Received: 29 March 2020 Revised: 26 April 2020 Accepted: 26 April 2020

DOI: 10.1002/eat.23289

CLINICAL FORUM

Cognitive-behavioral therapy in the time of coronavirus:

Clinician tips for working with eating disorders via telehealth
when face-to-face meetings are not possible

Glenn Waller DPhil1 | Matthew Pugh DClinPsy2 | Sandra Mulkens PhD3 |

Elana Moore MSc4 | Victoria A. Mountford DClinPsy5 | Jacqueline Carter DPhil6 |
Amy Wicksteed DClinPsy7 | Aryel Maharaj MEd8 | Tracey D. Wade PhD9 |
Lucene Wisniewski PhD10 | Nicholas R. Farrell PhD11 | Bronwyn Raykos PhD12 |
Susanne Jorgensen MSc13 | Jane Evans DClinPsy14 | Jennifer J. Thomas PhD15 |
9 16 17
Ivana Osenk BSc | Carolyn Paddock RD | Brittany Bohrer MA |
18 19
Kristen Anderson MA | Hannah Turner PhD | Tom Hildebrandt PsyD20 |
21 22
Nikos Xanidis DClinPsy | Vera Smit MA
1
Department of Psychology, University of Sheffield, Sheffield, UK
2
Central and North West London NHS Foundation Trust, London, UK
3
University of Maastricht, Maastricht, The Netherlands
4
South Yorkshire Eating Disorders Association, Sheffield, UK
5
Maudsley Health, Abu Dhabi, and South London and Maudsley NHS Trust, London, UK
6
Memorial University of Newfoundland, St. Johns, Newfoundland, Canada
7
NHS Specialist Eating Disorders Service, Sheffield, UK
8
University of Toronto, Toronto, Ontario, Canada
9
Blackbird Initiative, Órama Institute, Flinders University, Adelaide, South Australia, Australia
10
Center for Evidence Based Treatment, Shaker Heights, Ohio
11
Rogers Behavioral Health, Oconomowoc, Wisconsin
12
Centre for Clinical Interventions, Perth, Western Australia, Australia
13
Dorset All Age Eating Disorders Service, Bournemouth, UK
14
Eating Disorder Service, Greater Manchester Mental Health NHS Trust, Manchester, UK
15
Department of Psychiatry, Harvard Medical School, Boston, Massachusetts
16
Bedfordshire and Luton Community Eating Disorders Service, Luton, UK
17
UCSD Eating Disorders Center for Treatment and Research, San Diego, California
18
Chicago Center for Evidence-Based Treatment, Chicago, Illinois
19
Southern NHS Foundation Trust, Southampton, UK
20
Mount Sinai School of Medicine, New York, New York
21
Lanarkshire NHS CAMHS Eating Disorders Service, Lanarkshire, UK
22
Department of Eating Disorders, GZ Centraal, Hilversum, The Netherlands

This is an open access article under the terms of the Creative Commons Attribution License, which permits use, distribution and reproduction in any medium,
provided the original work is properly cited.
© 2020 The Authors. International Journal of Eating Disorders published by Wiley Periodicals, Inc.

1132 wileyonlinelibrary.com/journal/eat Int J Eat Disord. 2020;53:1132–1141.

WALLER ET AL. 1133

Correspondence
Glenn Waller, Department of Psychology,
University of Sheffield, Cathedral Court,
1 Vicar Lane, Sheffield, UK.
Email: g.waller@sheffield.ac.uk
Action Editor: Ruth Weissman
Abstract
Objective: The coronavirus pandemic has led to a dramatically different way of
working for many therapists working with eating disorders, where telehealth has
suddenly become the norm. However, many clinicians feel ill equipped to deliver
therapy via telehealth, while adhering to evidence-based interventions. This article
draws together clinician experiences of the issues that should be attended to, and
how to address them within a telehealth framework.
Method: Seventy clinical colleagues of the authors were emailed and invited to
share their concerns online about how to deliver cognitive-behavioral therapy for
eating disorders (CBT-ED) via telehealth, and how to adapt clinical practice to deal
with the problems that they and others had encountered. After 96 hr, all the sug-
gestions that had been shared by 22 clinicians were collated to provide timely
advice for other clinicians.
Results: A range of themes emerged from the online discussion. A large proportion
were general clinical and practical domains (patient and therapist concerns about
telehealth; technical issues in implementing telehealth; changes in the environ-
ment), but there were also specific considerations and clinical recommendations
about the delivery of CBT-ED methods.
Discussion: Through interaction and sharing of ideas, clinicians across the world
produced a substantial number of recommendations about how to use telehealth to
work with people with eating disorders while remaining on track with evidence-
based practice. These are shared to assist clinicians over the period of changed
practice.

