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 TEXT 1
https://www.psychologicalscience.org/observer/studying-people-in-their-local-environments

5 Studying People in Their Local Environments

NEIL A. LEWIS, JR.
Psychological science is ostensibly interested in the behavior and mental
processes of a variety of people, not just processes related to college students
and Mechanical Turk workers responding to surveys over the internet. Gaining
10 the generalizable knowledge we seek requires studying a variety of people in a
variety of contexts; it is the only way to know whether and how generalizable
our findings really are.

And if we want our research to inform social policies, then it should include a
broader composition of people and situations. Only then can we understand
15 how policies that are generated from our findings might differentially affect
individuals and subgroups.

Vehicles to Move Us Forward

The implications I’ve just outlined are the main reasons my colleagues and I
have been shifting our scientific work to include more mobile research methods.
20 In the Department of Communication at Cornell University, we have a mobile
research lab that allows us to diversify both the samples and settings in which
we conduct social scientific research. The lab was originally funded by the
National Institutes of Health, specifically for the purposes of including diverse
and hard-to-reach populations in research on health messaging.

2
25 The lab is the size of a small RV and is fully equipped with five private data
collection stations. It enables us to recruit and study people in their own
environments. To date, my colleagues and I have used it to study youth and
adults from rural and urban settings throughout the Northeast region of the
United States. For one set of studies, my colleagues wanted to examine how
30 socioeconomically disadvantaged youth and adult smokers respond to different
kinds of warning labels on cigarette packages. So they took the lab to a variety
of urban and rural communities to recruit participants. They not only learned
about how individuals attended to and processed the labels (via eye-tracking
and surveys), but also how living in those different environments affects
35 people’s smoking decisions. These lessons are important for both the science
and any policies that result from it.

My own ongoing research with the mobile lab is combining a variety of

methodological techniques including geographic air-quality mapping, eye-
tracking, and surveys to examine how people make sense of, and are motivated
40 to respond to, information about the environmental health hazards in their
surroundings. My collaborator in systems engineering used transportation data
to develop fine-grained maps depicting levels of air pollution in different
neighborhoods of the greater New York City area. Since we have rich
information about people’s differential exposure to pollutants, as well as data
45 about the demographic composition of neighborhoods, we have been taking the
lab to neighborhoods of differential exposure and composition to examine how
residents of those neighborhoods respond to the information as functions of
both their individual characteristics and features of their local environments.
Conducting the study in this way allows us to learn about relevant psychological
50 processes in an ecologically valid way.

As researchers, the mobile lab has had several benefits. First, it has forced us
to think more critically about factors that influence participants, and their
implications for both the theories we can advance and any practical knowledge
generated from our work. It provides vivid reminders that people are embedded
55 in broader ecological systems and that we must think carefully about how
multiple dimensions of those systems interact with individuals when developing
our models. That modeling and theorizing inevitably leads to important
discussions about measurement, construct validity, and generalizability across
samples and settings.

60 Human Rights Considerations

Using the mobile lab has also reminded us of another important lesson. In the
1948 Universal Declaration of Human Rights, the United Nations General
Assembly declared that “everyone has the right freely to…share in scientific
65 advancement and its benefits” (UNESCO, 2005). When we take the mobile lab
into (particularly underserved) communities, it provides opportunities for people

3
 to exercise that human right — to have their perspectives reflected in the
scientific record … a record that often influences the policies and practices that
govern their society. That reality is not lost on our participants. I have been
70 deeply moved by people’s gratitude for being allowed to participate in our study
because, to use their words, “no one usually cares what [they] think.” It is as if
they have learned from scientists that, to borrow from The Op-Ed Project
(2017), “some people narrate the world; other people have their world narrated
for them;” that there are some people who get to be part of the scientific record
75 and others who do not.

To quote Audrey Squire (2015), “historical exclusivity often has a way of turning
into present and institutionalized tragedy. Whose story gets told matters.” What
I’ve learned from using the mobile lab is that when we make decisions about
who to include in our studies, and which environments to study, we are
80 (implicitly) making decisions about whose psychological processes matter to us.
And those decisions have important implications for the knowledge we create,
and the policies and practices that are developed as a result of that knowledge.

The mobile lab was co-funded by the National Institutes of Health, Cornell
College of Agriculture and Life Sciences, and College of Human Ecology; some
85 of the ongoing research described in this article is funded by the David R.
Atkinson Center for a Sustainable Future.

References
90
Brick, C., Freeman, A. L. J., Wooding, S., Skylark, W. J., Marteau, T. M., &
Spiegelhalter, D. J. (2018). Winners and losers: communicating the potential impact of
policies. Palgrave Communications, 4(69). doi:10.1057/s41599-018-0121-9.
Bronfenbrenner, U. (1979). The Ecology of human development: Experiments by nature
95 and design. Cambridge, Massachusetts: Harvard University Press.
Byrne, S., Greiner Safi, A., Kemp, D., Skurkca, C., Davydova, J., Scolere, L., &
Niederdeppe, J. (2017). Effects of varying color, imagery, and text of cigarette package
warning labels among socioeconomically disadvantaged middle school youth and adult
smokers. Health Communication. doi:10.1080/10410236.2017.1407228.
100 Flake, J. K., Pek, J., & Hehman, E. (2017). Construct validation in social and
personality research: Current practice and recommendations. Social Psychological and
Personality Science, 8(4), 370-378.
Fried, E. I., & Flake, J. K. (2018). Measurement matters. Observer, 31(3).
Giner-Sorolla, R. (2019). From crisis of evidence to a “crisis” of relevance? Incentive-
105 based answers for social psychology’s perennial relevance worries. European Review of
Social Psychology, 30, 1-38.

4
 Goroff, D. L., Lewis, N. A., Jr., Scheel, A. M., Scherer, L. D., & Tucker, J. A. (2018,
November 1). The Inference Engine: A grand challenge to address the context
sensitivity problem in social science research. doi.org/10.31234/osf.io/j8b9a

110 Rohrer, J. M. (2018). Thinking clearly about correlations and causation: Graphical
causal models for observational data. Advances in Methods and Practices in
Psychological Science, 1(1), 27-42.
Simons, D. J., Shoda, Y., & Lindsay, D. S. (2017). Constraints on generality (COG): A
proposed addition to all empirical papers. Perspectives on Psychological Science, 12(6),
115 1123-1128.
Skitka, L. J., & Sargis, E. G. (2006). The internet as psychological laboratory. Annual
Review of Psychology, 57, 529-555.
The Op-Ed Project (2017, December 2). Write to change the world. New York, NY.
UNESCO.

120 UNESCO (2005). Universal declaration on bioethics and human rights. Retrieved
from: http://www.unesco.org/new/en/social-and-human-
sciences/themes/bioethics/bioethics-and-human-rights/

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12/3/2019 How does implicit bias by physicians affect patients' health care?

TEXT 2
CE CORNER

How does implicit bias by physicians affect

patients' health care?
Research is exploring how specific factors affect patients’ perception of treatment
By Tori DeAngelis
March 2019, Vol 50, No. 3
Print version: page 22

Overview
CE credits: 1
Learning objectives: After reading this article, CE candidates will be able to: 
1. Discuss research that suggests some health-care providers have implicit bias toward various patient groups.
2. Discuss how certain combinations of physicians and patients lead to poorer interactions.
3. Describe possible interventions to improve patient-physician interactions.

For more information on earning CE credit for this article, go to www.apa.org/ed/ce/resources/ce-corner.aspx (/ed/ce/resources/ce-corner) .

The theory of aversive racism, first posed in the 1970s, encompasses some of the most widely studied ideas in social psychology. According to
theory developers Samuel L. Gaertner, PhD, of the University of Delaware, and John F. Dovidio, PhD, of Yale University, people may hold negative
nonconscious or automatic feelings and beliefs about others that can differ from their conscious attitudes, a phenomenon known as implicit bias.
When there’s a conflict between a person’s explicit and implicit attitudes—when people say they’re not prejudiced but give subtle signals that they
are, for example—those on the receiving end may be left anxious and confused.

Lab studies have long tested these ideas in relation to employment decisions, legal decisions and more.
In 2003, the concepts received an empirical boost from “Unequal Treatment,” (https://www.nap.edu/catalog/10260/unequal-treatment-confronting-racial-
and-ethnic-disparities-in-health-care) a report from an Institute of Medicine (IoM) panel made up of behavioral scientists, physicians, public health
experts and other health professionals. The report concluded that even when access-to-care barriers such as insurance and family income were
controlled for, racial and ethnic minorities received worse health care than nonminorities, and that both explicit and implicit bias played potential
roles.
“The report really opened a lot of doors to further research on bias in care,” says Dovidio, who served on the IoM panel.
Psychologists and others are now building on the IoM findings by exploring how specific factors, including physicians’ use of patronizing language
and patients’ past experiences with discrimination, affect patients’ perception of providers and care. Research is also starting to look at how
implicit bias affects the dynamics of physician-patient relationships and subsequent care for patients with particular diseases, such as cancer and
diabetes.
Tackling this topic can be difficult because of the real-world challenges of getting medical professionals to engage in these studies, researchers
say. Another problem is that the main measure used to assess implicit bias, the Implicit Association Test (IAT), has come under fire in recent years
for reasons including poor test-retest reliability and the argument that higher IAT scores do not necessarily predict biased behavior.  
While this disagreement remains to be resolved, researchers are starting to use other measures and techniques to assess implicit bias, as well as
new methodologies to track patient attitudes and outcomes. And while the predictive power of the IAT may be relatively small, in the
aggregate, even small effects can have large consequences for minority patients (see Journal of Personality and Social Psychology
(https://psycnet.apa.org/PsycARTICLES/journal/psp/108/4) , Vol. 108, No. 4, 2015).

Implicit bias is called implicit for a reason—it’s not easy to capture or to fix, says Michelle van Ryn, PhD, an endowed professor at Oregon Health &
Science University (OHSU). But it is worth a deeper dive because of its implications for patient treatment on both a personal and a health-care
level, she says.
“Implicit bias creates inequalities through many difficult-to-measure pathways, and as a consequence,people tend to underestimate its impact,”
says van Ryn. “This kind of research is essential in making real progress toward health-care equality.”

How bias plays out

One of the first psychologists to apply theories of aversive racism and implicit bias in a real-world medical setting is social psychologist Louis A.
Penner, PhD, senior scientist at Wayne State University’s Karmanos Cancer Institute. Along with Dovidio, Gaertner and others, he asked patients
and physicians before a medical appointment about their race-related attitudes, and measured physicians’ implicit bias. The researchers also
video-recorded patients and physicians during the appointment and asked them to complete questionnaires afterward.
The team found that black patients felt most negatively toward physicians who were low in explicit bias but high in implicit bias, demonstrating the
validity of the implicit-bias theory in real-world medical interactions, says Penner (Journal of Experimental Social Psychology, Vol. 46, No. 2, 2010).

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12/3/2019 How does implicit bias by physicians affect patients' health care?

Researchers are also examining ways that providers may inadvertently demonstrate such bias, including through language. In a study in Social
Science & Medicine (Vol. 87, 2013), Nao Hagiwara, PhD, at Virginia Commonwealth University, and colleagues found that physicians with higher
implicit-bias scores commandeered a greater portion of the patient-physician talk time during appointments than did physicians with lower scores.
Those findings are consistent with research by Lisa A. Cooper, MD, of Johns Hopkins University School of Medicine and colleagues, who found
that physicians high in implicit bias were more likely to dominate conversations with black patients than were those lower in implicit bias, and that
black patients trusted them less, had less confidence in them, and rated their quality of care as poorer (American Journal of Public Health, Vol.
102, No. 5, 2012).

The individual words that physicians use can also signal implicit bias, Hagiwara has found. She looked at physicians’ tendency to use first-person
plural pronouns such as “we,” “ours” or “us” when interacting with black patients. According to social psychology theories related to power
dynamics and social dominance, people in power use such verbiage to maintain control over others of lesser power. In line with those theories,
she found that physicians who scored higher in implicit bias spoke more of these words than colleagues lower in implicit bias, using language
such as, “We’re going to take our medicine, right?” (Health Communication, Vol. 32, No. 4, 2017).

Specific diseases and populations

Another line of research is investigating physician and patient attitudes among patients with specific diseases. This work is shedding more light on
the role that patients may play in poor communication and relationship outcomes, and eventually aims to show whether poor communication
affects health outcomes.
In a study of black cancer patients and their physicians, Penner, Dovidio and colleagues found that, overall,
providers high in implicit bias were less supportive of and spent less time with their patients than providers low
in implicit bias. And black patients picked up on those attitudes: They viewed high-implicit-bias physicians as
less patient-centered than physicians low in this bias. The patients also had more difficulty remembering what
their physicians told them, had less confidence in their treatment plans, and thought it would be more difficult to
follow recommended treatments (Journal of Clinical Oncology, Vol. 34, No. 24, 2016).
In another study, Penner and colleagues looked more specifically at how past discrimination may influence
black cancer patients’ perception of care and their reactions to it. Patients who reported high rates of past discrimination and general suspicion of
their health care talked more during sessions, showed fewer positive emotions and rated their physicians more negatively than those who
reported less past discrimination and lower suspicion (Social Science & Medicine, Vol. 191, 2017).
“Individually and jointly, the race-related attitudes of both nonblack physicians and their black patients negatively affect what transpires during
their medical interactions and the outcomes that follow them,” Penner says.
Meanwhile, Hagiwara is focusing on black patients with Type 2 diabetes as part of a four-year study funded by the National Institute of Diabetes
and Digestive and Kidney Diseases (BMJ Open, Vol. 8, e022623, 2018). She and colleagues will assess the role of physician communication
behaviors as they relate to patients’ trust in and satisfaction with their providers, and then see how those interactions relate to health outcomes.
In addition to using surveys and video recordings of patient-physician interactions, the team will attempt to gain a deeper understanding of patient
reactions than previous studies. They’ll do this first by having patients view the videos without interruption as the team gathers their physiological
responses, including heart rate, skin conductance and eye gaze. Then, patients will watch the video a second time, stop the videos whenever
they have a positive or negative reaction to them, and explain why. The team will also stop the videos in places where they recorded patients’
physiological responses and ask patients additional questions to ascertain possible nonconscious responses. Six months later, the team will
examine how those findings influence health behaviors and outcomes by examining patients’ lab values, diabetes complications, and self-
reported treatment adherence—the first study to directly assess such health outcomes.
Focusing intensively on one disease “will help our understanding of the role of implicit bias in clinical outcomes,” Hagiwara says.

Medical students and more

While most implicit-bias studies in health-care treatment have been conducted with black patients and nonblack providers, other researchers are
investigating implicit bias in relation to other ethnic groups, people with obesity, sexual and gender minorities, people with mental health and
substance use disorders, older adults and people with various health conditions.
Medical school is one arena where this work is taking place. OHSU’s van Ryn, who is founder and head of a translational research company called
Diversity Science (http://www.diversityscience.org/)

in Portland, Oregon, is principal investigator in a long-term study of medical students and residents examining whether and how the medical
school and residency training environments might influence future doctors’ racial and other biases. For the past eight years, she, Dovidio and
colleagues have been surveying a cadre of 4,732 medical students attending 49 of the nation’s 128 allopathic medical schools, who first entered
medical school in 2010.
The study (http://www.changestudy.org/) , funded by a number of sources, including the National Institutes of Health, asks students on a regular basis
about their implicit and explicit attitudes toward racial and other minorities, and how these views might change over time.
In several studies using this data set, the team has found that student reports of organizational climate, contact with minority faculty and patients,
and faculty role-modeling were more strongly related to changes in implicit and explicit bias than their experiences with formal curricula or formal
training (Journal of General Internal Medicine (https://link.springer.com/journal/11606) , Vol. 30, No. 12, 2015). These include studies headed by health
services researcher Sean Phelan, PhD, of the Mayo Clinic, that examine medical student reactions to patients who are obese and who identify as
LGBT. In prospective studies of the initial medical student cohort, he found results similar to those involving race: for example, that students with
lower implicit-bias scores were more likely to have had frequent contact with LGBT faculty, residents, students and patients, and that those with
higher scores were more likely to have been exposed to faculty who exhibited discriminatory behavior (Journal of General Internal Medicine, Vol.
32, No. 11, 2017). 
In terms of race, van Ryn’s team also found that students who entered medical school with lower implicit-bias scores and many positive
experiences with people of different races were likely to build on those experiences during medical school, says Dovidio.

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12/3/2019 How does implicit bias by physicians affect patients' health care?
“It’s like a ripple effect,” he says. “They come into medical school with more positive racial attitudes, so during medical school they feel less
interracial anxiety and interact in more positive ways with patients. And those experiences of contact in medical school have an additive effect that
goes over and above their earlier contact experiences.”

How to intervene
Given the nonconscious and emotional nature of implicit bias, it is not easy to overcome. As a result, designing
interventions is tricky, Dovidio says. For example, he, van Ryn and their colleagues found that formal diversity
training in medical school has little or no effect on students’ levels of implicit bias over time. “It doesn’t do harm,
but it doesn’t do anything positive either,” he says.

Such findings suggest the importance of using psychological methods to address psychological problems,
Penner adds. “The goal of interventions shouldn’t be to confront physicians with their implicit bias and get them
to change it,” he says, “but rather to make it less important in their interactions.”
Promising strategies include those aimed at getting physicians to see a patient as an individual rather than as a stereotyped member of a group,
helping patients become more engaged with their treatment and fostering patients’ sense of being “on the same team” as their doctor (Journal of
General Internal Medicine, Vol. 28, No. 9, 2013).
Researcher Jeff Stone, PhD, a professor of psychology at the University of Arizona, is using some of these ideas in workshops he’s developed for
medical students. “For them, this is about how to improve their skills as a doctor or nurse,” he says. “We don’t just expose them to these ideas and
leave it at that—we have them practice them.”
For example, the workshop uses the strategy of individualizing patients to encourage medical students to question stereotypes about a patient’s
ethnic group, such as the notion that Hispanics don’t adhere to medical advice. Instead, a medical student may be told to ask all patients specific
questions about adherence, like whether they have finished all of their medications or have made an appointment for a referral. Stone has just
completed a study related to this work and is now examining whether changes in implicit bias correspond with better treatment of patients in the
clinic.

Another promising intervention, the prejudice habit-breaking intervention, is based on a theory developed by Patricia G. Devine, PhD, and William
T.L. Cox, PhD, of the University of Wisconsin—Madison. The intervention, which adopts the premise that bias, whether implicit or explicit, is a habit
that can be overcome with motivation, awareness and effort, includes experiential, educational and training components. A study by Patrick S.
Forscher, PhD, of the University of Arkansas, and colleagues found that compared with controls, people who received the intervention were more
likely after 14 days to feel concern about the targets of prejudice and to label biases as wrong, though that awareness later declined. However, in
a subsample of original participants two years later, those who received the intervention were more likely than controls to object to an online
essay endorsing racial stereotyping, the team found (Journal of Experimental Social Psychology (https://urldefense.proofpoint.com/v2/url?u=https-
3A__doi.org_10.1016_j.jesp.2017.04.009&d=DwMFaQ&c=7ypwAowFJ8v-mw8AB-
SdSueVQgSDL4HiiSaLK01W8HA&r=u2yC65FR6T3iE_qlT4nO9MrRdsmVbskhUsmYSvuD2zw&m=OpBA0cMgWG-
7pyj9Hlzc534Yno8gZZOI7vhN27kko74&s=-24Vp02BezoXM8B-YQk9sKae6BeRwd0dydEOtmWmXOY&e=) , Vol. 72, 2017).

What's next?
Psychologists who study implicit bias in health care acknowledge there is much more to learn. That includes discovering ways that patient-
physician interactions might lead to poorer health outcomes down the road, and conducting research on other populations besides black patients
and nonblack physicians. On a more discrete level, it includes achieving a better understanding of how situational factors like stress and time
constraints could activate bias and influence treatment decisions.
Researchers also acknowledge that individual interventions are just one way to reduce providers’ implicit bias. Equally important are systemic
interventions, the mission of van Ryn’s company, Diversity Science. The company helps organizations apply the best findings and interventions on
implicit bias to create inclusive cultures. Ways they do this include conducting climate assessments using evidence-based tools and
questionnaires, giving leaders feedback on that data, and providing ongoing training for all employees, including case demonstrations and
refreshers.

Also important is conducting this work with other disciplines and recognizing that environmental factors such as access to transportation and
proximity to toxic environments can play significant roles in health disparities, says Dovidio.
“When you put together physicians’ implicit bias, geography, patient attitudes, the patient-doctor interaction and organizational, historical and
structural factors,” he says, “you get a holistic picture of what can cause health disparities and specific avenues to remedy them. Understanding
how these processes contribute jointly to health-care disparities,” he adds, “is necessary for addressing such a persistent and complex problem—
one with life-or-death consequences.” 

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 Impacting Lives, Communities and Systems
TEXT 3
Aqua Vision: Addressing the needs of individuals with visual
impairments through community-built aquatic programming
Minnie Teng
P articipating in aquatic group exercises yields benefits beyond
physical fitness—it also improves mental health (Ourania,
Georgia, Ioannis, & Marina, 2011) and social inclusion (Dolan,
2016). Occupational therapists work with clients to promote
health and overcome physical, social and emotional barriers to
maximize clients’ quality of life (Mitchell & Unsworth, 2004).
This article illustrates an example of a student occupational
therapist engaging in community practice by identifying barriers
to participation through community immersion and forming
partnerships with relevant organizations to develop a program
that addresses these barriers (Doll, 2010).
Identifying a need through community immersion
As a person with intermittent strabismus, a visual disorder, I
volunteered for a support group for older adults experiencing
vision loss. One of the topics that repeatedly came up
during meetings was the limited number of physical and
social activities these older adults have access to. Many of
the participants mentioned a desire to engage in exercise,
as most used to be physically and socially active. Being an
aquafit instructor, I suggested aquafit, also known as water
aerobics. One man expressed interest in returning to aquafit
classes, but due to his limited vision he was not able to see
the instructor. Another woman shared her experience of
accidentally hitting another person when she tried aquafit.
Many participants expressed interest in aquafit, especially as
this activity can mitigate symptoms of other health conditions
present in this population, such as arthritis. Thus, I contacted
British Columbia (BC) Blind Sports, a charity dedicated to
providing sports and recreation opportunities for people
with visual impairments, to inquire about aquafit programs
adapted for the visually impaired, but found that there was no
such programming. Through my volunteer and community
immersion experience, barriers to participation in aquafit and
a need for accessible aquafit for the visually impaired were
identified.
Partnering up with community organizations
BC Blind Sports and the Canadian National Institute of the
Blind (CNIB) are leading organizations in BC that provide
services for people with visual impairments. These two
organizations employ staff members who are visually impaired
and are experts in providing advice on how to improve
accessibility for the visually impaired. When I approached the
staff of BC Blind Sports, they were very excited about the idea
of accessible aquafit and agreed to provide partial funding
OCCUPATIONAL THERAPY NOW VOLUME 19.4
for the pilot project in Vancouver. Personnel from CNIB
also helped to spread the word. Partnering with community
organizations shows acknowledgment that the knowledge
and experience of community members are as valued as the
knowledge and experience of occupational therapists (Doll,
2010). As a student occupational therapist, I led the pilot
project, applied for various community grants to help fund it,
and hosted fundraisers. The pilot project eventually received a
grant from the University of British Columbia.
Aqua Vision
Several meetings involving myself, stakeholders (such as
BC Blind Sports) and interested participants took place to
discuss how aquafit could be adapted to enhance accessibility.
Throughout the planning and implementation process, staff
members of BC Blind Sports who are visually impaired as
well as individuals from the visually impaired community were
involved. They contributed suggestions, such as to decrease
the volume of music during aquafit sessions to better enable
participants to hear instructions, to avoid the use of words
such as “this” and “that” (as these terms are visual references)
and to have the instructor wear a bright headband or cap for
visual contrast. One challenge persisted—how could clients
ensure they are at a safe distance from others? An idea came
to me one evening when I stepped into the shower—we could
try using non-slip mats as landmarks! Each participant is given
a mat that sticks to the bottom of the pool, to use as a tactile
landmark to gauge how far she or he can freely and safely
move her or his arms and legs (see below picture).
Over a year passed between the inception of the idea of
adapted aquafit and the actual implementation of Aqua Vision. In
the winter of 2016, the first accessible aquatic exercise program in
BC for the visually impaired was piloted—and it turned out to be
a great success!
Participants using non-slip mats during an Aqua Vision session
9
 Occupational therapists as social innovators
Following the success of Aqua Vision, other community
groups in British Columbia reached out and inquired about
providing accessible aquatic services for specific populations.
This community practice experience thus led to my founding
of the Aquafit for All Association, a non-profit organization
providing accessible aquatic opportunities for people of all
abilities. Occupational therapists possess unique knowledge
and skills related to identifying personal and environmental
factors that impact people’s engagement in important
and meaningful occupations. Using our understanding of
the impact occupations have on health and well-being,
occupational therapists have a role to play as social
innovators—to identify unmet needs in the community,
problem solve, collaborate with community groups and then to
develop programs that make a difference.
References
Dolan, S. (2016). Benefits of group exercise. http://www.acsm.org/public-
information/articles/2016/10/07/benefits-of-group-exercise
Doll, J. D. (2010). Program development and grant writing in occupational
therapy: Making the connection. Sudbury, MA: Jones & Bartlett Learning.
Mitchell, R., & Unsworth, C.A. (2004). Role perceptions and clinical reasoning
of community health occupational therapists undertaking home visits.
Australian Occupational Therapy Journal, 51, 13-24. doi:10.1111/j.1440-
1630.2004.00372.x
Ourania, M., Georgia, Y., Ioannis, T., & Marina, M. (2011). Psychological and
physiological effects of aquatic exercise program among the elderly. The
Sport Journal, 14.

