and make them de velop into positive behaviors. It is significant to let the children have the autonomy and the participation feeling. Positive absorption of active participation is greater than the passive discipline teaching. The trial and error learning game setting is advantageous to the mental development.

Children’s thinking mode and behavior mode

are influenced by the original psychological cognition mode and children of different age groups in kindergarten have different acceptance and absorption abilities for the s ame game activities, so the construction of game activities should be in accordance with children’s psychological cognitive structure.

As shown in Figure 3, the orange pentagram represents the psychological cognitive structure of 3-4-year-old children, i.e., cognitive models such as emotion, unconscious imitation, and prominent group psychology. The orange snowflake square represents the psychological cognitive structure of 4-5-year-old children, namely, the psychological structure of active exploration, intentional behavior and image thinking. The orange hexagon represents the psychological cognitive structure of 5 -6-year-old children, namely, the psychological structure of interest in learning and asking, abstract logical thinking, the desire of language expression, and increased intentional behavior. Under the same input of game activities, children of different age groups have different emphasis and ability development and exercise directions, and children of the same age group also have different cognitive results according to their own psychological cognitive structure. Therefore, kindergarten teachers only need to give children a more relaxed, free and respectful learning environment, so that children can maximize the development of their internal potentials without interference.

Figure 3. Cognitive models of children of different ages

3-4 year old

5-6 year old

4-5 year old

Input model Cognitive model Restoring model

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The same input information is compiled through different psychological cognitive structures, and each person reprocesses the input information according to his/her own existing knowledge structure. The obtained result depends on the original experience and knowledge inventory. Children of different age groups reprocess the same input model, and the obtained cognitive remodeling model has the characteristics common to each age group. Therefore, it is necessary to construct game activities pertinently for chi ldren of different ages.

The important period for the development of children’s ability to understand psychological emotion is 4-5 years old in the middle class of kindergarten. Thus, constructing game activities in mental health in kindergarten should aim at the cognitive psychology of 4 -5 years old children in the sensitive period of emotion understanding. It is easier to promote the development of young children’s emotional understanding by setting up game activities with role exchange and emotional alignment, and it is easier to establish friendly communication modes among young children, and to understand other people’s behaviors and make appropriate responses, thus reducing the number and frequency of attacks.

CASE STUDY ON THE CONSTRUCTION OF

GAME ACTIVITIES IN COGNITIVE PSYCHOLOGY

From the perspective of children’s own cognitive psychology, the psychological problems of children are mainly manifested as lack of sense of security and self -confidence, which leads to shyness, self-abasement and even depression. Adults usually analyze children’s behavior problems from the perspective of cognitive psychology of children’s ability because adults think that children’s ability is insufficient. Children’s learning exploration behavior, independent behavior and trial and error behavior are deprived, which results in children’s weak ability to resist setbacks, and weak self-confidence and independent learning ability. The problem behavior of emotional regulation disorder comes from the improper educational method. Excessive doting education will cause the children to be willful and self – respecting. Emotional disorder and aggressive behavior appear when their desire is not satisfied.

Lack of sense of security will lead to anxiety, crying, cowardice and self-abasement. Artificial hindrance deprives young children of their desire and curiosity, fear of failure, and aggression caused by abnormal emotional regulation which come from the deviation of children’s psychological cognitive structure. When the children’s inner needs are concerned and satisfied, their behaviors are enthusiastic, loving and positive. On the contrary, when the children’s inner needs are not concerned or ignored, their emotional color is black and negative and their behaviors are prone to appear anger, attack, and destruction.

This study observes and records the frequency of occurrence of anxiety behavior and the duration of attentiveness, and the period of data record is four months, one semester. A total of 80 groups of sample values are obtained and the trend map of the psychol ogical behavior improved by game activities is shown in Figure 4. It is found that constructing game activities in accordance with cognitive psychology meets the psychological needs of the children of the corresponding age group, and the abilities required for game activities accord with the mental ability range of the children. Children obtain sense of satisfaction and security through pleasant game activities, thus reducing their inner anxiety. When just going to kindergarten, children frequently appear anxiety behaviors. They gradually obtain emotional stability as shown by a solid pink line in Figure 4. Later, their learning focus gradually increases as shown by the blue dotted line in Figure 4.

Figure 4. A chart of mental behavior improved by game activity

0 10 20 30 40 50 60 70 80

Concentration

F r e q

u e n

c y /D

a y

Test times

Anxiety behavior

C o n c e n tr

a ti

o n /T

im e

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CONCLUSIONS

This study constructs game activities from the professional angle of cognitive psychology, and explores the relationship between mental health education in kindergarten and the effect of game activities on children’s mental health, and draws conclusions as follows:

(1) Based on the psychological cognitive characteristics of children, this study summarizes the psychological needs of kindergarten children of all ages, and understands the real mental health demands behind the problem behaviors.

(2) Based on children’s cognitive psychology, this study constructs appropriate game activities pertinently according to the psychological cognitive characteristics of different ages, to stimulate the children’s inner potentials purposefully.

(3) According to the children’s cognit ive psychology model, the mental health education curriculum in kindergarten is set up, and the children’s cognitive structure is reconstructed through game activities, so as to make them develop towards positive behavior.

The empirical study shows that th e construction of game activities based on cognitive psychology has positive effect on children’s psychology and behavior.

Acknowledgement

Social science fund project of Hebei province, Study on the gamification model of construction activity curricula in kindergartens, No: HB18JY054.

REFERENCES

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Donaldson, J. M., Vollmer, T. R., Krous, T., Downs, S., & Berard, K. P. (2011). An evaluation of the good

behavior game in kindergarten classrooms. Journal of Applied Behavior Analysis, 44(3), 605- 609.

Feshbach, S., & Price, J. (1984). Cognitive competencies and aggressive behavior: a developmental study. Aggressive Behavior, 10(3), 185-200.

Freitag, C. M., Feineis-Matthews, S., Valerian, J., Teufel, K., & Wilker, C. (2012). The frankfurt early intervention program ffip for preschool aged children with autism spectrum disorder: a pilot study. Journal of Neural Transmission, 119(9), 1011-1021.

Jobe, J. B. (2003). Cognitive psychology and self- reports: models and methods. Quality of Life Research, 12(3), 219-227.

Jones, D. E., Greenberg, M., & Crowley, M. (2015). Early social-emotional functioning and public health: the relationship between kindergarten social competence and future wellness. American Journal of Public Health, 105(11), e1- e8.

Kraybill, J. H., & Bell, M. A. (2013). Infancy predictors of preschool and post-kindergarten executive function. Developmental Psychobiology,55(5), 530-538.

Larson, K., Russ, S. A., Nelson, B. B., Olson, L. M., & Halfon, N. (2015). Cognitive ability at kindergarten entry and socioeconomic status. PEDIATRICS, 135(2), e440-e448.

Melhuish, E. C. (2011). Preschool matters. Science, 333(6040), 299-300.

Nacher, V., Garcia-Sanjuan, F., & Jaen, J. (2016). Interactive technologies for preschool game- based instruction: experiences and future challenges. Entertainment Computing, S1875952116300210.

Renaud, L., & Suissa, S. (1989). Evaluation of the efficacy of simulation game activities in traffic safety education of kindergarten children. American Journal of Public Health, 153(3), 307-9.

Warman, D. M., & Cohen, R. (2000). Stability of aggressive behaviors and children’s peer relationships. Aggressive Behavior, 26(4), 277- 290.

Reproduced with permission of copyright owner. Further reproduction prohibited without permission.

Revista Argentina de Clínica Psicológica 2020, Vol. XXIX, N°2, 854-859 DOI: 10.24205/03276716.2020.321

2020, Vol. XXIX, N°2, 854-859

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APPLICATION OF PSYCHOLOGICAL PREFERENCE AND EMOTIONAL GUIDANCE IN THE PERFORMANCE OF FILM AND TELEVISION ART: AN

ANALYSIS BASED ON BASED ON COGNITIVE PSYCHOLOGY

Dunru Xie

Abstract

The performance of film and television art enriches our life. The psychological preference and connoisseurship of the audience for film and television art may vary with age, gender, region and cultural background. Based on cognitive psychology, this study investigates the status quo of film and television art in the Internet era through a questionnaire survey, and explores the application of psychological preference and emotional guidance in the performance of film and television art. The results show that, from the perspective of cognitive psychology, the appreciation and evaluation of the audience for the performance of film and television art is a form of artistic accomplishment; the psychology and emotion of the audience is influenced by the plot, visual rhythm, special effects, color and animation of film and television art; the audience’s preference for film and television art is determined by the expressive force, infection, and the theme of performance. The research lays a theoretical basis for the quality and proliferation of film and television art.

Key words: Film and Television Art, Psychological Preference, Connoisseurship, Cognitive Psychology, Emotional Guidance.

Received: 18-05-19 | Accepted: 12-08-19

INTRODUCTION

Film and television have been dominant throughout the film and television art industry. As a tool of cultural industry or ideology, they can’t be separated from the support of the audience (Haslam Parsons, Omylinska-Thurston et al., 2019). The social conditions of China’s rapid development provide convenience for the change of film and television art. With the audience’s preference for the mainstream culture and the mainstream ideology, mass culture and consumer culture constantly conflict, collide and cons pire under the background of the rapid development of China’s film and television industry, constituting a diverse culture of film and television art (Halpern

Department of art design, Sichuan Film and Television University, Chengdu 61000, China. E-Mail: [email protected]

& O"Connor, 2013). Taking cognitive psychology as the basis for evaluating the aesthetic psychology of film and television embodies the complexity of the aesthetic system of film and television art. The aesthetic psychology displayed by people according to psychological preference and psychological emotion is active and comprehensive, including psychological factors such as emotional color, thinking association, aesthetic perception and plot understanding (Stambulova, & Wylle man, 2018; Krentz & Earl, 2013). Psychological emotion is the expression and evaluation of the relationship between people and the surrounding world, which is a complex psychological reaction and an attitude of the subject to the object (Dubey, Ropar, & Hamilton, 2016).

The performance of film and television art is related to film and television color, film and television special effects and film and television animation. Color, special effects and animation

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greatly enrich the performance means of film, and guide the audience’s emotion and preference through intense visual impact and auditory shock (Buchheim & Kolaska, 2016). The producers and designers of film and television art will follow people’s psychological preference, and will also consider guiding the audience’s emotion through the visual and auditory aspects of film and television art. Therefore, psychological preference and emotional guidance are the focus of film and television art design (Balietti Goldstone, & Helbing, 2016). Along with the development of the Internet, film and television works are widely produced with different levels of quality due to inadequate network supervision, leading to low quality of film and television art works. Thus, the current film and television art does n ot only refer to television and films. Short videos played with the help of new media are also classified as film and television art, with greater impact on people’s emotion and psychology (Levine-Madori & Bendel, 2013; Karasik, 2014). Based on the principle of cognitive psychology, this study investigates the status quo of film and television art under the Internet, and explores the application of psychological preference and emotional guidance in the performance of film and television art. This study prov ides a theoretical basis for the high quality development and transmission of film and television art.

PSYCHOLOGICAL MECHANISM OF AUDIENCE

ON THE PERFORMANCE OF FILM AND TELEVISION ART

The cultural types of film and television works are mainly divided into dominant cultural type, mass cultural type and elite cultural type. The audience of film and television art will vary with region, gender, cultural level and age, and their psychological preference is different (Smith & Reffin, 2006). The audience’s aesthetic level, cultural level and connoisseurship of film and television art are related to their psychological preference. When meeting their own preferred film and television works, the audience will consciously take advantage of the positive effects expressed by the film and television art works to improve them and build complete values of life (Quigley, Westall, Wade et al., 2014). College students are taken as the audience group to explore their preference for

themes of film and television art works. Figure 1 shows the statistics of theme type of films of college students, which clearly shows that male college students prefer science fiction films and action films, while female college students prefer comedy films and love films.

The audience’s psychological preference for film and television art is realized through aesthetic perception, and cognitive psychology is the basic condition for the formation of psychological preference. The co gnitive psychological activity of the audience is positive and initiative (Skavronskaya, Scott, Moyle et al., 2017). From the perspective of cognitive psychology, aesthetic cognition is fast. If aesthetic cognition is used as the psychological basis for elevating film and television art, it will be found that the aesthetic system is complex (Carrier, 2011). The audience’s psychological mechanism of film and television art is reflected in the role played in the cognitive process. The audience’s perception, imagination, association, expression and evaluation of film and television art performance are the most realistic and tedious psychological reactions.

Figure 1. Statistics of theme type of films of college students

100

120

140

160

180

OthersAction Literature

and art Cartoon

Science

fiction WarLoveComedy

N u m

b e r

o f

p e o p le

Male

Female

STUDY ON THE STATUS QUO OF FILM AND

TELEVISION ART UNDER THE INTERNET

Investigation and study on the status quo of film and television artistic accomplishment

Film and television artistic accomplishment is actually the artistic accomplishment in the course of designing, shooting and editing of film and television. According to cognitive psychology analysis, the thought exhibited by

APPLICATION OF PSYCHOLOGICAL PREFERENCE AND EMOTIONAL GUIDANCE IN THE PERFORMANCE OF FILM AND TELEVISION ART: AN ANALYSIS BASED ON BASED ON COGNITIVE PSYCHOLOGY

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the audience in enjoying and evaluating the artistic performance of film and television is also a form of artistic accomplishment. With the rapid development of the Internet, the impact of the Internet on the film and television artistic accomplishment is facing not only new opportunities, but also challenges of new technologies. In order to probe into the status quo of film and television artistic accomplishment, this study uses questionnaire survey. 1,000 questionnaires are distributed and 802 valid questionnaires are collected. Statistical analysis method is adopted to analyze. Figure 2 shows the audience’s understanding of the background of film and television culture. When people have finished watching a film and television work, most of the audience do not know the background of film and television culture. The survey data show that the audience’s understanding of the background of film and television culture accounts for less than 20%. Figure 3 shows the audience’s understanding of film and television art plots. The audience’s understanding of film and television art plot setting shows the same law as the cultural background. Most people don’t know why such an art plot is set and lack the ability to analyze the theme and artistic creation of film and television art. Figure 4 shows t he focus of the audience on film and television art. The focus of the audience on film and television art is influenced by gender factor. Female audience prefers to pursue film and television plots and actors, while male audience prefers to focus on film and television actors and directors, which is mainly influenced by psychological preference.

Figure 2. Audience’s understanding of film and television cultural background

3.33%

10%

13.33%

26.67%

46.67%

Ignorant

Basic understanding

General

Understanding

Very understanding

Figure 3. Audience’s understanding of film and television art plot

1.74%

6.94%

17.36%

25.35%

48.61%

Ignorant

Basic understanding

General

Understanding

Very understanding

Figure 4. Research on the audience’s focus on film and television art

100

120

140

Others Lens

language MontageClipPictureVoiceDirectorActorPlot

N u

m b

e r

o f

p e o

p le

Male

Female

Factors influencing the film and television

artistic accomplishment At present, the performance process of film

and television art is not limited to the professional staff engaged in film and television work. Anyone with mobile phone, camera and DV can become the producer and publisher of film and television works. The immediacy, sharing and diversity of network resources make the choice space of films and television works larger and larger, which puts forward higher request and challenge to people’s cognition ability and connoisseurship. Figure 5 shows the factors influencing the film and television artistic accomplishment, including environmental factors, educational factors and personal factor. The online film and television art resources increase the audience’s ability of self -selection and connoisseurship. Film and television art are not a pure commodity. It has numerous connections with art, literature and culture. The essence of film and television art performance lies in that it can’t be separated from the interests of the audience and the interest

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combination becomes the type. The preference of the audience determines the type of film and television, which is inseparable from the interest of the audience.

Figure 5. The influence factors of film and television artistic accomplishment performance

The influencing factors

of film and television

artistic accomplishment

performance

Environmental

factors

Educational

factors

Individual factors

The increase of network film and television

resources affects the ability of the audience to

choose independently

The audience's ability to appreciate the complex

and influential content of film and television

Insufficient attention

The content and form of film and television art

literacy education lack novelty

Lack of new media technologies and dedicated

staff

Low participation in film reviews

APPLICATION OF PSYCHOLOGICAL PREFERENCE AND EMOTIONAL GUIDANCE IN THE PERFORMANCE PROCESS OF FILM AND TELEVISION ART

An audience psychological analysis of film and television art performance

The use of new media and the audience’s evaluation of film and television art directly affect the audience’s emotion towards film and television art. Taking film and television as an example, once the score of a film is low or the word of mouth is poor, it directly affects the audience’s emotion or psychological preference. Figure 7 shows the use of new media. Most of the current film and television art is promoted in the form of posters, WeChat public number push, social network site or online forum. Figure 8 is the result of film review after watching film and television works. It can be clearly seen that the audience participating in the film review after watching film and television works is less than 30%, which is in a relatively low proport ion. Based on the mass psychological preference and cognition, it is very important to explore the audience’s psychological preference, psychological demand and psychological emotion in the history of film and television art. The creation and performance o f film and television art is to reflect the background of the times, objective facts or explain the truth, and the collision with the audience is the core of the expression of film and television art. Different from other art categories, film and televisio n art

is created for the audience, and the audience’s psychological preference and emotional guidance determine the score and value of film and television art. Therefore, the promotion and correction of the audience’s preference determine the significance of the existence of film and television art. Figure 6 is the division of the performance dimensions of film and television art. It mainly includes cognition, ability and awareness of film and television art, including cognition, selection, appreciation, speculation, creation and evaluation of film and television art.

Figure 6. The division of film and television art performance dimensions

Film and television

art literacy

Film and television art

media cognition

Film and television art

media ability

Film and television art

media awareness

Cognition

Choice

Appreciation

Speculation

Creation

Evaluation

Figure 7. Use of new media

9.8%

20.26%34.64%

20.92% 14.38%

WeChat public number push

Network forum

Poster

Social networking sites

Others

Figure 8. Review results after watching film and television art works

22.75%

16.08%

30.98%

24.31%

5.88%

Often

Occasionally

General

Few

Never

APPLICATION OF PSYCHOLOGICAL PREFERENCE AND EMOTIONAL GUIDANCE IN THE PERFORMANCE OF FILM AND TELEVISION ART: AN ANALYSIS BASED ON BASED ON COGNITIVE PSYCHOLOGY

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Case study of film and television art based

on cognitive psychology

Figure 9. Different examples of film and television art

(a) Stills of Monster Company

(b) The picture of Nezha

The film and television art plot, visual

rhythm, film and television special effects, film and television color and film and television animation impact the psychology and emotion of the audience. In terms of cognitive psychology, it takes only seven seconds for things to form a first impression in people’s thinking, and the first

feeling of the audience directly affects their psychological preference and emotion. With the improvement of people’s visual appreciation ability and the higher and higher require ment for film and television color, film and television animation and film and television special effects, the factors that determine the quality of film and television art are no longer the theme, but the expressive force and infection of film and television art. Figure 9 shows different example of film and television art. Figure 9 (a) shows stills of Monster Company. It can be seen that the visual elements of film and television works are very different. Grotesque humor and interesting animation impress the audience with exaggerated artistic modeling. Figure 9 (b) is stills of Nezha, which gains the audience’s psychological preference through film and television animation and color. Through the audience’s film review after watching the film, the film and television plot is highly praised. Figure 9 (c) shows the bullet scene of the Matrix, creating a scene with the same atmosphere as the whole film through special effects, and bringing a fresh feeling to the audience through plot setting and special effects. Film and television rhythm, film and television special effects, film and television color and film and television animation all create a clear artistic expression way, which is reflected in psychological cognition, psychological preference and psychological emotion in psychology through the change of visual rhythm.

CONCLUSIONS

Based on the principle of cognitive psychology, this study investigates the status quo of film and television art under the Internet, and explores the application of psychological preference and emotional guidance in the performance process of film and television art. Conclusions have been drawn as follows:

(1) The audience’s psychological mechanism of film and television art performance is reflected in the role played in the cognitive process. The audience’s perception, imagination, association, expression and evaluation of film and television art performance are the most realistic and tedious psychological reactions.

(2) Online film and television art resources increase the audience’s ability of self -selection and connoisseurship. The essence of film and

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television art performance lies in that it can’t be separated from the interests of the audience and the interest combination becomes the type. The preference of the audience determines the type of film and television, which is inseparable from the interest of the audience.

(3) Film and television rhythm, film and television special effects, film and television color and film and television animation all create a clear artistic expression way, which is reflected in psychological cognition, psychological preference and psychological emotion in psychology through the change of visual rhythm.

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Halpern, A. R., & O"Connor, M. G. (2013). Stability of art preference in frontotemporal dementia. Psychology of Aesthetics, Creativity, and the Arts, 7(1), 95-99.

Haslam, S., Parsons, A., Omylinska-Thurston, J., Nair,

K., Harlow, J., Lewis, J., Thurston, S., Griffin, J., Dubrow-Marshall, L., Karkou, V. (2019). Arts for the blues – a new creative psychological therapy for depression: a pilot workshop report. Perspectives in Public Health, 139(3), 137-146.

Karasik, R. J. (2014). Transcending dementia through the ttap method: a new psychology of art, brain, and cognition by linda levine madori. Educational Gerontology, 40(2), 152-153.

Krentz, U. C., & Earl, R. K. (2013). The baby as beholder: adults and infants have common preferences for original art. Psychology of Aesthetics, Creativity, and the Arts, 7(2), 181-190.

Levine-Madori, L., & Bendel, T. (2013). Research to practice: the ttap method a new psychology of art, brain and cognition. Alzheimer’s & Dementia, 9(4), 293.

Quigley, C., Westall, C., Wade, N. J., Longstaffe, K., Cavanagh, P., & Conway, B. R. (2014). Review: visual attention and consciousness, nystagmus in infancy and childhood, edgar rubin and psychology in denmark: figure and ground, cognitive search: evolution, algorithms, and the brain, the psychology of visual art: eye, brain and art. Perception, 43(6), 595-604.

Skavronskaya, L., Scott, N., Moyle, B., Le, D., Hadinejad, A., & Zhang, R., et al. (2017). Cognitive psychology and tourism research: state of the art. Tourism Review, 72(2), 221-237.

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Reproduced with permission of copyright owner. Further reproduction prohibited without permission.

Revista Argentina de Clínica Psicológica 2020, Vol. XXIX, N°1, 1016-1021 DOI: 10.24205/03276716.2020.142

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ANALYSIS ON UNCERTAINTIES IN JUDICIAL DECISION BASED ON COGNITIVE PSYCHOLOGY

Yongchao Li*

Abstract

A judicial decision is arrived at through fact reasoning, legal reasoning and decision reasoning. Due to the difference between judges in cognitive psychology, the above reasoning process is affected by uncertainty thought, resulting in uncertainties of the judicial decision. This paper explores deep into the uncertainties in judicial decision from the perspective of cognitive psychology, and puts forward some countermeasures. Specifically, the author analysed the cognition psychology of judges in the process of judicial decision, examined the manifestation of uncertainties in judicial decision, and conducted a psychological analysis of uncertainty thought. The results show that the cognitive psychology of law and justice is formed through long- term integration of learning and work; in the process of judicial decisions, judges are limited by their own cognition in the process of fact reasoning, legal reasoning and decision reasoning, resulting in an unfair judgment against one party; the uncertainties of judicial decision should be reduced from aspects of legislation, legal application procedures, the personal emotions and qualities of judges, as well as publicity and education. The research findings lay the basis for the application of cognitive psychology in judicial decisions.

Key words: Judicial Decision, Reasoning, Uncertainty Thought, Cognitive Psychology. Received: 19-02-19 | Accepted: 09-07-19

INTRODUCTION

The certainty of judicial decision is an important manifestation of formal rationality, mainly through the consistency of legal rules, but in any judicial decision system, "certainty" is the goal pursued (Foxall, 2014). At present, no jurist or legal institution's thought can occupy an absolute dominant position; it is only based on a certain angle, and absolute judicial uncertainty or certainty is one-sided (Rand, 2015). Moreover, the judicial decision process is a passive right, initiated on the litigation of the litigant, generally including th e identification of legal facts, the search for relevant legal norms, the subsumption according to the legal order, and the final declaration of judicial decisions (Vlek, 2010). In the entire judicial decision

Zhengzhou University School of Law, Zhengzhou 450001, China. E-Mail: [email protected]

process, the uncertainties of the judicial pro cess include the identification of legal facts and evidence collection and adoption, the timeliness of evidence, the criteria for the identification of evidence or facts, etc.; besides, considering the extreme complicatedness of the cases, the conflict of legal rules between judicial staffs is also a factor of uncertainty (Brinkman, 2017).

The judicial process is related to people's cognitive psychological state. As a special social psychological activity, judicial decisions formally express people's attitudes, concepts and theories about legal uncertainty, as well as their thoughts, perspectives, knowledge and psychology, etc. on judicial phen omena (Stone, 2010; Emma & Mcnaught, 2016). People's internal psychological behaviours are only ones that are no different from external behaviours while cognitive psychology is a by -product of behaviourism, in which people are active information explorers and do not change their thoughts and behaviours under the

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environmental stimuli (Cunliffe, 2014). The psychological cognitive process of law is a cognition collection of legal characteristics formed in the individual consciousness after long-term accumulation and integration, including the subtle learning in daily life, work and study (Bishop, 2017). It is the uncertainty in the process of judicial decision that makes it impossible to anticipate the legitimacy of one's actions and thus fail to correctly un derstand the outcome of the decision (Davies, 2012). Based on the theory of cognitive psychology, this paper aims to explore the uncertainty of ideas in the process of judicial decision and gives corresponding countermeasures.