KEYWORDS
cognitive-behavioral therapy, coronavirus, COVID-19, eating disorders, psychotherapy,
telehealth

1 | I N T RO DU CT I O N
On March 11, 2020, a coronavirus disease pandemic was declared by
the World Health Organisation (WHO). While this new virus (hereaf-
ter referred to as COVID-19) had first been identified several months
earlier, this declaration marked recognition that it was showing rapid
growth across many countries. Many governments focused their
efforts on reducing the risk of cross-infection, recommending and
enforcing social distancing (physical distance between individuals,
banning of meetings, cancellation of sporting fixtures, and closing of
schools, universities, shops, bars, restaurants, and workplaces).
This level of social isolation has had many social, economic and
health impacts. Among those impacts, many clinicians working with
outpatients with eating disorders have had to transfer from a norm of
face-to-face practice to delivering real-time treatment via videocon-
ferencing programs (ideally) or telephones, known as telehealth. For
many interventions, and particularly for psychological therapies, this
change to telehealth and the wider public concerns about the impact
of COVID-19 have required us to develop new ways of working at
very short notice. This change in practice means that there is a need
for substantial adaptability on the part of therapists, patients and
carers alike. At this stage in the spread of COVID-19 and our efforts
to contain and reduce it, the primary question that we are facing is:
what lessons do outpatient therapists need to learn about how to
adapt to telehealth methods?
Telehealth has been developed and shown to be effective broadly
(Backhaus et al., 2012). It has also been demonstrated that its effects
can be equivalent to those of face-to-face therapy in specific areas of
mental health, such as post-traumatic stress disorder (Acierno
et al., 2016, 2017; Morland et al., 2014, 2015; Yuen et al., 2015).
However, while telehealth is not new in the field of eating disorders,
its evidence base is less well developed. In part, this is because
evidence-based treatments have been predicated largely on face-to-
face contact (e.g., monitoring risk; the weighing of patients—Waller &
Mountford, 2015). There are some preliminary studies showing that
telehealth can be beneficial in treating eating disorders and obesity
(e.g., Abrahamsson, Ahlund, Ahrin, & Alfonsson, 2018; Anderson,
Byrne, Crosby, & Le Grange, 2017; Cassin et al., 2016; Giel
1134
et al., 2015; Hamatani et al., 2019; Sockalingam et al., 2017), but
fewer substantial studies that support this approach (e.g., Ertelt
et al., 2011; Mitchell et al., 2008). Kazdin, Fitzsimmons-Craft, and
Wilfley (2017) have identified telehealth as requiring further study
and development, though the limited evidence to date suggests we
can deliver effective therapies for eating disorders at a distance with
thoughtful planning and careful delivery (Sproch & Anderson, 2019).
In the case of cognitive-behavioral therapy for eating disorders
(CBT-ED), existing evidence-based protocols and practice
(e.g., Fairburn, 2008; Thomas & Eddy, 2018; Waller, Turner, Tatham,
Mountford, & Wade, 2019) mean that clinicians are used to working
face-to-face with their clients and carers. The need to transfer to a
telehealth approach with practically no notice meant that many CBT-
ED therapists needed to work out how to arrange a new way of work-
ing with their patients in just a few days. This need led to clinicians
beginning to share ideas and experiences that would be of use in CBT-
ED, but which also had the potential to support other therapies in mak-
ing this transition. The aim of this article is to share the ideas that were
generated by this process, to make available the clinical techniques and
process considerations of a number of experienced clinicians.
2 | METHOD
This report is based on the ideas shared on an online form, where clini-
cians could add their experiences and ideas about how to work with
eating disorders using telehealth methods. The work was not a research
study, so it was not appropriate to seek ethical approval. The form was
launched on March 24, 2020—13 days after the WHO had declared a
coronavirus disease pandemic, and at a stage where levels of response
to COVID-19 were substantially different across countries (e.g., China
was reporting a leveling off of new cases; Italy, Spain and other
European countries were enforcing curfews; Australia, the United King-
dom and parts of the USA were moving in the same direction; some
African countries were reporting their first cases). Thus, it was launched
as a means of allowing clinicians to share strategies when the situation
was moving toward telehealth.
The initial online form (a Google document, see Appendix A) was
distributed to approximately 70 clinical colleagues internationally,
who were known to be practicing CBT with eating disorder clients,
with the request that it should be passed on to allow others to con-
tribute. It was in English, so its uptake might have been limited among
clinicians from non-English-speaking countries. Participants were spe-
cifically asked: “In these times of social isolation, most of us are mov-
ing to online contact/telehealth working with our eating-disordered
patients. There have been a lot of enquiries in the last few days about
how to deliver CBT-ED online, and we thought that it would be far