About the author

Minnie Teng, BSc, is a first-year student in the Master of Occupational Therapy program at the University of British Columbia. She is the founder
of the Aquafit for All Association (aquafitforall.org) and can be reached at: minnie.teng@aquafitforall.org

Cover photo credit: Vickie Teng

Photo submitted by: Minnie Teng

Minnie says: “The image depicts

an Aqua Vision session where adults
We’re an
with visual impairments participate in important part
aquafit (water aerobics). This project
is the first of its kind, and means a of your team.
lot to these individuals as for some participants, this is the
only exercise they are able to participate in due to their
vision challenges.”
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 TEXT 4
2 Interconnections between social
representations and intervention
Denise Jodelet
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In human sciences, and particularly in social psychology, the notion of inter-

vention is acknowledged as a practice that corresponds to an explicit and
intentional project of a deliberate act of change. Differing from application, as
we will see further on, intervention is based on research aiming at determining,
on various levels, all the elements of a field in which the activity of an individual
or collective subject is carried out, in order to encourage transformation, to the
benefit of the latter (Dubost 2007). It can have, in this regard, a non-conformist,
reformative, or adaptive purpose.
This chapter puts forward some reflections of a theoretical nature on the means
through which the study of social representations (SRs) can articulate itself with
intervention practices. After having considered the forms that intervention takes,
I intend to show that they all implicitly or explicitly refer to a certain knowledge
of social representations and, in most cases, to an act upon them. Following, I
will suggest a model for the analysis of social representations found in the space
of concrete life, thus allowing an organic connection between its study and the
practices of intervention.

Theoretical perspectives and application

When working in concrete social situations or communities, the relation between
research and intervention is founded on two principles. First of all, the golden
rule of qualitative methodologies: the necessary honesty that the researcher
must demonstrate when carrying out fieldwork in order to not treat the people
who are providing information like inert matter from which data is extracted.
This requirement involves giving back the obtained results and presenting,
for discussion, the interpretations and conclusions that were found. Moreover,
it allows verifying the adequacy between the researchers’ interpretations of
their observations and the meaning given by the subjects under study to their
own behaviour. Second, such a procedure encourages participative research; it
can be useful to the process of social reflexivity, through which the knowledge
produced during the course of the study is taken into account and adopted by
the community, thus modifying it. These considerations bring us to differentiate

11
 Denise Jodelet
various forms and conditions of intervention, in which the role attributed to the
study of social representations must be clarified.
One first assertion is that if a study which uses the approach or the theory of
social representations (TSR) does not always imply a perspective of intervention,
on the contrary, all intervention necessarily presupposes consideration of SRs.
In order to clarify such relations that present certain ambiguities, it is important
to examine in detail the meaning of these two statements referring to more
general questions such as the relation between theory and application, or between
research and practice or action, or research and intervention.
Concerning independence between the study of social representations and
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application or intervention, it is worth emphasizing that the Theory of Social

Representations (Moscovici 1961) constitutes a scientific field in itself and does
not need to resort to application and even less to intervention in order to develop.
As a model of social thought, a theory of common sense, a psycho-sociology of
knowledge, this theory has to do with empirical material drawn from different
places, laboratory as well as social field. But it does not presuppose application
as an objective. The data are useful for the development of theoretical models to
analyse social products of a mental and symbolic type, without always implying
the concern of returning to the observed reality in order to use them. Moreover,
certain authors come to think that the purity of the theoretical propositions
would exclude a perspective of application or pragmatic use of them, in fields
close to social psychology (Garnier and Rouquette 2000). We find here the old
opposition between a conception of research considered fundamental and ‘pure’,
and another conception of research considered applied and often devalued.
However, one can question the legitimacy of this theoretical isolation, which
would result in a lack of social relevance. Effectively, in the fields of applied
psychology, such as health, education, social work, environment, etcetera, the resort
to the SRs approach has proved to be among the most productive. In these fields
the research is based on the characteristics of representational phenomena isolated
by the theory, for example: the conflicts between different forms of knowledge
(common sense versus scientific knowledge, traditional versus modern knowledge),
or the power of beliefs or ideologies to guide practices, or the importance of
communication in the orientation of behaviour and social relations. The appli-
cation of theoretical and methodological models ensures a better understanding of
the processes developing in these areas. Taking into consideration the results thus
obtained, we can say that application contributes to theoretical progress.
And, in fact, many contemporary social psychologists take applied research
as a new path towards theoretical research focused on problems of current
times (Himmelweit and Gaskell 1990), because there exists a complementarity
between research practices focused on theory and social problems, or because
the understanding acquired in a particular application field is useful for the
opening, the evaluation, and the development of theoretical models. This means
that theoretical progress is reached thanks to the applied research directed to
concrete situations that take into account cultural and social contexts along with
the elements involved in interaction and discursive practices.

12
 Interconnections between social representations and intervention
From application to intervention
The claim that there is no intervention which does not take into account SRs,
refers to the fact that the fields of application are domains of knowledge as well
as of action. It is not rare, although by no means obligatory, that application
takes the form of an intervention. Researchers deal with the study of SRs not
only as a toolbox to understand their reality, but also as a path of action upon it,
thus illustrating Lewin’s principle (1963) ‘No action without research; no research
without action.’ The concern related to a practice of intervention is linked to the
desire to modify the state of a field of action and transform the behaviours of
its actors towards improved adaptation or satisfaction. In this regard, the TSR
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offers openings. The definition of SRs as a filter through which to read the world,
a guide of action and an orientation of behaviours and communications, can
induce a reasonable objective of utilizing the theory’s achievements in order to
encourage a change based on the modification of SRs.
The case is even more evident in psycho-sociological or sociological models,
specifically devoted to practices that aim at change in defined social spaces (insti-
tutions, organizations, social movements, communities, etcetera). The latter are
the basis of concrete groups to which individuals pertain; they ensure a mediation
between personal and group life. Intervention thus appears both as the end and
the means of scientists, whose methodology takes the form of research-action.
The objectives of these research-actions are different: to solve concrete problems
experienced by social subjects and develop democracy in organizations and
communities, as Lewin advocated; to respond to social demands; to encourage
social progress through the adoption of practices related to public policies, as
in the case of health; to contribute to the empowerment of individuals and
groups who are alienated in their work, or socially underprivileged, dominated or
oppressed; to accomplish political goals, etcetera.
All these perspectives on intervention in favour of social change, no matter
what the scale, assume reference to SRs to be lay forms of knowledge and support
for identification. To illustrate this assumption one can simply consider the way
in which communitarian psychology, liberation psychology, sociology of social
movements make references to phenomena alluding to SRs. Fals Borda, Paulo
Freire, Ignacio Martìn Baró, Alain Touraine, to name only the most important,
emphasize that all social intervention whose objective is social transformation
depends on groups’ potentialities among which figures their proper knowledge. All
intervention focused on change of social reality implies an emphasis on popular
knowledge, the necessity of taking it into account in the interaction between the
researchers and the social groups. Also appears the importance of working on lay
forms of knowledge, in terms of consciousness-raising and formulation of new
necessities and identities.
Such positions represent a challenge for the approach of SRs and force us to
reflect upon the forms of a more organic integration in the processes of inter-
vention. The psycho-sociological and sociological models assume SRs to be linked
to social behaviours or objects of manipulation. But they neither analyse their

13
 80 Denise Jodelet
dynamic nor consider them as complex systems of thought encompassing subjec-
tivity in relation to others and society in a defined context.

Three forms of interconnection between social

representations and intervention
The interconnection between SRs and processes of intervention can take on
more or less slight and intentional forms in relation, or not, with practices. I will
examine three of these forms: when the exploration of SRs produces an effect of
modification in the way of thought; when the transformation of practices affect
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SRs’ state; when the intervention on SRs is intentionally directed to producing

change in the subjects’ way of being or behaviour.
Research focusing on SRs identification becomes an intervention due to the
contingencies of the research practice itself, particularly in the case of quali-
tative research. As in all research, the observed–observer relationship constitutes
an original situation that transforms the object and the subject under study
(Jodelet 2003). Such a process is particularly visible in in-depth interviews with
the close interaction between the researcher and his or her interlocutor. There
the subjects discover that through their narrations they elicit things they never
imagined they would think, or become conscious of forms of reasoning or
processes that were unclear to them. This type of intervention is, in a certain
way, shaped by the interview technique which facilitates the subject’s expression,
as Merleau-Ponty has stated (2004: 29): ‘A true interview gives me access to
thoughts of which I was not aware, not capable, and I sometimes feel as if
followed in a path unknown to me and that my words, thrown back to me by
the other, are being clarified for me’. In this case, the intervention is not made
in the perspective of change, but it can have a consciousness-raising effect, even
if not intentionally provoked.
It results from this that the exploration of SRs offers a resource that certain
models use, as in the case of clinical psycho-sociology, directed towards the
re-signification of the subjects’ situations and life experiences, without necessarily
presupposing a radical change. Psycho-sociologists consider that the space of
intervention ‘implies, before anything, a method of reshaping representations,
positions and behaviours based on an elaboration on their meanings. What
changes is the view of the social actors on situations, on themselves and on
others, which finds itself displaced by the work of elucidation […] In this sense, it
would be more adequate to use the term mobility, mobility of representations, of
thought, and, consequently, of practice’ (Giust-Desprairies 2004: 80).
On the contrary, there exist processes by which intervention aiming at a change
of individual or group behaviours will bring modifications to SRs. Such interven-
tions do not have the objective of studying SRs or taking them into account, but
modify them in a way that can or cannot be intentional. We can find examples
of this in behavioural therapies or in certain models of experimental social
psychology, such as the model of ‘commitment’, based on Festinger’s cognitive
dissonance theory. Suggested by Joule and Beauvois (1998), with the name ‘the

14
 Interconnections between social representations and intervention 81
foot in the door’, intervention produces a behavioural change through the initial
adoption of a behaviour associated with the desired practice. The technique,
which was applied to problems of public health in the case of AIDS, does
not focus on the representational dimension and considers its modifications as
collateral, secondary and marginal effects.
However, on the other hand, this relation between practice and SRs constitutes
the object of a theoretical elaboration suggested by the researchers of the Aix-en-
Provence School, who attribute changes in SRs to the influence of practices
(Abric 1994). In this case, the transformation of practices, whether it be sponta-
neous linked to the evolution of social and cultural models, or intentional due to
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the intervention of the researcher or the institutions in power, has a direct effect
upon the organization and meanings of SRs. We do find in that case a striking
illustration of the influence of intervention on SRs.
The third form of relation between SRs and intervention can be found
in numerous models that aspire to action at the level of society in terms of
social change. As I said previously, this is found in psychology (communitarian,
liberation, socio-clinical) as well as in psycho-sociology and sociology (of social
movements, of work, of organizations or institutions, etcetera). These disci-
plines advocate, in one way or another, knowledge of representations and
an action upon them, in order to base, mediate or direct intervention. The
authors postulate that social practice depends on the vision that social subjects,
individuals or groups, have of their reality through the interpretation that they
make of it. The intervention project consists in exploring social constructs elabo-
rated by the subjects, detaching those which obstruct or facilitate the desired
practices in order to correct or reinforce them, or reaffirm the importance of
those that support identity and favour a way of life and action which is both
authentic and in accordance with their necessities. Such an objective supposes
an identification of representations that are distributed in a given space of life
or action, and a particular work on the actors’ way of thinking in order to
modify the interpretations and, consequently, the practices. In these models of
intervention, even without always being mentioned as such or analysed in a
theoretical manner, social representations serve to find the means to help social
actors, groups or communities, to improve their life or working conditions, to
lead a satisfactory existence, fulfil their desires, respect their rights, strengthen
their power, or achieve objectives optimal for their well-being. Work on repre-
sentations is conceived in different ways.

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Routledge International Handbook of Migration Studies

Steven J. Gold, Stephanie J. Nawyn

Psychological acculturation

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Marc Bornstein
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3
Psychological acculturation
Perspectives, principles, processes,
and prospects

Marc Bornstein

Introduction
Acculturation traditionally includes “those phenomena which result when groups of individuals
having different cultures come into continuous first-hand contact, with subsequent changes in
the original culture patterns of either or both groups” (Redfield et al. 1936: 149–50, emphasis
added). Since this formative definition was first advanced, the sociological and anthropological
origins of acculturation theory and research have engendered continuing and appropriate focus
on group-level acculturation. However, it is well to recall that individuals do the actual migration
and adjustment. More than 200 million people today are said to live outside their country of
origin. That number tallies to 1 in ~30 individuals living on earth.
For the vast majority of international migrants, leaving their native country to settle in a new
country engenders daunting alternatives between allegiance to and association with one way of
life that includes family, social, and economic connections against usually contrasting economic,
philosophical, religious, and political conditions or investments. When considered in this way,
migration and acculturation constitute thoroughly transforming forces on individual people. On
this argument, we contend that a more encompassing approach to acculturation must embrace
dual processes of group cultural and individual psychological adjustment that result from contact
between two or more groups and their individual members.
This brief chapter outlines some prominent principles, processes, and prospects of this per-
spective on individual-level psychological acculturation. We first review relevant general theory about
migration and acculturation. We then differentiate individual-level from group-level acculturation.
Individual-level acculturation is not a uniform process as implied by a group-level approach.
Next, we distinguish and discuss variability of different sorts that constitutes the heart of indivi-
dual psychological acculturation. For brevity’s sake, we provide selected, rather than exhaustive,
illustrations. Psychological acculturation raises methodological, disciplinary, and policy con-
siderations, and we overview those also. Finally, we point to some profitable future directions
of theory development and empirical inquiry in the area of psychological acculturation.
Migration signifies physical relocation between geographic locales; acculturation signifies

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psychological adjustment. Acculturation is certainly a group phenomenon, and some aspects

of acculturation submit to group-level analysis; acculturation is also an individual phenom-
enon, and other aspects are better understood at an individual level. This chapter focuses on
the latter.

Acculturation: a group and individual phenomenon

Acculturation
When an individual from one culture emigrates to a new one, that individual conveys his or her
original culture. Acculturation is the study of how people with one culture negotiate adjustment
as they settle and adapt in a new culture. Twentieth-century theory and research on acculturating
groups and individuals was initially characterized by unidimensional and unidirectional models of
change where immigrants were seen to relinquish their culture of origin as they acquired a new
culture of destination. In short, acculturation equated to assimilation (Gordon 1964). Accumu-
lating evidence eventually suggested that most acculturating individuals adopt cognitions and
practices of the new culture while simultaneously retaining those of their old (e.g., celebrating
holidays of the culture of destination as well as holidays of the culture of origin). That is,
individual immigrants have (varying degrees of) competence in two cultures.

Group and individual

Acculturation takes place on both group and individual planes. Group-level processes and effects
provide a deeper understanding of global acculturation experiences and help to identify social
forces (e.g., attitudes toward immigrants, immigration policies) and aggregate acculturation tra-
jectories. However, just as different immigrant groups retain and adopt culture-specific cognitions
and practices differently, so too do different individual immigrants in a group. Indian migrants to
the United Kingdom may be considered to have acculturated because a large proportion of
Indians have, for example, learned to speak English. However, individuals within the migrant
Indian community vary widely in the ways they have adapted and differ considerably in their
level of acculturation, as for example in their English-language proficiency.
From the example just given, it is plain that the two planes of acculturation do not necessarily
change in lockstep, and there are good reasons for adopting a multi-level perspective of indi-
viduals nested within groups—and therefore of acculturation transpiring at the two levels. Fur-
thermore, each level certainly informs and influences the other. Compare the acculturation
histories of newer Mexican immigrants in New York City with more established Dominicans.
Mexicans are scattered across neighborhoods with low co-ethnic concentration, compared to
Dominicans many of whom have lived in a predominant urban enclave for over 50 years
(Yoshikawa 2011). Mexicans arrived in a period without a pathway to citizenship; in contrast,
many Dominicans experienced amnesty in the late 1980s following the Immigration Reform
and Control Act. Recent migrants from the Dominican Republic are much more likely to have
family members in the United States with residency or citizenship and accompanying language
and systems navigation skills than recent migrants from Mexico. Mexican parents and their
young children have lower availability of supports for child care and finances as well as fewer
multi-generational family networks. For children, this means that grandparents and other older
family members with English-language skills are far more likely to be present in Dominican
households than in Mexican households. In this way, individual acculturation patterns are
influenced by group histories of migration. Individual immigrants from the former Soviet

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M. Bornstein TEXT 5
Union (FSU) to Israel in the 1990s experienced reduced migration-related trauma because their
exodus comprised whole families.
In brief, acculturation involves complex processes that occur in individuals and in groups. On
the group plane, acculturation involves changes in social structures and institutions and in cul-
tural practices. On the individual plane, acculturation involves changes in a person’s cognitions
and practices broadly construed. At the group level, acculturation encompasses social change in
demographic, health, and economic systems in society and affects civic, educational, social ser-
vice, and legal systems. At the individual level, migrants often think, feel, and behave differently
from the native-born in a culture of destination and they also differ from one another on
indices of health, well-being, education, and so forth.

Psychological acculturation
International migration is not a single, discrete event involving movement from one geo-
graphically and socially bounded locality to another. Rather, international migration entails
dynamic exchanges, multiple domains, diverse resources, and imperative needs that are simul-
taneously unique and indigenous to multiple settings. Migration and acculturation are inherently
individual experiences that precipitate thoroughgoing changes of social identity and self.
Immigrants must negotiate new cultures and learn to navigate new systems. Just to communicate
effectively in their culture of settlement requires of immigrants new competencies in speaking,
listening, reading, and writing. Such transformations entail gaining new knowledge as well as
adjusting ingrained life scripts. Immigrants face multiple challenges in acculturating to a new
society—including deciding which cognitions or practices to retain from their culture of origin
and which to adopt from their culture of destination.
Not every individual enters into, participates in, or accommodates in acculturation in the
same way; one individual in a group may follow a course toward fuller assimilation, whereas
another in the same group may strive for a bicultural equilibrium. Individual differences are the
hallmark of psychological acculturation, and there is great variability in the ways individuals go
about acculturating as well as in the levels and types of acculturation they achieve. Here, we
discuss several kinds of variability that principally define psychological acculturation. Migration
transcends identity in the sense of who am I, and raises considerations of where do I fit and
what are my present and future roles within my new society. Individual level analyses focus on
images of self within place or context.
Along the way, considerations of variability elicit methodological, disciplinary, and policy
questions. For example, most studies measure acculturation at a single point in time and gen-
erally employ a cross-sectional research design. This methodological orientation leads to an
artificially cropped “snapshot” of acculturation and invariably to portrayals of acculturation
status as static. In reality, however, acculturation in individuals is dynamic and nonlinear, as
acculturating individuals retain some cognitions or practices of their culture of origin and
undergo periods of stabilization as well as change. Immigrants’ modes of acculturation may vary
over time as a function of ongoing experiences in their new culture, or new developments in
the original culture. Examinations of acculturation true to its process nature call for microgenetic
and longitudinal designs, preferably with multiple waves.

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 TEXT 6

CASE ANALYSES
FOR ABNORMAL
PSYCHOLOGY
Learning to Look Beyond
the Symptoms
Second edition

Randall E. Osborne, Joan Esterline Lafuze,

and David V. Perkins

20
 TEXT 6

INTRODUCTION

1 A Guiding Theme
If there is one statement that guides the nature and structure of this casebook, it
is “What you see isn’t necessarily what you get.” It is easy and perhaps efficient
to assume that what we see is reality. If we see a man on the street kick a dog,
for example, it is quite easy (and possibly even “safe” assuming you might have
to walk by this man) to conclude that this is an aggressive person. But what type
of information have we used to draw this rapid conclusion? We have based our
entire decision about the kind of person he is on one piece of behavioral evi-
dence. Although, certainly, what people do (how they act) can indicate the type
10 of person they are, there are other pieces of evidence available to us that we can
use to verify or nullify the accuracy of the impressions we have formed.

Forming Impressions—The Road to Bias and Back Again

Daniel Gilbert and his colleagues (e.g., Gilbert, Pelham, & Krull, 1988) have sug-
gested that the cognitive resources necessary for forming impressions of others is
limited. We cannot expend more of those resources (such as the amount of time
we have to consider what someone else is like) than we have available. At the
same time that we are expending mental resources to form impressions, we are
also utilizing mental resources to complete other cognitive tasks, such as trying
to remember what we were supposed to pick up at the grocery store. Thus, we
20 may not always have the mental resources available to truly consider the kind of
person we are observing or with whom we are interacting.
In addition, Gilbert and colleagues (1988) suggest that forming an accurate
impression requires a two-step process. To the extent that an individual does
not complete both steps, the resulting impression that is formed will be biased

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Introduction

in some fashion. The two steps required for forming an accurate impression are:
making a dispositional inference, and engaging in situational correction.
When making a dispositional inference, the person perceiving the behavior of
another will assume that the behavior indicates the type of person that is being
observed. With our example of the man kicking the dog, the perceiver (the per-
30 son witnessing the event and attempting to form an impression) will judge the
behavior at face value. In other words, if a man kicks a dog, he is an aggressive
person.
The second step in the impression formation process requires more effort
(therefore it will require the expenditure of more of our cognitive resources)
than the first. It is quite easy to assume that the behavior defines the person. It
is quite another thing, however, to assess the situation in which that behavior
is occurring and judge whether the situation could have had any impact on
that behavior. According to Gilbert and colleagues (1988), many impressions are
formed solely on the basis of the dispositional inference because perceivers are
40 often too busy or not highly enough motivated to engage in the more effortful
process of situational correction. In our dog example, situational correction will
require the perceiver to assess the situation and make appropriate adjustments to
his or her impression of the man.
Perhaps we could ask a few people who witnessed the same event what they
think the behavior indicates. Maybe some of these people will have more infor-
mation about what happened than we do. It is possible that one of the other
“witnesses” observed what led up to the kicking episode. Would you change
your opinion of the man, for example, if you discovered that his son is cower-
ing behind his leg and the dog had tried to bite the 5-year-old? Probably. In this
50 case, the situational-correction process would cause us to change our impression
of the man. What would happen to your impression if the other people present
tell you that the man was yelled at by his girlfriend and he just “stormed up to
the dog and kicked it in the ribs” after that? Maybe you would become even
more certain that this is an aggressive person. The point we are making is this:
When someone engages in a behavior, we have to know more than just what the
behavior was in order to understand why that behavior occurred.
Once biased impressions have formed, they are extremely resistant to change.
A teacher who has heard from another teacher that an incoming student is a
“behavior problem” will have a difficult time resisting the use of that biased
60 impression in interactions with that student. But recovery from bias is possible.
Gilbert and Osborne (1989) suggested individuals can correct biased impressions,
but only under a specific set of circumstances. Specifically, the person who has
formed the impression must have both: (a) the cognitive resources available to
reconsider that impression and, (b) must be motivated to expend the mental
energy that changing that impression will require (Osborne & Gilbert, 1992).
A clinician wanting to form an accurate impression of a client must focus
effort on doing so. This may require her or him to talk with the individual prior

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Introduction

to reading case history information. In this manner the clinician may begin to
form an impression without allowing prior information to introduce bias into that
70 process. If the clinician reads the case history first and a previous doctor has sug-
gested that the client might suffer from schizophrenia, could that prior conclusion
interfere with the current clinician’s ability to objectively observe and interview
that client? Yes. The beliefs that people have, whether those persons are clinicians
or laypersons, directly affect the assumptions those persons will make. Some-
times those assumptions—and the conclusions that will be drawn based on those
assumptions—will be valid and accurate. Many times, however, they will not be.