THE PROCESS OF JUDICIAL COGNITION

PSYCHOLOGY

Judicial decisions are based on legal ground, which is generated in social consciousness. The formation of legal consciousness is an important part of people's cognitive psychology. People's legal cognition process starts with sporadic le gal phenomena (Shapiro, Mixon, Jackson et al., 2015). One’s cognitive psychology begins from birth. Table 1 lists the four stages of cognitive development: at the sensorimotor stage, there develops a sense of good and bad, and the emotion will be more devoted to oneself; at the pre-operational stage, social behavioural activities begin to manifest, and there is no intentional concept in the process of cognitive psychology formation; at the concrete operational stage, human will and autonomy are mainly formed; at the formal operational, people's idealistic emotions appear and personality begins to form. Figure 1 shows the influencing factors of judicial cognition psychology, mainly including social learning, communication and mass communication, popularization of law, legal education, and legal research.

People's cognitive psychology of the judiciary needs to be taught and induced, e.g., in the course of people's growth or learning (Flanagan & Ahern, 2011). The process of communication is also an important channel for the formation of cognitive psychology, allowing people to share news, ideas and attitudes, and establish a cognitive identity and ideological resonance between people (Soboleva, 2013). The popularization and publicity of judicial knowledge has enabled people to directly

acquire judicial knowledge, gradually cultivated their awareness of judicial cognition, and continued to lay a solid legal foundation for the formation of a society ruled by law. Judicial lectures, seminars, reading clubs, and legal columns have all become common popularized forms of law so that people are always in contact with the law and obey the law, which can also greatly promote the cultivation of people's judicial cognition.

Table 1. Overview of each stage of cognitive development

Phase Principal variation

Perception- motion phase

The initial likes and dislikes emerge, and emotions pour out on

the self

Preoperational stage

For real social behavior to begin with, there is no concept of intention in moral reasoning

Concrete operational stage

The formation of will and the emergence of autonomy

Formal operation stage

The emergence of idealistic feelings, the formation of

personality began, began to adapt to the adult world

Figure 1. Formation of judicial cognitive psychology

Formation of judicial

cognitive psychology

Social learning

Communication and mass communication

Franco-prussian propaganda

Legal education

Legal research PSYCHOLOGICAL ANALYSIS OF UNCERTAINTY IN

JUDICIAL DECISIONS

The manifestation of uncertainty in judicial decisions

The uncertainty of judicial decisions is generated by the coordination and balance between the legality and rationality of the ruling. When the legal norms of the adjudicated cases are ambiguous or the facts are in conflict, the judges will have an idea of uncertainty; even if the legal norms of the judicial decisions are clear and the facts are clearly defined, the judicial officials may be subject to internal bias, the trade-off between morality and law, and the influence of public opinion, and also reveals the idea of uncertainty. Figure 2 shows the main

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manifestation of the uncertainty in terms of fact reasoning, legal reasoning, and decision reasoning in judicial decision. Among them, the uncertainty of fact reasoning includes that of causal connection and factual reasoni ng; the uncertainty of legal reasoning includes that of legal norms and legal interpretation; the uncertainty of decision reasoning includes that of statutory law and judge-made law, etc. Figure 3 shows the causes of uncertainty in judicial decisions, including the uncertainty of natural language, the limitations of legislation, the non – self-sufficiency of the legal system, and the subjective factors of judges.

Psychological analysis of uncertainty thought

The psychological analysis of uncertainty thought mainly includes the acquisition of psychological knowledge, the establishment of

psychological ideals, the cultivation of psychological emotions, the occurrence of psychological will and the establishment o f psychological beliefs. Due to the interaction of life experience and sociality, people will gradually integrate effective information into their existing psychological cognition and assimilate this information. The formation of uncertainty thoughts is related to human maturity, social activities and judicial activities. Among them, social activities have a more significant influence, because people's judicial psychological cognition depends on social interaction. From the perspective of cognitive psychology, the idea of uncertainty originates from the process of people pursuing justice, maintaining order and realizing the rule of law. Through long-term judicial research, the certainty of pursuing judicial decisions is mainly to satisfy the rules of conduct of all parties.

Figure 2. The main manifestation of the thought of uncertainty in judicial decision

The main performance of

the uncertainty thought

of judicial decision

Uncertainty of fact

reasoning

Uncertainty of

legal reasoning

Uncertainty in

decision reasoning

Philosophical questioning of

uncertainty in fact reasoning

Judicial analysis of uncertainty

in fact reasoning

Uncertainty of legal norms

Uncertainty of legal

interpretation

Uncertainty of decision

reasoning in statutory law

Uncertainty of decision

reasoning in judgment method

Diversity of the meaning of facts

Causal probability

Non-reproducibility of objective facts

The tailorability of normative facts

Legal doubts

Legal loopholes

Creativity of legal interpretation

Openness of legal interpretation

Figure 3. The causes of uncertainty thought in judicial decision

The causes of

uncertainty thought in

judicial decision

Uncertainty of natural language

Limitations of legislation

Insufficiency of the legal system

Subjective factors of judicial officers

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SIGNIFICANCE AND COUNTERMEASURES OF

IDEOLOGICAL UNCERTAINTY IN JUDICIAL DECISION

Theoretical analysis of judicial decisions and significance of ideological uncertainty

A complete judicial decision includes not only statutory judicial interpretations, but also interpretations given in the application of law and of the judge's authority. Current legislation and judicature are independent systems, and uncertainties arisen in the judicial process is placed above the will of the legislator. Ta ble 2 lists the current choice and reasons for rural dispute resolution; if people want to spend less time, they will choose cadre mediation to solve privately; if they want to spend the least, most will choose cadre mediation; if they prefer a more satisfactory solution, judicial decisions will be more effective through lawsuits. The judicial decision process must have clear objectives, strong feasibility and legal interpretation applicability. Figure 4 shows the logical diagram of the judicial decision behaviour management theory. If judicial decision -making behaviour management needs to follow the deductive logic from value to fact, the intrinsic logical relationship between legal value research and judicial form research cannot be ignored. Figure 5 shows the role of legal facts in judicial decisions. The judicial decision process needs to support facts by evidence; legal facts are formed through legal evaluation and legal tailoring, and then filed as the factual basis and premise of judicial decision. A complete judicial decision process also includes repetitive confirmation of the case facts and the outcome of the ruling based on legal normative logic, where repetitive confirmation is the last link in the decision reasoning.

Table 2. Choice and reasons of dispute resolution ways in rural areas

Lawsuit Cadre mediation

Compounding in private

Minimum time-

consuming

9.39% 45.23% 45.23%

Spend least 9.12% 51.92% 37.06% Successful

solution 48.29% 34.84% 17.97%

Figure 4. Schematic diagram of the theoretical management of judicial adjudication

Judicial

justice

Judicial

decision

behavior

Social needs

Judicial adjudication

Judging mechanism

Judge Motivation

Judge competence

Decision-making process

Influencing factor

Rule control

Conflict of responsibility

Judge experience

Social expectations

Judicial

management

measures

Compliance with applicable rules of law

Human resource management of judges

Judicial macro-management system

Court internal management system

Figure 5. The role of legal facts in judicial adjudication

Influence and countermeasure of

uncertainty in judicial decisions The judicial decision process is a logical

inference process, but this process is incomplete, thereby resulting in uncertainty. China's legislative institutions and judicial organs have different powers. The law can only be interpreted by the legislature, which leads to the fact that the judicial organs do not have universal inevitability in legal norms. Moreover, the facts of the case are probabilistic, so, for many times there exists no reasoning of an implication relationship between the preconditions and conclusions, seriously affecting the fairness and justice of the judiciary. The uncertainty of judicial decisions is relative and objective. Just because of the existence of

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relative situations or the amplification of objective conditions, its negative impact on the judicial system is very large, which will definitely bring unreasonable and unacceptable judgment to the parties, and make them suffer the loss of material, spirit, and even life. Figure 6 shows the legal normative process of judicial process. Clear rules are selected through the legal norm system and legal rules, and used to explain the rule of legal interpretation in the broad sense and select appropriate legal principles.

The uncertainty of judicial decisions should be reduced from the aspects of legislation, legal application procedures, judges' personal emotions and qualities, and publicity and education. Legislation should be forward – looking; laws and regulations should be formulated and updated in a timely manner to adapt to the changing realities of society. Furthermore, legislation should be as specific and operational as possible. The legal procedures should be initiated to limit the will of the judges and reduce their subjective psychology in the judicial decision process. From the perspective of subjective cognitive psychology, the judicial decision is the discretion of the judge; although the whole process is based on law and facts, ultimately it depends on the psychological role of the judges. Therefore, more stringent reforms must be carried out in the election and appointment system and procedures of the judges, and external supervision and institutional constraints on the judges should be strengthened so that the discretion of the judges is within the scope permitted by law and procedures. Strengthening the publicity of the legal and judicial process is an important measure to improve the judicial and legal cognition of the whole people. Only by enabling the whole people to understand the law and obey the law can the number of judicial decisions be greatly reduced, thereby reducing the uncertainty of judicial decisions.

Figure 6. The legal process of judicial adjudication

Legal

norm

system

Legal

rule

Clear

rules

A broad

interpretation

of the law

after the rule

Legal

principles

Legal norm proposition

CONCLUSIONS

Based on the theory of cognitive psychology, this paper explores the uncertainty in the process of judicial decision and gives corresponding countermeasures. The specific conclusions are as follows:

(1) Judicial lectures, seminars, reading clubs, and legal columns have all become widely used forms of law so that people are always in contact with the law and obey the law, which greatly promotes the cultivation of people's judicial cognition;

(2) The uncertainty in judicial decision is mainly reflected in the uncertainty of fact reasoning, the uncertainty of legal reasoning and the uncertainty of decision reasoning. Its causes include the uncertainty of natural language, the limitations of legislation, the non -self-sufficiency of the legal system, and the subjective factors of the judge;

(3) The idea of uncertainty arising in the judicial process is placed above the will of the legislator. The management of judicial decision – making must follow the deductive logic from value to fact, and the judicial decision process needs to support the facts by evidence; through legal evaluation and legal tailoring, legal facts are formed and then filed a as the factual basis and premise of judicial decisions;

(4) The uncertainty of judicial judgment is relative and objective. Measures should be formulated from the aspects of legislation, legal application procedures, judges' personal emotions and qualities, publicity and education, etc., to reduce the emergence of the uncertainty in judicial decisions.

Acknowledgement

This paper is supported by the National Social Science Fund of China: The theory of interior administrative act’s exteriorization , No. 14CFX011.

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Brinkman, J. T. (2017). “Thinking like a lawyer” in an uncertain world: The politics of climate, law and

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risk governance in the united states. Energy Research & Social Science, 34, 104-121.

Cunliffe, E. (2014). Judging, fast and slow: using decision-making theory to explore judicial fact determination. The International Journal of Evidence & Proof, 18(2), 139-180.

Davies, A. (2012). State liability for judicial decisions in European union and international law. International and Comparative Law Quarterly, 61(3), 585-611.

Emma, M. N. J., & Mcnaught, A. (2016). Exploring decision making around therapist self-disclosure in cognitive behavioural therapy. Australian Psychologist, 53(1), 33-39.

Flanagan, B., & Ahern, S. (2011). Judicial decision- making and transnational law: A survey of common law supreme court judges. International and Comparative Law Quarterly, 60(1), 1-28.

Foxall, G. R. (2004). What judges maximize: toward an economic psychology of the judicial utility function. Liverpool Law Review, 25(3), 177-194.

Rand, E. J. (2015). Fear the frill: Ruth Bader Ginsburg and the uncertain futurity of feminist judicial dissent. Quarterly Journal of Speech, 101(1), 72- 84.

Shapiro, D. L., Mixon, L. K., Jackson, M., & Shook, J. (2015). Psychological expert witness testimony and judicial decision making trends. International Journal of Law and Psychiatry, 42- 43, 149-153.

Soboleva, A. (2013). Use and misuse of language in judicial decision-making: Russian experience. International Journal for the Semiotics of Law- Revue internationale de Sémiotique juridique, 26(3), 673-692.

Stone, A. (2010). Democratic objections to structural judicial review and the judicial role in constitutional law. University of Toronto Law Journal, 60(1), 109-135.

Vlek, C. (2010). Judicious management of uncertain risks: ii. simple rules and more intricate models for precautionary decision-making. Journal of Risk Research,13(4), 545-569.

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Building a Testing-Based Training Paradigm From Cognitive Psychology Principles

Daniel Corral, Alice F. Healy, Erica V. Rozbruch, and Matt Jones University of Colorado Boulder

Cognitive psychology often produces findings that are relevant to educational instruc- tion. However, many of these studies rely on artificial conditions, which often fail to transfer to realistic settings, resulting in a disconnection between cognitive psychology and education. This article begins to address this issue by taking established principles from cognitive psychology and applying them to teach participants real academic concepts. We report a training paradigm that applies established principles from cognitive psychology: retrieval practice, feedback, self-paced studying, cognitive an- tidote, and levels of processing. This paradigm was used to teach undergraduates basic concepts of research design that are typically taught in university science courses. Participants studied PowerPoint-style slides that were divided into three sections. At the end of each section, participants were presented quiz questions. After each quiz response, the participant was shown the correct answer. This study also tested different forms of responding to quiz questions (between subjects): (a) fill-in-the-blank, (b) multiple-choice, and (c) fill-in-the-blank followed by a multiple-choice version of the same question. Participants completed two posttests, one immediately after training and another 1 week later. Both posttests consisted of items that tested retention and conceptual understanding. A control condition (wherein participants received no train- ing) was used to assess the effectiveness of the training paradigm. Participants who used this paradigm outperformed control participants on both posttests. However, no differences in performance were found among participants who used different forms of responding.

Keywords: retrieval practice, complex concept acquisition, technology-based learning and instruction, translational research

Supplemental materials: http://dx.doi.org/10.1037/stl0000146.supp

One of the primary challenges in education is finding effective methods that increase stu- dents’ retention and comprehension of course material. Factors that facilitate learning are thus of great interest to instructors. Over the past 70 years, many findings from cognitive psychology

have shed light on this goal. This work has led to the discovery of various learning principles (e.g., correct-answer feedback: Benassi, Over- son, & Hakala, 2014; self-paced study: Ariel, 2013; cognitive antidote: Healy, Jones, Lal- chandani, & Tack, 2017; levels of processing: Craik & Lockhart, 1972). One of the most ro- bust findings from cognitive psychology is that retrieving information from memory improves the retention of the information that was re- trieved (formally known as retrieval practice; Carrier & Pashler, 1992; Kang, Gollan, & Pa- shler, 2013; Kang & Pashler, 2014; Karpicke & Roediger, 2008; Pan & Rickard, 2018; Pyc & Rawson, 2010; Roediger & Butler, 2011; Roe- diger & Karpicke, 2006a, 2006b). Specifically, work on the testing effect has demonstrated that

This article was published Online First June 6, 2019. Daniel Corral, Alice F. Healy, Erica V. Rozbruch, and

Matt Jones, Department of Psychology and Neuroscience, University of Colorado Boulder.

This research was supported by National Science Foun- dation Grant DRL1246588.

Correspondence concerning this article should be ad- dressed to Daniel Corral, who is now at Department of Psychology, Iowa State University, W112 Lagomarcino Hall, Ames, IA 50011. E-mail: [email protected]

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testing learners on previously studied material (i.e., retrieval practice) often leads to better learning and retention than having them restudy that material (Butler, Black-Maier, Raley, & Marsh, 2017; Carpenter & Yeung, 2017; Eg- lington & Kang, 2018; Lehman & Karpicke, 2016; Pan & Rickard, 2018; Rickard & Pan, 2018). Retrieval practice has also been shown to aid learning in the classroom, as students who engage in retrieval practice, either through in- class clicker questions (Anderson, Healy, Kole, & Bourne, 2011, 2013; Mayer et al., 2009) or online practice quizzes (Carpenter et al., 2017; Corral, Carpenter, Perkins, & Gentile, 2019), often demonstrate better learning and retention than students who do not engage in these tasks.

On the other hand, many findings from cog- nitive psychology that appear to be relevant to education are often not translated to the class- room (Horvath, Lodge, & Hattie, 2017; Roedi- ger, 2013). One reason for this lack of cross- fertilization may be that cognitive psychology studies often use artificial learning tasks and materials (e.g., participants are asked to learn to distinguish among simple geometric figures; e.g., Corral, 2017; Corral & Jones, 2014; Corral, Kurtz, & Jones, 2018) that are not representa- tive of the concepts that are taught in the class- room (e.g., a physics professor teaching the concept of buoyancy). The use of artificial con- ditions and simplified stimuli and concepts is fairly common in cognitive psychology and may lead instructors to view findings from such studies with skepticism, as it may seem unlikely that a given effect will hold under more ecolog- ically valid conditions (Horvath et al., 2017; Oliver & Conole, 2003; Smeyers & Depaepe, 2013).

Adapting laboratory studies to real-world set- tings is a common issue in translational science— the application of laboratory findings to real- world settings—as researchers often struggle to apply findings from basic and theoretical re- search to real-world scenarios (Horvath et al., 2017; Oliver & Conole, 2003; Smeyers & De- paepe, 2013; Roediger, 2013; Woolf, 2008). One potential issue is that cognitive psychology studies typically use rigorous methodology to isolate the variable(s) of interest. Although this approach is appropriate for controlled scientific studies, it might not be conducive to translation in the classroom, which often involves many additional facets beyond what is required in a

laboratory experiment (Horvath et al., 2017; Oliver & Conole, 2003; Smeyers & Depaepe, 2013).

For example, although retrieval practice might aid learning and retention (Carrier & Pa- shler, 1992; Kang et al., 2013; Kang & Pashler, 2014; Pan & Rickard, 2018), an instructor might not know how to implement this principle in the classroom, as translation requires the in- structor to make various decisions about how to implement numerous facets of retrieval practice. In particular, an instructor must decide what type of retrieval practice to provide students (e.g., recall vs. recognition), when to present retrieval practice during a lecture (e.g., beginning of lec- ture vs. interspersed throughout lecture vs. end of lecture), as well as the type of feedback students should be presented after retrieval practice (e.g., no feedback vs. correct-answer feedback). As this example illustrates, each of these components offers the instructor an op- portunity to translate different learning princi- ples to the classroom, but this flexibility can produce uncertainty about when and how to apply these principles, and might thus make translation rather difficult.

Given these challenges, one way forward might be to develop a training paradigm that fully specifies each of its facets. The efficacy of this paradigm could then be tested in the laboratory with ecologically valid learning materials. With this aim in mind, the current article takes well- established learning principles from cognitive psychology and integrates them with current instructional practices that are used in the class- room to develop a training paradigm that can be easily implemented by educators to supplement instruction. We therefore build a training para- digm around retrieval practice, one of the most reliable principles in cognitive psychology (Roediger, 2013), and specify and include ad- ditional learning principles for each of its facets. Specifically, this training paradigm incorporates the following four learning principles: (a) re- trieval practice, (b) correct-answer feedback, (c) self-paced study, and (d) cognitive antidote. Correct-answer feedback involves showing par- ticipants the correct answer after they respond, and self-paced study allows them to control the time they spend studying. Cognitive antidote includes the idea that boredom or disengage- ment can be offset by alternating the tasks that learners complete, wherein two or more tasks

190 CORRAL, HEALY, ROZBRUCH, AND JONES

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are interspersed (as opposed to completing one task in its entirety and then the other).

These principles were selected for two rea- sons. The first reason is that each of these prin- ciples has been shown to aid learning and re- tention across numerous studies (e.g., retrieval practice: Brame & Biel, 2015; Carpenter, Pash- ler, & Cepeda, 2009; Carpenter & Yeung, 2017; Dunlosky, Rawson, Marsh, Nathan, & Willing- ham, 2013; Roediger & Butler, 2011; Rowland, 2014; correct-answer feedback: Benassi et al., 2014; Butler, Karpicke, & Roediger, 2007; Mc- Daniel, Anderson, Derbish, & Morrisette, 2007; Pashler, Cepeda, Wixted, & Rohrer, 2005; Vo- jdanoska, Cranney, & Newell, 2010; self-paced study: Ariel, 2013; de Jonge, Tabbers, Pecher, Jang, & Zeelenberg, 2015; Tullis & Benjamin, 2011; and cognitive antidote: Chapman, Healy, & Kole, 2016; Healy et al., 2017; Kole, Healy, & Bourne, 2008). The second reason is that by applying one of these principles for each facet that is involved in translating retrieval practice to a real-world paradigm we are able to fully specify this process (as discussed in detail in the Experiment and Training Paradigm and Method sections), which might greatly aid instructors in using or adapting this training paradigm.

It is important to note that none of these principles were manipulated between experi- mental groups, as our primary goal was to ex- amine the efficacy of the paradigm as a whole as compared to a control group that benefited from none of the training principles. This approach highlights an important distinction between lab- oratory studies and translational research. Lab- oratory studies take a reductionist approach, as their typical goal is to isolate underlying mech- anisms for a given phenomenon. In contrast, the goal of translational research is to produce a working, integrated system. As the example on translating retrieval practice demonstrates, translation is a complex process that involves multiple facets (Horvath et al., 2017; Oliver & Conole, 2003; Smeyers & Depaepe, 2013; Roe- diger, 2013; Woolf, 2008). Translation of a given learning principle is therefore likely to involve a multifaceted, complex training para- digm. Moreover, it is not clear that when a learning principle is translated and embedded within a larger system that any given compo- nent will aid learning, as it is possible that the different parts of the paradigm do not work well together and might offset or counteract the ben-

efits of any single component. For these rea- sons, it is essential for translational research to take a more holistic approach and examine whether a training paradigm as a whole im- proves learning.

However, as a secondary question, we exam- ine whether manipulating mode of responding (i.e., type of retrieval practice), which is integral to implementing retrieval practice, produces differential learning and retention across exper- imental groups. One possibility is that how par- ticipants respond to a given question affects the extent to which they encode its information. Thus, a fifth principle we incorporate into our training paradigm (by manipulating form of re- sponding) is levels of processing—the extent to which connections are formed between the in- formation that is encoded and long-term mem- ory (LTM; Craik & Lockhart, 1972; Craik & Tulving, 1975).

Recognition Versus Recall

When an instructor translates retrieval prac- tice to a real-world setting, he or she must decide what type of retrieval practice to use. Many studies on retrieval practice (e.g., Butler et al., 2017; Carpenter, 2009; Carpenter & Yeung, 2017) involve recall, wherein partici- pants must generate a response from memory. However, other forms of responding are possi- ble, such as selecting an answer from a list of multiple-choice options, a process that often relies on recognition memory (Jacoby, 1991).

Recognition and recall are two distinct mem- ory processes by which people access informa- tion from LTM (Kintsch, 1970). In a recogni- tion task, participants are presented with a given item and are asked to determine whether or not it matches information that was previously en- countered, as is often the case for multiple- choice questions. When students are presented with a multiple-choice question, they must se- lect the correct response from a list of options. The option that is selected is often determined by whether the student recognizes the given option as correct or finds it more familiar than other options (Marsh, Roediger, Bjork, & Bjork, 2007; see also Bjork, Little, & Storm, 2014; Little & Bjork, 2015). Likewise, in stud- ies on recognition memory, participants are typ- ically presented with a list of items and are asked to memorize them within an allotted pe-

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riod of time. At testing, participants are pre- sented with a series of items and are asked to select which of those items were on the studied list. Similar to multiple-choice responding, the items that are selected in a recognition memory task are those that participants recognize or find most familiar (Kahana, 2012).

In contrast to this process, recall involves the retrieval of information from LTM, as is often the case for fill-in-the-blank questions. Fill-in- the-blank questions require students to provide a short response by recalling information from LTM. The process of generating a response is often more challenging than recognizing a pre- viously encountered item (Anderson & Bower, 1972; Kintsch, 1970). As a result of this gener- ation, recall has been posited to lead to deeper encoding—a greater number of connections are formed between the information that was probed in LTM and the information that was recalled—than does recognition, which can con- sequently improve retention (Hogan & Kintsch, 1971).

The differential effects of recall and recogni- tion responding have been well documented in many memory experiments, but the manner in which they affect learning and transfer of knowledge is less clear. One prediction that follows directly from the experimental psychol- ogy literature is that, because questions that require recall processes (i.e., fill in the blank) lead to deeper encoding (Hogan & Kintsch, 1971; Kintsch, 1970), recall will produce supe- rior learning. Another prediction is that engag- ing in both of the retrieval processes (recall followed by recognition) will produce cumula- tive effects, thus leading to better learning and retention than either recall or recognition alone.

We tested these predictions by examining whether there are learning differences (mea- sured through performance scores at testing) between participants who are trained by engag- ing in retrieval practice that invokes recognition versus recall. We also examined whether engag- ing in both recall and recognition, wherein par- ticipants first attempt recall followed by recog- nition, can aid learning and retention above and beyond engaging in only one of these retrieval processes.

The comparison among these three experi- mental groups (recall, recognition, and recall- then-recognition) complements the main ques- tion of this study, which is a comparison of all

three of these groups to the control group. For this latter comparison, participants in the exper- imental groups were predicted to demonstrate better learning and retention than participants in the control group.

Experiment and Training Paradigm

We conducted a study to examine whether our training paradigm can be used to aid stu- dents in learning core scientific concepts that are typically taught in university-level statistics and research methods courses. These materials were chosen due to their direct relevance to all scientific fields (because these fields rely on sound research methodology), and thus wide applicability to education and instruction.

Three groups of undergraduate students, re- ferred to as the experimental groups, were trained under our paradigm. These groups var- ied only in the type of retrieval practice partic- ipants were given (recall vs. recognition vs. recall-then-recognition). Participants were first asked to study PowerPoint-style slides (in- cluded in the online supplemental materials) that were divided into three sections. Although the range of times participants were required or allowed to spend on each section was deter- mined before the study (explained further in the Procedure), within these time restrictions par- ticipants could choose how long they studied each slide within a given section (a form of self-paced studying). At the end of each section, participants were quizzed on the material for that section (thus, we implement the cognitive antidote principle by alternating between study and retrieval practice) and after each response were shown the correct answer (correct-answer feedback). These participants completed two posttests, one immediately after training and another 1 week later. It is important to note that the first posttest affords participants in the ex- perimental conditions additional retrieval prac- tice, which might further benefit learning (But- ler et al., 2017; Carpenter & Yeung, 2017; Eglington & Kang, 2018; Lehman & Karpicke, 2016; Pan & Rickard, 2018). For this reason, the first posttest can be viewed as another facet of the training paradigm.