more useful to make this a shared venture. In the table below, please
provide useful suggestions and your experience of them.” Participants
were asked to focus on how to develop CBT by telehealth; maintain
confidentiality; and avoid commercial promotions.
After 96 hr, all the suggestions that had been shared by 22 clini-
cians (the authors of this article) were collated for this article. It is
WALLER ET AL.
recognized that this is a relatively short timeframe, and that other sug-
gestions might be forthcoming (these remain available online). How-
ever, our priority was to make these clinical ideas available to the
wider clinical community while they were most potentially useful. The
suggestions here came from clinicians in the UK, Canada, Australia,
the USA, Abu Dhabi and the Netherlands.
3 | RE SU LT S
3.1 | Collaborative clinician guidance for working
via telehealth
The following are the domains that were identified as needing consid-
eration (headers) and the suggestions (bullet points) that clinicians
made based on their recent experience and flexible application of pro-
tocols. Several existing guidelines for delivering therapy by telehealth
routes were raised (see Appendix A) and seemed useful in general.
However, they did not address the transitions that clinicians were
going through in the current circumstances. Therefore, clinician expe-
rience was used to develop the following domains: patient and thera-
pist concerns about telehealth; technical issues in implementing
telehealth; changes in the environment; and implementing specific
CBT-ED methods remotely.
Local employment, supervisory, reimbursement and regulatory
frameworks were also raised as meriting attention. Obviously, clini-
cians should alert supervisors and employers to any such change in
therapy delivery method. Local or wider clinician peer groups to share
ideas and methods are also likely to be useful. Where healthcare is
covered by insurance, the eligibility of telehealth sessions for reim-
bursement should be checked, to ensure that the patients in not pres-
ented with an unexpected charge for their psychological therapy.
State or national guidelines should be considered, appropriate to
where the clinician is based. For example, the American Telemedicine
Association Guidelines (Turvey et al., 2013) should be considered
when working in the USA. Issues of working across geographical
boundaries might also need to be reviewed (e.g., a clinician might work
appropriately in their own state or country, but their license might not
automatically extend to undertaking the same work when the patient
is in a different regulatory area). Similarly, the web platform to be used
needs to be compliant with both employer and licensure regulations.
We should remember that the patients who we are seeing are
likely to be having the same experience of the changed circumstances
as ourselves and most other people, though their experience is likely
to be made more complex by the interaction with their existing levels
of anxiety, coping mechanisms and control issues, Therefore we
should monitor the patient's experience routinely, to ensure that we
can focus on both risk and the delivery of CBT-ED. Part of our role
is likely to be helping the patient to manage their anxiety
(e.g., normalizing it in the context of externally driven uncertainty and
loss of control) or to address it directly (e.g., ensuring that patients
understand that denying the danger of going to the gym actually adds
to their risk). In cases where emergency interventions might be
WALLER ET AL.
needed (e.g., suicidality expressed while in an online session), they
should be responded to appropriately (e.g., contacting emergency ser-
vices while the patient is on the line). However, as always, we should
consider whether any such threat is a means of communicating dis-
tress to the therapist and respond accordingly if that appears to be
the case.
It is noteworthy that the clinical experiences and suggestions that
emerged were partly specific to CBT-ED (the starting point for this
collaboration), but that the majority were applicable to a very wide
range of therapies. Therefore, to ensure that this generalizability is
emphasized, the therapy-specific suggestions are placed after the
more generic ones. Furthermore, it was evident that clinicians were
sometimes both delivering psychological treatments via telehealth
and managing medication, and this dual role should be considered
where appropriate. Finally, it is important to remember that the issues
and suggestions raised here are impressionistic, based on therapists'
own experiences and their reports of patient experiences. Therefore,
these should be used as possible avenues for clinicians to explore with
their patients, rather than being viewed as being based on more
robust evidence.
3.2 | Patient and therapist concerns about
telehealth approaches
It is clearly critical to engage the patient in undertaking therapy online,
particularly if they thought that they were going to receive face-to-
face treatment. However, we have found that addressing the points
below assist in that. Appendix B provides an outline letter regarding
online delivery of CBT-ED, to help the patient to understand and
engage in the process. The letter can easily be adapted to other psy-
chological therapies, of course.
The patient might see the telehealth approach as “second-best”. The
following concerns are largely ones that therapists raised as poten-