Treating the Symptoms Versus Seeking the Cause

Thousands of people a day will go to a medical doctor with some illness. Let us
say that you have some bacterial infection that is causing a severe cut on your
80 finger to hurt. The doctor may prescribe an over-the-counter painkiller to ease
the pain. Although this medication may provide temporary relief from the pain
caused by the infection, will it “cure” the problem? No. If the doctor is going to
provide you with a cure, it will have to be in the form of an antibiotic that can
“kill” the infectious agent.
This same analogy applies in understanding the relationship between the
symptoms of a disorder and the nature of the underlying cause. It would behoove
us to provide you with an example to clarify the point. If you saw someone sit-
ting on a bench waiting for the city bus and constantly waving his hands by his
ears, you might think that this is odd behavior. If you fall victim to this pattern
90 of thinking, however, you will have made the first mistake that will make it dif-
ficult to truly understand abnormal psychology. As a general rule in abnormal
psychology, the symptoms we can observe (in this case the waving of the hands)
are only a reflection of the underlying problem.
If we did not seek the causal explanation for why this man is waving his
hands by his ears, we may not truly provide him with the assistance he needs.
Maybe we decide to use a behavioral modification technique to get him to stop
engaging in the waving behavior. Would this “cure” the man? Certainly not.
What if we discover that the man is suffering from paranoid schizophrenia and
he is hearing voices telling him to do bad things. Suddenly, waving his hands by
100 his ears does not seem so odd anymore. In fact, given that he is hearing voices,
the behavior might make perfect sense. Since he is unaware of the source of the
voices, he may be attempting to shoo the sounds away.

The Components of Disorders

In order to aid you in connecting the affective, behavioral, and cognitive symp-
toms of each disorder, we will provide case information that focuses on all three.
After presenting this case information, then, each chapter will progress into

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Introduction

critical questions that will influence the diagnosis that is selected, cover potential
treatment options and the strengths and disadvantages of each, provide infor-
mation on case progress or setbacks, and conclude with information about the
110 typical prognosis (long-term probability of success) for such a case.
Major issues that confront clinical psychologists will be woven into the
cases. Clinical psychologists often confront difficulties in diagnosing various
disorders that are strikingly similar. How psychologists go about resolving
those issues will be incorporated into the text so that you can learn to engage
in the critical ref lection process that accurate diagnosis requires. Part of this
difficulty comes from the intricate underlying biology of the brain. A num-
ber of the disorders discussed will involve many of the same brain structures
or neurotransmitters or both. Only subtle differences, then, may determine
which disorder is at play.
120 We also incorporate into the text the relationship between diagnosis and treat-
ment. After exploring the potential diagnoses a clinician may consider based on
the prevalent symptoms in each case, potential treatment plans will be discussed.
These discussions of diagnosis and treatment are important, as they illustrate the
critical analysis process that clinicians must use. Treatment decisions are com-
plex and many crucial concepts must be considered in developing, maintaining,
assessing, and altering a treatment program.
You will become actively involved in the development of each case. Most
chapters will include “Critical Thinking and Questioning” pauses that engage you
in the analysis process. These reflection questions will also serve as springboards
130 into the next section of the chapter, as you are encouraged to reflect on unresolved
questions and issues that will then become focal points for discussion in that next
section of the chapter. You will be given the opportunity to utilize diagnostic
information and suggest a diagnosis before it is actually revealed in the chapter.
The same will occur when treatment strategies are discussed. The section follow-
ing the diagnosis will discuss the choices the clinician made and why those choices
were made. The emphasis is more on the critical analysis process and much less on
the specifics of actual treatment.
It is extremely important that you understand our use of terminology
throughout this text. Several times it might seem as if we do not make defini-
140 tive statements. You will notice that we often use terms such as “may be caused
by,” “might be indicative of,” or “normally is associated with.” Such cautious
wording is not an attempt to avoid making absolute statements. The nature of
mental illness and the relatively rapid increase in knowledge about these illnesses,
however, requires us to be cautious with our word choices. We have attempted
to provide you with the most accurate and most complete, yet most expansive,
coverage of the illnesses as we can. For this reason, many of the cases will include
a discussion of multiple potential causes as well as the multiple treatment paths
that may be considered.

24
 TEXT 7

OCCUPATIONAL
THERAPY
with Aging Adults
Promoting Quality of Life
through Collaborative Practice
Karen Frank Barney, PhD, OTR/L, FAOTA
Professor Emerita
Director, Reentry Program
Saint Louis University Prison Program
College of Arts & Sciences

Chair Emerita
Department of Occupational Science & Occupational Therapy
Edward & Margaret Doisy College of Health Sciences
Saint Louis University
St. Louis, Missouri

Margaret A. Perkinson, PhD, FGSA, FAGHE, FSfAA

Associate Research Scientist
Department of Sociology and Anthropology
University of Maryland Baltimore County
Baltimore, Maryland

Editor-in-Chief
Journal of Cross-Cultural Gerontology

Emeritus Faculty and Director of Gerontology Component

NAPA-OT Field School in Antigua, Guatemala

Copyright © 2016 by Elsevier, Inc. All

rights reserved
25
TEXT 7
Theoretical Models Relevant to Gerontological
Occupational Therapy Practice
Clare Hocking PhD, OTR/L, Phyllis Meltzer, PhD
CHAPTER OUTLINE
Being Aged: The Emergence of Theories of Aging
History of Gerontology Theories: Gerontology as a
Discipline
Being Aged: Gerontological and Psychological Models
of Aging
Disengagement Theory
Successful Aging
Activity Theory
Continuity Theory
Productive Aging
Reflections on Active Aging
Related Theories
Critical Perspectives
International Uptake of Active Aging
Models to Explain Being Occupied
Being in Context: Lawton’s Ecological Model
Models of Functioning
Summary
OBJECTIVES
s Identify theories and models of aging; gain understand-
ing of the validity of and exceptions to universal applica-
tions of each theory
s Envision possible applications of theories and models of
aging to occupational therapists’ gerontology-based
practice
s Interpret perspectives/theories of aging from an occupa-
tional viewpoint
s Interpret information derived from aged persons them-
selves regarding their views on elements of successful
aging
s Compare similarities between the development of the
disciplines of gerontology and occupational therapy
s Discuss attempts to define and identify successful aging
from a variety of viewpoints
Older age can be conceptualized from multiple perspectives:
as a biological progression, a developmental process, a social
phenomenon, and a lived experience. Although phenome-
nological understandings of living in advanced age are
relatively new, efforts have been made to bring the various
perspectives together into a holistic understanding of aging.
Occupational therapists are attuned to those efforts. Biopsy-
chosocial theory, for example, was promoted to occupational
therapists in the mid-1970s as being well suited to working
CHAPTER 4
in community settings and supporting their role in “teaching
skills for living.”50 Ideas concerning healthful aging have a
much longer history. Taoist, Islamic, Greco-Roman, Hebrew,
and Christian scriptures have provided observations about
health and aging, and through the centuries the different
schools of thought became intertwined. For example,
nineteenth-century philosophers influenced the thinking of
twentieth-century biologists.1
Occupational perspectives, such as those occupational ther-
apists and occupational scientists might propose, are largely
absent from the multidisciplinary discourse on aging. For ex-
ample, in the authoritative textbook Handbook of Theories of
Aging,9 the only mention of occupations besides caregiving
relates to hunting and foraging, which apparently influenced
the evolutionary determination of the human lifespan.39 In this
chapter, the focus is squarely on occupational perspectives of
aging. This chapter brings together theoretical understandings
of being aged, being occupied, being in context, and, as is the
case for some individuals, being affected by a health condition.
To set the scene we consider a range of theories of aging,
dwelling on those that speak to older people’s engagement in
the everyday world of doing. Acknowledging older people as
occupational beings, we provide an overview of the theories
occupational therapists draw from to explain the dynamic
relationship between people, their environment, and their
occupations, and how the things people do in older age affect
their health and well-being. To further explicate the context
of older people’s participation in occupations, a frequently
cited model that explains environmental influences on older
adults’ occupational engagement is described. Finally, be-
cause older age may be accompanied by the onset of chronic
health conditions, that theoretical basis is supplemented by
the World Health Organization’s International Classification
of Functioning, Disability and Health (ICF), which explains
the relationship between participation in the activities of
everyday life and having a health condition.71
Being Aged: The Emergence of Theories
of Aging
Theories of aging, which attempt to answer the questions of
how and what changes are part of the aging process, have a
very long history. Drawing on Hippocrates (460-377 BCE),
Aristotle (384-322 BCE) is credited with being the first West-
ern person to propose firm ideas about aging.1 The idea that
26
 SECTION I Conceptual Foundations of Gerontological Occupational Therapy
aging was not a disease but a normal stage of life during
which disease may occur is also longstanding, having been
proposed by Seneca (4 BCE-65 CE), who emphasized quality
of life over a diseased but long life. Cicero also maintained
that old age might have advantages if people maintain their
strength and interest in life.1
Current understandings of aging have been shaped by ger-
ontology, which emerged as a scientific field of inquiry in the
United States with the publication of E. V. Cowdry’s Problems
of Aging: Biological and Medical Aspects in 1939. The book was
a compendium of the work of experts from various medical
and biological disciplines who reviewed “the current state of
theories and knowledge on aging in their disciplines.”1 A great
number of “competing theories about senescence, explicating
continuities and changes from the cellular to the societal lev-
els”1 followed, spurred by the founding of two professional
organizations in the 1940s—the American Geriatrics Society
and the Gerontological Society of America—which encour-
aged researchers to create theories with cooperation from
researchers in other disciplines.
Sixty years later, the biomedical perspective prevails. Gov-
ernments and individuals are alert to the lifestyle factors that
give rise to heart disease, diabetes, and cognitive impair-
ments, and the need to actively manage those conditions to
stave off disability and death. Explanatory models, such as
psychoneuroimmunology, sefi to explain individuals’ sus-
ceptibility to chronic and infectious diseases in terms of the
links between their beliefs, psychological and stress re-
sponses, and neurologic and endocrine functioning. These
views overshadow life-course and biodemographic perspec-
tives, which acknowledge the influence of cumulative in-
equalities related to gender, race, low socioeconomic status,
and sexual orientation on the early onset and poor outcomes
of chronic health conditions.9 Public policy perspectives also
reveal how old-age policies are shaped by social processes
and in turn shape the experience of being aged.9
Psychological theories of aging are also pervasive. Perhaps
the best known was developed by Erik Erikson in his middle
age.23 Erikson’s theory of ego development encompassed the
lifespan and proposed that each stage, from infancy to old
age, represented a choice or crisis. Old age, he believed, led to
integrity and wisdom. Integrity should be the “dominant syn-
tonic disposition, in search of balance with an equally perva-
sive sense of despair,” whereas wisdom is a “detached concern
with life itself.”23 Joan Erikson, in her later years, stated in a
documentary film that these elements of the theory were not
necessarily right—in fact, they were “just plain wrong.” She
revised the theory of old age to include coping and facing
death as important components.21
History of Gerontology Theories: Gerontology
as a Discipline
The emergence of gerontology as a discipline parallels that
of occupational therapy in time and focus. During and fol-
lowing World War II, psychologists and people in related
disciplines became aware of the need for theories that could
TEXT 7
guide the creation of programs and practices to enhance the
lives of the aging. The goal became the search to identify the
determinants of “successful aging.” Early pioneers include
James Birren, one of the founders of gerontology during the
1940s, who established much of the framework of modern
gerontology theory.10 Havighurst30 defined one of the key
concepts, successful aging, as a feeling of happiness and
satisfaction with one’s current and past life, and Butler13
considered life review and reminiscence as meaningful.
Rowe and Kahn58 affected the vocabulary of gerontology by
identifying the differences between “usual” and “successful”
aging. Recently, older adults themselves, in focus groups
and research surveys, are creating their own definitions of
successful aging: considering themselves successful despite
chronic physical conditions and functional difficulties.64
Successful aging theories currently include, among others,
the concepts of productivity,58 adaptation,12 and resilience.29
New theories continue to be formulated in collaboration
with allied health professions and social scientists.
Being Aged: Gerontological and Psychological
Models of Aging
We discuss a range of psychosocial models of aging in the
following sections, as these more clearly incorporate occupa-
tional perspectives. We start with disengagement theory,
which is the most controversial.
Disengagement Theory
Disengagement theory is important, as it was the first theory
of aging proposed by gerontologists. Disengagement theory
purported that it was natural and inevitable that older people
would withdraw from society and increasingly focus on per-
sonal meanings. Although allowing that there would be
variations in timing,22 the theory postulated that this with-
drawal was mutual—members of society would also disen-
gage from older people as their abilities, knowledge, and
skills deteriorated and they ceased to perform the social roles
associated with work, family, and marriage.18
Fifty years later, however, disengagement theory seems too
accepting of the biomedical perspective that the years beyond
retirement are characterized by increasing decrepitude, senile
degeneration of physical and cognitive capacities, and patho-
logic processes. It also seems to perpetuate the ageist attitudes
prevalent in Western societies, which frame older people as
having less to offer than younger people and force them to
withdraw, whether they wish to or not.25 It is also controver-
sial because potentially mediating factors such as race, gen-
der, and social status were not recognized.1 Further, disen-
gagement theory may be based on a misinterpretation—that
the withdrawal from society it postulates is not preparation
for death, but rather a preference for interacting with the
people closest to them. That possibility, as framed by socio-
emotional selectivity theory, suggests that people who per-
ceive their time to be limited are more focused on the pres-
ent, prioritize happiness over new learning, and sefi
“emotionally rich interactions with significant others.”61 The
27
TEXT 7 CHAPTER 4 Theoretical Models Relevant to Gerontological Occupational Therapy Practice
theory is given weight by evidence demonstrating its applica-
bility to younger adults with life-threatening illness, who
similarly perceive their time to be limited. Disengagement
theory has largely been abandoned.25
Successful Aging
The concept of “active aging,” which is diametrically opposed
to disengagement theory, has been theorized since the early
1950s. It has taken on many guises over the years. One of
these guises, the theory of successful (as opposed to normal)
aging, was initially presented as a fact.31 Defined as a feeling
of happiness and satisfaction with one’s current and past
life,30 some researchers operationalized successful aging as
“life satisfaction, morale, happiness, and mental health.”46
More recent iterations have defined successful aging as “the
ability to maintain three key b›aviors or characteristics: low
risk of disease and disease-related disability, high mental and
physical function, and active engagement with life.”60 The
hierarchical nature of these components suggests that the
absence of disease and disability, and concomitant risk fac-
tors, makes it easier to maintain physical and mental func-
tions, which in turn indicates the potential for activity. The
aging adult must actually do some of the activities, whether
pertaining to social engagement with other people or pro-
ductive b›avior.
However, social science researchers have challenged the
parameters Rowe and Kahn58 proposed, arguing that success-
ful aging encompasses larger arenas of b›avior and condi-
tions. Older adults themselves certainly have a broader per-
spective. For instance, Strawbridge and associates64 found
that 867 older adults participating in the Alameda County
Study rated themselves as aging successfully despite chronic
physical conditions and functional difficulties that meant that
none of them met Rowe and Kahn’s criteria. Similarly, older
adults who discussed successful aging in focus groups in
California placed little emphasis on genetics, longevity, func-
tion, independence, or the absence of disease/disability.
Rather, in their opinion, successful aging centered on four
interrelated components: attitude/adaptation, security/stabil-
ity, health/wellness, and engagement/stimulation, It also re-
quired a positive attitude, realistic perspective, and the ability
to adapt.57 In studies that have recruited an older cohort,
however, such as the Leiden longitudinal study of people aged
85⫹, participants identified the effects that “longevity, physi-
cal, cognitive, psychological and social health and function-
ing” have on successful aging, and also acknowledged that it
is a process of adaptation involving “effective coping, living
circumstances (finances, neighborhood) and also overall life
satisfaction.”12 Ongoing exploration may validate older peo-
ple’s multidimensional definitions and contribute to theory
building.
Correlation studies also bring new understandings of what is
required for successful aging. For instance, in their study of suc-
cessful aging among 1825 Korean older adults, Jang, Choi, and
Kim37 measured a range of factors, including the presence of
chronic diseases, physical functioning, history of mental illness
and social activity participation, and subjective well-being.
They concluded that higher level of education was the most
important socioeconomic factor because it explained correla-
tions between successful aging and hous›old and personal
income, which the authors concluded was the result, for the
most part, of educational opportunities.
There is some agreement emerging from the research that
control of the social environment and material well-being are
requirements for successful aging. Equally, research has not
supported other assumptions, such as that minority older
adults (in the United States) are disadvantaged compared
with the larger population and that the additive effects of
marginalization are greater in old age than in middle age.
Rowe and Kahn’s 1987 definition of successful aging has also
been critiqued for not addressing ethnic differences, differ-
ences in experiences of life events and coping mechanisms,69
and differences in how older adults themselves perceive suc-
cessful aging. “Finally, criticism has been leveled on the suc-
cessful aging paradigm for vesting too much responsibility
within the individual for achieving this normatively desirable
state, thus risking further marginalization of high-risk seg-
ments of society, such as the poor and older women.”69
Activity Theory
Havighurst and colleagues’30 activity theory proposed
that normal aging is typified by continuing engagement in
meaningful occupations and relationships. The specific rela-
tionship predicted was between social activities and life satis-
faction, whereby higher levels of satisfaction would be associ-
ated with a higher frequency of activity and with informal
social activities rather than formal or solitary activities.49
Activity theory was more formally developed by Lemon,
Bengtson, and Peterson,44 who specified the relationship bet-
ween activity and well-being.
Activity theory is partially supported by evidence from
research. There is substantial support for a positive relation-
ship between the number and frequency of activities older
people participate in and their survival, functional and cogni-
tive status, physical health, psychological well-being, social
status, maintenance of skills and knowledge, and satisfaction
with life. Evidence from the Aging in Manitoba Study (AIM),
which is the largest and longest-running study on aging in
Canada, showed that levels of everyday activity reported
six years after the initial survey were positively related to hap-
piness, as well as better function and reduced mortality. How-
ever, participation in solitary occupations was also related to
happiness. Participants who engaged in handwork hobbies,
playing or listening to music, attending the theater, or reading
and writing were happier six years later than those who
did not.49
Other studies, however, have reported that some occupa-
tions that might be considered solitary, such as listening to
the radio and watching television, are negatively associated
with well-being. Also, because the studies do not establish
causality, it is not clear whether good health enables higher
levels of activity, being more active promotes good health, or
both. There is also some evidence that older people’s activity
levels can be irrational and excessive.33,53 In addition, the
28
 SECTION I Conceptual Foundations of Gerontological Occupational Therapy
evidence does not clearly show whether different kinds of
activities confer different kinds of benefits. For example, pro-
ductive activities might confer a sense of competence and
usefulness, but if they are not physically demanding, they
might not provide the known benefits of exercising. Finally,
the proposed association between life satisfaction and social
rather than solitary occupations has not been widely
researched and is not clearly supported.49
Continuity Theory
Atchley’s4,5 continuity theory elaborated on activity theory by
introducing a life-course perspective. It proposes that older
adults persist with the activities, b›aviors, opinions, beliefs,
preferences, and relationships that characterized them in
earlier stages of their lives, and that doing so is an adaptive
strategy for managing changes in their physical, social, and
mental status and the life events associated with growing
older. That is, with the support of their network of relation-
ships and social roles, older adults make decisions that pre-
serve occupations that are highly meaningful and other ac-
tivities that characterize their daily routines to sustain their
self-concept and lifestyle.40,43 Continuity theory is descrip-
tive, focusing on the relationship between the things people
do and their psychological functioning, rather than the ex-
tent of their involvement in various occupations.53 It rests on
the assumption that people’s personalities are stable, and that
personality influences the roles individuals assume, their in-
terest in those roles, and their life satisfaction.22
Although the theory is supported to some extent by re-
search findings, it does not account for the diverse outlooks
older people have on their everyday activities and the future,
the active choice some make to relinquish activities that
worry them, or the transfer of tasks to younger people.16 It
does not encompass documented reductions in the range of
activities with declining health or changes in the kinds of oc-
cupations people participate in as they age,49 such as the shift
toward activities that require less physical effort, and from
outdoors to indoor activities. It also fails to account for older
adults who initiate new occupations, such as widows who
take up new hobbies and exercise routines, and men who
begin to shop, clean, and cook after losing a spouse.53
Productive Aging
In the 1980s, active aging was reinterpreted as “productive
aging,” and in the United States, in the economic retrench-
ments of the Reagan administration, it was recast as civic
engagement—“volunteerism that places the responsibility for
solving social problems on the shoulders of American volun-
teers while government retreats.”47 Productive aging refers to
“all activities … that create goods or services of value,”58 in-
cluding paid, unpaid, self-defined, culturally defined, and
other activities. The concept of productive aging is supported
by reports regarding the activities of older adults, such as one
from the MacArthur Study of Successful Aging, which as-
serted that most older people do some productive work and
that “all in all, the amount of such work is substantial; and …
much of it continues throughout life.”58
TEXT 7
The link between remaining productive and successful ag-
ing lies in its outcomes. For example, older Japanese women
in the northern Okinawan village of Kijaha are the main con-
tributors to the occupation of basho-fu weaving. The fiber
they use requires intense labor to prepare it for the weaving
loom. As the women age they contribute less-intense physical
labor, but remain active in some aspects of the preparation
processes.69 In exchange for their continuing skilled contri-
bution, they receive symbolic capital,11 which refers to the
amount of honor and prestige possessed by a person with
regard to existing social structures. Symbolic capital relates to
the opinions of others as well as the individual, and it is ac-
crued “through self-maintenance of health, continued engage-
ment with society (in various cultural manifestations), and
pursuit of productive activity.”69 Through their participation in
basho-fu, the women are honored as living cultural treasures.
Reflections on Active Aging
Since the 1960s, postmodern perspectives have influenced
research and theory development in at least two ways. First,
researchers give more credence to people’s perception of their
own lives. Reflecting that credibility, members of a reference
group of older adults living in the United Kingdom were
asked for their opinion of active aging; they reported that
they prefer the notion of “comfortable, healthy aging.”16 Sec-
ond, there is increasing tolerance for diversity. That mind
shift plays out in the recognition that active aging may mani-
fest differently in early and later old age. Accordingly, the
concept of active aging has been criticized for representing
youthful or middle-aged perspectives that have been sup-
ported by research that has canvassed the views of people in
early old age.16
Picking up on such concerns, researchers now recognize
that older adults’ perspective of being active may be less
about actively working to achieve goals and more related to
taking pleasure in everyday occupations, relationships, and
events.16 Researchers have also argued for the need to inves-
tigate how the “oldest old” age successfully, based on mea-
sured differences between the younger and older cohorts.
People in the younger group are more physically and men-
tally fit than those of previous generations, retain the ability
to learn, have greater emotional intelligence and wisdom
than any other age group, and maintain their ability to adjust
to changed circumstances and health status. Among the old-
est old, even the healthiest have been found to have severely
impaired ability to learn and show declines in life satisfaction,
affect, identity, and psychological and medical status.
Although there is no agreed-on demarcation between the
young old and those living in advanced old age, a population
approach might place the transition at the chronologic age
where 50% of a cohort have died. In developed nations, that
would be 75 to 80 or 80 to 85 years of age, depending on how
the cut-off was calculated.7
The rest of the chapter intentionally omitted.
29
Carnes et al. BMC Health Services Research (2017) 17:835
DOI 10.1186/s12913-017-2778-y

TEXT 8
RESEARCH ARTICLE Open Access

The impact of a social prescribing service

on patients in primary care: a mixed
methods evaluation
Dawn Carnes1,2* , Ratna Sohanpal1, Caroline Frostick3, Sally Hull1, Rohini Mathur1, Gopalakrishnan Netuveli3,
Jin Tong3, Patrick Hutt4 and Marcello Bertotti3

Abstract
Background: Social prescribing is targeted at isolated and lonely patients. Practitioners and patients jointly develop
bespoke well-being plans to promote social integration and or social reactivation. Our aim was to investigate: whether
a social prescribing service could be implemented in a general practice (GP) setting and to evaluate its effect
on well-being and primary care resource use.
Methods: We used a mixed method evaluation approach using patient surveys with matched control groups
and a qualitative interview study. The study was conducted in a mixed socio-economic, multi-ethnic, inner city London
borough with socially isolated patients who frequently visited their GP. The intervention was implemented by ‘social
prescribing coordinators’. Outcomes of interest were psychological and social well-being and health care resource use.
Results: At 8 months follow-up there were no differences between patients referred to social prescribing and the
controls for general health, depression, anxiety and ‘positive and active engagement in life’. Social prescribing patients
had high GP consultation rates, which fell in the year following referral. The qualitative study indicated that most patients
had a positive experience with social prescribing but the service was not utilised to its full extent.
Conclusion: Changes in general health and well-being following referral were very limited and comprehensive
implementation was difficult to optimise. Although GP consultation rates fell, these may have reflected regression
to the mean rather than changes related to the intervention. Whether social prescribing can contribute to the
health of a nation for social and psychological wellbeing is still to be determined.
Keywords: Mixed methods, Evaluation, Social prescribing, Primary care

Background prescription, walking groups and the introduction of

Since the 1990s there has been a shift from the concept
of the biomedical health care model to the biopsychoso-
cial model of understanding health states and disease,
particularly for non-communicable chronic illnesses
such as back and neck pain [1]. In the last few years
there has been an emergence of interventions focusing
on the social component of care, such as social prescrib-
ing, art on prescription, exercise/physical activity on
* Correspondence: d.carnes@qmul.ac.uk; Dawn.carnes@hefr.ch
1
Queen Mary University of London, Barts and The London School of
Medicine and Dentistry, Centre for Primary Care and Public Health, 58 Turner
St, London E1 2AB, UK
2
University of Applied Sciences Western Switzerland, School of Health
Sciences, Route des Cliniques 15, 1700 Fribourg, Switzerland
Full list of author information is available at the end of the article
health trainers, with some evidence for behaviour change
[2–4]. These aim to help people manage their chronic
condition, prevent more serious health problems devel-
oping, and contribute to addressing health inequalities
by building social support networks.
The emergence of these interventions are in part due
to the aging population, increases in chronic conditions,
levels of social isolation and the growing burden of pro-
viding health care [5]. There is scope for providing new
and innovative interventions to promote the self-
management of chronic conditions potentially reducing
the need for physician led care. Despite the increase in
socially oriented health services, their effectiveness
remains uncertain: a review of 12 evaluations of UK

© The Author(s). 2017 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0
International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and
reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to
the Creative Commons license, and indicate if changes were made. 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.