Participants in a separate, control condition did not receive any training (i.e., were not shown any study materials or presented with any quiz questions) and were only asked to

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http://dx.doi.org/10.1037/stl0000146.supp

complete a single test, which was identical to the second posttest that participants who re- ceived the training paradigm completed. Post- test performance was compared between the control group and the trained groups.

The control condition was used to assess whether participants in the experimental condi- tions were indeed able to learn the concepts that were trained, as this condition provides a base- line measure of participants’ knowledge of the material. Although extensive work has shown that retrieval practice can indeed aid retention (e.g., Carpenter et al., 2009; Carrier & Pashler, 1992; Dunlosky et al., 2013; Kang et al., 2013; Karpicke & Roediger, 2008; Pyc & Rawson, 2010; Roediger & Butler, 2011; Roediger & Karpicke, 2006a, 2006b), most of this literature is limited to direct memorization and does not typically involve true concept learning. More- over, the limited work that has been conducted on this topic has yielded inconclusive results, as some of this work has shown a modest benefit of retrieval practice and testing on concept learning and transfer (Butler, 2010; Butler et al., 2017; Eglington & Kang, 2018; Pan & Rickard, 2018), but other studies have failed to replicate this finding (Peterson & Wissman, 2018; Tran, Rohrer, & Pashler, 2015; van Gog & Kester, 2012; Wissman, Zamary, & Rawson, 2018). It is therefore an empirical question as to whether these principles can be used to help people learn ecologically valid, complex concepts.

The three trained groups were defined ac- cording to the format in which they were quizzed during training: recall, recognition, and recall-then-recognition. Participants in the rec- ognition condition were provided with multiple- choice quiz questions, and participants in the recall condition were provided with fill-in-the- blank quiz questions. Participants in the recall- then-recognition condition responded to each quiz question twice, first with a fill-in-the-blank response and then with a multiple-choice re- sponse (multiple-choice options were shown only after the first response was given). This ordering was necessary to keep the multiple- choice options from contaminating the recall process for a given question, as the multiple- choice options might serve as memory cues for the correct response, and thereby trivialize the recall process.

Method

Participants

One hundred eighty-three undergraduate stu- dents participated for course credit in an intro- ductory psychology course at the University of Colorado Boulder. This population consists pri- marily of freshmen and contains approximately 45% women and 71% White students, with an average age of 20 (5% of the students are 25 years of age or older); 17% of this population is classified as low-income students. One hundred fifty-four of these participants were randomly assigned to three experimental conditions (be- tween subjects): recall only (n � 51), recogni- tion only (n � 51), and recall-then-recognition (n � 52). The other participants (n � 29) were sampled concurrently from the same population and were assigned to the control condition. True random assignment was not possible because the online system participants use to sign up for studies requires that one-part and two-part stud- ies (such as our control and experimental con- ditions, respectively) be posted as separate sign-up options. However, this system random- izes the order of listed studies and provides prospective participants with no information other than time and location, which allows for a degree of random assignment. Thus there is a mild self-selection issue, because participants who chose to sign up for one- and two-part studies might differ from one another (although all students were subject to the same class re- quirement of 6 hr of total research participation that semester). However, we stress that the number of sessions participants signed up for was the only difference in sampling procedure between the experimental and control condi- tions.

Design and Materials

All materials (instructions, study slides, and quiz and posttest questions) were presented on a computer monitor and were shown on a black background. All responses were entered using a computer keyboard. The training session con- sisted of PowerPoint-style slides that were mod- ified from an undergraduate statistics lecture, which covered basic principles of research methods. These slides were adapted to exclude extraneous information, and each slide was care-

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fully checked by the authors to ensure that each concept was fully explained. These slides cov- ered 16 concepts, which were divided into three sections, and each section followed a concep- tual progression (see Table 1). Section 1 (Slides 1–2) introduced the basic components related to scientific experiments. Section 2 (Slides 3– 6) introduced issues related to causal inference and nonexperimental studies. Section 3 (Slides 7–10) introduced methods that true experiments use to control for confounding variables and other related topics. Figure 1 shows an example study slide, Slide 9 from Section 3 in the train- ing session.

Question types. Five question types were created for this study: (a) repeated, (b) defini- tional, (c) transfer, (d) analysis, and (e) appli- cation; all test items for each question type are provided in the online supplemental materials. These question types were divided into two subsets. We refer to Question Types 1–3 as core questions and Question Types 4 –5 as concep- tual questions. The immediate posttest com- prised eight questions from each of Types 1–3. The retention test comprised eight different questions from each of Types 1–3, and 14 ques- tions from each of Types 4 –5.

Core questions. To increase the chance that condition differences would be detected, the core questions were pilot tested with two dif- ferent groups to ensure that no ceiling or floor effects were present; these participants were not trained on these materials. The first round of pilot testing was conducted with paid subjects from the university’s paid subject pool and the second with undergraduate students (within the first few weeks of the semester) in an upper division psychology course on research meth- ods. Given the course content, the participants in this latter group should have some back-

ground with these materials, and thus likely represent a more knowledgeable sample than the introductory psychology students who par- ticipated in the main experiment. The initial version of the core questions consisted of four multiple-choice options per question, but these materials proved too easy for students and were thus modified to be more challenging; one of these modifications was to switch from four multiple-choice options to five. This iterative process of pilot testing and revising these ma- terials was concluded once an intermediate level of performance was found (between 50 and 60%).

The core question types tested the basic con- cepts that participants encountered during train- ing. Repeated questions were identical in con- tent to the recognition version of the quiz questions that were used during the training session (see Figure 4). Definitional questions were the inverse of repeated questions: Partici- pants were shown a term and were asked to select the correct definition from the multiple- choice options, as shown in Figure 5. Transfer questions were similar to repeated questions,

Table 1 A Complete List of the Concepts and the Order in Which They Were Covered in Training

Section 1 (Slides 1–2) Section 2 (Slides 3–6) Section 3 (Slides 7–10)

1. Variables 4. Nonexperimental study 11. Independent and dependent variables 2. Hypothesis 5. Causal inference 12. Experimental control 3. Experimental study 6. Correlation 13. Confounds

7. Reverse causation 14. Random assignment 8. Third variable problem 15. Quasi-independent variables 9. Self-selection 16. Addressing confounds

10. Manipulation

Figure 1. Study Slide 9 from Section 3 of the training session.

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but the description of the tested term was grounded in a hypothetical scenario (as shown in Figure 6).

Each of the core questions thus provides a different measure of retention. Repeated ques- tions provide a direct measure of retention, as these questions can be answered correctly through rote memorization of the content that was trained and quizzed. Definitional questions measure whether participants can transfer their memory of the training material to the inverse of the concepts that were quizzed (i.e., matching a given term to the correct definition instead of matching a given definition to the correct term). In contrast, transfer questions provide a more robust measure of concept learning and transfer than definitional questions, in that they require participants to recognize the instantiation of a given concept in a superficially different sce- nario than what was encountered in training. Moreover, the transfer questions did not explic- itly define the corresponding concept (as the repeated and definitional questions did), and thus recognizing these concepts required that the participant actually comprehends their meaning. Transfer questions therefore provide a measure of both retention and concept learning, as these questions require participants to re- member a concept’s definition and comprehend its meaning.

Sixteen items were constructed for each core question type (i.e., repeated, definitional, and transfer), one covering each of the 16 concepts that were introduced during training (as dis- cussed in the first paragraph of the Design and Materials). Thus, there was a one-to-one corre- spondence among the three core question types in terms of the concepts they tested. For pur- poses of explaining the experimental design, we refer to the questions of each core question type as numbered 1–16, following the numbering of training concepts (see Table 1). For example, Question 8 tested the concept of the third- variable problem for all three question types. Core questions for each posttest were sampled using this numbering, as discussed in the fol- lowing paragraph.

The core questions were divided into two equal subsets. Each experimental participant completed one of these subsets during the im- mediate posttest and the other subset during the delayed posttest, with this assignment counter- balanced across participants within each exper-

imental condition. One subset covered even- numbered repeated questions and odd- numbered definitional and transfer questions; the other subset covered odd-numbered re- peated questions and even-numbered defini- tional and transfer questions. Thus for each posttest, repeated questions covered different concepts than did transfer and definitional ques- tions, whereas transfer and definitional ques- tions covered the same concepts. Because def- initional and repeated questions were the inverses of each other, this design avoided pre- senting participants highly similar questions on a given posttest.

Conceptual questions. Conceptual ques- tions consisted of 14 analysis and 14 application questions.1 The two conceptual question types (i.e., analysis and application) tested abstract principles that were not directly covered or quizzed during training, but which could be inferred with a sufficient conceptual grasp of the training material. Each of these questions con- tained a detailed description of a hypothetical experiment. Analysis questions required partic- ipants to determine which confounding vari- able(s), if any, were present (Figure 7 shows an example of an analysis question). Application questions required participants to determine how to eliminate confounding variables, if any were present (Figure 8 shows an example of an application question). Half of the analysis and application questions contained confounding variables, and half did not.

Conceptual questions thus tested the extent to which participants grasped the principles of sound research methodology, internal validity, and true experiments. These topics were chosen because they are of primary importance in re- search methods courses, and these questions examine the extent to which participants can transfer and apply the knowledge they acquired during training to complex study scenarios. For example, the question in Figure 7 examines whether participants can recognize the specific confounding in the hypothetical study scenario. Such recognition requires a strong grasp of the concepts of confounding, experimental manip-

1 Conceptual questions were not included on the first posttest so that we could administer them on the retention test (1 week later) to assess participants’ comprehension of the materials.

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ulation and control, true experiments, and inter- nal validity. Correctly answering these ques- tions therefore involves more than simply memorizing a given definition. For these rea- sons, conceptual questions provide a strong measure of concept learning and far transfer.

Procedure

Participants in the experimental training groups participated in two sessions, each lasting a maximum of 55 min. At the start of the study, these participants were told they would be shown slides that contained information about basic scientific principles.

Training session. The training session was partitioned into three sections. Participants were instructed to study each slide carefully, as they would be tested on the material later in the experiment. The study slides were shown one at a time at the center of the screen. A participant could view the next slide by pressing the right arrow key and the previous slide by pressing the left arrow key. Below each slide, a counter indicated which slide number the participant was viewing out of the total number of slides contained in the section, as well as which sec- tion the participant was working on (e.g., Sec- tion 2, Slide 2 out of 4). Participants could view slides only from the section they were studying and could not move ahead prematurely to the next section or return to a previous section once it was complete.

Navigating each section. Minimum and maximum time limits were implemented for each section, based on the number of slides contained in the section. These time constraints were meant to partially simulate real-world study conditions in which students are required to learn multiple concepts within a limited time frame. In such cases, students must devote a sufficient amount of study toward each concept to learn all the concepts, but must also balance the amount of time they allocate toward any single concept. Under such circumstances learn- ers can control the amount of time they spend studying any given concept (as in the present study).

At the start of each section, a prompt showed the participant the number of slides that were contained in the section and the maximum study time that would be allowed. Time limits were set to allow an average study time of 2.5–3.5

min per slide. This range was intended to ac- commodate a wide spectrum of preferred pacing across different students. Section 1 contained two study slides and Sections 2–3 each con- tained four. Section 1 ran for 5–7 min, and Sections 2 and 3 ran for 10 –14 min each.2

If participants attempted to move past the last slide in a section before the minimum study time had been reached, the screen was cleared and a prompt instructed them to return to the last slide by pressing the spacebar and to con- tinue studying for at least the minimum duration of time that remained in the section. Once a section’s minimum study time was reached, the screen was cleared and a prompt was presented that gave the participant the option of exiting the study phase by pressing the Enter key or continuing to study and returning to the slide they were previously viewing by pressing the spacebar. If participants elected to continue studying, they could continue navigating be- tween slides by pressing the left- and right- arrow keys. Once a section’s maximum time was exceeded, the screen was cleared and a prompt instructed the participant to press the spacebar to exit the section and continue to the quiz.

Quiz instructions. After studying each sec- tion, participants were given a self-paced rest break and were notified that they would be quizzed on the material that was covered in the section they had just completed. After complet- ing their study of the slides in the first section, all participants were provided specific details on the format of quizzes they were going to be administered. Participants in the recall condi- tion were instructed that they would need to type in a response for each quiz item. Partici- pants in the recognition condition were in- structed that they would be given a multiple- choice quiz and would be required to select a response for each quiz item. Participants in the recall-then-recognition condition were in- structed that they would be shown two versions of the same question for each quiz item—a fill-in-the-blank version followed by a multiple- choice version—and would need to respond to each accordingly. Additionally, after respond- ing to the first fill-in-the-blank question, these

2 These time limits were used to accommodate the con- straints of running a laboratory experiment.

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participants were shown a prompt reminding them they would be presented with two versions of each question throughout the quiz. All par- ticipants were asked to press the spacebar when they were ready to begin the quiz.

Quiz questions. Quiz questions were pre- sented at the end of each section, which queried the material for that section. Sections 1–3 con- tained three, seven, and six quiz questions, re- spectively (one per concept covered). The dis- play for all quiz and posttest questions included a text box, located directly beneath the question, where participants were asked to enter their responses. Each quiz question consisted of a description of a given term, and participants were required to either type the correct term (recall-only, as shown in Figure 2), select the correct term from a list of five multiple-choice options (recognition-only, as shown in Figure 3), or complete both of these tasks in succession (recall-then-recognition). For each quiz ques- tion in the recall-then-recognition condition, the participant was first provided with a fill-in-the- blank form of the question (as in Figure 2), followed by the same question in multiple- choice format (as in Figure 3).

Correct-answer feedback. After typing in a response, participants were required to press the enter key (this was also required for both posttests). Participants were then shown the cor- rect answer at the bottom of the display. In all experimental conditions, only the correct an- swer was shown; the corresponding letter op- tion was not displayed for multiple-choice items. Thus the feedback was identical in all conditions, matching verbatim the correct alter- native from the multiple-choice version of the question. For the recall-then-recognition condi-

tion, participants were not shown the correct answer until after they entered their second re- sponse, on the multiple-choice version of the question. After being shown the correct answer, participants were asked to press the spacebar when they were ready to move on to the next question. There was a 300-ms interval follow- ing the feedback for each question on the quiz (as well as each question on both posttests).

Immediate posttest. All questions in both posttests were presented in multiple-choice for- mat to explicitly test recognition learning, which is a common form of assessment in the classroom. The immediate posttest comprised 24 core questions, which were presented in a random order (different for each participant). After completing the immediate posttest, partic- ipants in the experimental conditions were thanked for their participation and reminded that they would be required to return in 7 days.

Delayed posttest. The delayed posttest consisted of 52 questions and followed the same procedure as the immediate posttest. Upon re- turning, participants in the experimental condi- tions were notified that they would be tested on

Figure 2. An example fill-in-the-blank quiz question. The correct response is self-selection.

Figure 3. An example multiple-choice quiz question. The correct response is option a.

Figure 4. An example from the repeated question type (identical to the recognition version of questions given during training). The correct response is option a.

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the material that was covered in the first session of the experiment (i.e., the previous week). The delayed posttest was partitioned into two sec- tions. The first section consisted of 24 core questions (the subset not used in that partici- pant’s immediate posttest, as explained in the Design and Materials section), and the second section consisted of all 28 conceptual questions. The order in which questions were presented within each section was randomized, separately for each participant.

Control group. Participants in the control condition were notified that they would be given a test on basic scientific principles. These partici- pants were only asked to complete a single test, which was identical to the delayed posttest that participants in the experimental conditions com- pleted. The rest of the procedure was identical to the second session that participants in the experi- mental conditions completed. Because there were two versions of this test, the version that was completed by each control participant was ran- domly selected, subject to the constraint that half of these participants completed one version and the other half completed the other version.

Results

Nine experimental participants were excluded from the analyses because they did not return for the second posttest (two from the recall-only con- dition, three from the recall-then-recognition con- dition, and four from the recognition-only condi- tion), leaving 174 total participants.

It is important to note that core and concep- tual questions assessed different aspects of par- ticipants’ knowledge of the training material. It was possible for participants to correctly answer

core questions by directly memorizing the training material. These questions hence provide a direct measure of retention. In contrast, conceptual ques- tions tested participants’ conceptual understand- ing, as they required participants to apply their knowledge of the training material to scenarios that tested these concepts’ underlying principles. As a result, it was not possible for participants to correctly answer conceptual questions just by memorizing the training material. Participants’ performance on core and conceptual questions was therefore analyzed separately.

Experimental Conditions Versus Control Condition

First, we examined whether participants in the experimental conditions were able to learn and retain the material they studied during the training session.3 Thus, performance on the core questions (i.e., repeated, definitional, and trans- fer) was compared between participants in the experimental and control conditions.

Performance on core questions. Figure 9 shows the mean performance on each type of core question for participants in the experimen- tal and control conditions. Performance by par- ticipants in the experimental conditions on the immediate posttest exceeded control partici- pants’ performance, Mexperimental-immediate � .76; Mcontrol � .49, t(172) � 8.47, p � .001, SE � .031, d � 1.74. Experimental participants’ de- layed posttest performance also exceeded control participants’ performance, Mexperimental-delayed � .69, t(172) � 6.19, p � .001, SE � .031, d � 1.28.

Performance on conceptual questions. Furthermore, participants in the experimental conditions (M � .30) outperformed participants in the control condition (M � .23) on concep- tual questions (analysis and application ques- tions), t(172) � 2.36, p � .020, SE � .029, d � .456. It is also important to note that participants in the control condition did not perform reliably above chance (20%) on conceptual questions, t(28) � .977, p � .337, SE � .029, d � .37, whereas participants in the experimental condi- tions performed significantly above chance, t(144) � 8.43, p � .001, SE � .012, d � 1.41.

3 All reported analyses comparing the experimental and control groups meet the assumption of equal variance, as indicated by Levene’s test.

Figure 5. An example item from the definitional question type. The correct response is option e.

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Recall Versus Recognition Versus Recall-Then-Recognition

A separate analysis examined whether there were performance differences on core questions among the experimental conditions, and if so, whether such differences depended on the test and question types. This analysis was a mixed-model analysis of variance with a between-subjects fac- tor of training condition (recall only vs. recogni- tion only vs. recall-then-recognition) and within- subject factors of question type (repeated questions vs. transfer questions vs. definitional questions) and test (immediate vs. delayed).

The analysis revealed a main effect of test, F(1, 142) � 34.68, p � .001, MSE � .032, �p2 �

.196, such that participants performed better on the first posttest than on the second. There was also a main effect of question type, F(2, 284) � 114.90, p � .001, MSE � .019, �p2 � .447, as participants performed best on repeated ques- tions. Additionally, there was an interaction be- tween test and question type, F(2, 284) � 3.29, p � .039, MSE � .02, �p2 � .023, as there was a greater decrease in performance between the first and second posttest for repeated and defi- nitional questions than for transfer questions (as shown in Figure 9). No differences in perfor- mance among the experimental conditions were found, and there were no interactions between condition and question or test type (all ps � .216, including all least-significant-difference post hoc comparisons among the experimental conditions). Likewise, no performance differ- ences were found among the experimental con- ditions on the conceptual questions (p � .979). Table 2 shows the mean performance of each experimental group on each of the core question types on the immediate and delayed posttests.

Exploratory Analysis

One concern with the analyses contrasting the three experimental conditions is that they may not adequately capture true differences that might exist in conceptual understanding among these groups. Conceptual questions were meant

Figure 6. An example item from the transfer question type. The correct response is option a.

Figure 7. An example item from the analysis question type. The correct response is option b.

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to capture such differences, but the challenging nature of these questions might have obscured the effects of the experimental manipulation. As noted in the second paragraph of the Results section, repeated and definitional questions could be correctly answered by memorizing the material presented during training, and thus they allowed for an adequate measure of reten- tion but not of conceptual understanding. Al- though memorization could be used for transfer questions, doing so was more challenging be- cause these questions were presented in novel contexts from what was encountered during training, and therefore required a deeper level of understanding. More specifically, it was neces- sary for participants to understand these con- cepts well enough to recognize them in unique scenarios. Transfer questions hence provide the best measure of conceptual understanding among the three core question types.

An exploratory analysis was thus conducted on transfer questions, to further examine whether participants who engaged in recall developed a better understanding and formed more durable memories of the concepts in the study material than did participants who did not engage in recall. Because participants in the recall-only and the recall-then-recognition conditions were asked to engage in recall during training, both groups were combined for this analysis. A mixed-model analysis of variance was used to test for an interaction between type of training (between-subjects factor: recall conditions vs. recognition-only) and test type (within-subjects factor: immediate vs. delayed posttests). Com- paring the immediate and delayed tests allows for an assessment of participants’ retention and conceptual understanding of the study material.

Figure 9B shows the mean performance on transfer questions by type of training and type of test. The analysis revealed a significant in- teraction between condition and test type, F(1, 143) � 3.97, p � .048, MSE � .026, �p2 � .027, as there was less of a decrease in performance between the first and second posttests for par- ticipants who engaged in recall (Mimmediate � .657; Mdelayed � .647) than for participants who engaged only in recognition (Mimmediate � .710; Mdelayed � .620). Thus, this exploratory analysis suggests that recall quizzing produced more du- rable knowledge that was less susceptible to forgetting, at least for the transfer questions, which required more conceptual understanding than the repeated or definitional questions.

Discussion

This article presents a training paradigm that is built on the principle of retrieval practice. Translating this principle into a real-world par- adigm requires addressing multiple facets, such as how much time to allow learners to study a given set of concepts, when to include retrieval practice, what type of retrieval practice to in- clude, and whether to provide participants feed- back on their responses. At each of these deci- sion points, we fully specified the translation process by implementing findings from basic experimental psychology, regarding interspersed retrieval practice, different forms of responding, a restricted form of self-paced studying, and cor- rect-answer feedback. To briefly summarize these facets: Participants were allowed to navigate the study slides within each section, permitting them to control which slides they spent more time studying (within the allotted time for each sec- tion). Concepts were divided into three sections, and interspersed retrieval practice was used, wherein participants were quizzed at the end of each section. After participants responded to a quiz question they were provided correct-answer feedback.

It is important to note that only form of responding was manipulated among the exper- imental groups (recall vs. recognition vs. recall- then-recognition), as the implementations of the other learning principles were held constant. Manipulating all of these principles as a unit enables a holistic test of their combined effect, which is more relevant to translation than is the reductionist approach of assessing each princi-

Figure 8. An example item from the application question type. The correct response is option d.

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ple individually. Moreover, if left unspecified, each of the facets can lead to ambiguity in regards to the translation of retrieval practice to a real-world paradigm. To avoid this ambiguity impeding translation (Horvath et al., 2017; Ol- iver & Conole, 2003; Smeyers & Depaepe, 2013; Roediger, 2013), we explicitly specify each facet of our training paradigm and base our

decisions for each on the vast literatures on the learning sciences.

This training paradigm was developed with the goal that it might serve as a teaching tool that can be used to enhance student learning. Thus, we were not specifically interested in whether any one of these principles could en- hance learning on its own, as each has been

Figure 9. (A) The experimental and control groups’ mean performance on each type of core question (repeated, definitional, and transfer questions) for each posttest. (B) Mean perfor- mance for transfer questions on each posttest for the recall conditions (recall condition and recall-then-recognition condition) and the recognition condition. Error bars indicate standard errors of the mean.

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shown to do so in the context of the laboratory. Instead, our goal was to examine whether these principles could be translated into a realistic, complex learning system to aid learners in ac- quiring ecologically valid concepts, which could then be used by instructors in the class- room. Thus, we were interested in whether com- bining all of these principles into a single inter- vention would substantively impact performance in a realistic educational learning task. This holistic approach is often appropriate for trans- lational research, because the translation of a given principle involves numerous facets be- yond the variables that are manipulated in the laboratory (Horvath et al., 2017; Oliver & Conole, 2003; Smeyers & Depaepe, 2013; Roe- diger, 2013). With these issues in mind, the training paradigm was constructed in a manner that would allow for instructors to directly apply (in cases where the same concepts as those presented in this study are covered) or easily modify and adapt the paradigm accordingly (changing out the study slides and quiz ques- tions), based on the course curriculum (dis- cussed further below).

The training paradigm was effective in help- ing participants in the experimental conditions learn the concepts they were taught during train- ing, and moreover these concepts were retained 1 week later. Importantly, the training paradigm also aided participants in correctly answering conceptual (application and analysis) questions, which required participants to have a thorough understanding of the study material. These question types tested complex scientific princi- ples, which, as many university professors who have taught a research methods course can af- firm, can be extremely difficult for students to learn and retain (as indicated by the control group’s chance performance on conceptual questions). Moreover, participants in the exper- imental conditions were not quizzed on these

question types during training and were not tested on them until 1 week after they com- pleted the training session. Thus, this finding seems to reflect the experimental participants’ genuine conceptual understanding of the study material.

Perhaps more important is the extent to which such concepts were learned by participants who received training. On each of the posttests that participants in the experimental conditions com- pleted, they outperformed control participants on core questions by approximately 20%, which amounts to a difference of two full letter grades. Notably, these learning gains were achieved with only a single training session, which con- sisted of less than an hour of actual training. Furthermore, participants who received training scored approximately 76% and 70% on the core questions in the first and second posttests, re- spectively, translating to passing letter grades of C and C–. This level of performance is notewor- thy given that the amount of training participants in the experimental conditions were given is many orders of magnitude less than the instruction and study time that students in actual statistics and research methods courses receive. Taken together, these findings serve as a powerful demonstration of how the current training paradigm can aid stu- dents in acquiring and subsequently retaining complex concepts.