tially being issues for the patient. Thus, they are hypothetical, but
ones where the clinician needs to be prepared as the current Corona-
virus situation continues and develops, in case they are raised by
patients.
• The therapist should stress that it is “business as usual” in therapy
terms:
 use the protocol explicitly; continue to maintain key elements
(e.g., agenda-setting, monitoring progress, behavioral change,
maintaining boundaries),
 remain professional in dress, timekeeping,
 stay on track (e.g., no distraction from the telephone, checking
email).
• If the patient has already started face-to-face therapy before mov-
ing to telehealth, this can be framed as a positive shift of responsi-
bility to the patient.
• If the patient asks to suspend therapy when they hear that the
therapy will be online, the first step should be to explore their con-
cerns and predictions and whether they can be addressed within
1135
therapy. It can be useful to ask the patient to experiment with
online now and if that does not work then they can try face-to-face
later, so they lose nothing but might get better earlier. This can
become a behavioral experiment where predictions are tested.
• Ensure that the therapy does not shift into a pattern of supporting
the patient in remaining unchanged. This active attitude by the
therapist reduces the risk of socializing the patient into becoming
passive because of the therapist's lack of belief in the possibility of
change.
Patient or therapist concerns that therapy cannot work in this way.
• Lots of positive reinforcement for changes that the patient does
make, to stress how well they are learning even in this context.
• Stress that they normally would be doing therapy 167 hr a week
without the therapist being there, so the amount of time that they
would be working without the therapist in the room is far more
useful and important than the time with the therapist present.
• Review the experience at the end of each session (use of the
session rating scale may be helpful) and reinforce the patient by
pointing out that you are covering the necessary material
with them.
• Consider the personal experience of therapists who are used to
working via telehealth. Several therapists shared that they had
already been working remotely in this way for many years and
reported that they find it works well. Such therapists might be
asked to coach teams and supervise clinicians who are new to
delivering treatment via telehealth.
3.3 | Technical issues
A large number of points raised related to practical issues, such as
what software platform is most useful for this work, and how to
ensure that work that is normally done using paper and pen can be
maintained under this new way of working. A wide range of experi-
ences and suggestions were shared. It is important for therapists to
remember that the options might seem daunting if they have not been
used before, but they are all relatively straightforward methods, which
can be learnt quickly by clinicians who are naïve about them (as was
the case for many contributing clinicians). Remember that the key is
to ensure that the patient and the therapist communicate—the thera-
pist is the key to delivery of the therapy, and the technology is just a
tool to making that possible.
3.4 | Technology experiences
• Software choices were generally positive about the use of Zoom,
Facetalk, Google Meets, Vsee, and Microsoft Teams, due to experi-
ences of reliability and quality of images.
 Others were seen as less reliable, and insufficiently secure for
this purpose (particularly Skype and Facetime),
 Reduce public accessibility on some platforms (e.g., do not share
links on social media), or there is a risk of inappropriate material
1136
being sent to you, including during sessions (e.g., “Zoom
bombing”),
 Local recommendations should be followed regarding appropri-
ate technology to use and gaining patient consent to use those
technologies,
 Make sure that you are working within your organization's
guidance regarding software use.
• Platforms that let more than two people take part (e.g., Vsee,
Zoom; Google Meet) can help with family involvement, but ask
people to turn off their microphones when they are not talking, to
help with audibility.
• Some platforms allow you to use “talk to text” (e.g., turn on “cap-
tions” in Google Meet'), to help those who have trouble hearing.
The transcription (in English, at least) is pretty good in Google
Meet, but you cannot save it.
• Privacy needs to be ensured as far as possible, which might mean
the patient and therapist using headphones if total privacy cannot
be guaranteed (e.g., the therapist or the patient having children
nearby).
• Remember to turn off alerts on your computer or phone, as they
will interrupt the session, and ask the patient to do likewise.
• Turn off “assistant” devices (e.g., Alexa, Siri, Google home), as they
could be recording and disseminating confidential information.
• The telephone alone can be used effectively if that is all that is
available but was generally felt to be less useful than video com-
munications, and there were concerns about patients having access
to therapists' personal numbers.
 Maybe start with audio and swiftly work up to video if the
patient has concerns about seeing their own image. Alterna-
tively, ask the patient to block looking at distressing parts of
their own image at first if they cannot tolerate it, but only for a