30
Carnes et al. BMC Health Services Research (2017) 17:835
TEXT 8
Fig. 1 Description of barriers and facilitators to social engagement via the social prescribing service
social prescribing services showed that the rigour of
evaluations was limited and that none of the evaluations
had an adequate control group [6]. However some of the
service evaluation reports indicated some beneficial
changes in anxiety, depression, wellbeing, social isolation
and general practice attendance [7, 8].
There is no standard definition of social prescribing
but we describe it as: a non-medical referral, or linking
service, to help people identify their social needs and
develop ‘well-being’ action plans to promote, establish or
re-establish integration and support in their communi-
ties, with the aim of improving personal wellbeing.
In January 2014 the London Borough of City and Hack-
ney Clinical Commissioning Group (CCG) commissioned
a pilot project for a social prescribing service in three
areas comprising 22 primary care general practices. The
aim of the social prescribing service was to improve
patient well-being and increase personal self-efficacy
shown by a reduction in primary health care resource use.
The aim of the evaluation was twofold: i) to assess the
effect of the service on mental wellbeing and primary
health care resource use and ii) to assess the whether
the service could be implemented as intended.
The aim of this paper is to present data about the
effect of the service on the people referred and the
implementation of the service from a patient
perspective.
Methods
We used a mixed methods approach to evaluate the
service and test its effect on patients. For the service
evaluation we monitored activity in the service and we
interviewed patients to explore their views and experi-
ences of the service. To compare the effect on patient
reported health related outcomes we used a matched
controlled group to assess ‘non-exposed’ patients using a
postal questionnaire survey. For health care resource use
we searched electronic patient records and compared
those referred into social prescribing with a propensity
matched control group. The evaluation period was from
the service inception, Feb 1st 2014 to January 31st 2016.
The setting
The social prescribing service was piloted in the London
Borough of City and Hackney which is characterised by
an extreme range of socio-economic deprivation and
affluence and a considerable ethnic mix [9].
Three areas in the borough were included and were
assigned a social prescribing coordinator. The coordinators
were trained in social work and employed by a managing
third sector (not-for-profit) organisation commissioned to
implement the service. Three social prescribing coordina-
tors were appointed and worked in the 22 GP surgeries
enrolled.
Population
The population of interest were patients in general
practices who were frequent attenders and, or socially
isolated. People were not referred if they were in acute
crisis, at risk to self and/or others, had uncontrolled
addictions or uncontrolled mental health problems.
The social prescribing service
Patients were referred to a Social prescribing coordin-
ator. At the first meeting with the coordinator, the
patients discussed their personal circumstances and if
possible a mutually determined well-being action plan
was devised. The action plan contained goals for im-
proving patient wellbeing, in some cases this involved
referring patients to community organisations and
services. If necessary a volunteer was assigned to help
the patient achieve their goals. Volunteers were trained
31
Carnes et al. BMC Health Services Research (2017) 17:835
by the Social prescribing coordinators to assist in the de-
livery of the service and provide additional support to
clients. Patients could receive up to six sessions with the
social prescribing coordinator and as many contacts with
the volunteer as required.
Evaluation of effect of service on patients
a) Patient reported mental wellbeing
All patients referred to the social prescribing service
were sent a questionnaire by the independent
evaluation research team, prior to their first
appointment (where possible) and after eight
months. Patients were asked basic demographic
information about: age, sex, employment status,
education status, English language fluency, and living
alone or not. We collected data about general health
[10], wellbeing [11], anxiety and depression [12],
number of regular activities, accident and emergency
visits in last 3 months and positive and active
engagement in life [13]. The eight month follow-up
questionnaire also included questions about
satisfaction.
The control group consisted of a randomly selected
group of patients from neighbouring areas not
involved in the social prescribing scheme. People
were selected and matched by: age, older than 23
and younger than 85 years, GP attendance (last
3 months) and at least one of the following:
depression, anxiety, type 2 diabetes. Exclusion
criteria were: palliative care and housebound.
A sample of 3000 people were invited to take part in
a questionnaire survey about their health and
wellbeing with a view to getting around a 10%
response rate (based on prior surveying experience
in this population) to match the number of patients
expected to be referred into the social prescribing
service (300 over a 12 month period). These
participants were given the same questionnaire as
those referred into social prescribing and were
followed up at 8 months.
Analysis: We compared questionnaire mean scores
from the social prescribing patients and the controls
at baseline and at 8 months.
b) Primary health care resource use
Primary health care use data were collected
electronically and anonymously from patient health
care records. All GP referrals into the social
prescribing scheme were flagged by a unique
identification code. Matched controls were identified
from the referring practice populations. For every
patient referred, up to 20 matched controls with
similar demographic characteristics were identified.
Demographics used to match patients were: age, sex,
TEXT 8
ethnic group, general practice (by Index of Multiple
Deprivation) and the presence of co-morbidities
(cardiovascular disease, respiratory and mental
health conditions). Using anonymised consultation
and prescribing data we compared annual GP
consultations and number of medications prescribed
(antidepressants, antipsychotics, anxiolytics,
nonsteroidal anti-inflammatory drugs and opioid
analgesics) for the year prior and the year following
the date of referral between social prescribing
attenders and their matched controls.
Analysis: We used non-parametric statistics and
linear regression to compare the social prescribing
group with the controls.
Evaluation of the service from a patient perspective
In this report we present information about the patients
and their perspectives of the service.
a) Activity
The commissioned service provider was requested
to keep monthly records of the number of people
referred into the service (by GP and practice), the
sex, age, number and type of contacts with the social
prescriber and volunteers and places that people
were referred to in the community setting.
b) Interviews with patients
We used a phenomenological approach to capture
patient experience, beliefs and opinions at one point
in time. We tried to access patients who had fully
engaged with the social prescribing service (2 or
more contacts), partially engaged (1 contact) and
those who did not engage at all (0 contacts). We
randomly sampled 100 patients from each category
to approach for interview. Subsequently we aimed to
interview 20 patients by using purposive sampling to
maximise the variety and range of patients
interviewed in terms of sex, age and ethnicity.
We conducted semi-structured interviews covering:
lifestyle (to establish their levels of social isolation),
the way they were referred into the service, what
they knew about the service, their level of
engagement in, and experience of the service and
recommendations for the future. Four of the authors
(DC, MB, CF, RS) conducted the interviews by
telephone and face to face where possible. Copious
notes were taken, interviews were not transcribed
verbatim. Signed consent was obtained from each
participant.
Analysis: We familiarised ourselves with the content
of the interviews and organised the data by
responses to questions (the topic areas). By
consensus we agreed on emerging themes and
sub-themes. Data was aligned with each theme and
32
Carnes et al. BMC Health Services Research (2017) 17:835 TEXT 8

sub-theme and any dissonant data or data left over Table 2 Demographic profile of participant and control patients
was considered separately. responding to the survey at baseline
Characteristics Control Group Intervention Group P-value
Results n = 302 n = 184
Quantitative evaluation Age (Median (IQR)) 58 (20) 56 (22) 0.376a
Twenty-two general practices referred patients into the so- Gender (n (%))
cial prescribing service (range: patients per practice 1–108). Female 164 (54) 103 (59)
The mean number of patients referred per month was 45 Male 137 (46) 72 (41) 0.354b
(range 25–59). A total of eighty-two community organisa-
Ethnicity (n (%))
tions were used in the delivery of the service, although most
participants were sent to 10% of these. The community or- White 170 (58) 88 (49)
ganisations were diverse and reflected the different interests Non-White 123 (42) 90 (51) 0.070b
of people, for example exercise classes, cookery lunch clubs, Living arrangement (n (%))
library visits, religious groups and ping pong. Nineteen Alone 106 (37) 101 (60)
volunteers were trained, 10 were used. With others 180 (63) 66 (40) < 0.001b
Of the patients referred (Table 1), 17% had more than
Work status (n (%))
one contact with the service, 14% had no contact at all
and the remainder had one contact. Patient reasons for Not paid 153 (53) 162 (91)
non-engagement following referral included: declined to Paid 136 (47) 17 (9) < 0.001b
participate, reason unknown, uncontactable, other com- Education (n (%))
mitments, ill health, moved away, unclear of reason for Up to 16 years 111 (39) 100 (58)
referral. 17 years or above 175 (61) 72 (42) < 0.001b
a b
Median test, Chi square test
Patient reported outcomes
The questionnaire response rate for the social prescrib- treatment effect our social prescribing service had on
ing group at baseline was 39% (184/475) and at 8 months people in the study. Both the non-adjusted and adjusted
38% (69/181). For the controls the response rate at base- models (taking into account the different demographic
line was 10% (302/3000) and at 8 months 42% (127/302) profiles) showed that the social prescribing service did
(Table 2). not have any statistically significant effects on patients’
The control and intervention groups differed in three general and mental health, wellbeing and active living
ways, the control group were more likely to be living changes. However there was a reduction in the number
with others, in paid work and were in full time educa- of activities between baseline and follow-up indicating a
tion for longer. negative effect.

Baseline data and change at 8 months Health care resource use

There was no statistically significant difference in any
outcome between baseline and 8 months (Tables 3 and 4).
Both the social prescribing group and the control
group showed positive changes in anxiety (though not
depression) over the 8 months period. However, the
control sample was in better mental health at baseline
(Table 3).
The change in patient reported outcome scores for
general health, depression, anxiety, wellbeing and active
engagement in life were analysed using a linear regres-
sion model (Table 4). This type of analysis predicts what
Across the participating general practices, the study
identified 381 patients referral to social prescribing. For
these 381 participants, 7540 controls, matched by age, sex,
ethnicity and co-morbidities were identified (Table 5).
The annual GP consultation rate in those referred to
social prescribing was significantly higher than in con-
trols both before and in the year following the date of
referral to social prescribing. The GP consultation rate
within controls was higher after their matched compara-
tor referral date compared to before, whilst the GP con-
sultation rate for those referred into social prescribing

Table 1 Engagement in service (Feb 2014 – Mar 2015)

Consultations between patient and social prescribing coordinator/volunteer Number (%) of people referred into social prescribing (n = 585)
No contact 81 (14)
Single consultation 405 (69)
Between 2 and 4 consultations 79 (14)
Between 5 and 6 consultations 20 (3)

33
Carnes et al. BMC Health Services Research (2017) 17:835 TEXT 8

Table 3 Comparison of outcome variables between baseline and 8 month follow-up

Outcomes Control Group Intervention Group
Baseline Follow-up Baseline Follow-up
n Mean (S.D.) n Mean (S.D.) n Mean (S.D.) n Mean (S.D.)
a
General health score 296 3.3 (1.00) 127 3.3 (1.02) 184 2.8 (1.00) 65 2.7 (0.95)
HADS Anxiety score (range 0–21)b 287 8.1 (5.47) 124 7.6 (5.43) 175 11.3 (5.02) 63 11.2 (5.02)
b
HADS Depression score (scale 0–21) 295 6.7 (5.22) 124 5.9 (5.22) 174 9.9 (5.08) 64 10.1 (5.06)
HADS score (scale 0–41)b 286 14.8 (9.88) 122 13.4 (9.99) 169 21.1 (9.57) 63 21.3 (9.36)
Wellbeing (past week) (range 0–6) 300 3.6 (1.52) 126 3.9 (1.44) 184 2.8 (1.47) 65 2.8 (1.44)
Active engagement in life score (scale 0–20)c 293 13.7 (3.92) 121 14.1 (3.89) 179 13.5 (3.88) 62 13.5 (3.83)
Number of regular activities (range 0–6) 302 2.8 (2.24) 126 2.9 (2.27) 184 1.9 (1.66) 43 1.3 (1.31)
A&E visits in past 3 months 289 0.3 (0.79) 121 0.5 (1.15) 47 0.3 (0.68)
a
General health scores 1 = very bad; 5 = very good. bAnxiety and depression Scores between 0 and 7 in both anxiety and depression scales are considered normal,
with 8–10 borderline and 11 or over indicating clinical ‘caseness’. cHeiQ Scale is between 5 and 20: 5 = poorly integrated; 20 = well integrated

was lower after the referral date compared to before would have liked more information about the service and
(Table 5). 62% (39/63) would recommend the service to others.
The analysis showed that the number of medications
prescribed to cases was significantly higher for those re- Patient interviews
ferred into social prescribing both before and after the Of the randomly selected 100 clients from the three differ-
intervention. The number of medications prescribed in- ent groups: full, partial and non-attenders, to be inter-
creased slightly in the controls after the referral date but viewed: fifteen people responded to the letters and
the number of medications prescribed in those referred consented to be interviewed. Of these, five people were
to social prescribing remained stable (Table 5). available for interview. The remainder were too busy,
non-contactable or did not want to participate. Examples
Qualitative evaluation for non-participation included: moved, unwell, in hospital.
Satisfaction with the service As our sampling method only generated five inter-
Most clients (55% 35/60)) were satisfied with the social views, we asked the managing organisation to contact an
prescribing service they received at 8 months, 70% (42/60) additional participants. This resulted in the completion
of 15 additional interviews which were well balanced be-
tween sex, ethnicity and age (63% were aged 50 years or
Table 4 Effect of social prescribing on general and mental
health, wellbeing and active living over) but all had engaged in the service. Of those inter-
viewed two people had been invited to social prescribing
Linear regression model on outcome differences (between baseline and
follow-up) against treatment group but did not attend, six attended one or two sessions the
Outcomes Non-adjusted Adjusteda remainder (7) three or more.
Coef. (95% Conf. Coef. (95% Conf.
Two strong themes emerged from the data about: I)
Interval) Interval) Processes and procedures and II) Engagement and
General health score −0.029 (−0.312, 0.127 (−0.221, outcomes. No dissonant data was found.
0.253) 0.475)
HADS Anxiety score (range 0–21) −0.542 (−1.837, −0.119 (−0.847, Theme I. Processes and procedures
0.752) 1.609) Sub themes included i) patients being overwhelmed by
HADS Depression score 0.679 (−0.566, 0.857 (−0.737, their care provision and ii) appropriateness and timing
(range 0–21) 1.924) 2.451) of the referral. This included GP ‘parentalism’ and where
HADS score (range 0–41) 0.232 (−2.113, 0.906 (−2.144, patient’s thresholds of needs were too high (or low).
2.577) 3.957)
Wellbeing (past week) −0.089 (−0.569, −0.013 (−0.623, “My GP knows me so well he probably just referred me
(range 0–6) 0.391) 0.596)
because he thought it would be good for me”
Active engagement in life score 0.023 (−0.957, −0.073 (−1.278, (Pt partially engaged)
(range 0–20) 1.004) 1.131)
Number of regular activitiesb −0.856 (−1.518, −0.897 (−1.729,
−0.194) −0.065)
a
Adjusted with control variables, including age, sex, ethnicity, work status and
living arrangement
“I had too many other things going on [family crises]”
b
p = 0.012 for non-adjusted model and p = 0.035 for adjusted model (Pt not engaged)