Type of Quizzing Format

Despite the evidence for the strong benefit of the training paradigm overall, performance ap- peared to be equivalent among the experimental conditions, suggesting that all three quizzing formats are equally effective. It is therefore unclear which format is ideal for presenting quiz questions for this training paradigm. One possibility is that the benefits of recall-based quizzing were masked by the fact that the ques-

Table 2 Mean (SD) Performance for Each Experimental Group on Each of the Core Question Types for Each Posttest

Immediate posttest Delayed posttest

Group Repeated Definitional Transfer Repeated Definitional Transfer

Recall .842 (.18) .732 (.22) .658 (.21) .753 (.18) .635 (.22) .660 (.20) Recognition .899 (.16) .747 (.19) .710 (.21) .790 (.17) .650 (.19) .620 (.23) Recall-then-recognition .872 (.13) .747 (.19) .656 (.22) .789 (.17) .694 (.18) .635 (.23)

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tion format of the posttests matched that of the quiz questions that were presented to the recog- nition group. Research on transfer-appropriate processing has shown that test performance is superior when the training and testing condi- tions are similar (Balota & Neely, 1980). Thus, performance for participants in the recognition- only condition may have been inflated, reducing the performance advantage for the recall condi- tions. Future work will be required to more directly test this possibility.

An exploratory analysis, which examined whether the decline in performance between the two posttests on transfer questions differed be- tween the recall conditions and the recognition- only condition, suggests that retention and transfer of concepts may have been stronger for participants who engaged in recall. Participants in the recall conditions performed equally well on the transfer questions on both posttests, sug- gesting that their memory for the concepts that were learned during training was not weakened by the 1-week delay between the first and sec- ond posttest. In contrast, performance on the transfer questions for participants in the recog- nition-only condition decreased considerably between the first and second posttests (by ap- proximately 9%), suggesting that their memory of the study material was somewhat tenuous in comparison to that of participants who engaged in recall during training. Thus, instructors who employ this training paradigm may wish to use a version that includes recall responding during quizzing. In the classroom, recall questions can be used during quizzing by asking students to write out their response to a given quiz question and then showing students the correct response (similarly to the type of feedback used in our paradigm4).

Guide and Implications for Instructors

Instructors who wish to use this paradigm to train students on different content (e.g., physics, chemistry, mathematics) can do so by simply following our training procedure (discussed above in the Method section), and replacing our slides and quiz questions with those that corre- spond to the topic of interest. In this process, we recommend creating training slides that are con- cise and devoid of superfluous information, so that the slides fully and clearly explain all of the concepts that are introduced. Additionally, in

cases where the training content builds on con- cepts that were introduced in earlier slides, we suggest presenting slides in a manner that fol- lows a conceptual progression.

One area that instructors might wish to devi- ate from our training procedure is in the amount of time that students are permitted to study a given slide. Here, participants’ study time was limited (although participants were given some autonomy in the amount of time they could spend studying) due to the time restrictions of the laboratory experiment. However, based on the principles of self-pacing (Ariel, 2013; de Jonge et al., 2015; Tullis & Benjamin, 2011), it might be more useful to allow participants full control over how much time they spend study- ing a given slide. On the other hand, one issue that this approach introduces is that some stu- dents might not spend a sufficient amount of time studying a given slide. Thus, it might be wise to keep a minimum study time in place for any given set of slides, but provide participants the ability to advance to the next set of slides once the minimum time has been reached.

Furthermore, as in our paradigm, we recom- mend that instructors quiz students on any con- cepts that are presented in the training slides. It is important to note that our quiz questions were presented in an abstract format so we could directly test participants’ ability to transfer their knowledge to novel scenarios during testing. This aspect of the training paradigm was thus implemented for reasons of experiment design, and instructors may or may not wish to adopt a similar approach.

We also recommend that instructors imple- ment an immediate posttest after training to assess how well participants are able to learn and retain the training material. This type of assessment can be particularly useful in helping both the student and instructor identify the as- pects of the material that the student does not yet fully grasp. One noteworthy finding is that participants performed best on repeated ques- tions, which were identical to the questions that were quizzed, and worst on transfer questions.

4 Instructors might also consider using more complex forms of feedback that encourage students to think carefully about the material, such as explanation feedback, wherein the correct answer is coupled with a detailed explanation (Butler, Godbole, & Marsh, 2013; Corral & Carpenter, 2019).

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However, performance decreased substantially on repeated (and definitional) questions be- tween the first and second posttest, whereas performance was relatively stable for transfer questions. One reason for this finding might be that rote memorization could be used to answer repeated (and definitional) questions, but trans- fer questions required conceptual understand- ing. Thus, when participants were given the second test 1 week later, they may have forgot- ten the information that was memorized during training. In contrast, because performance on transfer questions might have been driven by conceptual understanding, as opposed to rote memorization, performance on these questions might have been more stable. These findings and explanation are in line with work on levels of processing (Craik & Lockhart, 1972; Craik & Tulving, 1975), wherein information that is pro- cessed in a deeper and more meaningful manner (e.g., information that is comprehended by the learner) is more robust to decay than informa- tion that is learned through rote memorization (Symons & Johnson, 1997).

This explanation suggests that transfer items can better assess students’ knowledge than items that can be answered through rote mem- orization. Moreover, training performance on the latter type of items might lead both students and instructors to form an inaccurate perception of the student’s actual understanding of the tested content. This misperception can be prob- lematic in cases where pretests are used to help prepare students for an upcoming exam, as stu- dents might develop a false sense of security due to their high performance on the items that were memorized during study or training. Con- sequently, students might reduce their study time, leaving them ill-prepared for an exam. The find- ings presented here therefore have direct impli- cations for instructors who use clicker questions or pretests to assess their students’ knowledge of course material. Our findings suggest that any such assessments should incorporate trans- fer-like questions, which are fairly similar to the type of test questions that instructors often use on exams.

Lastly, although instructors can use this train- ing paradigm during lecture, it can also be ap- plied outside of the classroom. For instance, our training paradigm can be implemented as an automated tutoring system that is made avail- able to students. This option would allow stu-

dents autonomy over when they study, and also provide them a structured and controlled train- ing environment outside of the classroom. Our training paradigm might also be particularly well-suited for classroom laboratory courses (e.g., research methods, statistics), in which stu- dents are often required to complete assign- ments independently within a given time period (typically 1–3 hr). This context is highly similar to what participants in the experimental condi- tions encountered, and thus students in labora- tory courses might greatly benefit from a train- ing paradigm like the one used in the present study.

Limitations and Future Directions

From a translational and applied perspective, the implementation of multiple learning princi- ples within a single training paradigm is a par- ticular strength of this article. However, a lim- itation of this approach from a theoretical perspective is that we did not isolate and test each of these principles. Thus, we do not know the extent to which each of these principles affected learning, as we examined only their combined impact. Nevertheless, a researcher or instructor might be interested in this question. Thus, a potential direction for future work is to methodically vary which facets are included in the paradigm and compare those conditions to the full paradigm (e.g., full paradigm vs. para- digm without correct-answer feedback or full paradigm vs. paradigm without retrieval prac- tice).

One potential critique of the present study is that the control condition did not receive any instruction, and thus these results might be taken to demonstrate that the training paradigm merely leads to better learning than not receiv- ing training at all. However, as we state above, the materials used in this study were highly complex (particularly the conceptual question types) and it is by no means a given that they can be readily acquired, even with extensive training. Indeed, as many research method in- structors will likely attest, there are numerous students who fail to learn these exact concepts over an entire semester of rigorous instruction. Moreover, many training procedures fail to pro- duce learning whatsoever, as is exemplified in studies where participants in some conditions perform at chance (e.g., Johnstone & Shanks,

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2001; Quinn, Palmer, & Slater, 1999; Shanks, Johnstone, & Staggs, 1997). Thus, demonstrat- ing that this training paradigm benefits complex learning is a critical first step of the present work.

Nevertheless, an instructor might certainly be interested in the extent to which this training paradigm benefits learning above and beyond simply studying the materials. One way to an- swer this question in future work would be to provide one group of participants the full train- ing paradigm and another group the Power- Point-style slides for study. Another potential future direction is to examine how this para- digm might fare in comparison to how students typically study. Recent work suggests that stu- dents use suboptimal study strategies (Corral et al., 2019), and given that the training paradigm used here is premised on well-established learn- ing principles, we would predict learning to be better for students who use the training para- digm than for those who receive the same study materials and are left to their own devices. To build on this idea, a particularly strong test of this paradigm’s efficacy might be to select stu- dents in a course who are struggling (e.g., stu- dents with a letter grade of C- or lower) and randomly assign them to complete the training paradigm or to continue to study using their preferred method. These students’ progress could also be monitored throughout the semes- ter to examine whether the benefits of the train- ing paradigm are observed over an extended period.

Conclusion

Translating basic and theoretical research to- ward real-world applications can be challenging (Woolf, 2008) and often fails to occur in the fields of cognitive psychology and education. One reason for this failure is that many cogni- tive psychology studies require participants to learn artificial concepts, which can make in- structors skeptical of how well a given effect will transfer to the classroom. The current study lays out a blueprint for how principles from cognitive psychology, specifically the testing effect, form of responding, self-paced studying, and feedback, can be integrated to construct a valuable training paradigm. Furthermore, we have demonstrated the efficacy and applicabil- ity of this training paradigm with ecologically

valid learning materials. These materials cov- ered various core concepts of the scientific method, and quiz and posttest items were sim- ilar in structure and difficulty to exam questions that are typically presented to students in a university-level research methods course. The findings for the current study are thus applicable to educators from a wide range of scientific domains. However, the current project takes only a small step toward utilizing cognitive psychology to aid students with the learning of real academic concepts. If the translation of cognitive psychology principles is to improve in the domain of education, future work must care- fully demonstrate the efficacy of such principles with real academic concepts.

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Received April 19, 2018 Revision received March 26, 2019

Accepted April 10, 2019 �

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208 CORRAL, HEALY, ROZBRUCH, AND JONES

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Building a Testing-Based Training Paradigm From Cognitive Psychology Principles

Recognition Versus Recall
Experiment and Training Paradigm
Method

Participants
Design and Materials

Question types

Core questions
Conceptual questions

Procedure

Training session
Navigating each section
Quiz instructions
Quiz questions
Correct-answer feedback
Immediate posttest
Delayed posttest
Control group

Results

Experimental Conditions Versus Control Condition

Performance on core questions
Performance on conceptual questions

Recall Versus Recognition Versus Recall-Then-Recognition
Exploratory Analysis

Discussion

Type of Quizzing Format
Guide and Implications for Instructors
Limitations and Future Directions

Conclusion
References

INTRODUCTION

Intersection of Minority Health, Health Disparities, and Social Determinants of Health With Psychopharmacology and Substance Use

Hector I. Lopez-Vergara1, Tamika C. B. Zapolski2, and Adam M. Leventhal3, 4 1 Department of Psychology, University of Rhode Island

2 Department of Psychology, Indiana University–Purdue University Indianapolis 3 Department of Population and Public Health Sciences, Keck School of Medicine, University of Southern California

4 Institute for Addiction Science, University of Southern California

aaa Although the United States (U.S.) is an increasingly multicultural

society (Vespa et al., 2018), the incorporation of psychopharma- cology and basic behavioral addiction science into research on minority health and health disparities is underleveraged. Similarly, psychopharmacology and substance use research has often over- looked the societal context in which drugs are consumed. The relative schism of psychopharmacology and basic behavioral addic- tion science with research on minority health and health disparities is an area of opportunity for improving public health in an ever more diverse society (Muennig et al., 2018). In efforts to stimulate research on these topics, this special issue focuses on research addressing the intersection of minority health, health disparities, and social determinants of health (MHDS) with psychopharmacol- ogy and substance use. The articles in the special issue are transdisciplinary in nature,

encompassing topics that range in focus from how sociocultural variables at the individual and societal level influence risk for substance use, to statistical and methodological issues in execution on minority health and health disparities research, to etiology focused studies and clinical applications. The special issue begins with Ozga et al. (2021) who contextualize tobacco use health disparities in rural communities via a cumulative disadvantage framework. By reviewing the development of tobacco use

disparities among rural communities with the consideration of systemic and pharmacological factors that contribute to the dispa- rities, the authors identify potential points of macrolevel interven- tions, as well as articulate how health outcomes can be shaped by societal forces. This is followed by Phillips et al. (2021) who delineate the various factors that impact the development of tobacco use among Asian and Pacific Islander (API) youth using the National Institute on Minority Health and Health Disparities (NIMHD) multidimensional research framework, which serves as a tool to “unpack” distinct levels of analysis in the development of health disparities from cell to society. Reviewing psychometric critiques of cross-cultural research, Lopez-Vergara et al. (2021) emphasize the need to statistically test for the cultural equivalence of measurement (within a falsifiable psychometric framework) when making inferences across cultural groups in addiction and clinical science.

These reviews are followed by five novel studies examining sociocultural, MHDS, and psychopharmacological factors that influ- ence substance use risk across racial, ethnic, and sexual minority populations. First, in an empirical search for mechanisms of health disparities, Bacio (2021) uses structural equation modeling to inves- tigate drinking motives as pathways to problematic drinking among Latinx college students. Bacio (2021) provides evidence that socio- cultural variables may influence drinking among Latinx students via motivational pathways (drinking to cope), demonstrating how socio- cultural variables can influence individual-level processes. This is followed by Clifton et al. (2021), who compared differences in racial identity among Black young adults based on both explicit and implicit measurement strategies. By leveraging basic behavioral science principles, the authors provide an indirect way of assessing aspects of racially based self-concept that may be difficult to measure directly due to social desirability, as well as how such assessments relate to substance use outcomes among Black young adults. Next, demon- strating how intersectionality of identities can overlap with distinct risk and protective factors, Albuja et al. (2021) disaggregate corre- lates of increased alcohol involvement among Monoracial and Mul- tiracial Native American/American Indian college students.

Finally, in this section, we have two studies that utilize novel study designs to examine sociocultural factors, psychopharmacology, and substance use among minority populations. In an empirical study at the within-person level of analysis, Lewis et al. (2021) use a daily diary study to investigate the proximal effects of sexual minority

Editor’s Note. This is an introduction to the special issue “Intersection of Minority Health, Health Disparities, and Social Determinants of Health with Psychopharmacology and Substance Use.” Please see the Table of Contents here: http://psycnet.apa.org/journals/pha/29/5—WWS

Tamika C. B. Zapolski https://orcid.org/0000-0003-0675-560X None of the authors have a conflict of interest to declare. Hector I. Lopez-Vergara played a equal role in conceptualization, writing

of original draft, and writing of review and editing. Tamika C. B. Zapolski played an equal role in conceptualization, writing of original draft, and writing of review and editing. Adam M. Leventhal played an equal role in conceptualization, writing of original draft, and writing of review and editing. Correspondence concerning this article should be addressed to Hector I.

Lopez-Vergara, Department of Psychology, University of Rhode Island, 142 Flagg Road, Kingston, RI 02881, United States. Email: hlopez-verga [email protected]

Experimental and Clinical Psychopharmacology

427

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stress on alcohol involvement among sexual minority women, pro- viding insights into how experiences of marginalization can unfold in day-to-day drinking experiences and may intersect with negative reinforcement mechanisms underlying substance use. Leveraging experimentally induced nicotine withdrawal, Liautaud et al. (2021) show that symptoms of anhedonia may be a phenotypic feature of acute withdrawal among African–American smokers (which provides hypotheses for phenotypically personalized treatments) in a popula- tion subject to tobacco-related health disparities. The special issue concludes with articles addressing interven-

tions. Nalven et al. (2021) provide a systematic review of diversity inclusion in opioid pharmacological treatment trials, finding evi- dence that minoritized populations are frequently underrepresented in treatment trials; whereas Fogg et al. (2021) document that minoritized individuals are typically omitted from samples in the reemerging field of Psychedelic-Assisted Psychotherapies. Finally, in a remote adaptation to a contingency management intervention for problematic drinking, Koffarnus et al. (2021) show that a contingency management intervention for alcohol use disorder (with a participant-funded incentive) is effective but is less accessi- ble to participants with lower income and greater alcohol use. Overall, these articles provide a window into the breadth of issues

at the intersection of MHDS with psychopharmacology and substance use. Integrating the fields of psychopharmacology and basic behav- ioral addictions science with research on MHDS is not only of public health importance, but can help further elucidate our understanding of human behavior in all of its complexity. As demonstrated here, a better understanding of the synergy between societal context(s) and individual-level processes can lead to interventions tailored to specific risk and resilience factors; interventions that are personalized and contextualized have the potential to improve the health of our society. We are very grateful to the authors for their contributions to this special issue. We hope that professionals from various disciplines who read this special issue become inspired to bridge psychophar- macological and social determinants perspectives in their own work, and, in turn, accelerate scientific progress within each field.

References

Albuja, A., Straka, B., Desjardins, M., Swartzwelder, H. S., & Gaither, S. (2021). Alcohol use and related consequences for monoracial and multi- racial Native American/American Indian college students. Experimental and Clinical Psychopharmacology, 29(5), 487–500. https://doi.org/10 .1037/pha0000475

Bacio, G. A. (2021). Motivational pathways to problematic drinking among Latinx college drinkers. Experimental and Clinical Psychopharmacology, 29(5), 466–478. https://doi.org/10.1037/pha0000516

Clifton, R. L., Rowe, A. T., Banks, D. E., Ashburn-Nardo, L., & Zapolski, T. C. B. (2021). Examining the effects of implicit and explicit racial

identity on psychological distress and substance use among Black young adults. Experimental and Clinical Psychopharmacology, 29(5), 479–486. https://doi.org/10.1037/pha0000489

Fogg, C., Michaels, T. I., de la Salle, S., Jahn, Z. W., & Williams, M. T. (2021). Ethnoracial health disparities and the ethnopsychopharmacology of psychedelic-assisted psychotherapies. Experimental and Clinical Psychopharmacology, 29(5), 537–552. https://doi.org/10.1037/pha 0000490

Koffarnus, M. N., Kablinger, A. S., Kaplan, B. A., & Crill, E. M. (2021). Remotely administered incentive-based treatment for alcohol use disorder with participant-funded incentives is effective but less accessible to low- income participants. Experimental and Clinical Psychopharmacology, 29(5), 526–536. https://doi.org/10.1037/pha0000503

Lewis, R. J., Romano, K. A., Ehlke, S. J., Lau-Barraco, C., Sandoval, C. M., Glenn, D. J., & Heron, K. E. (2021). Minority stress and alcohol use in sexual minority women’s daily lives. Experimental and Clinical Psycho- pharmacology, 29(5), 501–510. https://doi.org/10.1037/pha0000484

Liautaud, M. M., Kechter, A., Bello, M. S., Guillot, C. R., Oliver, J. A.,

Banks, D. E., D’Orazio, L. M., & Leventhal, A. M. (2021). Anhedonia in

tobacco withdrawal among African-American smokers. Experimental and

Clinical Psychopharmacology, 29(5), 553–565. https://doi.org/10.1037/

pha0000474 Lopez-Vergara, H. I., Yang, M., Weiss, N. H., Stamates, A. L., Spillane, N. S., & Feldstein Ewing, S. W. (2021). The cultural equivalence of measurement in substance use research. Experimental and Clinical Psychopharmacology, 29(5), 456–465. https://doi.org/10.1037/pha 0000512

Muennig, P. A., Reynolds, M., Fink, D. S., Zafari, Z., & Geronimus, A. T. (2018). America’s declining well-being, health, and life expectancy: Not just a white problem. American Journal of Public Health, 108, 1626– 1631. https://doi.org/10.2105/AJPH.2018.304585

Nalven, T., Spillane, N. S., Schick, M. R., & Weyandt, L. L. (2021). Diversity inclusion in United States opioid pharmacological treatment trials: A systematic review. Experimental and Clinical Psychopharma- cology, 29(5), 511–525. https://doi.org/10.1037/pha0000510

Ozga, J. E., Romm, K. F., Turiano, N. A., Douglas, A., Dino, G., Alexander, L., & Blank, M. D. (2021). Cumulative disadvantage as a framework for understanding rural tobacco use disparities. Experimental and Clinical Psychopharmacology, 29(5), 429–439. https://doi.org/10.1037/pha 0000476

Phillips, K. T., Okamoto, S. K., Johnson, D. L., Rosario, M. H., Manglallan, K. S., & Pokhrel, P. (2021). Correlates of tobacco use among Asian and Pacific Islander youth and young adults in the U.S.: A systematic review of the literature. Experimental and Clinical Psychopharmacology, 29(5), 440–455. https://doi.org/10.1037/pha0000511

Vespa, J., Armstrong, D., & Medina, L. (2018). Demographic turning points for the United States: Population projections for 2020 to 2060. In Current population reports (pp. 25–1144). U.S. Census Bureau.

Received August 2, 2021 ▪

428 LOPEZ-VERGARA, ZAPOLSKI, AND LEVENTHAL

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https://doi.org/10.1037/pha0000503

https://doi.org/10.1037/pha0000484

https://doi.org/10.1037/pha0000474

https://doi.org/10.1037/pha0000512

https://doi.org/10.2105/AJPH.2018.304585

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Intersection of Minority Health, Health Disparities, and Social Determinants of Health With Psychopharmacology and Substance Use

References

Review Article

Psychoso

Psychopharmacology of COVID-19

Melanie Bilbul, M.D., C.M., F.R.C.P.(C), Patricia Paparone, M.D., Anna M. Kim, M.D., Shruti Mutalik, M.D., Carrie L. Ernst, M.D.

Background: With the rapid, global spread of severe acute respiratory syndrome coronavirus 2, hospitals have become inundated with patients suffering from corona- virus disease 2019. Consultation-liaison psychiatrists are actively involved in managing these patients and should familiarize themselves with how the virus and its proposed treatments can affect psychotropic management. The only Food and Drug Administration– approved drug to treat COVID-19 is remdesivir, and other off-label medications used include chloroquine and hydroxychloroquine, tocilizumab, lopinavir/ritonavir, favipiravir, convalescent plasma therapy, azithromycin, vitamin C, corticosteroids, interferon, and colchicine. Objective: To provide an overview of the major safety considerations relevant to clinicians who prescribe psy- chotropics to patients with COVID-19, both related to the illness and its proposed treatments. Methods: In this targeted review, we performed structured literature searches in PubMed to identify articles describing the impacts of COVID-19 on different organ systems, the

matics 61:5, September/October 2020

neuropsychiatric adverse effects of treatments, and any potential drug interactions with psychotropics. The articles most relevant to this one were included. Results: COVID-19 impacts multiple organ systems, including gastrointestinal, renal, cardiovascular, pulmonary, immunological, and hematological systems. This may lead to pharmacokinetic changes that impact psycho- tropic medications and increase sensitivity to psychotropic-related adverse effects. In addition, several proposed treatments for COVID-19 have neuropsychiatric effects and potential interactions with commonly used psychotropics. Conclusions: Clinicians should be aware of the need to adjust existing psycho- tropics or avoid using certain medications in some pa- tients with COVID-19. They should also be familiar with neuropsychiatric effects of medications being used to treat this disease. Further research is needed to identify strategies to manage psychiatric issues in this population.

(Psychosomatics 2020; 61:411–427)

Key words: COVID-19, psychotropic, psychopharmacology, side effects.

Received April 24, 2020; revised May 11, 2020; accepted May 12, 2020. From the Department of Psychiatry(M.B., P.P., A.M.K., S.M., C.L.E.), Icahn School of Medicine at Mount Sinai, New York, NY; Department of Medical Education (C.L.E.), Icahn School of Medicine at Mount Sinai, New York, NY. Send correspondence and reprint requests to Carrie L. Ernst, MD, One Gustave L. Levy Place, Box 1230, New York, NY 10029; e-mail: [email protected]

INTRODUCTION

With the rapid, global spread of severe acute respira- tory syndrome coronavirus 2 (SARS-CoV-2), hospitals have become inundated with patients suffering from COVID-19 infection. Remdesivir was recently approved by the US Food and Drug Administration (FDA) to treat severe COVID-19,1 and many other medications are either being studied in clinical trials or being used off-label and/or for compassionate use.2

As the pandemic spreads, consultation-liaison psychiatrists are being called upon to help manage the

psychiatric conditions of individuals with COVID-19 and are encountering challenging clinical scenarios of multiple medical comorbidities and unfamiliar drugs. Psychiatrists should familiarize themselves

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Psychopharmacology of COVID-19

with the mechanism of action of these treatments, neuropsychiatric side effects, and possible interactions with psychotropics. In addition, as COVID-19 affects multiple organ systems, psychiatrists will need to be aware of safety concerns inherent in prescribing psy- chotropics to these patients.

This article is divided into 2 main sections. The first provides an update on the organ systems that may be negatively impacted by COVID-19 and recommenda- tions for safer use of psychotropics in these patients. The second section reviews potential neuropsychiatric side effects of the early approved and investigational treatments for COVID-19 as well as pharmacokinetic and pharmacodynamic drug interactions when used concurrently with psychotropics. COVID-19 therapies reviewed include remdesivir, chloroquine, hydroxy- chloroquine, azithromycin, tocilizumab, lopinavir/ ritonavir, favipiravir, convalescent plasma therapy, cor- ticosteroids, interferon (IFN), vitamin C, and colchicine.