short time.
 Discuss preferences with the patient, and experiment with what
actually works better for them.
 Turn off your number when calling, to block the patient learning
your number, especially of the phone is your own. This can be
done in different ways (e.g., dialing 141 before the number in
the UK).
• Headsets can be useful to enhance audibility and ensure confiden-
tiality, but they also look unnatural (the “call-center” look), so use
only if necessary.
• Ensure that you and the patient have the necessary internet/phone
connections, and that costs are considered (e.g., if the patient has a
very limited internet connection or phone plan).
• Where using video links, camera placement at both ends should be
attended to, to ensure that both the therapist and patient can see
each other as well as possible (e.g., allowing both to read non-
verbal cues).
Communicating written material. Overall, the importance of con-
tinuing to get the patient to self-monitor and to report food intake and
psychological status was stressed, both on a session-by-session basis
and at the end of treatment. Similarly, it was widely suggested that
WALLER ET AL.
psychoeducation materials should be sent to the patients. A number of
recommendations were made for making this possible:
• Diaries and questionnaires can be completed as normal and
scanned/sent by email, completed electronically and emailed, or
completed on the patient's phone and sent in (all to arrive before
the treatment session, including ahead of the first session).
Platforms such as Zoom allow for sharing of documents in session.
• Resources were identified as being available for clinicians to access
freely, including diaries and psychoeducation materials (see Appen-
dix A).
• The TinyScanner app was recommended as allowing you to scan
from your phone to a pdf document for emailing. Patients are
reported to be very positive about this.
• Online diaries were recommended (including “Rise Up and
Recover” and “Recovery Record”).
• Patient consent and secure communication methods are also
important to ensure. It was agreed that a handout for patients on
how to prepare for CBT-ED via telehealth would be valuable, and
this is provided in Appendix B for clinicians to use and adapt as
appropriate.
3.5 | Impact of changes in the environment
While these impacts vary with the degree of enforced or voluntary
social isolation that countries implement at different stages in the
Coronavirus pandemic, the following suggestions were made:
• Where the patient experiences a reduction in opportunities to
exercise (e.g., closure of gyms; reduced opportunity to exercise or
spend time outdoors), that can lead to concerns about potential
impact on weight and fitness, as well as the loss of an anxiety man-
agement technique. In such cases, acknowledging that these out-
comes are possible but are context-dependent, and that any
changes are reversible following the period of reduced activity.
The attitude of “will there really be a better time to address your
eating disorder than now?” can be a helpful one to communicate to
the patient.
• Stress the potential positives of some of these environmental
changes (e.g., the closure of gyms and the lack of access to “binge
foods”), as they give the opportunity to learn that these behaviors
are not essential.
 However, where patients say that they believe that they are only
engaging in fewer behaviors because those behaviors are no lon-
ger available, it is important to reframe the situation, helping
them to attribute their progress to the cognitive and emotional
changes that they have been working hard to bring about
(e.g., “If you had really wanted to exercise, you could have done
it, but instead you chose to do the exposure work that helped
you face and reduce your anxiety, so well done.”).
• Supply chain problems, panic buying and limited opportunities to
shop can mean that there is limited access to some foods or
WALLER ET AL.
brands, and reduced opportunities to expose and experiment with
foods. In such cases, reviewing the pattern of healthy eating and
how it can be achieved flexibly is important, so that the patient is
aware that nutritional needs can still be met, even if anxiety is
raised to do so (e.g., trying a novel food or brand).
• A small number of patients express a fear of exposure to the
COVID-19, and its consequences. While it is important not to
downplay that risk, the following should be raised in order to
ensure that the patient stays on track:
 Using online resources to explain how to eat a healthy, balanced
diet (e.g., British Dietetic Association; American Academy of
Nutrition and Dietetics, The Real Food Guide), which will sup-
port general health (including maintaining the immune system)
to maximize ability to cope with any infection (see Appendix A),
 Following Governmental and WHO advice regarding reducing
the risk of COVID-19 infection.
• Where the patient wants to talk about their anxiety about COVID-19
to the exclusion of the CBT-ED, address:
 The importance of eating to ensure health (see above),
 Controlling what one can, so focusing on recovery from the eat-
ing disorder,
 Using the patient's experience of tolerating anxiety in their eating
disorder treatment to manage their anxiety regarding COVID-19,
 The validity of their concerns about COVID-19 can be
addressed and used to support the importance of taking care of
their physical health (including addressing the eating disorder).