34
Carnes et al. BMC Health Services Research (2017) 17:835
Table 5 Comparison of GP consultation and medication use before and after referral date between those referred to social
prescribing and controls
Social prescribing N control Median (IQR)
Annual GP consultation rate before referral 7540 2.9 (0.6–5.8)
Annual GP consultation rate after referral 7540 3.3 (0–6.4)
Two-sample Wilcoxon rank-sum (Mann-Whitney) p = 0.014
test for non-parametric data
No. of medications 6 months before referral 7540 0 (0–1)
No. of medications 6 months after referral 7540 0 (0–1)
Two-sample Wilcoxon rank-sum (Mann-Whitney) p = 0.022
test for non-parametric data
Some interviewees were not sure what social prescribing
was and who the service delivery organisation was,
despite having been referred.
“I have no idea who or what you are talking about,
but sounds a good idea, I don’t know why I was
referred……..” (Pt not engaged)
Names used for social prescribing coordinators included:
wellbeing coordinators, managing organisation support,
social prescribers, counsellors, navigators, link workers,
supporters, members of the general practice team.
The coordinators established themselves as part of the
general practice services, in part because the one to one
consultations that happened in the general practice
surgeries. As a consequence users did not recognise the
term social prescribing but only remembered their
coordinators. This was mainly because the people we
interviewed saw so many different health care profes-
sionals they had lost track of who they were seeing.
“I don’t know who she was [in terms of health care
professional]……I can’t remember her name…..errr but
she was very nice” (Pt engaged)
“The problem is there are lots of services and lots of
names, I get confused” (Pt partially engaged)
Theme II. Engagement and outcome
The sub themes focused on the coordinator and patient
relationship and understanding of the service. Where
contact with wellbeing coordinators was established, this
left a lasting impression either because expectations
were surpassed or because expectations were unmet
(often illustrating a lack of understanding about the ser-
vice). The role of coordinators seemed to work best
when they addressed some of the entrenched health and
well-being issues patients had, illustrating that the role
TEXT 8
N referred into Median (IQR) Two-sample Wilcoxon rank-sum
social prescribing (Mann-Whitney) test for
non-parametric data
377 8.3 (5.8–12.1) p < 0.001
377 7.3 (4.7–10.7) p < 0.001
p = 0.001
377 2 (1–3) p < 0.001
377 2 (1–3) p < 0.001
p = 0.156
of a social prescribing coordinator was more than
logistical coordination but important for facilitating the
self-management of life skills and thus the health condi-
tions. Wellbeing co-ordinators dealt with a range of
needs from straightforward sign-posting to, what was in
essence, a more intensive coaching-style intervention.
Some of the most positive outcomes reported by
patients resulted from experiencing sessions which
allowed them the time to explore their situation more
fully and work collaboratively to set realistic goals for
the future.
“It’s done me a world of good, taken me out of the
house, given me a routine and given me a sense of
purpose and …hope. It’s given me back my confidence”
(Pt engaged)
“It [social prescribing] gave me the motivation to think
I might be ready to go back to work” (Pt engaged)
“It [a voluntary organisation return to work scheme]
allowed me to keep my hand in, so when I was ready
to go back to work [this meant] I wouldn’t have not
been working since 2012………….I’ve [now] got
references and skills that are current” (Pt engaged)
Overall interpretive analysis
Figure 1, illustrates the process of social prescribing in
City and Hackney. It shows three phases in the process,
first with the GP, then the social prescriber and finally
the patient’s/client’s entry into the voluntary sector or
the community. The ‘successful’ clients moved through
each stage and emerged after exposure to all three stages
as ready to move on or requiring further support. The
reasons for not going through each stage are shown in
the orange boxes and include: lack of understanding,
35
Carnes et al. BMC Health Services Research (2017) 17:835
lack of perceived need, overwhelmed by other health
needs, logistical problems getting out and about.
Discussion
All the participating general practices referred patients
into the service. Of the patients referred 69% received at
least one contact, either by telephone or face to face,
only 17% received two or more contacts. This limited
exposure to the service may partly explain the lack of
impact on outcomes.
Those referred into social prescribing seemed to fit the
referral criteria. They consulted more frequently and
were prescribed more medication than the controls, and
were significantly more likely to be living alone and
unemployed. They were more anxious, depressed, they
rated their general health and wellbeing worse than con-
trols but interestingly their level of positive and active
engagement in life were about the same.
There were no significant changes in general health,
wellbeing, anxiety, depression, levels of positive and
active engagement in life over time in either the social
prescribing or the control groups. A finding which is dif-
ficult to explain is the reduction in number of activities
in the intervention arm. In contrast the qualitative study
showed there were strong and powerful narratives about
the impact social prescribing had on some patients.
The consultation data needs interpreting with care be-
cause: i) there were a large number of controls, so a
small rise in the median value for consultation rate over
time for controls (2.9 to 3.3) was statistically significant
and ii) the statistically significant drop in median GP
consultation rate from 8.3 to 7.3 was in part, because
GPs referred patients because they had higher than
average rates of attendance (alongside perceived social
isolation) so the identified changes may represent regres-
sion to the mean, rather than a change related to the
efficacy of the intervention. Without evidence from a
randomised controlled trial it would be premature to
conclude that social prescribing reduced GP consult-
ation rates.
Strengths and limitations of this evaluation
The major strength of this evaluation is that it had two
control groups: one for the comparison of patient
reported outcomes by questionnaire, and the other for
primary health care resource use using electronic patient
records. This is the most comprehensive control group
comparison to date.
A weakness however is the response rates, as with any
evaluation of this nature in communities where English
fluency and literacy is varied, it is difficult to collect data
via postal questionnaires. The response rate at 8 months
from those referred into social prescribing was only 14%
(69/475). Furthermore, we do not have data about which
TEXT 8
clients actually went to which activities, organised by
which voluntary organisations and how many times they
went. The impact of the social prescribing service in the
community organisations is not discernible but we do
know that a large number of diverse organisations, activ-
ities and events were recommended.
Findings in relation to other studies
The findings for social prescribing type of initiatives are
comparable to other trials and evaluations of self-
management programmes [14, 15] in that the evidence
for effectiveness is inconsistent, small to moderate, at
best, and only on some outcomes [6, 7, 16]. Health care
resource use and subsequent evidence of reduction, and
hence cost, remain powerful indicators for commis-
sioners to fund these sorts of interventions. Two other
studies reported promising data about health care re-
source use reduction as did we but whilst this data
shows promise as with the other two studies the results
have to be viewed with caution. Our qualitative study
elicited strong positive narratives similar to case studies
reported in other evaluations [17–19] but the quantita-
tive data did not support or reflect the strength of these
narratives throughout the whole referred group.
Due to the complex nature of these patients, long term
multiple health states and social conditions, resolution
perhaps is not the end goal but better quality of life and
/or mental wellbeing. Given the discrepancy between the
qualitative and quantitative literature on social prescrib-
ing, it could be that the standard health outcome mea-
sures do not capture the ‘non-health’ related outcomes
that reflect patient priorities and their perspective of their
own health and wellbeing [20]. Another point worth mak-
ing, is that interventions of this nature that require the
person’s active participation, engagement and commit-
ment might be ‘exposure’ or ‘dose’ dependent, at present
little is known about levels of patient exposure and inter-
vention fidelity that might affect outcome [21–24].
Implications for practice and research
Fidelity, making sure the service is delivered as it should
be can be difficult, the problems encountered in the im-
plementation of this social prescribing service have been
experienced by others and recommendations to optimise
service reported elsewhere [22]. From our evaluation
experience we would emphasise the following:
1. The social prescribing has a patient recognisable
identity
2. Coordinators are located in the GP surgery
3. Co-ordinators have non-clinical training, strong
interpersonal and motivational skills.
4. Assessment of outcomes are those important to
patients
36
Carnes et al. BMC Health Services Research (2017) 17:835
Further research is needed from the GPs point of view.
We propose that being able to share the needs of highly
dependent patients with a social prescribing service is
valuable in itself. Further work may need to be done to
establish the right measurement tools and the appropri-
ate timescale for data collection and a cluster rando-
mised controlled trial with a full health economic
analysis might provide more robust evidence for policy
makers and commissioners thinking of this type of
service provision. More work is also needed to ensure
optimal delivery of social interventions to understand
their potential effects. The concept of delivering social
interventions on the theoretical assumption that build-
ing social self-efficacy can relieve congestion in the GP
surgery may be misguided. Perhaps a better conception
is to give value to self-efficacy and social capital and
consider other mechanisms to reduce attendance at GP
surgery.
Conclusion
Changes in general health and well-being following re-
ferral were very limited. Comprehensive implementation
was difficult to optimise and possibly explains the poor
quantitative outcomes in comparison with the positive
narratives reported by those fully engaging with the ser-
vice. Although GP consultation rates fell, these may have
reflected regression to the mean rather than changes
related to the intervention. Social prescribing is still in
relative infancy and the health benefit of social and psy-
chological well-being as part of the overall health of a
nation strategy is still to be determined.
Abbreviations
A&E: Accident and emergency department; CCG: Clinical Commissioning
group; GP: General practitioner; HADS: Hospital anxiety and depressions
scale; NHS: National Health Service; UK: United Kingdom
Acknowledgments
We would to thank: Prof Heather Cage, Kate Homer, Gail Findlay, Kevin
Sheridan for their contribution to this study.
Funding
City and Hackney Clinical Commissioning Group, London, which is part of
the National Health Service UK. The funding body did not play a role in the
design, collection, analysis or interpretation of data.
Availability of data and materials
The dataset(s) supporting the conclusions of this article is available from the
corresponding author (Dawn Carnes d.carnes@qmul.ac.uk). An anonymised
data set from the questionnaire surveys can be made available to
researchers working in this field who have: a valid research question /
objective, can clearly state the purpose of use and who are in a position to
sign a QMUL and UEL standard data sharing agreement.
They must be able to ensure their institution can comply with the data
protection and security standards expected for handling and storing medical
data.
Authors’ contributions
DC and MB designed the study. DC wrote the first and managed the
production of subsequent drafts of the manuscript. Each author contributed
to their appropriate parts of the manuscript. DC, RS conducted the
TEXT 8
intervention arm data collection, MB, CF conducted the control arm
intervention, DC, MB, RS, CF conducted the evaluation interviews, SH, RM
conducted the search and did the analysis for GP consultation and
prescribing data, JT, GN conducted the analysis of the control data and the
linear regression models. PH advised the research team on general practice,
read and commented on all drafts of the manuscript. All authors read and
approved the final manuscript.
Ethics approval and consent to participate
This study was approved by the University of East London Ethics Committee
and is consistent with the Declaration of Helsinki.
Consent to participate in the study was gained from participants in the
questionnaire survey and the qualitative interviews. Participants received
information about the study and the research study team was available at
any point to clarify participant questions to ensure consent was informed.
Participants were ensured that all data would be anonymised and no
identifiable information would be published or reported. For the propensity
matched controls we using existing data that was de-identified and
de-linked to any other identifiable data before acquisition and analysis,
therefore individual consent was not required.
Consent for publication
There are no details or images requiring written informed consent in this
publication.
Competing interests
The authors declare that they have no competing interests.
Publisher’s Note
Springer Nature remains neutral with regard to jurisdictional claims in
published maps and institutional affiliations.
Author details
1
Queen Mary University of London, Barts and The London School of
Medicine and Dentistry, Centre for Primary Care and Public Health, 58 Turner
St, London E1 2AB, UK. 2University of Applied Sciences Western Switzerland,
School of Health Sciences, Route des Cliniques 15, 1700 Fribourg,
Switzerland. 3University of East London, Institute for Health and Human
Development, Water Lane, Stratford, London E15 4LZ, UK. 4City and Hackney
Clinical Commissioning Group, Queensbridge Group General Practice, 24
Holly Street, London E8 3XP, UK.
Received: 4 April 2017 Accepted: 6 December 2017
References
1. Waddell G. The back pain revolution. New York: Churchill Livingstone; 1999.
ISBN 0-443-06039-8
2. Thomson L, Camic PM, Chatterjee HJ. Social prescribing: a review of
community referral schemes. London: Universtiy College London,
Canterbury Christ Church University; 2015. Available at: http://www.
artsandminds.org.uk/wp-content/uploads/2015/10/Social_Prescribing_
Review_2015.pdf. Accessed 13.12.2017.
3. Sanchez A, Bully P, Martinez C, et al. Effectiveness of physical activity
promotion interventions in primary care: a review of reviews. Prev Med.
2014;76:S56–67.
4. Jepson RG, Harris FM, Platt S, et al. The effectiveness of interventions to
change six health behaviours: a review of reviews. BMC Public Health.
2010;10:538.
5. Global Burden of Disability Group (GDB), HALE collaborators. Global,
regional and national disability adjusted life years for 306 diseases and
injuries and health life expectancy for 188 countries 1990-2013: quantifying
the epidemiological transition. Lancet. 2015;386(10009):2118.
6. Wilson P, Booth A. Evidence to inform the commissioning of social
prescribing. University of York Centre for reviews and dissemination. 2015
(Feb). Available at: https://www.york.ac.uk/media/crd/Ev%20briefing_social_
prescribing.pdf. Accessed 13.12.17.
7. Kimberlee R, Jones M, Powell J. Measuring the economic impact of the
wellspring healthy living centre's social prescribing wellbeing programme
for low level mental health issues encountered by GP services. Project
Report. South West Forum, UK. 2013. Available from: http://www.
37
Received: 19 March 2018 Revised: 16 August 2018 Accepted: 19 August 2018

DOI: 10.1002/da.22867

RESEARCH ARTICLE TEXT 9

Prediction of major depressive disorder onset in college

students

David D. Ebert1 Claudia Buntrock1 Philippe Mortier2

Randy Auerbach3,4 Kiona K. Weisel1 Ronald C. Kessler5
Pim Cuijpers6 Jennifer G. Green7 Glenn Kiekens2 Matthew K. Nock8
Koen Demyttenaere3,4 Ronny Bruffaerts3,4

1 Department of Clinical Psychology and Psychotherapy, Friedrich–Alexander University Erlangen–Nüuremberg, Erlangen, Germany

2 Department of Neurosciences, Universitair Psychiatrisch Centrum KU Leuven, Belgium

3 Department of Psychiatry, Harvard Medical School, Boston, MA, USA

4 Center for Depression, Anxiety and Stress Research, McLean Hospital, Belmont, MA, USA

5 Department for Health Care Policy, Harvard Medical School, Boston, MA, USA

6 EMGO Institute for Health and Care Research, VU University Amsterdam, Amsterdam, the Netherlands

7 School of Education, Boston University, Boston, MA, USA

8 Department of Psychology, Harvard University, Cambridge, MA, USA

Correspondence
David Daniel Ebert, Clinical Psychology and
Psychotherapy, Friedrich–Alexander University
Erlangen–Nüremberg Nägelsbachstraße 25a,
90152 Erlangen, Germany.
Email: david.ebert@fau.de
Funding information
National Institute of Mental Health,
Grant/Award Number: NIMH;R01MH070884;
the Pfizer Foundation; Bristol-Myers
Squibb; Eli Lilly and Company; Ortho-McNeil
Pharmaceutical; GlaxoSmithKline; the US Public
Health Service, Grant/Award Numbers:
R13-MH066849, R01-MH069864, R01
DA016558; the Fogarty International Center,
Grant/Award Number: FIRCA R03-TW006481;
the Pan American Health Organization; John D.
and Catherine T. MacArthur Foundation
Background: Major depressive disorder (MDD) in college students is associated with substantial
burden.
Aims: To assess 1-year incidence of MDD among incoming freshmen and predictors of MDD-
incidence in a representative sample of students.
Method: Prospective cohort study of first-year college students (baseline: n = 2,519, 1-year
follow-up: n = 958)
Results: The incidence of MDD within the first year of college was 6.9% (SE = 0.8). The most
important individual-level predictors of onset were prior suicide plans and/or attempts (OR = 9.5).
The strongest population-level baseline predictors were history of childhood–adolescent trauma,
stressful experience in the past 12 months, parental psychopathology, and other 12-month mental
disorder. Multivariate cross-validated prediction (cross-validated AUC = 0.73) suggest that 36.1%
of incident MDD cases in a replication sample would occur among the 10% of students at highest
predicted risk (24.5% predicted incidence in this highest-risk subgroup).

Conclusions: Screening at college entrance is a promising strategy to identify students at risk of

MDD onset, which may improve the development and deployment of targeted preventive inter-
ventions.

KEYWORDS
depression, epidemiology, health services, mood disorders, suicide/self-harm

This is an open access article under the terms of the Creative Commons Attribution-NonCommercial-NoDerivs License, which permits use and distribution in any
medium, provided the original work is properly cited, the use is non-commercial and no modifications or adaptations are made.

c 2018 The Authors. Depression and Anxiety published by Wiley Periodicals, Inc.

Depress Anxiety. 2018;1–11. wileyonlinelibrary.com/journal/da

38

1 INTRODUCTION
Major depressive disorder (MDD) is one of the leading causes of dis-
ability worldwide (Vos et al., 2012) and also one of the most common
mental disorders among college students (Auerbach et al., 2016, 2018;
Farabaugh et al., 2012). Depression in college students is associated
with lower academic performance (Hysenbegasi, Hass, & Rowland,
2005), substantial role impairment (Alonso et al., 2018), increased
risk for college dropout (Arria et al., 2013), increased levels of anxi-
ety (Rawson, Bloomer, & Kendall, 1994), physical illness, decreased
physical activity, unsafe sexual behavior, increased levels of smoking
(Cranford, Eisenberg, & Serras, 2009), alcohol and drug dependency,
poorer quality of life, self-harming behaviors (Serras, Saules, Cranford,
& Eisenberg, 2010), and an increased risk of suicide (Eisenberg, Hunt, &
Speer, 2013). Together, this underscores the importance of developing
tools that identify students at greatest risk to develop MDD during
this critical period of development.
Early identification of students at risk for MDD may allow to effec-
tively deploy preventive interventions during college and thereby
reduce the incidence, prevalence, severity, duration, and consequences
of future depressive episodes as well as of other mental disorders (van
Zoonen et al., 2014). To support clinical decision-making and resource
allocation, universities need tools that accurately identify students at
high risk of developing depression in the near future.
Although there is a fair amount of studies that estimate the preva-
lence of MDD among college students, studies on the incidence of
MDD among representative incoming students are much scarcer.
Zivin, Eisenberg, Gollust, & Golberstein (2009) estimated the inci-
dence of depression in college students at approximately 5% per
year, but they did not identify risk parameters that predict MDD
incidence.
Several studies of risk indicators for MDD among college students
have been carried out, but most of them were limited by being based
on cross-sectional rather than prospective data and thus, cannot disen-
tangle the cause from the effect (Brandy, Penckofer, Solari-Twadell, &
Velsor-Friedrich, 2015; Leino & Kisch, 2005). Moreover all prior stud-
ies focused only on the coefficients of individual predictors rather than
developing composite risk measures (Mahmoud, Staten, Hall, & Lennie,
2012). Furthermore, individual-level effect sizes merely identify spe-
cific risk indicators for individuals. However, for prevention purposes,
it is important to select risk indicators that are associated with the
largest potential health gain at population level. Risk indicators that
will lead to the largest population health gain should not only be linked
to heightened risk of developing a depression on an individual-level,
but should also be prevalent in the target population. By estimating the
population attributable risk proportion (PARP), it is possible to identify
the number of cases that would not occur in the population, if a specific
risk indicator were eliminated.
The aims of the current study were to: (1) estimate the 1-year inci-
dence of MDD among college freshmen who were without MDD in the
12 months prior to college enrollment, and further, among these indi-
viduals to, (2) examine individual-level, and (3) population-level pre-
dictors of 1-year incidence of MDD. Finally, we aimed (4) to evaluate
the prediction accuracy of a baseline multivariate risk prediction model
TEXT 9 EBERT ET AL .
Key Points
• We investigated whether MDD during the first year of col-
lege can be predicted using baseline data.
• Strongest predictors on the individual level were prior sui-
cidal behaviors, but when taking also the prevalence of the
risk factor into account (OR ≥ 2/PARP ≥ 15%), preventive
approaches should focus on students with traumatic expe-
riences, a recent break-up with a romantic partner, serious
ongoing arguments with people close to them, and those
with recent stressful life events. A multivariate risk predic-
tion algorithm was able to predict the incidence of MDD,
with 36.1% of all cases occuring in the 10% of students at
the highest predicted risk.
• Screening at college entrance is promising to identify stu-
dents at high risk for MDD onset, which may improve
the development and deployment of targeted preventive
interventions.
aimed at identifying college freshmen at highest risk for MDD onset
over the subsequent 12 months.
2 METHOD
Longitudinal data were obtained from the Leuven College Surveys
(LCS), which are part of the WHO World Mental Health Surveys Inter-
national College Student project (WMH-ICS). Full procedures of the
LCS have been reported elsewhere (Mortier et al., 2017). In the aca-
demic year 2014–2015, all 4,130 Dutch-speaking incoming freshmen
aged 18 years or older were invited to participate in the baseline sur-
vey. The inclusion of the baseline sample consisted of three consec-
utive stages, with different refusal conversion strategies to increase
final response rates: In the first stage, the baseline survey was part of a
routine psychomedical check-up. All incoming freshmen (i.e., complete
enumeration or census sampling) were sent a standard invitation let-
ter for this check-up. This means that all units of the freshmen popu-
lation were eligible to complete the survey on a desktop computer in
the waiting room of the students’ mental health center. One reminder
letter for the medical check-up was sent by mail by the students’ men-
tal health center. In a second stage, nonrespondents to the first stage
were personally contacted using customized emails containing unique
electronic links to the survey. Two reminder emails were sent with a
1-week interval. By implementing this stage, we removed the physical
barrier between the initial nonrespondents and the mental health cen-
ter, since the survey could then be completed on a personal computer
at home. The third stage was identical to the second stage, but addi-
tionally included an incentive, that is, a raffle for store credit coupons.
Two reminder emails were sent with a 1-week interval. When includ-
ing the reminder (e)mails used in each stage, the maximum amount of
contacts was set to eight attempts. A total of 2,519 students completed
39
EBERT ET AL .
the baseline survey, equivalent to a baseline response rate (RR) of 61%.
Students were contacted for a follow-up survey 12 months after the
baseline assessment, using a similar sampling design to the one used at
baseline. Personalized emails with unique electronic links to the survey
were sent, including up to seven reminder emails. Beginning with the
fifth reminder email, emphasis was put on a store credit coupon raf-
fle. The survey was delivered fully digital and all survey sections were
presented in a precise predetermined order.
Of the students who responded at baseline, 958 (38%) responded
to the follow-up survey (57.5% response rate after adjusting for
nonparticipation due to college dropout). Earlier reports of the
WMH-ICS initiative have shown that lifetime- (22.4%, 95%CI: 21.2–
23.7) and 12-month mental disorders (19.1%, 95%CI: 17.9–20.2) are
somewhat lower in the LCS sample, than average prevalence rates
of the countries included in the first prevalence estimates assessed
in eight participating WMH-ICS countries (Auerbach et al., 2018).
The study's protocol was approved by the University Hospital Leuven
Biomedical Ethical Board (B322201215611). Informed consent was
obtained from all subjects who participated in the study. Students who
reported any past year STB or nonsuicidal self-injury were presented
with links to local mental health resources.
3 MEASURES
The WMH-ICS survey instrument includes multiple screening instru-
ments measuring a wide range of mental health outcomes. The
included assessments are described below.
3.1 Socio-demographic variables
Socio-demographic characteristics of freshmen were obtained from
the KU Leuven student administration office, including gender, age,
nationality, parent financial situation, parent education, familial
composition, university group membership, and secondary school
educational type.
3.2 Parental psychopathology and traumatic
experiences in childhood–adolescence
Traumatic experiences in childhood and adolescence (i.e., prior to the
age of 17) were assessed using 19 items adapted from the Composite
International Diagnostic Interview (CIDI) (Kessler & Üstün, 2004),
the Adverse Childhood Experience Scale (Felitti et al., 1998), and
the Bully Survey (Swearer & Cary, 2003). Items assessed parental
psychopathology (i.e., any serious mental or emotional problems,
substance abuse, suicidal thoughts and behaviors or death by suicide,
criminal activities or interpersonal violence), physical abuse, emotional
abuse, sexual abuse, neglect, bully victimization (i.e., direct verbal or
physical bullying, indirect bullying or cyberbullying), and dating vio-
lence. Items were rated on a 5-point Likert scale (“never,” “rarely,”
“sometimes,” “often,” and “very often”). Confirmatory factor analysis
using our data showed a strong unidimensional structure of responses
(Comparative Fit Index = 0.991; Tucker–Lewis = 0.988; root mean
square of approximation = 0.019). To obtain dichotomously coded
TEXT 9
variables, “rarely” was used for all items, except bully victimization
which had a cut-off of “sometimes” (Nansel et al., 2001).
3.3 Stressful events experienced in the past
12 months
Stressful events were assessed using 12 items taken from well-
validated screeners (Bray & Hourani, 2007; Brugha & Cragg, 1990;
Vogt, Proctor, King, King, & Vasterling, 2008). Items assessed life-
threatening illness, accidents or death of a family member or close
friend, interpersonal events (i.e., break-up with a romantic partner,
serious betrayal by someone else than partner), physical or sexual
assault, and legal problems (i.e., time spent in jail).
3.4 Twelve-month mental disorder
The CIDI Screening Scales (CIDI-SC) (Kessler & Üstün, 2004; Kessler
et al., 2013) were used to assess two mood disorders (major depressive
disorder and [hypo]manic episodes), two anxiety disorders (general-
ized anxiety disorder and panic disorder), and drug use disorder (abuse
or dependence either on cannabis, cocaine, or any other street drug,
or on a prescription drug either used without a prescription or used
more than prescribed to get high, buzzed, or numbed out). The CIDI-SC
consists of a range of DSM-IV-based screening scales containing well-
validated self-report items that were developed to deliver reliable esti-
mates of mental disorder diagnoses. Concordance with blinded clinical
diagnoses in clinical reappraisal studies were in the range AUC = 0.70–
0.78 (Kessler et al., 2013). Information on lifetime and 12-month MDD
was assessed by asking respondents about age, age of onset of MDD,
and most recent age with MDD.
The Alcohol Use Disorders Identification Test (AUDIT) (Saunders,
Aasland, Babor, De la Fuente, & Grant, 1993) is a 10-item screening
tool developed by the WHO to determine alcohol consumption, risk
for alcohol dependence, and alcohol-related harm. The AUDIT is
well-validated in college students (DeMartini & Carey, 2012). Consis-
tent with prior recommendations (Babor, Higgins-Biddle, Saunders,
& Monteiro, 2001), the AUDIT was used to identify students with
12-month “risky or hazardous drinking” and students with 12-month
“risk for alcohol dependence.”
A modified version of the Columbia Suicidal Severity Rating Scale
(Posner et al., 2011) was used to assess 12-month suicidal thoughts
and behaviors (STB), including suicidal ideation, suicide plans, and sui-
cide attempts. After the assessment of outcomes with suicidal intent,
12-month nonsuicidal self-injury (NSSI) also was assessed (Nock,
Holmberg, Photos, & Michel, 2007).
3.4.1 Analyses
All analyses were performed with SAS version 9.4, Mplus version 7.4,
and R version 3.3.2. Nonresponse propensity weights (Rosenbaum
& Rubin, 1983) were used to adjust for possible bias caused by final
nonresponse. Multiple imputation by chained equations (van Buuren,
2007) was used to adjust for survey attrition and within-survey
item nonresponse. All analyses were conducted in the subsample
without 12-month MDD at baseline. Lifetime MDD was added as
40

a covariate in all analyses. Incidence was reported as a weighted
proportion (%) and associated standard error (SE). Logistic regres-
sion analysis was used to test the individual-level strength of the
association between baseline risk indicators and the onset of MDD.
All analyses were adjusted for lifetime history of MDD. Measures of
association were reported as odds ratios (OR) and associated 95%
confidence intervals (95%CI). Firth's penalised likelihood estimation
was applied to avoid overfitting and inconsistent estimators due to
data sparseness (Firth, 1993). The population-level impact of baseline
risk indicators on the onset of MDD was estimated by population
attributable risk proportions (PARPs) (Krysinska & Martin, 2009)
using the predicted probabilities resulting from the logistic regression
equations as a summary predictor (Nock, Borges, & Ono, 2012).
PARPs could be interpreted as the proportion of cases that would
be prevented if the targeted risk indicator were fully blocked in the
population.
Finally, a multivariate model was estimated, including socio-
demographic variables, childhood–adolescent traumatic events,
12-month stressful experiences, 12-month risk for mental disorders,
and lifetime history of MDD. Nagelkerkes pseudo-R2 was used as
a measure of total effect size. Based on the multivariate equation,
individual-level predicted probabilities were created, receiver oper-
ating characteristic (ROC) curves were generated, and to evaluate
prediction accuracy area under the curve (AUC) values were cal-
culated. Predicted probabilities were then discretized into deciles
(10 groups of equal size ordered by percentiles) and cross-classified
with observed cases to visualize the concentration of risk associated
with high composite predicted probabilities. We defined sensitivity
as the proportion of cases found among predefined proportions
of respondents (e.g., 10%) with the highest predicted probabilities.
Positive predictive value (PPV) was defined as the probability of
actually developing an MDD when estimated among the 10% of
respondents with the highest predicted probabilities. We used the
method of leave-one-out cross-validation (Efron & Gong, 1983) to
correct for the over-estimation of prediction accuracy when both
estimating and evaluating model fit in a single sample. Although
leave-one-out cross-validation shows a downward bias of true predic-
tion accuracy compared to other cross-validation techniques (Smith,
Seaman, Wood, Royston, & White, 2014), this method was preferred
as it allows for the straightforward cross-validation of multiple
imputed datasets.
4 RESULTS
4.1 Sample description
Descriptive characteristics of the sample can be found in Table 1. The
majority of the sample was female (54.5%), only few participants (6%)
were of non-Belgian nationality and 15.3% of the students indicated
that they were raised in households, in which their parents financial
situation was difficult. Parental education was high for both parents
for the majority of the students (63.4%), only few students (14.8%)
indicated that neither of their parents had a high education level. As
TEXT 9 EBERT ET AL .
can be seen in Table 3, the burden of mental disorders in the sample
was quite high. Approximately, one-third of all students experienced
at least one 12-month disorder (35.2%), and 28.6% reported exactly
one, 5.3% exactly two, and 1.3% three or more 12-month mental dis-
orders. Approximately, half of the sample (52.5%) reported at least
one traumatic experience before the age of 17; with 28.4% experienc-
ing parental psychopathology as the most reported type of traumatic
experience, followed by bully victimization (25.4%). Every second stu-
dent also reported at least one 12-month stressful life event (52.5%,
Table 2).
4.2 Twelve-month incidence of MDD during college
freshman year
Twelve-month prevalence of MDD at baseline was 11.0% (95%CI:
10.0–12.0%, n = 277/2,519). Among the remaining cases without 12-
month MDD (n = 2,242), lifetime prevalence of MDD was only 3.5%
(95%CI: 2.9–4.2%; n = 79). All analyses were restricted to the 2,242
students who had no history of MDD during the 12 months prior to the
baseline survey. The incidence of depressive disorder in the first year
after college matriculation was estimated at 6.9% (95%CI: 5.3–8.4%;
n = 154/2,242). Most of these cases were first-onset incidence cases
(94.15%; n = 145/154).
4.3 Individual- and population-level predictors of
12-month MDD incidence
Models adjusting for lifetime MDD at baseline (Tables 1–3) revealed
the following key findings. First, socio-demographic variables did not
significantly predict the onset of MDD in students in their first year
of college. Second, the most important predictors of MDD onset at
the individual level were 12-month suicide plans and/or attempts
(OR = 9.55), sexual abuse prior to the age of 17 (OR = 8.01), three or
more 12-month mental disorders other than MDD (OR = 6.27), three
or more 12-month stressful events (OR = 4.29), and 12-month gener-
alized anxiety disorder (OR = 4.11). However, the impact of these pre-
dictors at population level were all small (PARP < 12%) due to the low
prevalence of these predictors.
Third, large proportions of MDD onset were attributable to any 12-
month mental disorder at baseline (other than MDD, PARP = 25.6%),
any childhood–adolescent trauma (PARP = 31.5%), and any stressful
experience in the past year (PARP = 34.5%). Specific associations
regarding stressful experiences included: break-up with a romantic
partner, romantic partner cheated, serious betrayal by someone else
than partner, and serious ongoing arguments or break-up with a
friend or family member (median OR = 2.7; median PARP = 13.5%).
In relation to any childhood–adolescent trauma, specifically parental
psychopathology, emotional abuse, sexual abuse, and dating violence
(median OR = 2.7; median PARP = 12.5%) were significantly associ-
ated with MD. With regard to being at risk for comorbid mental health
issues, specific associations included generalized anxiety disorder,
nonsuicidal self-injury, suicidal ideation, and suicide plans and/or
attempts (median OR = 3.9; median PARP = 6.7%).
41
EBERT ET AL .
TEXT 9
TA B L E 1 Socio-demographic Variables as Baseline Predictors for Depression Onset during Follow-up