Given the limited literature in this area, we un- dertook a nonsystematic narrative review that was focused on practical clinical concerns. We used a structured PubMed search using the following search terms in combination with the names of the medica- tions mentioned previously: “COVID-19”, “coronavi- rus”, “Psychotropic medications”, “QT prolongation”, “Psychiatric side effects”, “Neuropsychiatric side ef- fects”, “drug interactions”, and pertinent organ sys- tems, for example, “hepatic”, “renal”, “hematological”, “pulmonary”, and “cardiac”. This was followed by a search of manufacturer’s package inserts for pertinent facts about specific medications, including drug interactions.

We selected the aforementioned medications as they were the ones most commonly being used in health care settings and clinical trials at the time of prepara- tion of this article, although we are aware that this is a rapidly evolving field and thus this list is not meant to be comprehensive.

IMPACT OF COVID-19 ON PSYCHOTROPIC DRUG SAFETY

COVID-19 is believed to impact multiple organs, including the liver, kidneys, lungs, and heart, as well as the immune and hematological systems.3 Damage to these organs or systems may lead to pharmacokinetic changes that impact absorption, distribution,

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metabolism, and/or excretion of psychotropic medica- tions as well as increased sensitivity to certain psycho- tropic adverse effects. As such, clinicians should be aware of the potential need to make adjustments to existing psychotropic regimens or avoid using certain psychotropic agents if such safety concerns arise (Tables 1 and 2).

Hematological Effects

An early report noted the presence of lymphopenia (lymphocyte count less than 1.0 3 109/L) in 63% and leukopenia (white blood cell count less than 4 3 109/L) in 25% of patients with COVID-19.4 It has been pro- posed that lymphopenia is a feature of severe COVID- 19 cases and may serve as a poor prognostic factor. Contributing factors likely include direct infection of lymphocytes and cytokine storm.5 It therefore seems prudent to use caution and consider avoiding medica- tions that have the potential to further impact white blood cell production, particularly lymphocytes. By contrast, clinicians might determine that it is acceptable from a safety standpoint to continue psychotropics which have only been associated with agranulocytosis and neutropenia, assuming the patient does not have a secondary bacterial infection. Several psychotropics have been implicated in hematological adverse effects, including leukopenia, neutropenia, and agranulocy- tosis. The most commonly implicated psychotropics include carbamazepine and clozapine, but there is a class effect FDA warning on all first and secondary generation antipsychotics for the potential association with leukopenia, neutropenia, and agranulocytosis, as well as a number of published case reports. Carba- mazepine is more likely to be associated with an early transient leukopenia but has also been associated with agranulocytosis and aplastic anemia.6

While the leukopenia and lymphopenia observed in patients with COVID-19 may be less of a concern for clozapine prescribers in the setting of a normal neutrophil count, clozapine deserves unique mention given several potential challenges associated with its use during the COVID-19 pandemic. These challenges have been recently reviewed along with recommendations for management in a consensus statement by Siskind and colleagues.7 Patients on clozapine may have difficulty accessing routine absolute neutrophil count moni- toring, and the FDA has released guidance allowing health care providers to use medical judgment to delay

Psychosomatics 61:5, September/October 2020

TABLE 1. Potential Psychotropic Safety Concerns in COVID-19 Organized by Drug Class

Drug class Specific drugs Problem Solution

Antipsychotics Clozapine Patients with difficulty accessing ANC monitoring May be associated with increased risk of pneumonia and its complications

Levels can increase with acute infection leading to clozapine toxicity

COVID-19 associated with leukopenia and lymphopenia; unclear impact on neutrophils; clozapine associated with neutropenia and agranulocytosis and more rarely lymphopenia or aplastic anemia

COVID-19 associated with seizures; clozapine can lower seizure threshold

Reduce frequency of ANC monitoring at discretion of provider

Education of patients and urgent clinical assessment including ANC for those with symptoms of infection

Consider halving clozapine dose in patients with fever, pneumonia, and/or flu-like symptoms; temporarily discontinue clozapine if toxicity emerges

Monitor complete blood count (CBC); if persistent white blood cell abnormalities, weigh risks versus benefits of continuing clozapine; when total white blood cell count is decreased but neutrophil count is normal, consider continuing clozapine

Recognize potential for lowered seizure threshold; assure nontoxic clozapine level; consider holding clozapine, decreasing dose, or adding antiepileptic

Other antipsychotics

COVID-19 associated with decreased white blood cell and lymphocyte counts; rare reports of antipsychotic-associated aplastic anemia or lymphopenia, especially with phenothiazines (chlorpromazine, fluphenazine, thioridazine)

Coagulation abnormalities (PT and aPTT prolongation, thrombocytopenia) are observed in patients with COVID-19; rare reports of thrombocytopenia associated with multiple antipsychotics

Concern for COVID-19 associated tachyarrhythmias and cardiac injury and potential for several medications being used to treat COVID-19 to cause QT prolongation; all antipsychotics with potential for QT prolongation

Acute liver injury in patients with COVID-19; antipsychotics (especially chlorpromazine) with potential for drug-induced liver injury

COVID-19 associated with seizures; all antipsychotics can lower seizure threshold

Monitor CBC; if persistent hematologic abnormalities (e.g., lymphopenia, neutropenia, thrombocytopenia) weigh risks versus benefits of continuing antipsychotic agent

Baseline EKG for QTc; caution in patients with baseline prolonged QTc and/or other risk factors for drug-induced QT prolongation and TdP; daily EKG and electrolyte monitoring, reduce other risk factors, and cardiology consult in high-risk cases if opt to use antipsychotic; case-by-case risk-benefit discussion

Monitor liver function tests and avoid chlorpromazine in patients with liver injury; risk versus benefit assessment for other antipsychotic use

Consider avoiding antipsychotics (especially clozapine, quetiapine, olanzapine, and first- generation drugs) or adding antiepileptic drug (AED) in patients who have seizures

Antiepileptics Carbamazepine COVID-19 associated with leukopenia and lymphopenia; leukopenia and rare reports of aplastic anemia associated with carbamazepine use;

Acute liver injury in patients with COVID-19; carbamazepine with potential for drug-induced liver injury

Monitor CBC; if persistent white blood cell abnormalities or aplastic anemia, use alternative AED

Monitor liver function tests and avoid carbamazepine in patients with liver injury

Valproic acid Coagulation abnormalities (PT and aPTT prolongation, thrombocytopenia) observed in patients with COVID-19; valproic acid associated with thrombocytopenia

Acute liver injury in patients with COVID-19; valproic acid with potential for drug-induced liver injury

Monitor platelet count; avoid valproic acid if thrombocytopenia

Monitor liver function tests and avoid valproic acid in patients with liver injury

Gabapentin COVID-19 with potential for acute kidney injury; gabapentin clearance dependent on intact renal function

Adjust gabapentin dose based on renal function

Bilbul et al.

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TABLE 1. (Continued)

Drug class Specific drugs Problem Solution

Selective serotonin reuptake inhibitors (SSRIs) and serotonin norepinephrine reuptake inhibitors (SNRIs)

All Coagulation abnormalities observed in patients with COVID-19 and many patients with COVID-19 receiving anticoagulation; SSRIs and SNRIs associated with impaired platelet aggregation and abnormal bleeding

Concern for COVID-19–associated tachyarrhythmias and cardiac injury and potential for several medications being used to treat COVID-19 to cause QT prolongation; citalopram with potential for QT prolongation

Acute liver injury in patients with COVID-19; duloxetine with a potential for drug-induced liver injury

Monitor coagulation factors and platelet count; weigh risks and benefits for individual patient but consider avoiding SSRIs and SNRIs in patients with recent bleeding or high risk for bleeding (e.g., thrombocytopenia, concurrent anticoagulation therapy, history of hemorrhage); can instead use nonserotonin reuptake inhibitor antidepressant such as bupropion

Baseline EKG for QTc; caution in patients with baseline prolonged QTc and/or other risk factors for drug-induced QT prolongation and TdP; consider using SSRI other than citalopram in high-risk cases

Monitor liver function tests, avoid duloxetine in patients with liver injury

Bupropion COVID-19 associated with seizures; bupropion can lower seizure threshold

Avoid bupropion in patients with seizures or lowered seizure threshold

Lithium COVID-19 with potential for acute kidney injury; lithium clearance dependent on intact renal function; lithium with nephrotoxic potential

Adjust lithium dose based on renal function; consider temporarily holding lithium until acute kidney injury resolves

Benzodiazepines All COVID-19 associated with delirium; benzodiazepines can exacerbate delirium

COVID-19 associated with prominent respiratory symptoms; benzodiazepines can suppress respiratory drive

Lopinavir/Ritonavir contraindicated with midazolam and triazolam (and can raise levels of some other benzodiazepines) due to CYP450 inhibition

Avoid or taper existing benzodiazepines in patients with delirium if possible

Weigh risks versus benefits in using benzodiazepines in patients with prominent respiratory symptoms; a low dose may be able to be used safely in nondelirious patients

Avoid midazolam and triazolam and consider using lorazepam, temazepam, or oxazepam in patients taking lopinavir/ritonavir

ANC = absolute neutrophil count; aPTT = activated partial thromboplastin time; COVID-19 = coronavirus disease 2019; EKG = electrocardiogram; PT = prothrombin time; TdP = torsades de pointes.

Psychopharmacology of COVID-19

laboratory testing for drugs subject to Risk Evaluation and Mitigation Strategy.8 While there are no data yet available on COVID-19 in patients on clozapine, it has been suggested that clozapine is associated with a higher risk of pneumonia and its complications. Ex- planations include aspiration, sialorrhea, sedation, and poorly understood effects on the immune system.7,9

Patients should be educated on symptoms of pneu- monia and urgently evaluated by a clinician if symp- toms of infection emerge. Complicating the picture further, elevation of clozapine levels has been observed with multiple acute viral and bacterial infections. This may in part be related to effects of systemic infection and inflammation on CYP450 enzymes.10 Clinicians should closely monitor clozapine levels and consider reducing the dose by up to a half in patients with fever and other signs of infection.

Coagulation abnormalities such as prothrombin time and activated partial thromboplastin time

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prolongation, thrombocytopenia, and disseminated intravascular coagulation are also frequently observed in patients with COVID-19. At the same time, many patients with COVID-19 experience increased throm- botic risk and may be prescribed prophylactic antico- agulants.5 These factors may impact the decision to prescribe psychotropics that have been associated with platelet dysfunction and increased bleeding risk (e.g., selective serotonin reuptake inhibitors [SSRIs] and valproic acid). Clinicians should be especially mindful of using these medications in patients who have other risk factors for bleeding, such as concomitant anti- coagulation therapy and a history of significant bleeding event.

Cardiac Effects

There is limited available information regarding car- diovascular involvement in COVID-19 infection,

Psychosomatics 61:5, September/October 2020

TABLE 2. Potential Psychotropic Safety Concerns in COVID-19 Organized by Organ System

Organ system affected by COVID-19

Systemic effects and symptoms Potential psychotropic safety concerns

Hematologic Lymphopenia Coagulopathy (increased PT, aPTT; decreased platelets)

Consider avoiding medications that can negatively impact white blood cell production

Highest risk: carbamazepine, clozapine, olanzapine Moderate risk: all first and second generation antipsychotics (especially low-potency conventionals)

Rare reports: TCAs, benzodiazepines (chlordiazepoxide), gabapentin, and valproate

Consider avoiding medications that can increase bleeding risk (via thrombocytopenia or impaired platelet aggregation): valproic acid, SSRIs, SNRIs

Cardiac Concern for tachyarrhythmias, heart failure, myopericarditis, acute cardiac injury

Several medications being used for COVID-19 (azithromycin, hydroxychloroquine, chloroquine, lopinavir/ritonavir) reported to prolong QT interval

Caution with psychotropics known to prolong QTc and in patients with other underlying risk factors for QT prolongation

Highest risk: antipsychotics, citalopram, tricyclic antidepressants

Hepatic Risk of acute liver injury, especially in severe cases In patients with hepatic injury or failure: Consider avoiding psychotropics that can also cause serious drug- induced liver injury: chlorpromazine, carbamazepine, valproate, duloxetine, and nefazodone.

Refer to prescribing information to determine if dose adjustments are needed

Renal Acute kidney injury has been observed, particularly in patients with COVID-19–associated acute respiratory distress syndrome (ARDS) and preexisting chronic kidney disease

Consider dose adjustment with some psychotropics (e.g., lithium, gabapentin, topiramate, pregabalin, paliperidone, and duloxetine)

Consider avoiding potentially nephrotoxic drugs

Nervous system Central nervous system: headache, dizziness, impaired consciousness, ataxia, stroke, delirium, seizures

Peripheral nervous system: impaired taste/smell/ vision, neuropathic pain

In patients with delirium, caution with deliriogenic medications: benzodiazepines, opioids, sedative-hypnotics, and those drugs with strong anticholinergic effects (tertiary amine tricyclic antidepressants, low-potency first-generation antipsychotics, some second-generation antipsychotics, benztropine, and diphenhydramine)

Caution with medications that can lower seizure threshold: antipsychotics and certain antidepressants (bupropion, tricyclics)

Pulmonary Cough, shortness of breath, pneumonia and ARDS In COVID-19 patients with anxiety or panic symptoms, weigh risks versus benefits in using benzodiazepines in patients with prominent respiratory symptoms, given potential to suppress respiratory drive

aPTT = activated partial thromboplastin time; COVID-19 = coronavirus disease 2019; PT = prothrombin time; QTc = corrected QT interval; SNRI = serotonin norepinephrine reuptake inhibitors; SSRI = selective serotonin reuptake inhibitor; TCA = tricyclics antidepressant.

Bilbul et al.

although tachyarrhythmias and heart failure have been described with other SARS beta-coronavirus in- fections.11 A recent report described acute myoper- icarditis in a patient with COVID-19,12 and a meta- analysis found acute cardiac injury in at least 8% of patients with COVID-19.13 It has been suggested that COVID-19 most likely has an arrhythmogenic effect.14

Proposed mechanisms of myocardial injury include derangement of angiotensin-converting enzyme 2 signal pathways, cytokine storm, and myocarditis. In addi- tion, several medications being used off-label in the

Psychosomatics 61:5, September/October 2020

management of COVID-19 (azithromycin, hydroxy- chloroquine, chloroquine, and lopinavir/ritonavir) have been reported to prolong the QT interval. QT prolon- gation, particularly in those with underlying medical risk factors, has been linked to lethal ventricular ar- rhythmias, such as torsades de pointes.

A complete discussion of the cardiac side effects of psychotropics is beyond the scope of this article, except to note that it has been well described in the literature that a number of psychotropic medications can prolong the QT interval. Although the data are often difficult to

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Psychopharmacology of COVID-19

interpret because of confounding factors, antipsy- chotics, tricyclic antidepressants, and the SSRI cit- alopram appear to be the agents of most concern. It is difficult to stratify antipsychotic medications by QT prolongation risk. Of the typical antipsychotics, thio- ridazine causes the greatest QT prolongation, although intravenous haloperidol has also been implicated. The greatest risk among the atypicals appears to be related to ziprasidone and possibly iloperidone. Aripiprazole and possibly lurasidone have been associated with the lowest risk based on available data.15

Health care providers should be aware of the baseline corrected QT interval (QTc) and all concomi- tant medications, laboratory test results, medical comorbidities, and family history before prescribing psychotropics in patients with COVID-19. Caution should be used in patients with a baseline prolonged QTc and/or other risk factors for drug-induced QT prolongation and torsades de pointes: the use of QT- prolonging medications, cardiac comorbidities, age .65, female sex, family history of sudden cardiac death, hypokalemia/hypomagnesemia, and illicit sub- stance use. If QT-prolonging medications are used in a patient with a QTc .500 ms or other significant risk factors, electrocardiograms should be monitored frequently (daily in high-risk cases), potassium and magnesium should be repleted, cardiology involvement should be considered, and every attempt made to reduce risk factors.15 In patients who test positive for COVID-19 but are already taking a psychotropic drug that has inherent potential for QTc prolongation, risk- benefit decisions must be made on a case-by-case basis regarding continuation versus switching to an alterna- tive medication.

Hepatic Effects

Several studies have reported acute liver injury, particularly in severe COVID-19 cases.4,16,17 The etiology of the liver injury is not known, and hy- potheses include viral infection, drug-induced liver injury, and systemic inflammation due to cytokine storm or hypoxia.16 Laboratory abnormalities observed include elevated aspartate aminotransferase, alanine aminotransferase, and bilirubin.17 Liver function tests should be monitored, and if abnormal, consideration should be given to avoiding psycho- tropics that can also cause hepatic injury or making dose adjustments if heavily dependent on hepatic

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metabolism. As most psychotropics are lipid soluble and require hepatic metabolism before clearance, clinicians should review the package insert to deter- mine if a dose adjustment is needed. In addition, many psychotropics (valproate, carbamazepine, tri- cyclic antidepressants, serotonin norepinephrine re- uptake inhibitors, and second-generation antipsychotics) have been associated with mild hep- atoxicity that manifests with modest, transient in- creases in liver enzymes. Only a few are thought to have a high risk of causing serious drug-induced liver injury, including chlorpromazine, carbamazepine, valproate, duloxetine, and nefazodone.18,19 Such high-risk psychotropics should be preferentially avoided in patients with COVID-19–associated liver disease.

Renal Effects

Acute kidney injury has been observed, particularly in patients with COVID-19–associated acute respiratory distress syndrome and preexisting chronic kidney dis- ease. Several causes have been proposed, including impaired gas exchange, hemodynamic alterations, sepsis, and an inflammatory/immune reaction involving release of circulating mediators that cause injury to kidney cells.20 In such patients, avoiding potentially nephrotoxic drugs, such as lithium, may be required. In addition, psychiatrists should be aware of any renal impairment and make necessary dose adjustments as per the manufacturer’s prescribing information. Psy- chotropics highly dependent on renal excretion include lithium, gabapentin, topiramate, pregabalin, and pal- iperidone. Many other psychotropics have caused renal excretion of active metabolites. Levels of these medi- cations or their metabolites can increase in the setting of impaired renal clearance such that reduced dosing or avoiding the medication may be required. For example, administration of duloxetine is not recommended for patients with severe renal impairment (CrCL of ,30 mL/min).18

Neurological Effects

Based on similarities between SARS-CoV2 and other coronaviruses, it is thought likely that SARS-CoV2 has a neuroinvasive potential,21 but there remain many unanswered questions about neurological manifesta- tions of COVID-19. Initial observations note a variety of neurological syndromes in patients with COVID-19,

Psychosomatics 61:5, September/October 2020

Bilbul et al.

particularly the more severely affected ones. These include stroke, delirium, seizures, and an encephalitis- type presentation. A recent article from Wuhan22 re- ports neurologic symptoms in 36.4% of patients with COVID-19, falling into 3 categories: (1) central nervous system symptoms or diseases (headache, dizziness, impaired consciousness, ataxia, acute cerebrovascular disease, and seizure); (2) peripheral nervous system symptoms (impairment in taste, vision, and smell, neuropathic pain); and (3) skeletal muscular injury. It is not known whether these neurologic syndromes are a direct effect of the virus entering the central nervous system or an indirect response to the cytokine storm that patients are experiencing. A specific prevalence rate of delirium was not reported but is presumed to be very high and to contribute to poor adherence with care and other safety concerns. Certainly, for patients with severe COVID-19 infections, there are many other po- tential etiologies of delirium, including organ failure, hypoxia, sepsis, medication effects, and electrolyte/ metabolic abnormalities. Observational studies have in fact reported high rates of benzodiazepine use for sedation in ventilator-dependent patients with COVID- 19.23 Environmental factors such as isolation from family members and difficulty mobilizing patients also contribute.24

In patients with COVID-19 and delirium, clinicians should be mindful about prescribing benzodiazepines, opioids, and drugs with strong anticholinergic proper- ties (tertiary amine tricyclic antidepressants, low- potency antipsychotics, benztropine, and diphenhy- dramine) as these medications have the potential to cause or exacerbate confusion, sedation, and/or falls. Clinicians should also be cautious about prescribing psychotropics that can lower the seizure threshold in patients with seizures or structural brain lesions. Such medications include most antipsychotics (especially clozapine, quetiapine, olanzapine, and first-generation antipsychotics)25 and certain antidepressants (bupro- pion, tricyclics).26

Pulmonary Effects

As the lung is considered the primary organ that is affected by COVID-19, most patients present with respiratory symptoms, such as cough and shortness of breath. Affected individuals may develop pneumonia and acute respiratory distress syndrome leading to high supplemental oxygen requirements and, in the most

Psychosomatics 61:5, September/October 2020

severe cases, invasive ventilation.4 Psychiatric consul- tants may be asked to evaluate and manage patients with COVID-19 and anxiety or panic symptoms in addition to respiratory distress. While there may be circumstances in which the use of small doses of a benzodiazepine is appropriate, it is important to be aware of the potential of benzodiazepines to suppress respiratory drive, particularly at higher doses. Clini- cians therefore need to consider risks versus benefits in using benzodiazepines in patients with prominent res- piratory symptoms.

PSYCHIATRIC CONSIDERATIONS OF PROPOSED COVID-19 TREATMENTS

Many of the proposed COVID-19 treatments have the potential for neuropsychiatric side effects as well as drug-drug interactions. These are reviewed in the following section and summarized in Table 3.

Remdesivir

Remdesivir is an antiviral medication that interacts with RNA polymerase and evades proofreading by viral exonuclease leading to a decrease in viral RNA.27

On May 1, 2020, the US FDA issued an Emergency Use Authorization to use remdesivir for treatment of suspected or confirmed severe COVID-19 infection,1

with severe defined as “patients with an oxygen saturation #94% on room air or requiring supple- mental oxygen, mechanical ventilation, or extracorpo- real membrane oxygenation.” The Emergency Use Authorization was based on early promising data from a randomized double-blinded, placebo-controlled28 and an open-label trial.29 Remdesivir is administered by infusion, with a treatment course of 5 or 10 days, depending on severity of disease.

Neuropsychiatric Effects

No information is available regarding neuropsychiatric side effects, but administration has been associated with infusion-related reactions that can present with hypo- tension, diaphoresis, and shivering.1 Such symptoms might be misconstrued as a panic attack.

Psychotropic Considerations

Remdesivir carries a risk of transaminase eleva- tions,30 specifically but not limited to alanine

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TABLE 3. Psychiatric Side Effects and Drug Interactions with Proposed COVID-19 Treatments

Proposed COVID-19 treatment

Mechanism of action Psychiatric side effects Drug-drug interactions

Azithromycin Used with hydroxychloroquine.

Antibacterial (primarily) Antiviral and anti- inflammatory (potential)

Psychotic depression, catatonia, delirium, aggressive reaction, anxiety, dizziness, headache, vertigo, and somnolence

� Risk of QTc prolongation—caution with psy- chotropics known to prolong QTc

� Risk of hepatotoxicity—caution with hepato- toxic drugs

Chloroquine and hydroxychloroquine

Anti-inflammatory Antiviral: interference with virus-receptor binding

Immune-modulating effects

Psychosis, delirium, suicidality, personality changes, depression, nervousness, irritability, compulsive impulses, preoccupations, and aggressiveness

� Risk of QTc prolongation—caution with QT prolonging drugs. Do not use outside of the hospital setting or a clinical trial due to risk of heart rhythm problems (FDA)

� Metabolized by CYP3A4—potential drug in- teractions with CYP3A4 inhibitors (e.g., flu- voxamine) and inducers (e.g., carbamazepine, oxcarbazepine, modafinil)

� Risk of hepatotoxicity—caution with hepato- toxic drugs

� Risk of seizures—caution with psychotropics that can lower the seizure threshold

� Higher risk of neuropsychiatric side effects when combined with CYP3A4 inhibitors, low- dose glucocorticoids, alcohol intake, family history of psychiatric disease, female gender, low body weight, and supratherapeutic dosing

� Long half-life (40 h)—adverse effects and drug- interactions may continue for days after the drug has been discontinued

Colchicine Anti-inflammatory Immune modulator: targets IL-6 pathway, inhibition of NLRP3 inflammasome. May attenuate cytokine storm.

At toxic doses: delirium, seizures, muscle weakness, depressed reflexes

� Narrow therapeutic index—potential for toxicity

� Caution in renal and hepatic failure � Caution with P-gp and CYP3A4 inhibitors (e.g., fluvoxamine)

� CYP3A4 inducers may decrease levels Convalescent plasma therapy

Antibody containing convalescent plasma from patients who have recovered from viral infections

No specific psychiatric effects (Note: allergic reactions can produce shortness of breath and palpitations that mimic panic attacks)

Potential psychological effects for donors

� There are no specific interactions (Note: patients who develop transfusion reactions might receive steroids or diphenhydramine which can have negative synergistic effects with existing psychotropics.)

Corticosteroids Immune modulators and anti-inflammatory: may lessen cytokine storm and hyperinflammation syndrome

Depression, mania, agitation, mood lability, anxiety, insomnia, catatonia, depersonalization, delirium, dementia, and psychosis

� Inconsistently reported to be weak CYP3A4 and CYP2C19 inducers

� Phenytoin—increases hepatic metabolism of systemic corticosteroids

� Caution with bupropion—lowers seizure threshold

� Majority of neuropsychiatric side effects occur early in treatment course, usually within days, and dosing is the most significant risk factor (i.e., at prednisone equivalents of .40 mg/d)

Favipiravir Antiviral: RNA-dependent RNA polymerase inhibitor

No information � Possible QT prolongation

Psychopharmacology of COVID-19

aminotransferase elevations up to 20 times the upper limit of normal.1 This may impact the decision to use hepatically metabolized psychotropics, such as valproic acid.

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Chloroquine and Hydroxychloroquine

Chloroquine, a synthetic form of quinine used for the treatment and prophylaxis of malaria, and

Psychosomatics 61:5, September/October 2020

TABLE 3. (Continued)

Proposed COVID-19 treatment

Mechanism of action Psychiatric side effects Drug-drug interactions

Interferon Immune modulator, antiproliferative, and hormone-like activities

Antiviral

IFN alpha: boxed warning for “life-threatening or fatal neuropsychiatric disorders.” Specific effects include fatigue, mood disorders, suicidality, anxiety disorders, irritability, lability, apathy, sleep disturbance, and cognitive deficits

IFN beta: fatigue, weight loss, myalgia, arthralgia

� No known pharmacokinetic interactions with psychotropics

� Potential for bone marrow suppression—safety concerns with some psychotropics (e.g., carba- mazepine, valproate, and clozapine)

� May lower seizure threshold: caution with psychotropics that also lower seizure threshold

Lopinavir/Ritonavir Antiviral Lopinavir: protease inhibitor

Ritonavir: boosts plasma levels of lopinavir

Possible abnormal dreams, agitation, anxiety, confusion, and emotional lability

All protease inhibitors associated with paresthesias, taste alterations, and neurotoxicity

� Extensively metabolized by cytochrome P450– risk of multiple possible interactions

� May get increased concentrations of coad- ministered CYP3A4 or CYP2D6 substrates

� May get decreased concentrations of CYP1A2 or CYP2B6 substrates

� Contraindicated with pimozide, midazolam, and triazolam due to increased drug levels and potentiation of adverse effects

� Lowers concentrations of some psychotropics (e.g., bupropion, methadone, lamotrigine, and olanzapine)

� Other potential side effects that may impact psychotropic use: Stevens Johnson syndrome, diabetes mellitus, QTc prolongation, pancrea- titis, neutropenia, hepatotoxicity, and chronic kidney disease

Remdesivir Only FDA-approved medication for severe COVID-19

Interacts with RNA polymerase, leads to decrease in viral RNA

No information � No information is available about pharmaco- kinetic drug-drug interactions

� Risk of elevated aminotransferase levels (e.g. ALT up to 203 upper limit of normal)— caution with potentially hepatotoxic psychotropics

Tocilizumab Immune modulator: recombinant humanized monoclonal antibody that acts as an IL-6 inhibitor; may lessen cytokine storm

Possible positive effects on depressive symptoms

� No major interactions reported

Vitamin C Enhances immune response, antioxidant and reducing agent

No evidence for neuropsychiatric adverse effects;

Of note, lower levels associated with depression, confusion, anger, delirium

� Coadministration with barbiturates may decrease the effects of vitamin C

ALT = alanine aminotransferase; COVID-19 = coronavirus disease 2019; FDA = Food and Drug Administration; IFN = interferon; IL = interleukin; P-gp = P-glycoprotein.

Bilbul et al.

hydroxychloroquine, a derivative compound used in the treatment of inflammatory disorders such as rheumatic arthritis and systemic lupus erythematosus, are being considered as a possible treatment for COVID-19 infection. Interest in these medications is in part because of their potential for interference with

Psychosomatics 61:5, September/October 2020

virus-receptor binding and immune-modulating ef- fects.31 The most promising study is a small open- label trial from France,32 although a recent large observational study showed that the risk of intuba- tion or death was not significantly higher or lower among patients who received the drug than among

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Psychopharmacology of COVID-19

those who did not.33 The authors suggest that their findings do not support continued use of the drug in patients with COVID-19 outside of clinical trials.

Neuropsychiatric Effects

Neuropsychiatric side effects of chloroquine and hydroxychloroquine include psychosis, delirium, agita- tion, suicidality, personality changes, depression, and sleep disturbances.34,35 Risk factors for hydroxychloroquine-induced neuropsychiatric effects may be concurrent use of CYP3A4 inhibitors or low- dose glucocorticoids, alcohol intake, family history of psychiatric disease, female gender, low body weight, and supratherapeutic dosing.36

A number of mechanisms have been postulated for the pathogenesis of hydroxychloroquine-induced neuropsychiatric effects, such as cholinergic imbal- ance due to acetylcholinesterase inhibition, inhibition of the serotonin transporter protein, and N-methyl-D- aspartate and gamma aminobutyric acid antagonism.34

Psychotropic Considerations

Hydroxychloroquine and chloroquine can cause heart conduction disorders, including QT interval prolon- gation, bundle branch block, atrioventricular block, and torsades de pointes.37 On April 24, 2020, the FDA issued a safety announcement against the use of hydroxychloroquine or chloroquine for COVID-19 outside of the hospital setting or a clinical trial because of risk of heart rhythm problems.38 Caution should be used when combining them with QT- prolonging psychotropics. These agents can also be hepatotoxic39 and epileptogenic,40 so caution should be exercised in patients with hepatic disease, or in conjunction with psychotropics that may be hepato- toxic or may lower the seizure threshold.

Both chloroquine and hydroxychloroquine are metabolized by CYP3A4,41 so CYP3A4 inhibitors (e.g., fluvoxamine) could raise plasma levels and increase the potential for adverse effects. By contrast, CYP3A4 in- ducers, such as carbamazepine, oxcarbazepine, and modafinil, could decrease levels of chloroquine or hydroxychloroquine, potentially rendering them less effective. Given hydroxychloroquine’s long half-life (40 h), the potential for continued adverse effects and drug interactions may continue for days after the drug has been discontinued.35

420 www.psychosomaticsjournal.org

Tocilizumab

Tocilizumab is a recombinant humanized monoclonal antibody that acts as an interleukin-6 receptor inhibi- tor42 and is FDA approved to treat several types of arthritis.43 Tocilizumab is being trialed in patients with severe COVID-19 and elevated interleukin-6 because interleukin-6 appears to be involved in cytokine storms that have been observed in critically ill patients with COVID-19.44

Neuropsychiatric Effects

Data from rheumatic arthritis patients suggest that tocilizumab may have some positive effects on depres- sive symptoms in rheumatoid arthritis45,46; however, unpublished data from a small study surprisingly sug- gest that patients who received tocilizumab after allo- geneic hematopoietic cell transplantation experienced worse symptoms of depression, anxiety, pain, and sleep.47

Psychotropic Considerations

No major interactions have been reported.

Favipiravir

Favipiravir is an antiviral thought to act as an RNA- dependent RNA polymerase inhibitor.48 It was approved in China in February 2020 for treatment of influenza,48 and there are current trials evaluating its efficacy on SARS-Cov-2. It is not currently approved for use in the United States.

Neuropsychiatric Effects

No published information is available.

Psychotropic Considerations

There is no published information available. One published case report suggested a mild QT prolonga- tion in a patient with Ebola virus who received favipiravir.49

Lopinavir/Ritonavir (Kaletra)

Lopinavir/Ritonavir is an antiviral medication used to treat HIV-1 infection.50 The 2 medications work syn- ergistically: Lopinavir is a protease inhibitor, and ri- tonavir helps to boost plasma levels of lopinavir by

Psychosomatics 61:5, September/October 2020

Bilbul et al.

inhibiting its metabolism.50 Unfortunately, a recently published randomized, controlled, open-label trial found no additional benefit with lopinavir-ritonavir treatment in hospitalized patients with SARS-CoV-2 as compared with standard care.51

Neuropsychiatric Effects

The manufacturer’s prescribing information lists possible psychiatric side effects, including abnormal dreams, agitation, anxiety, confusion, and emotional lability although there is limited information in pub- lished case reports or trials regarding the incidence of such effects.50 Protease inhibitors as a class have been associated with neurological adverse events, such as paresthesias, taste alterations, and neurotoxicity.52

Psychotropic Considerations

Protease inhibitors are extensively metabolized by the cytochrome P450 system and have been shown to interact with many drugs, including psychotropics.53

The use of ritonavir may lead to increased concentra- tions of coadministered drugs that are CYP3A4 or CYP2D6 substrates or decreased concentrations of CYP1A2 or CYP2B6 substrates, many of which are psychotropics.

The use of lopinavir/ritonavir is contraindicated with medications that include pimozide, midazolam, and triazolam because of increased drug levels and potentiation of adverse effects. The use of benzodiaze- pines not dependent on CYP metabolism (lorazepam, temazepam, or oxazepam) is recommended. Owing to CYP450 enzyme or glucuronidation-inducing effects, ritonavir-boosted protease inhibitors also have been shown to lower concentrations of some psychotropics (e.g., bupropion, methadone, lamotrigine, and olanza- pine), thus leading to increased dose requirements for these medications.53

As most psychotropics are substrates for CYP isoenzymes, there are many additional theoretical in- teractions, but the clinical significance varies by agent. Clinicians should assess each potential interaction individually by reviewing available literature and manufacturer’s prescribing information.

Other potential nonpsychiatric side effects that may have implications for psychiatrists include Stevens Johnson syndrome, diabetes mellitus, QTc prolonga- tion, pancreatitis, neutropenia, hepatotoxicity, and chronic kidney disease.50

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Convalescent Plasma Therapy

Antibody containing convalescent plasma from recov- ered patients has been used with some success as a last resort to treat severe viral respiratory infections such as SARS-CoV, Middle Eastern respiratory syndrome- CoV, and Ebola, although large clinical trials are ab- sent.54 Trials are currently underway to study the effectiveness of convalescent plasma therapy in the treatment of individuals with severe respiratory failure associated with COVID-19.

Neuropsychiatric Effects

When used for the treatment of other severe acute viral respiratory infections, convalescent plasma ther- apy was not associated with serious adverse events,55

although in general, plasma transfusions can cause a range of adverse events from mild fever and allergic reactions to life-threatening bronchospasm/anaphylaxis, transfusion-related acute lung injury, and transfusion- associated circulatory overload.56

Specific neuropsychiatric effects have not been re- ported, although allergic reactions, cardiovascular complications, and bronchospasm can produce symp- toms such as shortness of breath and palpitations that mimic panic attacks.

A potential psychological adverse effect of conva- lescent plasma therapy relates to ethical concerns about coercion, confidentiality, and privacy of the prospective donors that were initially raised during the Ebola outbreak57 and led to a World Health Organization document providing guidance on the ethical use of convalescent plasma.58

Psychotropic Considerations

There are no specific interactions between psychotro- pics and plasma transfusions, but patients who develop transfusion reactions might receive steroids or diphen- hydramine which can have negative synergistic effects with existing psychotropics.

Azithromycin

Azithromycin is an antibacterial agent which may have antiviral and anti-inflammatory activities.32 It is under investigational use for treatment of COVID-19 when given in conjunction with chloroquine or hydroxy- chloroquine. In one small French study (n = 20), azi- thromycin added to hydroxychloroquine was

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Psychopharmacology of COVID-19

significantly more efficient for virus elimination than hydroxychloroquine alone.32

Neuropsychiatric Effects

Side effects that have been reported include psychotic depression, catatonia, delirium, aggressive reaction, anxiety, dizziness, headache, vertigo, and somnolence.59,60

Psychotropic Considerations

Azithromycin has not been implicated in pharmacoki- netic interactions with psychotropics but has been associated with QTc prolongation and life-threatening torsades de pointes arrhythmias. It has also been associated with hepatotoxicity.61

Vitamin C

High-dose intravenous vitamin C (ascorbic acid), an antioxidant and reducing agent, has been investigated in the treatment of sepsis because of its enhancement of the immune response.62 In the intensive care setting, vitamin C administration has been correlated with preventing progressive organ dysfunction and reducing mortality in sepsis and acute respiratory distress syn- drome63 and is being investigated in critically ill pa- tients with COVID-19.

Neuropsychiatric Effects

There are no known adverse neuropsychiatric conse- quences of high-dose intravenous vitamin C adminis- tration, but some studies have associated lower levels of vitamin C with depression, confusion, and anger.64

Vitamin C deficiency has also been identified as a possible risk factor for delirium.65

Psychotropic Considerations

Coadministration with barbiturates may decrease the effects of vitamin C.62

Corticosteroids

Corticosteroids are involved in immune function, inflammation, and carbohydrate metabolism and are used in the treatment of endocrinopathies, autoimmune disorders, and asthma/allergies.66 In previous pan- demics, such as SARS and Middle Eastern respiratory syndrome, corticosteroids were not recommended

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because of the concern that they may exacerbate lung injury.67 Given evidence suggesting that severe COVID-19 may be associated with a cytokine storm and hyperinflammation syndrome,67 corticosteroids may have a role in treatment.

Neuropsychiatric Effects

The neuropsychiatric side effects of corticosteroids have been well described in the literature and include depression, mania, agitation, mood lability, anxiety, insomnia, catatonia, depersonalization, delirium, and psychosis.66 Most neuropsychiatric side effects occur early in the treatment course, usually within days, and dosing is the most significant risk factor (i.e., at pred- nisone equivalents of .40 mg/d).66

Psychotropic Considerations

Corticosteroids have been inconsistently reported to be weak CYP3A4 and CYP2C19 inducers,68 which could lead to decreased effects of CYP3A4 or CYP2C19 substrate psychotropics.69 In addition, phenytoin has been shown to increase hepatic metabolism of systemic corticosteroids.70

Interferon

IFNs are glycoproteins that have immunomodulatory, antiproliferative, and hormone-like activities.71 IFN alpha and beta have anti-SARS-CoV-1 activity in vitro, and IFN beta reduces the replication of Middle Eastern respiratory syndrome-coronavirus in vitro.72,73 Based on this information, IFN has been considered as a potential treatment for COVID-19, including in com- bination with ribavirin, a guanosine analogue with a broad-spectrum antiviral potency.74

Neuropsychiatric Effects

IFN alpha has a boxed warning for “life-threatening or fatal neuropsychiatric disorders.”75 Specific effects include fatigue, mood disorders, suicidality, anxiety disorders, irritability, lability, apathy, sleep distur- bance, and cognitive deficits.76 Side effects of IFN beta can include fatigue, weight loss, myalgia, and arthralgia,77 but not generally depression. Given the potential for significant psychiatric side effects of IFN alpha, it is important for clinicians to screen for base- line psychiatric history and monitor closely for emer- gence of any symptoms.

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Bilbul et al.

Psychotropic Considerations

There are no known pharmacokinetic interactions with psychotropics, but clinicians should be mindful of the potential for bone marrow suppression which may raise safety concerns with concurrent use of psychotropics, such as carbamazepine, valproate, and clozapine. In addition, seizures in conjunction with bupropion use have been reported.78

Colchicine

Colchicine is a plant-derived alkaloid with anti- inflammatory properties that is used for a variety of rheumatological and cardiac conditions.79 It is hy- pothesized that colchicine could treat COVID-19 through targeting the overactive interleukin-6 pathway.80

Neuropsychiatric Effects

Colchicine does not typically produce any neuropsy- chiatric effects, but at toxic doses, it can cause delirium, seizures, and muscle weakness.81

Psychotropic Considerations

Colchicine has a narrow therapeutic index, and atten- tion must be paid to potential drug interactions that might increase toxicity. Colchicine is metabolized by CYP3A4 and excreted via the P-glycoprotein transport system as well as cleared by the kidneys through glomerular filtration. Dose adjustment is recommended with concurrent use of CYP3A4 or P-glycoprotein in- hibitors as well as in patients with hepatic or renal impairment.82 CYP3A4 inducers can lead to increased metabolism and theoretically decreased effectiveness of colchicine.

DISCUSSION

COVID-19 and its treatments can impact many organ systems and contribute to a host of drug interactions and neuropsychiatric effects. This can have safety im- plications for use of psychotropics, which are highly metabolized by the hepatic cytochrome p450 system and carry their own potential for drug-interactions and end-organ adverse effects.

While there are no absolute contraindications to the use of psychotropics in patients with COVID-19, psychiatrists must be mindful of potential adverse

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effects and conduct a thoughtful risk-benefit analysis as part of their clinical decision-making process. For example, chloroquine, hydroxychloroquine, and azi- thromycin have the potential for QT prolongation, which can be problematic in patients with tenuous cardiac status. Generally, psychiatrists might avoid antipsychotic medications in the setting of a prolonged QT interval. However, in our experience, hyperactive delirium in patients with COVID-19 is highly prevalent, manifests with severe agitation that can be difficult to treat, and leads to dangerous behaviors such as removing oxygen or assaulting staff. While there is limited evidence to support the use of any interventions in the management of agitation in COVID-19– associated delirium, most consultation-liaison psychia- trists consider antipsychotics such as haloperidol the gold standard for managing agitation in delirious pa- tients. In these situations, the consultation-liaison psy- chiatrist should assist the medical team in reasoning through the cardiac risks of using an antipsychotic balanced against effective management of the agitation. The use of an antipsychotic with cardiology involve- ment and frequent electrocardiogram monitoring or telemetry may be deemed acceptable. Alternatives such as alpha-2 agonists (dexmedetomidine and clonidine) or antiepileptics (valproic acid) should be considered if the individual patient’s cardiac risk is determined to be high and/or if the antipsychotic is clinically ineffective. Melatonin has been proposed for addressing con- sciousness and sleep-wake cycle disturbances in delir- ious patients with COVID-19, especially given its potential for antioxidative, anti-inflammatory, and immune-enhancing effects.83 With the exception of patients who chronically use alcohol or benzodiaze- pines and may be at risk for withdrawal, benzodiaze- pines should be avoided if possible and considered only as a last resort for highly agitated delirious patients for whom other treatments are unavailable or ineffective. Early delirium screening and nonpharmacological strategies to prevent or treat delirium such as frequent orientation and early mobilization should be used if practically feasible.24

As another example, we have observed many nondelirious patients with COVID-19 and significant anxiety in the setting of respiratory distress. In some cases, the anxiety leads to requests to leave against medical advice or refusal to remain isolated. For these patients, psychiatrists should consider whether the benefit of a low-dose benzodiazepine outweighs the

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potential risk of respiratory depression. The use of benzodiazepines may be reasonable in patients with adequate oxygen saturation and in the absence of confusion or a depressed sensorium. Depending on the individual patient’s circumstances and symptoms, alternative medications such as gabapentin, buspirone, hydroxyzine, a low-dose atypical antipsychotic, or a SSRI may be appropriate. Nonpharmacological/psy- chosocial interventions (e.g., behaviorally oriented therapies) should also be used.

Other important tasks for the psychiatrist treating a patient with COVID-19 include review of all medica- tions, monitoring for neuropsychiatric side effects of medications such as hydroxychloroquine or corticoste- roids, and differentiating between primary psychiatric symptoms versus those that are secondary to COVID- 19 or other medications.

Interestingly, several psychotropics, including haloperidol and valproic acid, were recently named on a list of FDA-approved medications with potential for in vitro action against SARS-CoV-2.84 Fluvoxamine is also under investigation for its potential to reduce the

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inflammatory response during sepsis by inhibiting cytokine production,85 and melatonin for its anti- oxidative and anti-inflammatory properties.86 If more data become available, psychiatrists might consider preferentially using these agents if clinically appropriate.

In summary, psychiatrists must be aware of the likelihood of encountering patients with COVID-19 infection and must remain cognizant of the neuropsy- chiatric effects and drug-drug interactions of COVID- 19 treatments as well as the end-organ effects of COVID-19.

Funding: This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

Disclosure: C.L.E. receives royalty payments from American Psychiatric Publishing, Inc. The other au- thors report no proprietary or commercial interest in any product mentioned or concept discussed in this article.

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75. PEGASYS (peginterferon alfa-2a) injection – Highlights of Prescribing Information [Internet]. FDA. 2020. Available from: https://www.accessdata.fda.gov/drugsatfda_docs/ label/2017/103964s5270lbl.pdf. [Accessed 20 April 2020].

76. Davoodi L, Masoum B, Moosazadeh M, Jafarpour H, HaghshenasMR,MousaviT:Psychiatricsideeffectsofpegylated interferon-aandribavirintherapyinIranianpatientswithchronic hepatitis C: a meta-analysis. Exp Ther Med 2018; 16:971–978

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Psychopharmacology of COVID-19

Introduction
Impact of COVID-19 on Psychotropic Drug Safety

Hematological Effects
Cardiac Effects
Hepatic Effects
Renal Effects
Neurological Effects
Pulmonary Effects

Psychiatric Considerations of Proposed COVID-19 Treatments

Remdesivir

Neuropsychiatric Effects
Psychotropic Considerations

Chloroquine and Hydroxychloroquine

Neuropsychiatric Effects
Psychotropic Considerations

Tocilizumab

Neuropsychiatric Effects
Psychotropic Considerations

Favipiravir

Neuropsychiatric Effects
Psychotropic Considerations

Lopinavir/Ritonavir (Kaletra)

Neuropsychiatric Effects
Psychotropic Considerations

Convalescent Plasma Therapy

Neuropsychiatric Effects
Psychotropic Considerations

Azithromycin

Neuropsychiatric Effects
Psychotropic Considerations

Vitamin C

Neuropsychiatric Effects
Psychotropic Considerations

Corticosteroids

Neuropsychiatric Effects
Psychotropic Considerations

Interferon

Neuropsychiatric Effects
Psychotropic Considerations

Colchicine

Neuropsychiatric Effects
Psychotropic Considerations

Discussion
References

The Journal of Psychohistory 48 (2) Fall 2020

Psychopharmacology for the Psycho-Historian: The Evils of “Big Pharma,” Lobbying, Corruption and Serious Side Effects of Medications

Doctors pour drugs of which they know little, to cure diseases of which they know less, into patients of which they know nothing.

—Moliere (1622-1673, French dramatist)

ABStrACt: Psychohistorians have an interest in understanding terrorism, gun vio- lence, suicide, homicide, war crimes and other forms of criminal activities. In some of these situations side effects of medications, often psychotropics were considered a contributing factor to the violence and aggression involved in these acts. there are cases of war criminals who claimed their medications caused them to murder innocent civilians. In several mass gun shooting, the gun industry claimed that the offender was on psychiatric medication and claimed that mental sickness and the side effect of medication caused their homicidality. In several civil cases, drug manufacturers have been sued and a number of them settled their case without a court finding and without claiming responsibility for any wrong doing. However, in other cases they were held liable resulting in million-dollar fines. We review scientific articles on the side effects of psychiatric medications and the presence of any connection to violence, suicide and criminal activities. We also explore cor- ruption in a number of pharmaceutical companies and their financial relationship with government officials and prescribers.

A PSyCHO-HISTORICAL PERSPECTIvE: TALK vS DRUGS

Telling stories and tales to share learning and provide healing has ex-isted since ancient times. The collection of Middle Eastern folk tales commonly known as the “1001 Nights” illustrated the healing effect these

JamsHid a. marvasti & claire c. olivier

101Evils of Psychopharmacology; Implications for Psycho-Historians

stories could have.1 They provided “sessions” for the listeners as they took in the lessons and integrated them as a talking remedy. The difference from the Freudian school is that through folk tale type of storytelling the doctor does the talking, sharing tales that meet the patients’ concerns. In the 1970’s and 1980’s metaphors, and fairytales were used as a therapeutic intervention by Milton Erikson, Peseschkian and Bettelheim. While hair- dressers and bartenders filled the role of amateur modern therapists listen- ing to their clients and offering life stories.2

Clinical literature indicates a replacement of talk therapy by pharmaco- therapy during the last 30-40 years. In the 1970’s, the treatments of choice were psychotherapy, behavioral therapy, and/or environmental therapy. However, it gradually changed to the point that treatment now relies heav- ily on medication. There are multiple reasons for this change. One is the pressure from the insurance companies and the managed care industry to use drugs, which are cheaper and may possibly work faster (on the sur- face).3 Because certain psychiatric symptoms are connected to neurotrans- mitters, insurance companies may encourage doctors to use medications to modify these neuromessengers to minimize symptoms.4 Yet inhibiting these neurotransmitters may not cure the patient. Researchers are trying to connect mental disorders to biochemical causes. If such connections are found, it is believed that the most effective approach would be a biochem- ical treatment. However, in our opinion, various types of therapy (psycho- therapy, somatic (body based) therapy, etc.), may also positively impact a person’s brain chemistry, without negative side effects.

PREvALENCE OF UTILIzING PSyCHIATRIC MEDICATIONS Many Americans have come to expect substances to provide instant relief. Legal substances such as coffee, tea, alcohol and marijuana (in states where it is legal) are commonplace and can help provide energy, comfort, cre- ativity, relaxation and distraction. When these methods are not enough to combat one’s mood the media is more than willing to step in and provide other suggestions. Marketing in the media and news provides a way to de- crease the unknown about medications, regardless of their veracity. Adults then become more comfortable asking doctors about medications they see on the television for them or their children.5

In regards to prevalence of medication utilization, IQVia, the compa- ny that is the best source for physician prescribing data, reported that in 2017, over 7,200,000 children under 17 were on psychiatric medication.6 The highest number of children were on ADHD medication, followed by antidepressants, then antipsychotics, and finally anti-anxiety agents.7 The

102 Jamshid A. Marvasti & Claire C. Olivier

total of people (all ages in the US) taking psychiatric medications in 2017, was over 80,200,000.8

NATURE OF SIDE EFFECTS AND FDA IMPACT ON WARNING LABELS Side effects are generally dose oriented (which means that they may in- crease if the dose increases) and time related. Time related refers to how the body can adjust to side effects over time; therefore, they may decrease gradually and some of them eventually disappear.

The range of side effects of psychiatric medications may include insig- nificant and temporary ones (e.g., dry mouth, frequent yawning, stuffy nose), those which are significant and permanent, (e.g., tardive dyskine- sia-uncontrollable jerky movements of the body), and finally, life threaten- ing disorders (e.g., serotonin syndrome, neuroleptic malignant syndrome, suicidality or aggression).9 Almost all antidepressant and antipsychotic medication may cause akathisia which is a neurological disorder charac- terized by a feeling of inner restlessness, rocking while standing or sitting, lifting the feet as if marching on the spot, and constantly crossing and un- crossing the legs while sitting. The other name for akathisia is Restless Leg Syndrome, however the restlessness may not be limited to the legs. It may transfer to the upper extremities and generally can include a feeling of “in- ner tension.” Clinical literature indicates that this kind of internal tension and severe anxiety/restlessness may result in aggression or suicidality.