Bivariate Modela
Prevalence Subsample no. 12-m MDD
n (w) % (w) (SE) OR 95%CI PARP (%)
I. Socio-demographic variables
Being male 1,021 45.5 0.9 0.68 (0.41–1.12) −14.4
Age > 18 years 495 22.1 0.8 1.40 (0.83–2.37) 7.0
Non-Belgian nationality 134 6.0 0.4 1.48 (0.63–3.45) 3.2
Parents’ financial situation difficult 344 15.3 0.7 1.05 (0.53–2.07) 1.0
Parental educationb
Both parents high 1,422 63.4 1.0 (ref) – –
Only one parent high 487 21.7 0.8 0.95 (0.54–1.68) −0.8
None of parents high 333 14.8 0.7 1.03 (0.51–2.10) 0.7
c
Nonintact familial composition 472 21.0 0.8 1.23 (0.68–2.20) 4.3
College-related socio-demographics
University Group membership
Human Sciences 1,171 52.2 0.9 (ref) – –
Science & Technology 623 27.8 0.8 0.61 (0.35–1.07) −12.7
Biomedical Sciences 448 20.0 0.7 0.61 (0.31–1.17) −9.3
Non-GSE pre-educational level 131 5.8 0.4 1.33 (0.49–3.57) 1.9

Note. Significant odds ratios/PARPs are shown in bold (𝛼 = 0.05); OR = odds ratio; PARP = population attributable risk proportion; GSE = general secondary
education.
a
The bivariate associations are based on a separate model for each row, with the variable in the row as the only predictor in the model, adjusted for lifetime
MDD at baseline.
b
High degree of parental education defined as holding a college bachelor degree or more.
c
Nonintact familial composition defined as parents being divorced or separated.

Fourth, a positive dose–response relationship was found within 5 DISCUSSION

each domain, with MDD risk among students who had three or more
risk indicators substantially elevated both at the individual level (ORs
between 3.4 and 6.3) and at the population level (PARPs between 4.0
and 16.2%). Finally, when considering both individual- and population-
level effects, the most important risk indicators (i.e., OR ≥ 2 and PARP
≥ 15%) were any traumatic experience prior to the age of 17, break-up
with a romantic partner in the past year, serious ongoing arguments or
break-up with a friend or family member in the past year and three or
more stressful life events in the last 12 months.
4.4 Multivariate model for MDD onset during
freshman year
The total effect size (Nagelkerke pseudo-R2) of risk indicators was
0.23. The prediction model had a reasonable performance with a cross-
validated AUC of 0.73 (SE = 0.04). The 10% of students at highest
predicted risk for subsequent onset of MDD within the first 12 months
after college matriculation included 36.1% (SE = 6.1) of all observed
MDD cases (Table 4). The probability of MDD onset in this 10% of
respondents was 24.7% (SE = 4.9). The only significant predictors in
the final model, when adjusted for all other risk domains, were suicidal
ideation (OR = 2.88; 95%CI = 1.10–7.56; PARP = 4.4%) and suicide
plans and/or attempts (OR = 6.77; 95%CI = 1.55–29.62; PARP = 3.9%).
A full overview of the multivariate estimates can be found in the
supplementary materials.
5.1 Main findings
This prospective study examined the onset of MDD in a large represen-
tative sample of college students. In the first year of college, the inci-
dence of MDD was estimated at 6.9%. Among the 10% of students with
the highest predicted risk of MDD onset based on our model, approxi-
mately one out of four developed MDD. Suicidal plans and/or attempts
were most strongly associated with MDD onset at the individual
level. The largest population-level effects, however, were found for
any 12-month mental disorder at baseline (PARP = 25.6%), a history
of any childhood–adolescent trauma (PARP = 31.5%), and stressful
experiences in the past 12 months (PARP = 34.5%).
5.2 Limitations
Several limitations are noteworthy. First, response rates were moder-
ate (61.0% at baseline; 57.5% at follow-up). However, these response
rates compare favourably to those achieved in other large-scale
prospective college student surveys (39–44%) (Eisenberg et al.,
2013; Paul, Tsypes, Eidlitz, Ernhout, & Whitlock, 2015). In addition,
state-of-the-art missing data techniques were applied to increase
the representativeness of the findings. Nonetheless it is possible that
systematic nonresponse might have biased results. Second, baseline
risk for mental disorders was not assessed by diagnostic interviews

42
 TEXT 9 EBERT ET AL .

TA B L E 2 Childhood–Adolescent Traumatic Experiences and 12-Month Stressful Experiences as Baseline Predictors for Depression Onset
during Follow-up

Bivariate Modela
Prevalence Subsample no. 12-m MDD
n (w) % (w) (SE) OR 95%CI PARP (%)
II. Twelve-month stressful experiences
Life-threatening illness or 481 21.5 1.1 1.18 (0.60–2.34) 3.9
injury of a friend or family
member
Death of a friend or family 437 19.5 1.0 1.07 (0.52–2.20) 1.7
member
Break-up with a romantic 394 17.7 1.0 2.63 (1.37–5.09) 20.3
partner
Romantic partner cheated 87 3.9 0.5 3.81 (1.11–13.07) 8.5
Serious betrayal someone else 210 9.4 0.7 2.35 (1.07–5.17) 10.4
than partner
Serious ongoing arguments or 284 12.7 0.8 2.78 (1.46–5.31) 16.7
break-up with friend or
family member
Life-threatening accident 22 1.0 0.3 2.60 (0.21–32.11) 1.9
Seriously physically assaulted 65 2.9 0.4 1.22 (0.18–8.09) 1.2
Sexually assaulted or raped 8 0.4 0.1 2.26 (0.13–38.25) 0.6
Any serious legal problem 44 1.9 0.3 2.20 (0.31–15.73) 2.6
Any stressful event 1,177 52.5 1.2 2.12 (1.20–3.75) 34.5
Number of stressful experiences
0 1,065 47.5 1.2 (ref) – –
1 620 27.6 1.1 1.53 (0.83–2.82) 8.8
2 355 15.9 0.9 2.04 (1.01–4.13) 9.8
3+ 202 9.0 0.7 4.29 (1.85–9.96) 16.2
F-test (p-value)b F = 2.69
(0.046)
III. Traumatic experiences (≤ age 17)
Parental psychopathology 637 28.4 1.1 1.96 (1.13–3.39) 19.7
Physical abuse 96 4.3 0.5 2.01 (0.74–5.45) 4.0
Emotional abuse 329 14.7 0.8 2.51 (1.34–4.71) 16.4
Sexual abuse 18 0.8 0.2 8.01 (1.64–39.06) 3.6
Neglect 116 5.2 0.5 1.44 (0.51–4.05) 2.4
Bully victimization 570 25.4 1.1 1.19 (0.68–2.09) 4.5
Dating violence 115 5.1 0.5 2.94 (1.03–8.40) 8.5
Any traumatic experience 1,141 50.9 1.2 2.00 (1.17–3.43) 31.5
Number of traumatic experiences
0 1,099 49.1 1.2 (ref) – –
1 688 30.7 1.1 1.46 (0.80–2.66) 9.0
2 272 12.1 0.8 2.57 (1.28–5.15) 11.4
3+ 181 8.1 0.7 3.43 (1.52–7.74) 11.7
F-test (p-value)b F = 3.04
(0.029)
Note. Significant odds ratios/PARPs are shown in bold (𝛼 = 0.05); OR = odds ratio; PARP = population attributable risk proportion.
a
The bivariate associations are based on a separate model for each row, with the variable in the row as the only predictor in the model, adjusted for lifetime
MDD at baseline.
b Cochran–Armitage trend test. The F-test evaluates significance (𝛼 = 0.05) of 200 pooled Cochran–Armitage 𝜒 2 (3) linear trend tests.

43
EBERT ET AL .
TEXT 9
TA B L E 3 Twelve-Month Mental Disorders as Baseline Predictors for Depression Onset during Follow-up

Bivariate Modela
Prevalence Subsample no. 12-m MDD
n (w) % (w) (SE) OR 95%CI PARP (%)
IV. Twelve-month mental disorders
Generalized anxiety disorder 70 3.1 0.3 4.11 (1.75–9.70) 7.5
Panic disorder 23 1.0 0.2 0.94 (0.07–12.05) 0.2
Broad mania 22 1.0 0.2 2.75 (0.58–12.98) 1.6
Low risk for alcohol use disorder 1,660 74.0 0.8 (ref) – –
Risky or hazardous drinking 505 22.5 0.8 1.17 (0.69–1.96) 3.3
Risk for alcohol dependence 77 3.4 0.4 1.34 (0.39–4.63) 1.2
Drug abuse/dependence 25 1.1 0.2 1.93 (0.39–9.41) 1.0
Nonsuicidal self-injury 161 7.2 0.5 2.53 (1.28–5.02) 8.7
No STB 2,154 96.1 0.4 (ref) – –
Suicidal ideation 64 2.9 0.3 3.76 (1.65–8.57) 5.9
Suicide plans and/or attempts 24 1.1 0.2 9.55 (2.96–30.78) 5.0
Any mental disorder 790 35.2 0.9 2.12 (1.34–3.36) 25.6
Number of mental disorder
0 1,452 64.8 0.9 (ref) – –
1 641 28.6 0.9 1.76 (1.09–2.86) 14.3
2 119 5.3 0.4 3.34 (1.55–7.19) 7.8
3+ 30 1.3 0.2 6.27 (1.85–21.33) 4.0
F-test (p-value)c F = 4.16
(0.006)
Note. Significant odds ratios/PARPs are shown in bold (𝛼 = 0.05); STB = suicidal thoughts and behaviors; OR = odds ratio; PARP = population attributable
risk proportion.
a The bivariate associations are based on a separate model for each row, with the variable in the row as the only predictor in the model, adjusted for lifetime

MDD at baseline.
b Cochran–Armitage trend test. The F-test evaluates significance (𝛼 = 0.05) of 200 pooled Cochran–Armitage 𝜒 2 (3) linear trend tests.

but with self-report measures and a categorical cut-off scoring system.
The latter measures were well-validated screening scales used in prior
general population surveys that have shown high concordance with
with blinded clinical diagnoses in clinical reappraisal studies (Kessler
et al., 2010). However, it remains unknown whether screening scale
performance is different among college students. Although we plan to
carry out clinical reappraisal studies to address this limitation in future
iterations of the WMH college surveys, this has not yet been done
and caution is consequently needed in interpreting results regarding
prevalence estimates. Third, the survey was conducted among fresh-
men in one Belgian college. The findings might not generalize to college
students from other universities in different countries or cultures.
Finally, although we included a large set of known risk indicators for
MDD onset, some important risk indicators were not assessed, such
as subsyndromal depression, chronic somatic conditions, personality
traits/disorders, psychotic experiences/disorders, poor self-perceived
health, low emotion regulation skills, low self-esteem, low resilience,
and neuroticism (Berking, Wirtz, Svaldi, & Hofmann, 2014; Cole &
Dendukuri, 2003; Ebert, Hopfinger, & Berking, 2017; Korten, Comijs,
Lamers, & Penninx, 2012; Pelkonen, Marttunen, Kaprio, Huurre, &
Aro, 2008; Wild et al., 2016). As a result, the strength of the composite
risk index found here should be considered a lower bound estimate
compared to the estimate that might be obtained in future research
that includes additional predictors. A related limitation is that we
used conventional research analysis methods to develop the risk
model. It is likely that we will be able to improve on this performance
in planned cross-national analyses using machine learning methods
(Kessler et al., 2016, 2017). Finally, we did not assess serious life
events during follow-up. Therefore, we do not know which MDD
incidence cases are due to baseline vulnerability and which due to
exposure to random traumas that could not be predicted at baseline
(e.g., sexual assault, death of a parent). Such information would not
only be important to inform about strategies to improve prediction
accuracy of the algorithm, but also relevant for the development of
appropriate prevention strategies. This should be explored in future
studies.
5.3 Implications for clinical practice and future
research
Our study has relevant implications for clinical practice and future
research. First, to the best of our knowledge, this study is among the
first that prospectively estimated the 1-year incidence proportion of
MDD in students during their first year of college. The reported inci-
dence proportion is somewhat higher than the estimated incidence of
MDD among college students based on the World Health Organization

44

TA B L E 4 Concentration of Risk of Depression Cases in Different
Proportions of Incoming Freshmen at Highest Predicted Risk based on
a Multivariate Modela Including all Risk Factors
Depression Onset
% at Highest
Predicted Risk Sensitivity (%[SE])b PPV (%[SE])c
100 100.0 (0.0) 6.9 (0.8)
90 96.0 (2.4) 7.3 (0.9)
80 91.8 (3.4) 7.9 (1.0)
70 87.4 (4.1) 8.6 (1.2)
60 82.7 (4.8) 9.5 (1.3)
50 77.2 (5.2) 10.6 (1.5)
40 71.0 (5.9) 12.2 (1.8)
30 63.1 (6.3) 14.4 (2.3)
20 52.4 (6.5) 17.9 (3.0)
10 36.1 (6.1) 24.7 (4.9)
a See the model in the supplementary materials covering multivariate model
construction (Supplementary Tables 1 and 2). Model-based AUC values
were 0.78 [SE = 0.03] for depression onset. Cross-validated AUC values
were 0.73 [SE = 0.04].
b Sensitivity = proportion of depression cases found among the row % of
respondents at highest predicted risk, based on cross-validated predicted
probabilities.
c
Positive predictive value (PPV) = probability of effectively developing a
depression when being among the row % at highest predicted risk, based
on cross-validated predicted probabilities.
(WHO) World Mental Health Surveys (Auerbach et al., 2016). Differ-
ences may be explained by geographical or methodological differences
(i.e., adjustment for college attriters or the use of retrospective designs
in the WHO surveys). Our data suggest that the first year in college
constitutes a risk period for the onset of MDD. In fact, the vast majority
of observed MDD cases were incidence cases (94.8%), thus this period
in life seems to be an opportune point in time to intervene preventively.
Second, our study further adds to the cumulating evidence that the
development of risk-prediction for psychiatric disorders is feasible
(Bernardini et al., 2017) and provides evidence that a multivariate
prediction model can be a useful tool to accurately predict the
onset of MDD during college. Prediction accuracy (AUC = 0.73) was
comparable to the few prediction algorithms that have been evaluated
for depression within a general population (AUC = 0.71) (Nigatu, Liu,
& Wang, 2016) and primary care samples (AUC = 0.82) (Bellon et al.,
2011) and are also comparable to other fields of medicine (Karnes
et al., 2017; ten Haaf et al., 2017). However, to achieve optimal perfor-
mance, recalibration of models is needed prior to applying the models
to a new population. As predictors included in the model contribute
to a model's calibration capacity, it is important to develop target
group-specific prediction algorithms because predictors for the risk
of MDD onset and their predicted values may differ among different
population segments (i.e., college students). The risk prediction algo-
rithm could be used to predict future MDD among incoming freshmen.
More research on the validation of such specific risk prediction models
is warranted; nevertheless, it is a promising methodology and enables
interesting opportunities for the development of individualized
approaches for MDD in emerging adults. Data on self-reported risk
factors could easily be collected by means of regular student surveys.
TEXT 9 EBERT ET AL .
The assigned predicted probabilities could then be used as a way to
delineate those at highest risk for onset of MDD in the following year.
However, although risk-prediction algorithms might be of high value
for detecting students at risk, for developing mental health problems,
it should be noted that relying only on procedures based on students
self-reports might be not sufficient to detect students at risk, and other
measures such as staff training and awareness campaigns should not
be neglected. Students considered to be at high risk could be offered
preventive interventions, for example delivered through the internet
(Buntrock et al., 2016, 2017; Ebert et al., 2018; Harrer et al., 2018).
Based on our model, over one third of MDD cases will occur in the 10%
of students at highest predicted risk. However, this does not imply that
students at lower risk do not warrant preventive interventions. More
research is needed to obtain information on the needs of students
who are associated with different risk levels and which interventions
work best at varying levels. Due to high comorbidity rates between
emotional disorders (Beekman et al., 2000) and overlapping risk
factors (de Graaf, Bijl, Smit, Vollebergh, & Spijker, 2002), such studies
should also explore relative advantages of disorder versus trans-
diagnostic and individual tailored preventive interventions (Weisel
et al., 2018). In addition, clinical outcome and cost-effectiveness
research based on varying risk thresholds should be conducted so
that intervention decisions derived from the prediction model are
evidence-based.
Third, the population-level estimates offered relevant insights into
the design of future interventions. Based on individual-level effect
sizes, one could argue preventive interventions should focus on stu-
dents who have been either sexually abused or who had suicide plans
or attempts (OR > 8). However, the impact of these factors on a pop-
ulation level overall was very low (PARP < 5%) due to low prevalence.
In contrast, targeting students who experience any childhood–
adolescent trauma, such as emotional abuse, could have a beneficiary
effect for about one third of subsequent depression onsets. Also, the
incidence of depression among these students designated to be at high
risk (24.7%) is sufficiently high that the cost-effectiveness of a preven-
tive intervention has a reasonable chance of being within an actionable
range. Likewise, targeting students whose parents have a mental disor-
der could potentially reduce one fifth of depression cases (19.7%). Tar-
geting students at college entry who broke recently up with a romantic
partner, could have preventive effects for one fifth of subsequent MDD
cases. In general, offering such specific interventions, subsequent to a
screening at college student entrance, might result in a more develop-
mental approach to the prevention of depression during adolescence
and emerging adulthood which may ultimately help decrease the large
burden associated with this disorder in young people.
Finally, prevalence estimates of STBs were, potentially due to the
exclusion of MDD baseline cases in the present study, somewhat lower
than recent estimates of STB cross-national prevalence rates (Mortier
et al., 2018). These low prevalence rates lead, as stated above, to a com-
parable low proportion of MDD cases in the population attributable to
STBs. However, due to the disabling nature of STBs and their adverse
consequences, there nevertheless is a clear need for interventions
that are specifically designed to reach this underreached population
(Mortier et al., 2018) and help affected students to cope effectively.
45
EBERT ET AL .
ACKNOWLEDGMENTS
The Leuven College Survey was carried out in conjunction with the
World Health Organization World Mental Health (WMH) survey initia-
tive and is a part of the World Mental Health International College Stu-
dent project. The WMH survey is supported by the National Institute
of Mental Health (NIMH; R01MH070884), the John D. and Catherine
T. MacArthur Foundation, the Pfizer Foundation, the US Public Health
Service (R13-MH066849, R01-MH069864, and R01 DA016558),
the Fogarty International Center (FIRCA R03-TW006481), the
Pan American Health Organization, Eli Lilly and Company, Ortho-
McNeil Pharmaceutical, GlaxoSmithKline, and Bristol-Myers Squibb.
A complete list of all within-country and cross-national WMH pub-
lications can be found at http://www.hcp.med.harvard.edu/wmh/. In
Belgium specifically, these activities were supported by the Belgian
Fund for Scientific Research (11N0514N/11N0516N/1114717N), the
King Baudouin Foundation (2014-J2140150-102905), and Eli Lilly
(IIT-H6U-BX-I002). In Germany, the preparation of this paper was
funded by BARMER.
DECLARATION OF INTEREST
None.
ORCID
David D. Ebert https://orcid.org/0000-0001-6820-0146
Claudia Buntrock https://orcid.org/0000-0002-4974-5455
Philippe Mortier https://orcid.org/0000-0003-2113-6241
Randy Auerbach https://orcid.org/0000-0003-2319-4744
Kiona K. Weisel https://orcid.org/0000-0003-1800-0044
Ronald C. Kessler https://orcid.org/0000-0003-4831-2305
Pim Cuijpers https://orcid.org/0000-0001-5497-2743
Glenn Kiekens https://orcid.org/0000-0001-8747-3385
Ronny Bruffaerts https://orcid.org/0000-0002-0330-3694
REFERENCES
Alonso, J., Mortier, P., Auerbach, R. P., Bruffaerts, R., Vilagut, G., Cuijpers, P.,
… Kessler, R. C. (2018). Severe role impairment associated with men-
tal disorders: Results of the WHO World Mental Health Surveys Inter-
national College Student Project. Depression and Anxiety, 35, 802–814.
https://doi.org/10.1002/da.22778
Arria, A. M., Caldeira, K. M., Vincent, K. B., Winick, E. R., Baron, R. A., &
O'Grady, K. E. (2013). Discontinuous college enrollment: Associations
with substance use and mental health. Psychiatric Services, 64, 165–172.
https://doi.org/10.1176/appi.ps.201200106
Auerbach, R. P., Alonso, J., Axinn, W. G., Cuijpers, P., Ebert, D. D.,
Green, J. G., … Bruffaerts, R. (2016). Mental disorders among
college students in the World Health Organization World Mental
Health Surveys. Psychological Medicine, 46, 2955–2970. https://doi.org/
10.1017/S0033291716001665
Auerbach, R. P., Mortier, P., Bruffaerts, R., Alonso, J., Benjet, C., Cuijpers,
P., … & Murray, E. (2018). WHO World Mental Health Surveys Inter-
national College Student Project: Prevalence and predictors of mental
disorders. Journal of Abnormal Psychology, 127(7), 623–638.
Babor, T., Higgins-Biddle, J. C., Saunders, J. B., & Monteiro, M. G. (2001). The
alcohol use disorders identification test: Guidelines for use in primary
care. Geneva, Switzerland: World Health Organization.
TEXT 9
Beekman, A. T., de Beurs, E., van Balkom, A. J., Deeg, D. J., van Dyck, R., & van
Tilburg, W. (2000). Anxiety and depression in later life: Co-occurrence
and communality of risk factors. The American Journal of Psychiatry, 157,
89–95. https://doi.org/10.1176/ajp.157.1.89
Bellón, J. A., de Dios Luna, J., King, M., Moreno-Kustner, B., Nazareth, I.,
Monton-Franco, C., … Torres-Gonzalez, F. (2011). Predicting the onset
of major depression in primary care: International validation of a risk
prediction algorithm from Spain. Psychological Medicine, 41, 2075–2088.
https://doi.org/10.1017/s0033291711000468
Berking, M., Wirtz, C. M., Svaldi, J., & Hofmann, S. G. (2014). Emo-
tion regulation predicts symptoms of depression over five years.
Behaviour Research and Therapy, 57, 13–20. https://doi.org/10.1016/
j.brat.2014.03.003
Bernardini, F., Attademo, L., Cleary, S. D., Luther, C., Shim, R. S., Quar-
tesan, R., & Compton, M. T. (2017). Risk prediction models in psy-
chiatry. The Journal of Clinical Psychiatry, 78, 572–583. https://doi.org/
10.4088/JCP.15r10003
Brandy, J. M., Penckofer, S., Solari-Twadell, P. A., & Velsor-Friedrich, B.
(2015). Factors predictive of depression in first-year college students.
Journal of Psychosocial Nursing and Mental Health Services, 53, 38–44.
https://doi.org/10.3928/02793695-20150126-03
Bray, R. M., & Hourani, L. L. (2007). Substance use trends among active
duty military personnel: Findings from the United States Department of
Defense Health Related Behavior Surveys, 1980–2005. Addiction, 102,
1092–1101. https://doi.org/10.1111/j.1360-0443.2007.01841.x
Brugha, T. S., & Cragg, D. (1990). The list of threatening experiences:
The reliability and validity of a brief life events questionnaire.
Acta Psychiatrica Scandinavica, 82, 77–81. https://doi.org/10.1111/
j.1600-0447.1990.tb01360.x
Buntrock, C., Berking, M., Smit, F., Lehr, D., Nobis, S., Riper, H., … Ebert,
D. (2017). Preventing depression in adults with subthreshold depres-
sion: Health-economic evaluation alongside a pragmatic randomized
controlled trial of a web-based intervention. Journal of Medical Internet
Research, 19, e5. https://doi.org/10.2196/jmir.6587
Buntrock, C., Ebert, D. D., Lehr, D., Smit, F., Riper, H., Berking, M., & Cuijpers,
P. (2016). Effect of a web-based guided self-help intervention for pre-
vention of major depression in adults with subthreshold depression a
randomized clinical trial. JAMA - Journal of the American Medical Associa-
tion, 315, 1854–1863. https://doi.org/10.1001/jama.2016.4326
Cole, M. G., & Dendukuri, N. (2003). Risk factors for depression among
elderly community subjects: A systematic review and meta-analysis.
American Journal of Psychiatry, 160, 1147–1156. https://doi.org/
10.1176/appi.ajp.160.6.1147
Cranford, J. A., Eisenberg, D., & Serras, A. M. (2009). Substance use behav-
iors, mental health problems, and use of mental health services in a
probability sample of college students. Addictive Behaviors, 34, 134–
145. https://doi.org/10.1016/j.addbeh.2008.09.004
de Graaf, R., Bijl, R. V., Smit, F., Vollebergh, W. A. M., & Spijker, J. (2002).
Risk factors for 12-month comorbidity of mood, anxiety, and substance
use disorders: Findings from the Netherlands Mental Health Survey
and Incidence Study. American Journal of Psychiatry, 159, 620–629.
https://doi.org/10.1176/appi.ajp.159.4.620
DeMartini, K. S., & Carey, K. B. (2012). Optimizing the use of the AUDIT for
alcohol screening in college students. Psychological Assessment, 24, 954–
963. https://doi.org/10.1037/a0028519
Ebert, D. D., Hopfinger, L., & Berking, M. (2017). Emotion regulation pro-
tects against recurrence of depressive symptoms following inpatient
care for major depressive disorder. Behavior Therapy, 48, 739–749.
https://doi.org/10.1016/j.beth.2017.03.003
Ebert, D. D., Van Daele, T., Nordgreen, T., Karekla, M., Compare, A., Zarbo,
C., … Baumeister, H. (2018). Internet- and mobile-based psychological
46
 Music Therapy
TEXT 10