Phenobarbital, which is used for the treatment of epilepsy, is associated with memory disorders, hyperactivity, irritability, aggression, inattentive- ness, learning difficulties and depressed mood.10 Benzodiazepines such as Va- lium and Ativan may cause disinhibition in children and also in adults with TBI (traumatic brain injury). They may become aggressive and hyperactive. Long term use of Lithium may cause kidney and thyroid damage which may lead to cognitive dulling, weight gain, tremors and slowed down movement.

CHANGES TO THE LABEL OF PSyCHIATRIC MEDICATION WARNING There were approximately 14,775 cases reported to the US FDA’s MedWatch system between 2004-2012, which noted that a number of psychiatric drugs had violent side effects. In 1,500 cases there was homicidal ideation/ homicide. There were over 8,000 cases of aggression and approximately 3,280 cases of developing mania.11 Drug companies have been forced to change their warning labels over time, given the severity of side effects or the discovery of new negative impacts.

In 2004, the FDA requested drug companies to change the warning la- bel of 10 popular antidepressants. Patients who were on these medications were to be closely monitored for increased depression or suicidality. Addi-

103Evils of Psychopharmacology; Implications for Psycho-Historians

tionally, the FDA shared that agitation, hostility, impulsivity and mania (among other side effects), had been reported by child and adult patients who were taking these antidepressants.12 Yet the Black Box label change to Selective Serotonin Reuptake Inhibitor (SSRI) antidepressants regarding possible suicidality in 2004, only warned patients up to age 18. It was not until 2007 that the FDA extended this warning to people under age 24.13

In 2007, the FDA changed the label of the ADHD medication Desoxyn (methamphetamine), to include multiple warnings regarding potential side effects of: aggression, bipolar disorder and psychotic symptoms.

In 2009, warning labels of drugs for smoking cessation and depression (Zyban and Wellbutrin) were changed to include warnings of hostility, agi- tation, and suicidal ideation/behavior.

In 2011 in Australia, a safety update on the psycho-stimulant medica- tion Provigil stated that this drug was associated with aggressive behavior, suicidal ideation/behavior, psychosis and mania, among other warnings. In 2010 the FDA in the U.S. added “aggression,” to the warning label.14

The most frequent prescribed SSRI antidepressants are Prozac, Paxil, Zoloft, Effexor, Cymbalta, Lexapro and Celexa. Their side effects may in- clude the development of mania and psychosis which may result in poor judgment and violence. Additionally, these medications may also cause somnambulism, or sleepwalking. Dr. Ohayon conducted a sleep study poll of nearly 16,000 adults in the U.S.15 He found that people who were taking an antidepressant were twice as likely to experience sleepwalking. Despite this clinical research, sleepwalking is not listed as a side effect for most anti- depressants. Legally if someone commits a crime while sleepwalking, they are not held responsible, as the defendant, “does not have the capacity to form intent.”16

Additionally, in 2017, the FDA changed the label of ADHD medication Dyanavel XR (amphetamine) to include the warning that it may exacer- bate behavior disturbance symptoms or thought disorders for those with a history of psychotic diagnosis. More significantly, this medication could cause psychotic symptoms including hallucinations or mania for patients with no previous psychotic symptoms.17

CRIMINAL ASPECTS OF PSyCHIATRIC MEDICATIONS AND DRUG MANUFACTURERS

Case of Wesbecker Trial In 1989 Joseph Wesbecker killed 8 people and injured 12 at his workplace, before committing suicide and a case was brought against the drug man- ufacturer. Wesbecker had been taking an SSRI antidepressant (Prozac) for

104 Jamshid A. Marvasti & Claire C. Olivier

one month before committing these crimes.18 Dr. Breggin was the scientific and medical expert for the case. He was asked to evaluate for the plain- tiffs the scientific basis for the claim that the antidepressant was causing violence and suicide. Additionally, he was to evaluate the potential negli- gence of the manufacturer, Eli Lilly, in how it developed and marketed this medication, which included any possible attempts to minimize the risk of drug-induced suicide and violence.19

Initially, it appeared that Eli Lilly had won the case, as this medication was found not to be at fault. However, the judge then found out the trial had been rigged, as the manufacturing company had paid the plaintiffs to withhold damaging evidence.20 As part of the settlement in 1994, the drug manufacturer released internal documents from 1985 which showed evi- dence that the risks of this drug outweighed the benefit.

Even without knowing how much the drug was at fault in the Wesbecker case, what is still significant is the possible withholding of information by drug manufacturer. Eli Lilly conducted research on animals which demon- strated that previously friendly cats began showing aggressive behavior (such as growling and hissing) when given this medication. This response was consistent with their unpublished work on a SSRI (Sertraline).21 While Eli Lilly denied that suicidality could be caused by medications, unpub- lished reports showed healthy volunteers on this antidepressant dropping out of the clinical trials because of developing akathisia and suicidality. Yet published reports by Eli Lilly did not include material on behavioral toxic- ity. Additionally, Kaufman stated that in other clinical trial reports, it was not mentioned that this drug company had been co-prescribing Benzodi- azepines (tranquilizers) along with this SSRI antidepressant to minimize the agitation caused by this drug alone.22

Case of Donald Schell In Wyoming in 2001, Donald Schell murdered his wife, daughter and granddaughter before shooting himself under the influence of another SSRI antidepressant (Paxil). The plaintiff was awarded a multimillion-dol- lar settlement.23 As put forth by Anne Thompson, “plaintiffs’ lawyers have argued for years that the so-called miracle antidepressants have a darker side that pharmaceutical makers have hidden from the general public, oc- casionally with lethal consequences.”24 In her article Thompson reviews the legal case of Donald Schell who had been taking this drug for only 48 hours before his crimes. This was a ground-breaking case because it was the first time a jury found a pharmaceutical company liable for the homicides committed by a person taking an antidepressant. A key element of the case were internal documents by the pharmaceutical company, which showed that they were aware that a small number of people could become violent

105Evils of Psychopharmacology; Implications for Psycho-Historians

as a side effect. Despite having this information, the company did not in- clude such warnings about aggression or suicide on drug packaging.

It was not contested that Schell had been depressed. He had previous- ly been on a different antidepressant medication. Yet he had no significant marital problems and loved his daughter and granddaughter, so there was no apparent motivation for the murder. The plaintiffs’ lawyer Vickery, fo- cused the argument on whether it is, “possible for the drug to produce a violent reaction in some people.” A critical element was Vickery’s win in pre-trial when a motion by this drug company was overruled. They had wanted to exclude testimonies by two expert witnesses, Dr. Healy a psychia- trist and Dr. Maltsburger an associate clinical professor of psychiatry at Har- vard. Healy was known for his lectures and writings regarding SSRIs and how they should have warning labels. His own research illustrated that one in four healthy volunteers on this medication could develop agitation and sui- cidality. He shared that these results were supported by studies that Beecham labs had conducted at the request of the manufacturer. Within their inter- nal confidential documents, were the results of a study with 2000 healthy volunteers taking either a placebo or anti-depressant. The plaintiffs’ team shared that in these results were hundreds of volunteers who had negative side effects, like attempted suicide which Beecham physicians stated were either, “possible, probably, or definitely caused by this SSRI anti-depressant.”

The defense put forth that their medication was very effective and could have been for Schell if he had been able to take it for a longer duration. They also claimed that two pills couldn’t have caused his actions. However, the plaintiffs showed the results from their study included volunteers experienc- ing anxiety, nightmares, hallucinations and other symptoms within two days of taking this drug. Two other volunteers attempted suicide within 2-3 weeks.

Although the plaintiffs asked for $25 million, the 8-person jury award- ed $8 million. The manufacturer was found to be 80% at fault, Schell 20%. Therefore, his relatives received $6.4 million. This was a significant win as it encouraged other plaintiff lawyers to begin taking up antidepressant cases.25

Case of Stewart Dolin In 2010 in Chicago, Stewart Dolin, a 57-year-old attorney, committed sui- cide by jumping in front of a train.26 His wife sued GlaxoSmithKline (GSK), a drug manufacturer, because just days before his suicide he started taking a generic version of an SSRI anti-depressant (Paxil). The suit claimed that GSK did not sufficiently warn Dolin’s doctors, about the suicidal risk for adults using this drug. The suit held that Dolin would not have taken his life if he had not taken this medication. The Black Box warning on the medication stated that there was a suicide risk but only for children and young adults up to age 24. During the trial it was argued that the manu-

106 Jamshid A. Marvasti & Claire C. Olivier

facturer had known for 20 years that this medication could trigger suicidal behavior in a person of any age but hid the risk and ignored numerous sui- cides committed during clinical trials.

GSK had claimed no fault because they had not manufactured the ge- neric version, however the judge ruled that they were responsible for the label. However, they stated they were not responsible because the FDA did not require them to add a suicidal risk on the warning label. The 9-panel jury found this company liable in 2017 for the charges and Dolin’s widow was awarded $2 million for damages and $1million for the suffering of her husband. However, the original suit asked for $39 million in damages.27 The defense later appealed and in 2018, the verdict was overturned. GSK claimed that they had repeatedly asked the FDA to update this drug’s warn- ings to include risk of suicidality to adults. The 7th Circuit panel found that the FDA would have rejected an adult suicide warning and that this drug company was following the FDA’s mandated drug label warning.28

One wonders if the FDA could be sued for negligence if they had been provided with clinical studies which supported a known risk of older (over 24 years old) adult suicide, yet did not require this information on medica- tions’ labels. While the FDA is entrusted with ensuring the safety of all food and drug products in the United States, it is not clear how some medications are approved to be on the market despite a mix of success and failure during clinical trials. During the pre-market trials of one of the SSRI antidepressants, 16 people taking this medication attempted suicide, two successfully.29 Yet it was still FDA approved in 1987, without a warning label of possible suicidali- ty. The German version of the FDA would not allow this medication to come to their market until it included a suicide warning on the label in 2004.30

PHARMACEUTICAL COMPANIES PAyOUT Pharmaceutical companies have been in the news for years regarding claims of false advertising or promoting their medication for unapproved usage. Additionally, they are accused of being more focused on making a profit than in disclosing all significant information about their drugs and the side effects they cause. Major drug companies have had to settle hundreds of millions of dollars in government cases or are under investigation.31

In 2005, the major drug company Eli Lilly, had to pay out $690 mil- lion in a lawsuit to settle claims by 8000 plaintiffs that an antipsychotic (Zyprexa), had caused diabetic and hyperglycemic side effects. They also had to pay an additionally $500 million in 2007 for another 18,000 suits against the same medication.32

In 2009, the same company, Eli Lilly, paid a $515 million dollar fine, in addition to pleading guilty to criminal charges, that it unlawfully promot-

107Evils of Psychopharmacology; Implications for Psycho-Historians

ed their antipsychotic medication (Zyprexa) for uses that had not been FDA approved which included treating dementia. They settled an addi- tional federal civil investigation paying out $800 million to the federal government and various states.

In 2009, Pfizer, a major drug company, was ordered to pay $2.3 billion by the U.S. Department of Justice in criminal and civil fines. They were charged with illegal promotions to encourage doctors to use several of their products including Geodon, an antipsychotic. Additionally, to curb fur- ther similar offenses they were monitored for five years by the Department of Health and Human Services Office of Inspector General.33

In 2009, another maker of an SSRI anti-depressant GlaxoSmithKline (GSK) was found guilty of failing to adequately warn doctors of the risks of using their medication (Paxil) during pregnancy. Lyam Kilker, age 3, was born with heart defects which his mother attributed to this medication, taken during her pregnancy. He was one of the first out of approximately 600 similar cases, and his family was paid $2.5 million in damages.34

THE ISSUES OF KICKBACKS Psychiatrist, Michael Reinstein, had his license suspended for overprescrib- ing clozapine, an antipsychotic medication. In the case brought against him he was accused of submitting 140,000 false claims that involved kick- backs from drug manufacturers. Additionally, the disciplinary board stated that he did not consider alternative treatments that would have been less harmful to his patients. This antipsychotic is known for having seizures as one of its side effects. The company which makes the generic version of this anti-psychotic, had to pay over $27 million for persuading Dr. Rein- stein to overprescribe their drug.35

Case of Andrew yount Andrew Yount was a 4-year-old boy when he was prescribed an antipsy- chotic, Risperdal, for his behavioral problems and ADHD.36 Yet this drug had only been approved by the FDA for adult schizophrenia. However Johnson & Johnson, the pharmaceutical company, began to market this drug to doctors, encouraging them to prescribe it to children for a range of behavioral concerns. The FDA has specifically rejected it for the pediatric population because there was not enough data to show its safety. This an- ti-psychotic increased the hormone prolactin which promoted the growth of female breasts, and affected Yount and thousands of other boys. These boys became men with full sized breasts, a condition that is irreversible un- less they are surgically removed. Some of these men have won settlements against the manufacturer, which included Yount, who received $76 mil-

108 Jamshid A. Marvasti & Claire C. Olivier

lion. In their 2016 annual report, Johnson & Johnson stated that they have 18,500 lawsuits against them related to this medication.37

LOST COURT CASES WHEN MEDICATIONS WERE USED AS A DEFENSE Although there are multiple drug lawsuits and settlements against large drug manufacturers,38 there are also cases that claiming medications as a cause of abnormal behavior were ruled out. Following are a few of these cases:

Texting suicide case In the Commonwealth v Michelle Carter case, better known as the “texting suicide case,” Carter had been sending text messages to her boyfriend Roy, encouraging him to kill himself, which he ultimately did.39 A psychiatrist for the defense claimed that Carter’s use of antidepressants made her invol- untarily intoxicated and delusional in thinking she was helping Roy. She was later convicted of involuntary manslaughter. While it is reasonable that defense attorneys will use whatever material, they can to help their clients, psychiatrists testifying in court have an obligation to share relevant psychi- atric clinical science that illustrates the current reality of understanding.

“Ambien Excuse” Roseanne Barr, a television actress, had to face consequences for posting a racist comment on twitter. She blamed her bad behavior on her pre- scription medication Ambien in response to public outrage, however the medical community has found this excuse hard to believe. Ambien is a sedative hypnotic prescribed as a sleeping aid in patients with insomnia. Although the side effects of the psychotropic medication include con- fusion, drowsiness and muscle weakness, the drug maker tweeted that, “…racism is not a side effect of any Sanofi medication.” Ms. Barr was certainly not thinking clearly in her “Ambien blackout” when she “sleep tweeted,” but that does not excuse or explain the racist nature of her post. Ms. Barr was tried in the Court of Public Opinion and her sitcom was cancelled. Allen Frances M.D, a psychiatrist at Duke University com- mented in a STAT News article, “Allowing fake medical excuses to go un- challenged has 3 harmful consequences: encouraging more bad behavior, discouraging those who really need medications from using them, and unfairly stigmatizing the mentally ill.”40

Sleeping Pill Crime Brian Browning killed his wife while she was asleep, but blamed his ac- tions on Unisom, a sleeping pill he had been taking. Browning’s doctor had shared that this medication could trigger behavior outside of one’s normal

109Evils of Psychopharmacology; Implications for Psycho-Historians

character. However, the courts in Australia, where this took place, did not accept this argument and Browning was convicted. The court acknowl- edged that Browning’s judgement and emotional abilities could have been impacted, however there were other factors to consider that carried more weight. Browning had claimed that Unisom caused psychosis, yet evidence showed that psychosis is not one of the side effects, therefore this assertion was abandoned at the trial.41

U.S. SOLDIER WHO MURDERED AFGHANI CIvILIANS Some of the U.S. veterans who have been involved with war crime activ- ities have claimed that their medications contributed to their crimes.42 One such case involved Army Staff Sgt. Robert Bales, who was charged with murdering 16 Afghani civilians during his deployment in 2012, but believes that his homicidal behavior was tied to taking Lariam, a prophy- lactic antimalarial drug given to troops in endemic regions.43 This drug is controversial since it has a number of neurological and psychiatric side effects (hallucinations, anxiety, paranoia) and can cause vestibular prob- lems (inner ear functioning affecting balance, eye movement and causing vertigo). Due to its side effects profile, in 2009, the Defense Department made it a last-choice option for the U.S. military, only to be used in areas with drug-resistant strains of malaria. In 2013 the FDA placed a Black Box warning on Lariam. Bales cited a number of possible contributing factors for his war crimes, such as traumatic brain injury (TBI) which he sustained in 2009. This is significant because U.S. Military regulations stipulate that Lariam is not allowed for individuals with TBI because of its likelihood to cross the blood-brain barriers and cause psychotic, homicidal or suicid- al behavior. However, there was no documented evidence that Bales was taking Lariam, yet it is not uncommon for deployed service members to be issued this drug without it being recorded in their medical records. It is possible that Bales was experiencing hallucinations and psychosis during the massacre if he was administered Lariam in direct contradiction to the U.S. military rules.44 In order to avoid the death penalty, Bales pleaded guilty to 16 counts of murder and six counts of assault and attempted murder. He was sentenced to life in prison without the possibility of pa- role. His legal team had asked the U.S. Army Court of Criminal Appeals to review his life sentence, given that the implications of being prescribed this drug, in addition to witness information, were not part of the orig- inal investigation. His appeal was denied however, and his life sentence stands.45 If he runs out of options in the courts, Bales may seek clemency from President Trump.46

110 Jamshid A. Marvasti & Claire C. Olivier

DRUG COMPANIES AS REPEAT OFFENDERS? There are several explanations as to why major pharmaceutical companies continue to be repeat offenders. As Morgan Statt mentioned in her article, “Taking Big Pharma to Court,” one is that drug companies are permitted to provide the funding for clinical trials.47 The National Institute of Health puts a portion of its budget toward the cost of research trial however, the amount has been drastically decreased in recent years. Obviously the source of money should not dictate the result of trial. But, there are those who believe one who finances the project, possibly can shape the research to its own benefit. For example drug companies may exclude certain popula- tions (like the elderly) from the trials, (even if that population is most likely to need the medication), in order to have more positive outcomes. Addi- tionally, government investigations revealed that certain research studies regarding antipsychotics were ghostwritten by the drug companies’ market- ing department and then signed by well-known physicians. In this way the study falsely appears to be conducted independently by physicians.48 Dr. Stefan Kruszewski, a psychiatrist who previously worked as a paid speaker for multiple drug companies shared that in the beginning, he was able to speak about the drugs related to the science. Later he was told what to say, which included false data. One presentation included information about an antipsychotic drug which was promoted as having no neurological side effects. He stated, “‘They made it all up. It was never true.”’49

Lobbying The health and pharmaceutical companies are also a very powerful lob- bying group and just in the first quarter of 2017 they spent $78 million in their lobbying efforts.50 There is a concern that there is a conflict of interest between these companies and the FDA. In 1992 the Prescription Drug User Fee Act was passed (and is renewed every 5 years) which allowed the FDA to collect fees for processing medication approvals. While originally meant to offer the FDA a nominal resource, as of 2017 it accounted for over 40% of the FDA’s budget. Raising the question of how neutral the FDA can be towards these companies’ demands regarding getting certain drugs to the market. While this regulation was altered in May 2018, prescription drug user fees still have a major impact on the FDA’s overall budget. These fees accounted for 45% of the agency’s FY2018 total fundung.51

Members from the 7 largest pharmaceutical companies appeared before the Senate Finance Committee in February of 2019 to discuss high drug costs.52 The committee criticized the companies of finger pointing and greedy policies, including only cutting costs of drugs which were not draw- ing in much money. Yet it is important to note that the members of this committee also took a combined $7.9 million in campaign contributions

111Evils of Psychopharmacology; Implications for Psycho-Historians

from the pharmaceutical industry during the last 6-year Senate election cycle. Pharmaceutical Research and Manufacturers of American (PhRMA) alone spent $28 million on lobbying efforts in 2018 to impact federal poli- cy regarding drug pricing bills.53

New Legislation Two senators, Grassley and Klobuchar have put forth two bills to lower costs of prescription drugs. One is aimed at limiting “pay-for-delay deals,” where pharmaceutical companies are paying generic companies to delay releasing generic versions of their drugs; if there is no generic option, the public is forced to buy the more expensive name brand. The second bill would allow U.S. citizens to buy medications from Canada for lower prices.54

A HISTORICAL AND ETHICAL PERSPECTIvE There were various periods of psychopharmacology, from its conceptual be- ginnings in the 18th century, to the start of modern psychopharmacology in the 1950’s and now its present-day usage. However ethical concerns arose during each time period naming the potential dangers of these med- ications.55 One historical perspective on psychopharmacology suggests that its rise was not necessarily caused by more effectiveness in medica- tion treatment of nuanced psychiatric diseases.56 Rather, a combination of pharmaceutical marketing, advances in science, political/economic situa- tions, changes in mental health care and a desire for a quick fix, supported the success of psychopharmacology. There is an ongoing mindset/hope in Western culture that technology and science can create a magic pill which will cut through the messiness of being human and provide simple solu- tions for madness and misery. Doctors Braslow and Marder put it this way. “It is not that psychopharmacology has failed. Instead, we have failed our patients by adopting a myopia that sees only symptoms and their allevi- ation by psychoactive drugs.”57 Yet with a fragmented health care system, psychiatrists may feel these drugs are all they can offer.

In the world of medications, researchers are also exploring drugs which could target the memory processes for those suffering with PTSD like vet- erans.58 While the desire for a remedy that could disrupt dysfunctional aversive memories is warranted, it does raise the question of how is our humanity impacted? One of the significant challenges in this drug research is the ability to be selective when attempting to alter aversive memories.59 One doctor who lectures in medical ethics, Dr. Daniel Sokol, made this point, ‘‘Removing bad memories is not like removing a wart or a mole. It will change our personal identity since who we are is linked to our mem- ories.’”60 Additionally, would a drug that removed memories, also prevent those who take it from feeling remorse, or learning from their mistakes?61

112 Jamshid A. Marvasti & Claire C. Olivier

CONCLUSION We have illustrated the various types of court cases that have arisen re- garding the potential connection between psychiatric medication and vio- lence. Yet as Kaufman stated, “While manufacturers have a vested interest in exonerating their drugs, plaintiffs have an interest in blaming it, and defendants in exonerating themselves. We need careful, independent anal- ysis of existing study data.”62 However, clinical trials have demonstrated that there can be side effects from psychiatric medications which may im- pact suicidality and aggression/homicidality. Additionally, we have report- ed how various pharmaceutical companies have a history of withholding unfavorable clinical research and at times, falsely marketing medications.

There are some physicians, such as Allen Frances,63 who believe that the pattern of illegal activity committed by various pharmaceutical companies will not stop unless a few of these companies’ executives are handcuffed and sentenced to jail.

Literature has put forth various recommendations to improve the health of our nation. One idea concerns the relationship between drug company sales representatives and physicians. Doctors should not receive any kind of reward or compensation for giving patients certain medications, nor should drug companies be allowed to advertise directly to consumers. Drug companies spend billions of dollars to advertise to the public, who are then encouraged to ask their physician for a specifically advertised medication. Yet the public does not know the actual clinical trial results of this med- ication. Furthermore, when a drug company pays for a clinical trial, an independent party should review the details and results before they are submitted to the FDA. Drug companies must disclose all of their research, instead of cherry-picking favorable results.

Jamshid A. Marvasti, M.D. is a child and adult psychiatrist practicing at Prospect Manchester Hospital, Manchester, Connecticut. He is a clinical assistant professor of psychiatry at the University of New England College of Osteopathic Medicine. Dr. Marvasti has published and edited a number of articles and books including War Trauma in Veterans and Their Families (2012), and Psycho-Political Aspects of Suicide Warriors, Terrorism, and Martyrdom (2008). He can be reached at [email protected].

Claire C. Olivier, MSW Received her master’s degree from the University of Cali- fornia at Berkeley. Ms. Olivier previously wrote a chapter entitled, “The Battle Af- ter the War: Cultural Challenges for those Coming Home,” in Dr. Marvasti’s book War Trauma in Veterans and Their Families (2012), and contributed to Dr. Marvasti’s earlier book, Psycho-Political Aspects of Suicide Warriors, Terror- ism and Martyrdom (2008). She can be reached at [email protected]

113Evils of Psychopharmacology; Implications for Psycho-Historians

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12. Ibid 13. Kauffman J: “Selective Serotonin Reuptake Inhibitor (SSRI) Drugs: More Risks than

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18. Healy D, Herxheimer A, Menkes D: Antidepressants and Violence: Problems at the In- terface of Medicine and Law.

19. Breggin P: Wesbecker-Prozac Product Liability Suits. Available at https://breggin .com/wesbecker-prozac-product-liability-suits/ Accessed March 15, 2019

20. Ibid 21. Kauffman J: Selective Serotonin Reuptake Inhibitor (SSRI) Drugs: More Risks than Benefits? 22. Ibid 23. Hilts PJ: “Jury Award $6.4 Million in Killings Tied to Drug.” NY Times, June 08, 2001 24. Thompson A: Paxil Maker Held Liable in Murder/Suicide. Will $6.4 Million Verdict

Open a New Mass Tort? Baum Hedlund Aristei Goldman. July 9, 2001. Available at https://www.baumhedlundlaw.com/drug-injury-press-releases/paxil-maker-held-li- able-in-murder-suicide.php Accessed March 7, 2019

25. Ibid

114 Jamshid A. Marvasti & Claire C. Olivier

26. CBS (Chicago): Jury Awards $3M to Widow Who Sued Drug Firm Over Husband’s Suicide. April 21,2017. Available at https://chicago.cbslocal.com/2017/04/21/jury- awards-3m-to-widow-who-sued-drug-firm-over-husbands-suicide/ Accessed March 15, 2019

27. Ibid 28. Bellon T: U.S. appeals court says GSK cannot be sued over generic drug suicide. Re-

uters. August 22, 2018. Available at https://www.reuters.com/article/us-gsk-lawsuit/ u-s-appeals-court-says-gsk-cannot-be-sued-over-generic-drug-suicide-idUSKCN- 1L72D1 Accessed March 15, 2019

29. Walker A: “Take Two of These and Sue Me in the Morning; The Emergence of Litiga- tion Regarding Psychotropic Medication in the United States and Europe.” Arizona Journal of International and Comparative Law. 2002. Vol.19. No.2. Available at http:// arizonajournal.org/wp-content/uploads/2015/11/Walker.pdf Accessed March 1, 2019

30. Ibid 31. Wilson D: “Side Effects May Include Lawsuits.” The New York Times. October 2,

2010. Available at https://www.nytimes.com/2010/10/03/business/03psych.html Accessed March 9, 2019

32. Citizens Commission on Human Rights: Chronology of Sample Lawsuits about Psy- chotropic Drugs. Available at https://files.ondemandhosting.info/data/www.cchr .org/files/education/appendix/10-chronology-of-sample-lawsuits.pdf Accessed Feb- ruary 15, 2019

33. Ibid 34. The Telegraph: GSK antidepressant Paxil to blame for baby’s heart defects, U.S. jury

rules. October 15, 2009. Available at https://www.telegraph.co.uk/news/health/ news/6335822/GSK-antidepressant-Paxil-to-blame-for-babys-heart-defects-US-jury- rules.html Accessed March 12, 2019

35. Harrison P: Psychiatrist Suspended for Antipsychotic Overprescribing. Medscape. August 12, 2014. Available at https://www.medscape.com/viewarticle/829790 Accessed March 9, 2019

36. Liston B: Makers of Risperdal Sued for Breast Development in Boys. Mad in Ameri- ca. July 21, 2017. Available at https://www.madinamerica.com/2017/07/risperdal- sued-breast-development-boys/ Accessed March 17, 2019

37. Ibid 38. Saunders J: Top Eight Largest Drug Lawsuit Settlements of All Time. Saunders Walk-

er. October 23, 2017. Available at https://www.saunderslawyers.com/top-eight- largest-drug-lawsuit-settlements-time/ Accessed March 2, 2019

39. Knoll J, Annas G: “Warning: Antidepressants may cause messaging manslaughter.” Psychiatric Times. September 19, 2017. Vol 34:9. Available at http://www.psychiatric times.com/psychopharmacology/warning-antidepressants-may-cause-messaging- manslaughter Accessed March 19, 2019

40. Biscaldi L: Roseanne Barr’s “Ambien Excuse” Tried in the Court of Public Opin- ion. Medical Bag. June 6, 2018. Available at https://www.medicalbag.com/medicine/ ambien-excuse-roseanne-barr-tweets/article/771396/ Accessed March 21, 2019

41. Loughnan A: The drugs made me do it: can prescription side-effects be an excuse for crime? The Conversation. July 8, 2016. Available at http://theconversation.com/the- drugs-made-me-do-it-can-prescription-side-effects-be-an-excuse-for-crime-45821 Accessed March 29, 2019

42. Marvasti JA, Podolski J E: Forensic Aspects of Combat Trauma and PTSD: Special Vet- erans’ Court, Malingering, And Criminal Conduct, In War Trauma In Veterans And Their Families: Diagnosis And Management of PTSD, TBI and Comorbidities Of Combat Trauma. Edited by Marvasti JA. Springfield, IL: Charles Thomas Publishers, 2012, pp154-168

115Evils of Psychopharmacology; Implications for Psycho-Historians

43. Kime P: “U.S. Soldier Who Murdered Afghan Civilians Blames Malaria Drug Used By Army.” Miami Herald. August 8, 2017. Available at https://www.miamiherald.com/ news/nation-world/national/article165990147.html Accessed March 13, 2019

44. Ibid 45. Associated Press: Court upholds ex-soldier’s life Sentence In Slaying Of Afghan

Civilians. Army Times. September 28, 2017. Available at https://www.armytimes .com/news/your-army/2017/09/28/court-upholds-us-soldiers-life-sentence-in- slayings-of-afghan-civilians/ Accessed March 28, 2019

46. Kime P: Ex-soldier Who Shot Up Afghan Village May Seek Clemency From Pres- ident, Lawyer Says. McClatchy Washington Bureau. June 20, 2018. Available at https://www.mcclatchydc.com/news/nation-world/national/article213092124.html Accessed March 19, 2019

47. Statt M: Taking Big Pharma to Court: Why Lawsuits Have Little Effect on Drug Company. Mad in America. February 22, 2018. Available at https://www .madinamerica.com/2018/02/big-pharma-lawsuits-little-effect-drug-companies/ Accessed March 26, 2019

48. Wilson D: Side Effects May Include Lawsuits. October 2, 2010. 49. Ibid 50. Statt M: Taking Big Pharma to Court: Why Lawsuits Have Little Effect on Drug Company.

February 22, 2018. 51. Dabrowska A, Green V: The Food and Drug Administration (FDA) Budget: Fact

Sheet. Congressional Research Service. Updated September 12, 2018. Available at https://fas.org/sgp/crs/misc/R44576.pdf Accessed March 25, 2019

52. Evers-Hillstrom K: Senators Publicly Grill ‘Big Pharma’ Executives After Accepting Millions From Industry. Open Secrets. February 26, 2019. Available at https://www .opensecrets.org/news/2019/02/senators-grill-big-pharma-executives/ Accessed March 16, 2019

53. Ibid 54. Smith J: Senators Grill Pharma Execs Over Prescription Drug Prices. Yahoo Finance. Feb-

ruary 26, 2019. Available at https://finance.yahoo.com/news/senators-grill-pharma- execs-over-prescription-drug-prices-154953281.html Accessed March 22, 2019

55. Barbara JG: History of Psychopharmacology: From Functional Restitution to Function- al Enhancement. 2015. 489-504. 10.1007/978-94-007-4707-4_26. Available at https:// www.researchgate.net/publication/283653231_History_of_Psychopharmacology_ From_Functional_Restitution_to_Functional_Enhancement Accessed April 8, 2020

56. Braslow JT, Marder SR: History of Psychopharmacology. Annu.Rev.Clin.Psychol. 2019. 15:25–50. Available at https://www.annualreviews.org/doi/pdf/10.1146/ annurev-clinpsy-050718-095514 Accessed April 5, 2020

57. Ibid 58. Giustino TF, Fitzgerald PJ, Maren S: Revisiting propranolol and PTSD: Memory erasure

or extinction enhancement? Neurobiol Learn Mem. 2016 Apr; 130: 26–33. Available at https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4818733/ Accessed April 8, 2020

59. Ibid 60. Derbyshire D: Pill to erase bad memories: Ethical furor over drugs ‘that threaten

human identity.’ Daily Mail. February 16, 2009. Available at https://www.dailymail .co.uk/news/article-1145777/Pill-erase-bad-memories-Ethical-furore-drugs- threaten-human-identity.html Accessed April 6, 2020

61. Ibid 62. Kauffman J: Selective Serotonin Reuptake Inhibitor (SSRI) Drugs: More Risks than Bene-

fits? 2009 63. Frances A: Saving Normal. New York, NY: HarperCollins Publishers, 2013.

Copyright of Journal of Psychohistory is the property of Association for Psychohistory Inc. and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.

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422422 Can psychopharmacology improve cognitive rehabilitation? Caixeta and Caixeta

http://dx.doi.org/10.1590/1980-57642018dn13-040009

Original Article

This study was conducted at the Universidade Federal de Goiás Faculdade de Medicina – Neurology, Goiânia, GO, Brazil.

1Universidade Federal de Goiás Faculdade de Medicina – Neurology, Goiânia, GO, Brazil. 2Federal University of Goiás Faculty of Medicine Ringgold standard institu- tion – Post-Graduation, Goiânia, GO, Brazil.

Leonardo Caixeta. Universidade Federal de Goiás Faculdade de Medicina – Neurology – Avenida Cristo Rei, 626, Setor Jaó – 74605-020 Goiânia GO – Brazil. E-mail: [email protected]

Disclosure: The authors report no conflicts of interest.

Received August 01, 2019. Accepted in final form September 25, 2019.

Therapeutic synergism How can psychopharmacology improve cognitive rehabilitation?

Leonardo Caixeta1,2 , Victor Melo Caixeta1,2

ABSTRACT. Despite recent advances in cognitive rehabilitation of patients with cognitive disorders, there are many

major obstacles to the optimized global use of this therapeutic resource. Objective: The authors outline the concept of ‘therapeutic synergism’, i.e. the concurrent use of pharmacological and cognitive rehabilitation therapies to maximize

functional benefits, addressing the optimization of therapeutic approaches for cognitive disorders. Methods: Three psychopharmacological and rehabilitation interrelationship paradigms are presented in three different clinical settings.

Results: Paradigm 1: Behavioral and cognitive symptoms that hinder a cognitive rehabilitation program, but can be improved with psychopharmacology. Paradigm 2: Cognitive symptoms that hinder cognitive rehabilitation, but can be

improved with anticholinesterases. Paradigm 3: Behavioral symptoms that hamper the use of cognitive rehabilitation,

but can be improved by psychotropic drugs. Conclusion: Judicious use of psychotropic drugs in cognitive disorders can benefit, directly or indirectly, cognitive functions, thereby favoring other treatment modalities for cognitive impairment,

such as neuropsychological rehabilitation.

Key words: cognitive rehabilitation, treatment engagement, psychopharmacology, synergism.

SINERGISMO TERAPÊUTICO: COMO A PSICOFARMACOLOGIA PODE MELHORAR A REABILITAÇÃO COGNITIVA?

RESUMO. Apesar dos recentes avanços na reabilitação cognitiva de pacientes com distúrbios cognitivos, existem muitos e

graves obstáculos ao uso otimizado globalmente desse recurso terapêutico. Objetivo: Os autores destacam o conceito de ‘sinergismo terapêutico’, ou seja, o uso simultâneo de terapias de reabilitação farmacológica e cognitiva, maximizando os

benefícios funcionais, a fim de abordar a otimização da abordagem terapêutica dos distúrbios cognitivos. Métodos: Três paradigmas de inter-relacionamento psicofarmacológico e de reabilitação são apresentados em três contextos clínicos

diferentes. Resultados: Paradigma 1: sintomas comportamentais e cognitivos que dificultam um programa de reabilitação cognitiva, mas podem ser melhorados com a psicofarmacologia. Paradigma 2: sintomas cognitivos que dificultam a

reabilitação cognitiva, mas podem ser melhorados com anticolinesterásicos. Paradigma 3: sintomas comportamentais que

dificultam o uso da reabilitação cognitiva melhorada por drogas psicotrópicas. Conclusão: O uso criterioso das drogas psicotrópicas nos distúrbios cognitivos pode beneficiar, direta ou indiretamente, as funções cognitivas, favorecendo,

portanto, outras modalidades de tratamento para o comprometimento cognitivo, como a reabilitação neuropsicológica.

Palavras-chave: reabilitação cognitiva, tratamento, psicofarmacologia, sinergismo.

Despite recent advances in cognitive rehabilitation of patients with cognitive disorders, there are many major obstacles to the optimized global use of this therapeutic resource. Some patients may find it difficult to adhere to cognitive rehabilitation due to

the lack of insight regarding cognitive deficits, or because of compromised brain systems, or even general difficulty in performing daily tasks, sense of hopelessness, lack of energy and apathy, symptoms that may be due to the disease itself or associated to depression

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423Caixeta and Caixeta Can psychopharmacology improve cognitive rehabilitation?

or other comorbid psychiatric disorders.1 For cognitive rehabilitation methods to be effective, patients must be adequately engaged and motivated not only to begin a rehabilitation process, but also to remain involved in the intervention until a therapeutic dosage can be achieved.1 Many patients do not benefit from rehabilitation or can- not be indicated for this procedure because of partially treated behavioral symptoms, either for lack of a diagno- sis, or for inadequate or underdosing of medications. On the other hand, misuse of drugs by patients, especially medications with cognitive effects, can compromise the efficacy of cognitive rehabilitation.2

Notwithstanding recent evidence suggesting that concurrent pharmacological and behavioral methods may maximize functional benefits for patients suffer- ing from, for example, dementia,3-5 there is an inex- plicable scarcity of studies concerning the therapeutic synergism between psychopharmacology and cognitive rehabilitation, reflecting the unfortunate absence of contact between these two domains: pharmacological (biomedical approach) and non-pharmacological (essen- tially the psychological approach).

In this article, we present three paradigmatic cases on how these two domains can be interconnected and through which strategies the psychopharmacological approach can optimize the implementation of cognitive rehabilitation techniques to enhance improvement in real-world functioning.

METHODS Using a qualitative approach, the main principles or strategies of association between psychoactive drugs and cognitive rehabilitation used in the Memory Clinic at the Federal University of Goiás (UFG), in Central Brazil, were reviewed. We focused attention on pharma- cological management that addresses the optimization of cognitive rehabilitation techniques.

The Institute of Memory at the UFG is a referral cen- ter for cognitive disorders in Central Brazil with 20 years of experience in the evaluation, diagnosis and multidis- ciplinary treatment of cognitive disorders. Centers such as this have academic credentials to seek, through their accumulated experience, some subjective principles that govern conduct and therapeutic strategies in areas where there is little literature.

RESULTS We identified three models of interaction between psychoactive drugs and cognitive rehabilitation that seek to optimize rehabilitation methods. Each of these models will be exemplified by a clinical case illustrating

the way psychopharmacology and cognitive rehabilita- tion interact.

CASE 1 Paradigm 1: Behavioral and cognitive symptoms that hinder a cognitive rehabilitation program, but can be improved with psychopharmacology

Cloney (fictitious name), 25 years old, is a patient with invasive developmental disorder (autistic syn- drome), presenting with severe behavioral and cognitive changes. The behavior alterations that prevented a cog- nitive rehabilitation approach included impulsivity and aggressiveness (he took the papers from the teacher’s desk and ripped them up compulsively, despite being asked not to do so several times; whenever a child passed him by, he would grab them by the arm and attack them; he presented several episodes of direct violence towards people who assisted him; disobeyed commands and did not respect the social limits and rules previously imposed), dysphoria, compulsive overeating, motor rest- lessness and hyperactivity. Cognitive disorders included severe mental retardation, with impairments in several cognitive domains. The cognitive disorders that most affected his functional adaptation and social life were cognitive inflexibility, insight absence, Theory of Mind deficit, impaired decision-making, expressive language difficulties, and severe attention deficit. Cloney also pre- sented extreme intolerance to any modification of his environment, reacting aggressively when this occurred (he broke everything around him).

Due to prejudice held by both his mother and the multi-professional care team, Cloney was not taking any medication for his disorder. After explaining to them how modern psychopharmacy could help him control some of his worse behavioral issues, and maybe even improve some of his basic cognitive functions, thereby allowing a rehabilitation approach, a pharmacological regimen was started consisting of aripiprazole 15mg/ day (prescribed to improve social behavior, reduce aggressiveness and control restlessness), fluoxetine 20 mg/day (indicated to control compulsive overeating and dysphoria) and methylphenidate 40mg/day (prescribed to improve attention span, and reduce both hyperactiv- ity level and appetite).

One month after starting on this medication, Cloney showed a marked improvement in many aspects of his behavior, which also presented as benefits in a variety of cognitive functions: 1) motor restlessness ceased and, consequently, he could sit still in a chair, focusing his attention better, allowing a better verbal approach and eye-to-eye interaction; 2) impulsivity also ceased,

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424 Can psychopharmacology improve cognitive rehabilitation? Caixeta and Caixeta

and his actions became more predictable, improving the safety of the care team since they could prevent cer- tain responses or undesired actions; 3) improved many aspects of his relationships, as he obeyed social rules (started to accept his mother and teachers’ authority) and became more sociable in general, so he could engage in group interactions, including with other children; 4) he became more tolerant to the limits established and to the external rules imposed, eliminating the explo- sive reactions when his immediate desires were denied; 5) it became easier to negotiate with him on decisions that involved immediate desires – after medication he started to accept that his desires may be satisfied in exchange for some effort (for example, helping his mother or following teachers’ requests). These improve- ments promoted a better-structured cognitive-behavior base, more amenable to the application of adequate rehabilitation techniques. Before the psychopharma- cological intervention, even simple cognitive-behavior approaches were impossible. Currently, Cloney is rea- sonably engaged in cognitive rehabilitation, and his team of health professionals and teachers, as well as the other students and patients, no longer fear him.

CASE 2 Paradigm 2: Cognitive symptoms that hinder cogni- tive rehabilitation, but can be improved with anti- cholinesterases

Homero (fictitious name), 74 years old, is a patient with Alzheimer’s disease, naïve to treatment with anti- cholinesterases (most effective medication group for this dementia).4 As the treatment with galantamine did not work because of side effects (severe nausea, tachycardia and dizziness), the family were reluctant to try this pharmacological group again. A glutamatergic antagonist (memantine) was prescribed, without any significant benefit in cognition, particularly in memory.

Homero presented a severe memory deficit and inability to learn new information, which made neu- ropsychological rehabilitation approaches even harder. Despite the three sessions he had every week, there was no effective improvement of the patient, comparing to previous sessions, so it was not possible to advance to the next phases of the process. The family noted no ben- efits in the social-functional sphere. Since there was no benefit of the neuropsychological rehabilitation, the therapeutic approach was discontinued.

Donepezil (another anticholinesterase, although with more favorable side-effect profile) was then pre- scribed at the dosage of 10mg/day in order to improve cognitive outcome, especially recent memory and, con-

sequently, enhance his learning mechanisms. Three months after starting use of the medication, Homero presented a clear memory improvement, and his attention capacity was better, favoring the learning process. In fact, the improvement was very evident when he resumed rehabilitation: his attention span had developed, he could maintain recently learned information available for longer in working memory (for example, during the execution of a task, he could gather information that was necessary later for use in a new task).

CASE 3 Paradigm 3: Behavioral symptoms that hamper the use of cognitive rehabilitation, but can be improved by psycho- tropic drugs

Thelma (fictitious name), 67 years old, suffering from depression (not previously diagnosed) associated with dementia in Parkinson’s disease. Despite being in use of an anticholinesterasic drug and memory defi- cit improvements achieved, her greatest difficulty was adhering to the cognitive rehabilitation. Thelma pre- sented intense fatigability, being incapable of remaining in continuous consultation for more than five seconds. Her low attentional span impaired all the rehabilitation approaches that relied on attention for task execution. She also exhibited economy of effort with many answers like “I don’t know”. She had a pessimistic attitude to cog- nitive rehabilitation, believing that she couldn’t obtain any benefit from it, and was unable to develop any involvement or affective bonding with the rehabilitation professional, proving averse to the activity. In many situ- ations, she was anxious and irritated with the activity, creating ploys to leave and stop the process.

Thelma was referred to a psychiatrist who diagnosed masked depression. She was started on a noradrenergic antidepressant (mirtazapine 30 mg /day). A month later, clear improvement in the patient’s mood was observed: she was more active and had more physical/men- tal energy, was more interested in the ongoing tasks, regained the pleasure associated with social contact and other activities, could maintain her attentional focus for much longer, could see the point in investing, more actively, in the rehabilitation. Indeed, after the depres- sion treatment, her involvement and performance in the cognitive rehabilitation activities increased markedly.

DISCUSSION From the reported cases, we can infer three models of interaction between psychopharmacology and cognitive rehabilitation:

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425Caixeta and Caixeta Can psychopharmacology improve cognitive rehabilitation?

1. In the patient receiving psychotropic drugs for an underlying disease state where cognitive rehabilita- tion is indicated in order to improve the residual cogni- tive deficits associated with the disease (for instance, in schizophrenia, in which the medication is necessary to control the disease, but does not always act on the com- mon cognitive symptoms of this medical condition);6,7

2. In patients with executive dysfunction (one of the areas in which cognitive rehabilitation is known for having more limited results), the use of some drugs can optimize treatment (for example, the use of memantine in patients with cognitive inflexibility, such as in the case of pathological gamblers);8

3. Many patients may not be suitable for cognitive rehabilitation due to psychiatric symptoms that hinder the full conducting of the process (e.g. aggressive, agi- tated patients that are incapable of therapeutic bonding, or apathetic and asthenic patients that do not engage sufficiently in the therapeutic process).1,9 In others, despite attempts to rehabilitate, they have only dis- crete or diminished improvement because of psychiatric symptoms. In both cases, medication may be used as an agent for reducing dysfunctional behavior, allowing the application of the rehabilitation in a safe and effective manner, or improving results when the rehabilitation is already underway, but in a limited way.

Our study highlights the concept of ‘therapeutic synergism’, i.e. the concurrent use of pharmacological and cognitive rehabilitation therapies maximizing func- tional benefits in order to address the optimization of the therapeutic approach for cognitive disorders.

Many other authors have been working on this approach in different scenarios and within different rationales.5,8,10-13 The three paradigms presented describe different scenarios in which a precise drug intervention (precision that must be almost ‘surgical’) helps in the process of cognitive rehabilitation in many ways.

In the first paradigm, the psychopharmacological intervention must provide the basic conditions to ensure the patient can be indicated for cognitive rehabilita- tion, otherwise they would not be an eligible candidate.

In the second paradigm, the pharmacological inter- vention in cognition enables and facilitates the rehabili- tation, which may then have a real chance of success. In other words, the prescription of a cognitive enhancer to augment cognitive rehabilitation outcomes, based on a rationale in which a cognitive enhancer proceeds by tar- geting more basic discrete cognitive skills, so that cogni- tive rehabilitation can progress to more complex skills. This assumes that the basic skills must be refined before

more complex skills can work effectively. Some authors also claim that, currently, cognitive training exercises are used to improve basic cognitive skills, but pharma- cotherapy holds promise as a more effective treatment.5

In the third paradigm, the pharmacological interven- tion in behavior optimizes the response to the ongoing rehabilitation process, since it overcomes an obstacle to fully exploit the therapeutic process. For cognitive rehabilitation therapies to be successful, patients must be adequately involved and motivated not only to begin cognitive intervention but also to keep engaged in the rehabilitation program until a therapeutic dosage can be reached.1

In a literature review about cognitive rehabilitation, Manzine & Pavarine14 found that, in most of the stud- ies reviewed, cognitive rehabilitation can provide more benefit for the patient’s rehabilitation when combined with other interventions, such as pharmacological treatment. Provided that both treatment modalities are aligned and optimized, the synergistic therapeutic effects become evident. To this end, it is fundamental that the attending physician is aware of the whole thera- peutic program in which the patient is engaged, hav- ing consistent notions of how one treatment modality may impact (positively or negatively) the other, and of how delicate the relationship dynamic is between them. Without such tools, there is a risk of wrongly assessing the risk-benefit ratio involved in each pharmacological choice. In practice, unaware physicians run the risk of prescribing a medication option that may, in some cases, have negative effects on the patient’s cognitive function and also on their cognitive rehabilitation.

In conclusion, judicious use of psychotropic drugs can benefit, directly or indirectly, cognitive functions, thereby favoring other treatment modalities for cogni- tive impairment, such as neuropsychological rehabilita- tion. This finding reflects those of other authors.10-12 For- tunately, with better knowledge of the available drugs in general (and psychotropics in particular), greater invest- ment in medical training, as well as a better technical and affective rapport between medical and non-medical professionals, a more optimistic scenario will be possible in the coming years.

Author contributions. Leonardo Ferreira Caixeta and Victor Melo Caixeta: conceptualization, data curation, formal analysis, funding acquisition, investigation, methodology, project administration, resources, soft- ware, supervision, validation, visualization, writing – original draft, writing – review & editing.

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RESEARCH ARTICLE Open Access

Attitudes towards psychopharmacology and psychotherapy in psychiatric patients with and without migration background Eva J. Brandl1,2*†, Nora Dietrich1,2†, Nicoleta Mell1,2, Johanna G. Winkler1,2, Stefan Gutwinski1,2, H. Joachim Bretz1,2 and Meryam Schouler-Ocak1,2

Abstract

Background: Sociodemographic factors, attitude towards treatment and acculturation may be important factors influencing the decision of immigrants to seek and maintain psychiatric treatment. A better understanding of these factors may significantly improve treatment adherence and outcome in these patients. Therefore, we investigated factors associated the attitude towards psychotherapy and medication in a sample of psychiatric outpatients with and without migration background.

Methods: N = 381 patients in a psychiatric outpatient unit offering specialized treatment for migrants were included in this study. Attitude towards psychotherapy was assessed using the Questionnaire on Attitudes Toward Psychotherapeutic Treatment, attitude towards medication with the Drug Attitude Inventory-10. Acculturation, symptom load and sociodemographic variables were assessed in a general questionnaire. Statistical analyses included analyses of covariance and hierarchical regression.

Results: Patients of Turkish and Eastern European origin reported a significantly more positive attitude towards medication than patients without migration background. When controlling for sociodemographic and clinical variables, we did not observe any significant differences in attitude towards psychotherapy. Acculturation neither influenced the attitude towards psychotherapy nor towards medication.

Conclusion: Our study indicates that sociodemographic and clinical factors may be more relevant for patients´ attitudes towards treatment than acculturation. Considering these factors in psychiatric treatment of patients with migration background may improve treatment outcome and adherence.

Keywords: Migrants, Attitude, Medication, Psychotherapy

© The Author(s). 2020 Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated in a credit line to the data.

* Correspondence: [email protected] †Eva J. Brandl and Nora Dietrich contributed equally to this work. 1Charité Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Department of Psychiatry and Psychotherapy, Campus Mitte, Berlin, Germany Charité Universitätsmedizin Berlin, Berlin, Germany 2Psychiatrische Universitätsklinik der Charité im St. Hedwig Krankenhaus, Große Hamburger Str. 5-11, 10115 Berlin, Germany

Brandl et al. BMC Psychiatry (2020) 20:176 https://doi.org/10.1186/s12888-020-02585-1

http://creativecommons.org/publicdomain/zero/1.0/