Today
WFMT online journal
Volume 14, No. 1

Music Therapy Today publishes articles that are related to music therapy
education, practice, and research. Categories may include, but are not li-
mited to Editorials, Presidential Notes, Position Statements, Curriculum
Reports, Clinical Case Studies, Research Reports, Service Projects, World
Congresses Proceedings, Interviews, Book Reviews, and Online Resources.

2018 WFMT. All rights reserved. ISSN: 1610-191X

47

Implementing a Song as a Reward for
Transition from Free-Play Time to a
MUSICTHERAPYTODAy, Volume 14, No. 1, 2018
Group Activity
Kumi Sato
Shigeki Sonoyama
Abstract
Even though there are substantial numbers
of studies investigating transition strategies,
there is still an interest in and the need for
research on transition due to its frequent oc-
currence in everyday life. Research suggests
implementation of music as a prompt effec-
tive to promote smooth transitions; how-
ever, the effect of music implemented as a
reward has not been discussed yet. Since re-
wards are used as commonly as prompts in
educational settings, the current study exam-
ined the effect of a song as a reward for
younger children with developmental disabi-
lities during transitions, in comparison with
the effect of a song as a prompt. The parti-
cipants were three children at the age of 3 or
4, who required support to initiate and com-
plete transitions, especially from free-play
time to a group activity. The result indicates
two of the participants initiated the transi-
tion faster when the song was implemented
as a prompt (Intervention A), whereas the
time they took after initiation of the transi-
tion was reduced when the song was imple-
mented as a reward (Intervention B). For the
other participant, implementing the song as
a reward was effective to decrease the time
needed for initiating and completing the
TEXT 10
Resumen
A pesar de que hay un número considerable
de estudios que investigan estrategias de tran-
sición, todavía existe un interés y la necesidad
de investigar sobre la transición debido a su
frecuente ocurrencia en la vida cotidiana. Los
estudios existentes sobre este tema sugieren
la implementación de la música como un
medio eficaz para promover transiciones sin
problemas; sin embargo, el efecto de la mú-
sica implementada como recompensa no se
ha discutido aún. Debido a que las recompen-
sas se utilizan con tanta frecuencia como pau-
tas en entornos educativos, el estudio actual
comparó el efecto de una canción como re-
compensa para niños con trastornos del desa-
rrollo durante las transiciones, con el efecto de
una canción como aviso. Los participantes
eran tres niños con edades de 3 ó 4 años, que
requerían apoyo para iniciar y completar las
transiciones, especialmente del tiempo de
juego libre a una actividad grupal. El resultado
indica que dos de los participantes iniciaron la
transición más rápidamente cuando la can-
ción se implementó como aviso (Intervención
A), mientras que el tiempo que tomaron des-
pués del inicio de la transición se redujo
cuando la canción se implementó como re-
compensa (Intervención B). Para el otro par-
48

transition. The effect of these interventions
on their independence during the transition
MUSICTHERAPYTODAy, Volume 14, No. 1, 2018
will be discussed also.
Keywords: song, reward, transitions, children
with developmental disabilities, single-sub-
ject research design
Implementing a song as a reward for transi-
tion from free-play time to a group activity as
interest in and needs of therapeutic use of
music is growing in the area of education, re-
searchers have investigated its effect to teach
children, especially individuals with disabili-
ties who need special support. Since learning
in a similar environment, which children with-
out disabilities have, is one of the general
goals for children with disabilities, research in
music therapy has shown how music can as-
sist them acquiring necessary or expected
skills (Katagiri, 2009; De Mers, Tincani, Van
Norman, & Higgins, 2009; Register, Darrow,
Standley, & Swedberg, 2007). Some studies
were conducted in a school or home setting
so that the participants can maintain the skills
after termination of the music therapy inter-
vention without additional training (Kern,
Wakeford, & Aldridge, 2007; Kern, Wolery, &
Aldridge, 2007; Pasiali, 2004; Register &
Humpal, 2007). Music was used to deliver a
cue or create a structure in these studies; in
other word, music was provided to promote
specific behaviors before the target behaviors
occur.
In practical educational settings, however, re-
wards are selected and offered as much as
prompts, depending on social context and
environmental conditions, to enhance appro-
priate behaviors of children. Therefore, ha-
TEXT 10
ticipante, la implementación de la canción
como recompensa fue efectiva para disminuir
el tiempo necesario para iniciar y completar la
transición. También se discutirá el efecto de
estas intervenciones en su nivel de indepen-
dencia durante la transición.
Palabras clave: canción, recompensa, transi-
ciones, niños con discapacidades del desarrollo.
ving a larger selection of alternative rewards
would be beneficial for practitioners because
they can attempt to find which type of re-
wards is suitable for the child and provide the
best support. Contrary to importance and
popularity of rewards in educational settings
(Hoffmann, Huff, Patterson, & Nietfeld, 2009),
research on use of music as a reward is limited
in music therapy literature. Lim (2010) stated
that music stimuli worked as both a prompt
and an automatic reward, but the function
of music as a reward was not directly exa-
mined in this study. Although research has
explored effective use of music as a prompt,
potential effect of music as a reward has not
investigated yet.
Research on effective strategies incorpora-
ting rewards is needed in other area of dis-
ciplines also. Sterling-Turner and Jordan
(2007) conducted a literature review of re-
search on interventions to support transi-
tions in individuals with autism, and they
pointed out most of the available studies exa-
mined interventions using some kinds of
prompts including verbal prompts/audio
cues, visual support, and video priming.
They argued the need for further studies in-
vestigating consequent components in tran-
sitions. Even though there is a substantial
number of empirical studies about promo-
ting smooth transitions, interest in research
49

associated with transitions is ongoing due to
its frequent occu-rrence in daily life and the
MUSICTHERAPYTODAy, Volume 14, No. 1, 2018
likelihood that children with disabilities find
it challenging.
A few studies about the effect of rewards in
transition times include the research con-
ducted by Waters, Lerman, and Hovanetz
(2009). The participants were two 6-year
old boys diagnosed with autism, and they
had difficulty terminating a preferred activ-
ity and initiating a non-preferred activity.
The results indicate that a visual schedule,
which is a commonly used prompt, would
not be effective by itself, and it should be
combined with appropriate rewards and
limited access to preferred activities, that
is extinction. Cote, Thompson, and McKer-
char (2005) provided three typically deve-
loping toddlers with interventions for tran-
sitioning from the play area to the toileting
area. They found that the participants’
compliance increased if access to preferred
activities was not allowed after the initial
instruction; moreover, the effect was even
more significant when a reward (e.g. a toy
to carry with) was delivered with the ex-
tinction procedure, compared to when a
verbal warning was given 2 minutes prior
to a transition. Hanley, Tiger, and Ingvarsson
(2009) investigated strategies to increase
preschoolers’ selection of non-preferred
but academically important activities during
free-play time. Although their research was
not conducted in scheduled transitions,
they encouraged the participants to transi-
tion from a preferred activity to a non-pre-
ferred activity in the free-play period. The
results revealed embedded reinforcement,
such as decorating the activity area with
popular children’s cartoon characters, in-
creased and maintained the participants’
engagement in originally non-preferred ac-
tivities.
TEXT 10
The effect of music in promoting smooth
transitions has been examined also (Gad-
berry, 2011; Register & Humpal, 2007). The
results of these studies demonstrated musi-
cal interventions decreased transition times
as well as increased independence in the par-
ticipants during transitions. In the guideline
for identifying appropriate transition support,
music and singing are also listed as an exam-
ple of auditory prompts besides verbal war-
nings and timers (Hume, Sreckovic, Snyder, &
Carnahan, 2014). However, music was incor-
porated as a prompt in these models. There-
fore, the current study will examine the effect
of music provided as a reward in transition
times, compared to the effect of music pro-
vided as a prompt.
Furthermore, since transition requires a se-
quence of tasks including terminating an
engaged activity, physically moving or shif-
ting attention, and preparing for the next
activity, what part of transition a child find
it challenging should be different. Some
children might need support to start physi-
cally moving even though they can finish
the previous activity without any prompts
(Sterling-Turner & Jordan, 2007). Others
might need prompts to terminate an en-
gaged activity though they can quickly clean
up and move to a different area once they
finish the previous activity. Hume, Srec-
kovic, Snyder, and Carnahan (2014) argued
how important it is to individualize transi-
tion support because the best intervention
and when it should be implemented varies
depending on the child’s chronological/de-
velopmental age or abilities. In addition to
comparing the effect of music as a reward
and its effect as a prompt during transitions,
the authors will deeply discuss how diffe-
rently each participant in this study, who
had different learning needs, responded to
the interventions.
50

Method
MUSICTHERAPYTODAy, Volume 14, No. 1, 2018
Setting
This study was conducted at a day treatment
facility in Japan, which provides services for
children with developmental disabilities un-
der 6 years old. Children and their parents
can decide how many days in a week they use
the services depending on the child’s learning
needs. Most of the children uses the services
approximately 3 hours a day to learn self-care
or academic skills, which cannot be ad-
dressed on an individual basis at regular pre-
school/kindergarten and go to regular pre-
school/kindergarten for the rest of the day.
Some children come to the facility to practice
learning in a group before they start going to
regular preschool/kindergarten.
After a circle time in the morning, at this faci-
lity, each child follows a schedule shown on
own schedule board, which is planned for in-
dividual learning needs to be addressed. The
basic schedule includes: circle time, toilet,
hand washing, snack, pre-academic tasks,
free-play time (i.e. unconstructed play), group
activity, lunch, tooth brushing, and going
home. In this daily schedule, not all of the chil-
dren were able to have smooth transitions
from free-play time to group activity. There-
fore, music intervention was implemented to
encourage children finish playing, putting toys
away, and having a seat for the next activity.
Participants
The purpose of this study and its procedure
was clearly explained to parents of three chil-
dren who needed support during transitions
from free-play time to group activity. Their pa-
rents understood: (a) this study was approved
by the University of Tsukuba Ethics Committee
for Research in the Faculty of Human Sciences;
TEXT 10
(b) pseudonyms would be used as information
of their child would be kept strictly confiden-
tial; and (c) they had a right to withdraw from
the study if they thought their child would not
benefit by participating in it. All of the parents
were willing to have their child participate in
the study and signed the consent form.
Kenta was a 4-year-old boy diagnosed with
Autism Spectrum Disorders. His score on the
Tsumori-Inage Infant Developmental Scale,
which is a parent questionnaire–based test
commonly used in Japan (Kurita, Osada,
Shimizu, & Tachimori, 2003), was 75 indicating
the severity of the disability was mild. Impro-
ving attention span was one of the challenges
for him and he required frequent prompts to
stay on task. Sometimes he didn’t use the
bathroom even though he spontaneously said
he wanted to use it and went into the room.
Kenta could engage in a task/activity relatively
longer if there were no peers around; in other
words, he was greatly influenced by other
peers’ behaviors. When he heard the timer,
which was used as the signal for cleaning up
at the day treatment facility, he often said “It’s
time to clean up” or “Let’s put toys away” to
peers. However, he didn’t finish playing if
other peers were still engaging in the play.
Sara was a 4-year-old girl who had no speci-
fied developmental delays. According to the
Tsumori-Inage Infant Developmental Scale
she took at 27 months, her developmental
age was diagnosed as 21 months (DQ 78). At
the time of the study, Sara had no difficulty
understanding verbal directions or expressing
her needs in words except when she had
tantrums. She also spoke to her peers often
though she rarely played interactively with
them. Sara was able to perform most of the
tasks independently without much physical
support; however, she spent long time com-
pleting a task since her movements were
51
 TEXT 10

slower generally. She had a tendency to re- Beat

fuse new or unfamiliar activities because of
MUSICTHERAPYTODAy, Volume 14, No. 1, 2018

her anxious personality. 4/4 64

3/4 3
Masa was a 3-year-old boy diagnosed with no
specified developmental delays. His DQ score 2/4 31
on the Tsumori-Inage Infant Developmental
others** 2
Scale, that he took at 26 months was 62.
However, by the time of the study, he was **These two songs are played in 6/8 beats.
able to communicate verbally with adults or
peers. Although he had the ability to perform Tempo (BPM)
most of the tasks, the child care aides consis-
tently needed to provide prompts for him. Presto (168-208) 2
Masa particularly had difficulty in finishing his Allegro (120-168) 48
play. He understood he was supposed to put
toys away if he heard the sound of a timer, Moderato (108-120) 16
but he often said “I don’t want to” or “Wait!” Andante (76-108) 23
and refused to finish playing.
Adagio (66-76) 3
Songs
Largo (40-66) 8

The authors conducted a brief analysis of chil-

dren songs to investigate some characteristics
in popular and well-known children songs in
this culture. A CD set with 100 children songs
(Minnna, 2014) was selected for the analysis
because it included both new and traditional
songs. Table 1 shows the characteristics of
well-known children songs. It implies songs in
a major key, in 4/4 beats, and at a faster
tempo are preferred. Moreover, 53 out of 100
songs used repeated sounds, words, or ono-
matopoeia to create some rhythmic patterns.
Based on the brief analysis, two original songs
were composed for this study; “Clean Up, Up,
Up!” was to use as a prompt to encourage
children putting toys away, and “Well Done,
Finished!” was to use as a reward to praise
for cleaning up (See Appendix). Both songs
were composed in a major key in 4/4 beats
and played at a faster tempo between 120
and 168 BPM. Additionally, repeated sounds
were included in the lyrics to create some
rhythmic patterns.

Table 1. Brief analysis of 100 children songs in Prior to the study, many of the child care aides
Japan. reported they felt uncomfortable leading the
songs because they didn’t have an advance
Key music educational background. Some studies
major 92 indicated live music was more effective than
recorded music (Gadberry, 2011). However,
minor 3 since the authors placed importance on de-
veloping teaching strategies, which can be im-
others* 5
plemented easily without special instruction,
*Others include traditional folk songs using spe- the songs were recorded instrumentally and
cial melodic scales. played with a CD player for the child care aides

52

to sing along in this study. Two recorded CD
were placed at the facility for the child care
MUSICTHERAPYTODAy, Volume 14, No. 1, 2018
aids to learn the songs.
Procedure
This study was conducted using a single-sub-
ject research design across participants. The
data was collected for four weeks in each
phase and follow up data was taken one
month after the termination of interventions.
The latency until the participant initiated the
cleaning task, the total transition time until the
participant required to have a seat for the next
activity, the number and kinds of prompts pro-
vided, toy categories the participant was play-
ing with, and the child care aide who sup-
ported the participant were recorded. A video
camera was set up in the corner of the room
to record the latency, the total transition time,
and the prompts later; in addition, the first au-
thor was present every time to record the toy
categories and the child care aides on a data
collection sheet.
Baseline. When a timer rang as a signal to fi-
nish playing and put toys away, the child care
aides gave a verbal prompt such as “Please
put your toy away.” Then, they waited for 1
minute without providing any other prompts
to see if the participants spontaneously start
cleaning up. Additional prompts were given
as much as the participants needed to finish
playing, put toys away, and have a seat for the
next activity after the 1-minute interval. Ver-
bal praises were provided for completing the
cleaning task as it had been practiced at the
facility.
Interventions and follow-up. The basic pro-
cedures during Intervention A (the song pro-
vided as a prompt) were identical to those in
the baseline phase except that the song
“Clean Up, Up, Up!” was played with a CD
TEXT 10
player when the timer rang, instead of pro-
viding a verbal direction. For Intervention B
(the song provided as a reward), the basic
procedures during were identical to those in
the baseline phase except that the child care
aides sang “Well Done, Finished!” along with
the participants after they had a seat, instead
of providing verbal praises. In the follow-up
session, the procedure was identical to the
baseline phase.
Interobserver agreement. The first author
watched the video recordings of all sessions
as the first observer. Then, the second ob-
server, who was a doctoral student studying
special education, watched the video recor-
dings and collected the data for 40% of all
sessions for Masa, 38% of sessions for Kenta,
and 35% of sessions for Sara. The IOA rate
was assessed by the length of time each par-
ticipant required after the initiation of the
cleaning task, which was calculated by sub-
tracting the latency from the total time taken.
The mean duration per occurrence IOA was
97% for Masa, 96% for Kenta and Sara.
The number of verbal, visual, and physical
prompts were recorded separately by the
same observers. Any verbal directions were
defined as verbal prompts, and visual cues in-
cluding pointing, showing a picture card, pre-
senting a box to put the toys in, or demonstra-
ting the cleaning task were defined as visual
prompts. Physical contacts including tapping,
holding a hand, or holding the participant up
were defined as physical prompts. The exact
agreement IOA for Masa was 67% in verbal
prompts, 100% in visual prompts, and 78% in
physical prompts. The exact agreement IOA for
Kenta was 60% in verbal prompts, 100% in vi-
sual prompts, and 100% in physical prompts.
The exact agreement IOA for Sara was 80% in
verbal prompts, 60% in visual prompts, and
100% in physical prompts.
53

Results
MUSICTHERAPYTODAy, Volume 14, No. 1, 2018
Figure 1 shows the total transition time as
well as latency to initiation of the cleaning
task, which required the participants to fi
nish an engaged activity, and the time after
initiation of the cleaning task, which re-
Figure 1. The filled circles represent the total
transition time. Two different dotted areas
represent the latency to initiation of the
cleaning task (low density) and the time af-
ter initiation of the cleaning task (high den-
sity) respectively. The blank circle in the fol-
low-up session represents the latency.
TEXT 10
quired the participants to complete the
cleaning task, physically move to another
area, and have a seat for the next activity.
The number of data points is different since
how many days in a week each child used
the facility was decided by their parents, de-
pending on their learning needs. Kenta re-
quired slightly less time for the transition
during Intervention A, while the transition
time Sara took was reduced in Intervention
B. The total time Masa spent on the transi-
tion decreased when the song was imple-
mented as a reward; however, it increased
again as the intervention continued.
Table 2 shows the mean time of before (i.e.
latency) and after initiation of the cleaning
task in each phase respectively. Kenta and
Masa initiated the cleaning task faster du-
ring Intervention A; on the other hand, in
regard to the time required after initiation
of the task, their compliance was increased
in Intervention B, when the song was deli-
vered as a reward. They did not spend much
time once they finished playing and started
putting toys away. Sara was stably able to
start putting toys away within 100 seconds
during Intervention B. Although she com-
pleted the cleaning task quickly during
Baseline without considering the toy cate-
gories she was playing, she required less
time after initiation of the task in Interven-
tion B, in a comparison between Interven-
tion A and B.
Table 3 shows the average number of
prompts provided for each participant. For
Sara and Masa, the number was the mini-
mum in every kind of prompts during Inter-
vention B. Although the number of prompts
provided for Kenta decreased in Intervention
A, it increased again in Intervention B. He re-
quired more verbal and physical prompts in
this phase compared to baseline.
54
 TEXT 10

Table 2. The mean of latency and the time after initiation of the task in each phase.
MUSICTHERAPYTODAy, Volume 14, No. 1, 2018

Baseline Intervention A Intervention B

Latency 158.7 72.8 146.4
Kenta
After 121.7 141.0 94.7

Latency 227.5 199.2 41.6

Sara
After 34.8 137.0 102.8

Latency 209.9 141.9 176.0

Masa
After 107.0 160.6 80.2

Table 3. The average number of prompts provided for each participant.

Baseline Intervention A Intervention B

verbal 3.7 2.4 6.0

Kenta visual 3.0 1.0 1.6

physical 1.3 0.6 1.4

verbal 3.5 4.6 2.0

Sara visual 2.5 3.8 1.4

physical 1.3 1.6 0.6

verbal 5.6 5.7 5.1

Masa visual 4.4 1.0 1.0

physical 2.7 2.9 2.4

Discussion tive for them to complete the cleaning task

The total transition time required for the
transition decreased in either Intervention
A or B in every participant. However, how
these musical interventions functioned was
different in each participant. The mean time
of before and after initiation of the cleaning
task implies implementing a song as a prompt
was effective for Kenta and Masa to finish
playing and start putting toys away, whereas
implementing a song as a reward was effec-
and be ready for the next activity in shorter
time. On the other hand, for Sara, imple-
menting a song as a reward was effective to
finish playing as well as be ready for the next
activity. In terms of how independently the
participants completed the transition, Table
3 suggests the amount of support Sara and
Masa required was decreased as the study
continued, and it can be concluded they
learned what is expected during the transi-
tion.

55

Detailed discussion on each participant
MUSICTHERAPYTODAy, Volume 14, No. 1, 2018
Kenta. Kenta regularly told his peers to put
toys away when he heard the sound of the
timer though he did not initiate the cleaning
task until the child care aides gave him the di-
rection. He had difficulty staying on task, and
his behaviors were highly influenced by other
peers’ behaviors; for example, he stopped his
hands and stared at a peer for a while if the
peer started crying. Kenta often played with
Masa, and he followed Masa especially for
the initiation of the cleaning task. If Masa
started the cleaning task faster, he could start
it faster. If Masa took time to finish playing,
Kenta needed time to finish playing.
When a song was implemented as a prompt
during Intervention A, Kenta stared at the
child care aide singing the song, and he was
able to start putting toys away immediately af-
ter the song. He sometimes stopped his hands
if he saw peers still playing, yet he could
restart the cleaning task and have a seat with
a few verbal prompts usually. He said “Let’s
start (the next activity)” and invited peers to
come after him when he became ready for the
next activity. Kenta’s behaviors during Inter-
vention B were very similar to what was ob-
served in the baseline phase. He told his peers
or himself to put toys away when he heard the
sound of the timer; however, he could not
spontaneously initiate the cleaning task until
prompts were provided after the 1-minute in-
terval. One of the reasons why the total tran-
sition time dropped dramatically in the follow-
up session is that Masa was absent on that
day. If Kenta was playing alone, he followed
directions without difficulty.
Kenta needed fewer prompts in Intervention
A, yet this is partly because he had the same
child care aide for support during this phase.
Although he showed a great interest in the
TEXT 10
song implemented in Intervention B and sang
it along with a smile, he required more
prompts to initiate the cleaning task. There-
fore, it is difficult to conclude that musical in-
terventions helped him improve his inde-
pendence during the transition. Since he still
needed a certain amount of support to stay
engaged, the song as a prompt would be
more effective for him, in terms of the total
transition time.
Sara. Sara strongly refused to finish paying
and put toys away at first. She expressed her
anger not only by saying “No” but also by cry-
ing loudly or thrashing her arm and legs.
Thus, while she spent time regulating herself,
the child care aides put most of the toys away
and left one piece for her to complete the
cleaning task. Due to this flexible response to
her behaviors, the time required after initia-
ting the cleaning task was significantly shorter
in the baseline phase, besides the difference
in the toy categories she preferred playing
with in each phase. The child care aides had
been struggling to have her finish playing
without difficulty and put all the toys away by
herself.
In the beginning of Intervention, A, Sara
stared at the child care aide singing the song,
yet after a while, she started refusing to finish
playing. However, those behaviors were gra-
dually decreased, and she did not exhibit any
behaviors, which refuse the cleaning task, at
all after Day 8. One possible reason for this
sudden change is she preferred playing with
the same toy from that point. It was a set of
finger puppets, and she did not have to share
it with other peers like blocks; therefore, she
might have been highly satisfied with her
playtime before finishing the play. Sara liked
the song implemented as a reward and some-
times sang it by herself although she had
never sung a song during music activities.
56

Sara was able to put all the pieces of the toy,
which she preferred playing in the second
MUSICTHERAPYTODAy, Volume 14, No. 1, 2018
half of the study, back to the original place by
herself. She spent longer time to complete
the cleaning task since her movements were
slow, yet the child care aides respected her
independence and did not provide additional
help unless she asked for it. The decrease in
the number of prompts suggests her inde-
pendence during the transition improved
throughout the study. Although the toy cate-
gories are considered as one of the factors
which reduced the total transition time, a
song as a reward was more effective to ad-
dress her learning needs generally.
Masa. At the beginning of the study, Masa re-
fused to finish playing almost every time he
heard the sound of the timer. He knew the
timer meant it was time to put toys away be-
cause he asked the child care aides “Did it
ring?” and then said “I’m not coming.” In ad-
dition, even though he put toys away, he
could not have a seat immediately after that.
He lied down on the floor and rolled around
until the child care aid took him to the chair.
Therefore, finishing the play and having a seat
for the next activity were both challenging for
him.
During Intervention A, the frequency of his
verbal refusals to finish playing decreased
gradually, and Masa became able to initiate
the cleaning task with a few verbal prompts.
He sometimes sang a part of the song along
with the recorded music. However, he still
had difficulty having a seat, thus the time re-
quired after the initiation of the cleaning task
did not improve much. When the song was
implemented as a reward in Intervention B,
Masa showed a great interest in the song. He
said “yay!” and had a seat immediately if the
child care aide told him he was going to sing
the song. Masa became less interested in
TEXT 10
the song gradually, however, and this could
be the reason why the total transition time
he required increased towards the end
again.
In the second half of the study, Masa often
had a seat with a toy in his hand immediately
after he heard the sound of the timer. He was
redirected to put the toy back to the original
place as the cleaning task was a part of the
transition practiced at the facility, yet his be-
havior told he became able to shift his atten-
tion to the next activity in shorter time. His
behaviors were easily changed by health con-
ditions or feelings as well as how much time
he could have for free-play time on the day,
thus his performance during the transition
was variable overall. If he could not have a
smooth transition, he usually had difficulty
engaging in an activity later on the day. Al-
though there was not a significant decrease
in the total transition time, some changes,
which would probably lead to the decrease in
the time in the future, were observed in his
behaviors.
Limitations and implications
In order to closely examine the difference in
the effects between two interventions, Inter-
vention A and B should have been repeated
in an A-B-C-B-C design; furthermore, the
combined effect needs to be investigated in
addition to the independent effect of each in-
tervention. However, besides this study was
conducted at the end of a school year, Sara
and Masa decided to terminate the use of the
services and go to regular kindergarten/
preschool in the next school year. Additio-
nally, since it was carried out during winter,
some participants were absent for a longer
period due to their health conditions, and
thus it was difficult to collect data as much as
scheduled.
57

The authors respected the management po-
licy of the facility and determined not to as-
MUSICTHERAPYTODAy, Volume 14, No. 1, 2018
sign a specific child care aid to each partici-
pant. If each participant had the same child
care aid throughout the study, however, the
data, especially the number of prompts taken
to analyze the change in their independence,
would have been more validate.
In addition, the sample size was limited be-
cause there were not many children using the
services more than three days a week regu-
larly at the time of study. Recruiting more par-
ticipants at the day treatment facility or other
educational support centers is needed for fu-
ture research to increase research validity as
well as examine if the findings could be gener-
alized.
The result of this study implies music as a
prompt could be effective to encourage initia-
ting a task whereas music as a reward could
be effective to completing a task. Further-
more, it suggests how and when musical in-
terventions should be implemented would be
different depending on individual learning
needs. Since rewards are commonly used in
practical educational settings as well as
prompts, additional research is needed to ex-
plore more strategies to implement music as
a reward so that educators, parents, and other
specialists working for children with special
needs can have a larger repertoire of alterna-
tive teaching strategies. It is highly recom-
mended future research considers use of
recorded music so that those who are not mu-
sic therapists or who do not have an advance
music educational background can incorpo-
rate the strategy without special training.
References
Cote, C. A., Thompson, R. H., & McKerchar, P.
M. (2005). The effects of antecedent inter-
TEXT 10
ventions and extinction on toddlers’ com-
pliance during transitions. Journal of Ap-
plied Behavior Analysis, 38, 235-238.
De Mers, C. L., Tincani, M., Van Norman, R. K.,
& Higgins, K. (2009). Effects of music ther-
apy on young children’s challenging be-
haviors: A case study. Music Therapy Pers-
pectives, 27(2), 88-96.
Gadberry, D. L. (2011). The effect of music on
transitions and spoken redirections in a
preschool classroom (Doctoral disserta-
tion). Retrieved from ProQuest Central;
ProQuest Dissertations & Theses Global.
(Order No. 3458216)
Hanley, G. P., Tiger, J. H., & Ingvarsson, E. T.
(2009). Influencing preschoolers’ free-play
activity preferences: An evaluation of sa-
tiation and embedded reinforcement.
Hoffmann, K. F., Huff, J. D., Patterson, A. S., &
Nietfeld, J. L. (2009). Elementary teachers’
use and perception of rewards in the
classroom. Teaching and Teacher Educa-
tion, 25, 843-849.
Hume, K., Sreckovic, M., Snyder, K., & Carna-
han, C. R. (2014). Smooth transitions: Hel-
ping students with autism spectrum disor-
der navigate the school day. Teaching Ex-
ceptional Children, 47, 35-45.
Katagiri, J. (2009). The effect of background
music and song texts on the emotional un-
derstanding of children with autism. Jour-
nal of Music Therapy, 46(1), 15-31.
Kern, P., Wakeford, L., & Aldridge, D. (2007). Im-
proving the performance of a young child
with autism during self-care tasks using em-
bedded song interventions: A case study.
Music Therapy Perspectives, 25(1), 43-51.
Kern, P., Wolery, M., & Aldridge, D. (2007).
Use of songs to promote independence in
morning greeting routines for young chil-
dren with autism. Journal of Autism & De-
velopmental Disorders, 37, 1264-1271.
Kurita, H., Osada, H., Shimizu, K., & Tachimori,
H. (2003). Validity of DQ as an estimate of
58
 TEXT 11

5 News

A few questions about ‘mental disorders’

How many times have you seen a video on Facebook about mental
disorder? How about an over-reaching headline on the same topic,
10 something like “Depression: Solved by science”?

21 August 2018

Such communications can be great. They package complex issues into bite-
size pieces and keep the public informed about a vital research topic. They also
have a dark side.

15 By oversimplifying things, and showing us lots of images of brains, these kinds

of communications instil us, the viewers and readers, with confidence.
Confidence that science understands mental disorders and that neuroscience in
particular will soon solve them.

Unfortunately this confidence is not warranted. Psychiatry is effectively in crisis,

20 at least in regards to its diagnostic system. The DSM-5 (the Holy Bible big-bad-
list of official mental disorders) is riddled with issues and confidence in it is
waning. One brief example: there are currently so many criteria for post-
traumatic stress disorder that you can meet those criteria in 636,120 different
ways.

25 In 2013, Thomas Insel, then director of the National Institute of Mental Health
(NIMH) in the US, put it plain when he said: “Patients with mental disorders
deserve better.”

Responding to such issues, many researchers are putting their confidence in

neuroscience. Insel himself wrote the above statement while releasing the

59
30 NIMH’s solution to the diagnostic crisis: a research funding framework called
RDoC. RDoC explicitly focuses on understanding the brain, putting topics like
culture and values largely to the side. Why? Because the first of RDoC’s stated
core assumptions is that mental disorders are brain disorders.

Don’t get me wrong, studying the brain has huge potential, but this is a big
35 assumption. The truth is that the fundamental question “What is mental
disorder?” is still hotly debated. It is this question that interests me.

I’ve been working from a school of thought known as 3e Cognition (or

sometimes ‘enactive embodiment’). I’ll spare you the details. Effectively, 3e
Cognition takes the emphasis off the brain alone and instead considers the
40 whole person – as a brain and body system – trying to survive and flourish
within their physical and social environment.

This view recognises the importance of the brain but allows for a more
comprehensive perspective; through the brain and body and out to culture and
environment. Taking such a perspective, it is difficult to see how mental
45 disorders can simply be brain disorders, as per the assumptions of RDoC. With
its broader perspective, the assumptions of 3e Cognition seem a much better
basis from which to seek to understand mental disorder.

It can also help us determine what counts as mental disorder and what doesn’t.
If you have a heart attack, we can all easily agree this is a bad thing. But the
50 story is different when it comes to mental disorder.

If you are seeing things that aren’t there, this may be psychosis. Alternatively, it
might be a valued spiritual experience. These two options are likely to look the
same in the brain. But if you consider the person’s culture and values, these are
very different things.

55 I have been trying to show that 3e thinking can help with this distinction. It
allows us to talk about the biological stuff going on but also the individual’s
values and culture. All under a single scientifically minded framework.

For example, say ‘Mary’ is seeing visions of her dead grandmother. Is this
mental illness? 3e thinking would encourage us to ask, “Is this working for this
60 person?” Perhaps Mary values these experiences, perhaps it is helping her with
other difficulties in her life.

My PhD has so far been concerned with trying to understand what the concept
of metal disorder looks like from a 3e perspective. As I move into the second
half of my project, I am starting to shift my focus to the question ‘If this is what
65 mental disorders are, then how should we best seek to explain them?’

60
 The field of mental health is at a crossroads. We have acknowledged many
issues in the way we recognise and understand disorder. We need to respond
to this, but blind confidence is dangerous in the face of complexity. If we only
focus on the brain, I’m sure we will discover some amazing things, but our
70 understanding of mental disorders will remain incomplete, and we will thereby
be doing a disservice to those that suffer them.

Kristopher Nielsen is a member of the Explanation of Psychopathology and

Crime research lab at Victoria University of Wellington. This article is an
adaptation of his presentation as a finalist in the University’s Three Minute
75 Thesis competition.

61
 Anthropological Forum
A Journal of Social Anthropology and Comparative Sociology

TEXT 12
ISSN: 0066-4677 (Print) 1469-2902 (Online) Journal homepage: http://www.tandfonline.com/loi/canf20

Mind Change: How Digital Technologies Are

Leaving Their Mark on Our Brains, by Susan
Greenfield

Julian Ch Lee

To cite this article: Julian Ch Lee (2015) Mind Change: How Digital Technologies Are Leaving
Their Mark on Our Brains, by Susan Greenfield, Anthropological Forum, 25:3, 315-317, DOI:
10.1080/00664677.2015.1021442

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Published online: 24 Mar 2015.

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62
Date: 23 March 2016, At: 21:17

for kayaks and umiaks, quivers for arrows, and
even nets for catching birds; thread was made
from their sinews, needles and scraping tools
from their bones, and their antlers were beauti-
fully and intricately carved. Sealskin was likewise
used for tents and for covering kayaks, and seal
intestines, especially from the Bearded Seal,
furnished waterproof undergarments. The
ivory of walruses, whenever this could be
obtained, was used mainly in making decora-
tions. Whales, particularly the Beluga, gave fat
(used for fuel and light) as well as meat and
skin, and their stomachs were used as bags.
Downloaded by [Purdue University Libraries] at 21:17 23 March 2016
Parts of the Arctic Hare were valued in shamanic
rituals. Descriptions and illustrations of all this
are accompanied in the book by traditional
tales featuring animals, some entertaining,
some didactic, some rather sad.
There is a table of Inuit terms for animals and
their parts, an appendix of his biological collec-
tions now in the Smithsonian, and a glossary.
There are photos of many of the specimens
(including the material culture items), and a
large number of atmospheric black-and-white
photos, many of them taken by Turner
himself. Bryony Anderson’s drawings of the
animals add flavour. There is a map on pages
12–13; I wish this could have been more acces-
sible—perhaps a frontispiece—because I con-
stantly needed to look at it to remind myself
of where particular places were. This is my
only criticism of what is otherwise a well-
produced, informative, and important book.
TEXT 12
Mind Change: How Digital Technologies Are
Leaving Their Mark on Our Brains, by Susan
Greenfield. Rider, London, 2014, xv + 368 pp.,
preface, figures, tables, notes, further reading,
index. ISBN 978-1-84604-430-4 (hardback).
JULIAN CH LEE
School of Global, Urban and Social Studies
RMIT University
© 2015 Julian ch lee
http://dx.doi.org/10.1080/00664677.2015.1021442
Book Reviews
The title of Susan Greenfield’s new book, Mind 1
Change, intends to suggest that the presence of
digital technologies is having social and psycho-
logical impacts that are similar in scale to climate
change. And in the same way as the present and
forecasted impacts of climate change are largely
negative, so too are the impacts of the ‘screen
culture’ which is arising from the ever-present
and always-on digital devices to which most
now reach for and engage with within 15
minutes of consciousness each day (17).
Books that treat the impact of digital technol- 2
ogies on people and society can often be highly
optimistic, wholly pessimistic or seek place
themselves between the cyber-utopians and
cyber-dystopians. Greenfield’s book clearly
falls within the second category, and surveys
the array of concerns that she has about the
impacts of the hyper-connected state of society
and the impacts of spending so much time
engaging with a screen, the behavioural out-
comes of which she refers to as ‘screen culture’.
While many who teach undergraduates can
share anecdotes of student inattentiveness in 3
class as they browse Facebook, and have
heard student complaints about the length of
even modest readings, Greenfield draws on
an array of research findings, particularly in
the fields of psychology and neuroscience, to
support her perspective that digital technol-
ogies are having largely negative impacts on
people, including on their attention spans. A
key premise of this perspective is that a key
feature of the brain is its neuroplasticity, that
is, its ability to be shaped, both functionally
and physically, by the environment with
which it engages. Ipso facto, if the present
environment of many brains is one of immer-
sion in interactions taking place on screens,
that environment must be conditioning
people’s brains in particular ways, with
impacts feeding through to everything from
their identities to their societies.
Those familiar with neuroscience might find
Chapters 5 and 6 to be a fairly standard and 4
brief introduction to the subject. However, as
63
 Book Reviews
Greenfield moves into Chapters 7 and 8, ‘How
the brain becomes a mind’ and ‘Out of your
mind’, one begins to see where she is going
with her argument. In short, she argues that
what we understand to be a human ‘mind’, as
opposed to just a brain, relies on maturing
from an on-going focus on the present
moment, as is the case for young children,
towards a greater encompassment of the
more abstract past and future. However, the
kinds of environments created by digital tech-
nologies and the internet continually reinforce
an in-the-moment state of consciousness
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which does not cultivate a strong sense of self,
inward self-knowledge, and wider context
into which to embed present experiences.
Greenfield argues that they instead promote
more emotional and in-the-moment con-
sciousness seen in children and many schizo-
phrenics, and not that seen in otherwise
‘normal’ adults (99). Digital technology is
therefore leading us to ‘lose our minds’.
In the remainder of the book Greenfield
5 explores how three areas of digital technology
foster this. Those areas are social networking,
video games, and surfing the web. In each she
describes how the logics and experiences of
each of these areas cultivates an array of qual-
ities, almost all of which are socially or indivi-
dually undesirable. With respect to social
networking, for example, the use of Facebook,
which Greenfield uses to stand in for social net-
working per se, is unlike most ‘real-world’ inter-
actions in that there are always people to
interact with at a given moment, and that infor-
mation shared is subject to people’s approval or
otherwise, which can be instant, thus possibly
instantly satisfying a craving for affirmation,
even when one’s posts are idealised or distorted
representations of one’s life. And here begins a
possible vicious cycle where one compares the
inflated achievements and experiences of
others with one’s own mundane life, thus
damaging self-esteem, leading one to feel ever
less inclined to engage with others offline, and
to confine oneself ever more to the social
network where inflated versions of one’s own
life can be posted, and validated (123–126).
The impacts to which Greenfield refers are
not just left to stand to reason. Rather, 6
throughout, she draws on available research
that provides evidence for the personal
and social impacts she believes digital tech-
nologies are creating. For example, she cites
research that indicates that social network
use is associated with lower levels of
empathy in people (135–141). However,
while she is always careful to note that corre-
lation is different from causation, as people
with lower levels of empathy might be
drawn to social networking because of diffi-
culties in real-world experiences, she also
presents arguments for how and why, to con-
tinue with the example of social networks a
little further, the paucity of non-verbal cues
in social networks would stifle the develop-
ment of empathy.
In an area of study where there is a great deal
of opinion often unbacked by evidence, Mind 7
Change is an engaging survey of some of the
psychological and social impacts of our immer-
sion in digital technologies and interactions
with screens. Her pessimistic orientation
cannot just be dismissed as being just a biased
opinion when she has assembled so much evi-
dence to support her viewpoint.
However, as one reads Mind Change, one
wonders whether social scientists who have
8
long written about digital communities would
concur, and whether Greenfield’s evidence is
sufficient to contradict the views of researchers
who have come to more sanguine, or at least
equivocal, views about the impacts of digital
technology. It is hard to tell because Greenfield
seldom engages with the findings and opinions
of such researchers. Readers could therefore
develop a feeling that Greenfield has not
addressed the other side of the argument suffi-
ciently enough to be fully convincing.
An example of where some social scientists
would depart from Greenfield is in her use of
the term the ‘real-world’, as opposed to the
9
64

online world. Many would contest this div-
ision as an overly stark separation of the
‘real’ and the digital. Others would prefer to
refer to ‘online’ and ‘offline’ worlds or selves,
rather than use the word ‘real’ with its negative
or dismissive implications about the online
world. Generally, however, one can see the
point Greenfield is making. For example, ‘In
real life, actions always have consequences
and, as we know only too well, cannot be
reversed. Unlike video games, no one can
become undead … ’ (222).
Another aspect of Mind Change that might
10
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dissatisfy some is the rapidity with which some
topics are addressed. It is a broad ranging
book and some phenomena are treated quite
cursorily. An example is her discussion, or
more accurately, mention, of trolls and trolling.
Trolling receives a paragraph (154) and is
depicted without much nuance, unlike, for
example, The Dark Net by Jamie Bartlett, who
discusses the viewpoints of trolls he has inter-
viewed, leading the reader to a greater under-
standing, although not necessarily acceptance,
of people who troll and their motivations.
Mind Change therefore might be better
11 thought of as a provocation, an intervention
intended to stoke debate on an issue which
she regards as of great significance and
concern. That she takes a particular angle
and that she has a particular argument are
both clear, and therefore readers should con-
sider its merit in view of other angles and
opposing arguments in order to reach their
conclusions. The book should be of interest
to academics interested in a passionate but
pessimistic assessment of the impact of
digital technologies. It should also be of inter-
est to non-academics, and has certainly been
written for such an audience in mind.
Blood will out: Essays on liquid transfers and
flows, edited by Janet Carsten. Journal of the
Royal Anthropological Institute Special Issue
Book Series. Wiley Blackwell, Malden, 2013,
Book Reviews
viii+187pp.,
figures, index. ISBN 978-1- 1186-5628-0
(paperback).
LARA MCKENZIE
Anthropology and Sociology
The University of Western Australia
© 2015 Lara McKenzie
http://dx.doi.org/10.1080/00664677.2014.989940
What is blood? Can we theorise blood? What
would a theory of blood, spanning cultures
and histories, look like? These are questions
that Janet Carsten asks in the introductory
chapter of her edited volume Blood will out,
originally published as a special issue in the
Journal of the Royal Anthropological Institute
(2013). To date, Carsten argues, blood lacks
anthropological and sociological theoris-
ations. Yet it cuts across the realms of politics,
religion, kinship, and the body, having a
‘propensity to travel within, between, and
beyond all of these’ (2). In this volume,
Carsten and her fellow contributors work
towards answering the questions she poses,
developing an ‘anthropology of blood’ which
encapsulates the many unstable meanings,
associations, and anatomies of blood.
The book works as a series of case studies,
moving across time, space, and various facets
of social life, with Carsten highlighting conti-
nuities as well as discontinuities in blood’s
symbolism. Some chapters are global in their
reach. Kath Weston, for instance, discusses
the metaphors of blood in global economic
discourse, reflected in the use of terms like
lifeblood, liquidity, and circulation. Such
metaphors, she argues, envision global finan-
cial institutions and their corresponding
social relations in terms of ‘the integrated,
self-regulating, self-sustaining qualities of a
biological life-form’ (33). The use of organic
analogies such as these help to establish ‘the
economy’ as a natural and unquestionable
force (33). Weston shows how the metaphor
of blood underscores a ‘diagnostic regime’
that aims at ensuring economic ‘health’, thus
65