3.6 | CBT-ED related techniques, and how to apply
them in the telehealth context
The following are adaptations of existing CBT-ED techniques, as
described in evidence-based approaches (e.g., Becker, Farrell, &
Waller, 2019; Fairburn, 2008; Waller et al., 2007, 2019), as suggested
by clinicians here.
Eating adequately. Obviously, changes in eating behaviors are cen-
tral to the nutritional, cognitive and emotional needs of all patients
with eating disorders. Patients can be concerned that particular foods
and brands will not be available, and that this will mean that they can-
not eat as planned. Suggestions around this area included:
• Maintain a stance of “no excuses—you can do this and can rise to
the challenge”
• Enhancing the psychoeducation that we would normally deliver,
stressing the importance of eating the wide range of nutrients that
are needed, and that those are available in a wide range of foods:
 Include information that is COVID-19 specific (see Appendix A).
• Encouraging exposure to new foods and brands, to overcome spe-
cific supply issues.
• Changing food shopping patterns (e.g., different shops; using
online shopping for food)
• Use existing quarantine food plans (food with an appropriate shelf
life and nutritional balance—see Appendix A).
1137
Exposure therapy. Exposure therapy is much easier to deliver
when the individual has wider opportunities to experience
unpredictable situations and to take risks that enhance their expe-
rience of anxiety and their consequent learning. Levels of isolation
and inactivity clearly limit such opportunities. Apart from how to
conduct mirror exposure for body image (see below), the following
clinical experiences and suggestions were shared:
• Using imaginal exposure where in vivo is not possible, including
getting patients to prepare plans for exposure post-lockdown
(as this will act as exposure in itself).
• Use virtual social eating opportunities (e.g., booking dates with fri-
ends to eat on webcam, or just catching up over coffee and a
snack). This can also provide an opportunity to wear avoided/less
concealing clothes in virtual company, if body concealment is a
safety behavior.
• Consider using the therapy session as an opportunity to conduct
food and/or body-related exposure activities.
• Use more take-out and delivery food options, where the contents
and calorie contents are not known, to enhance anxiety.
• Given the tendency for binge-eating episodes to occur in social iso-
lation, stress to the patient that the current social climate is an
opportune time to utilize cue exposure to break the association
between social isolation and binge eating.
Weighing and linking it to eating. Open weighing is a core element
of CBT-ED (Waller & Mountford, 2015). However, we also want to
ensure that weighing does not turn into checking, which might mean
that we have previously advised the patient to get rid of their own
scales. Therefore, we need to adapt the usual protocols to telehealth
approaches. Suggestions were:
• Ask the patient to get out the weighing scales that we asked
them to put away, or order a new set online, for use only in this
therapeutic context. Until scales are available, then self-
measuring using specific items of clothing can be used as a
substitute.
• Complete weight charts electronically based on the readings, so
that you can send the patient a copy by email (an Excel version
was offered by one colleague).
• Explain to the patient that scales differ and that their initial weight
might differ from their last reading on the therapist's scales (and
that their own scales might have greater variability).
• Get the patient weighed by other professionals if they have medi-
cal appointments.
• Ask family and carers to assist with this process if appropriate (but
there needs to be a positive justification for doing so, as this could
cause further difficulties).
• Ensure that the patient self-weighs during the session, so that you
can implement the process of enhancing “hot” cognitions by dis-
cussing food intake just before weighing, to enhance excessive
weight predictions and consequent learning about true weight out-
comes (Waller & Mountford, 2015).
1138
There were a number of concerns about how to ensure reliable and
valid weight measurements when the therapist was not present to check
on the process. While there was mention of very high-tech scales that
would send in weight readings electronically, these were not expected to
be available in the great majority of cases. Lower-tech suggestions
included:
• Ask the patient to video or photograph the scales to send in the
reading to validate their stated weight,
• Ask family to monitor the readings to help the patient to be open
about their weight, if necessary (but not automatically, and consid-
ering the potential drawbacks).
Drawing diagrams. As above, it is possible to share weight charts by
email. However, CBT-ED uses a number of other diagrammatic tools
(energy graphs; cognitive records; pie charts; formulations). With screen
sharing, these can be discussed in real time with the patients and can
even be typed up or drawn in real time with some practice. Suggestions
included:
• If you are using a good enough resolution video platform (see
above for recommendations) that allow sharing, then you can draw
the diagram and show it to the patient as you proceed. If you are
doing this, remember to:
 check that the patient can see it,
 suggest that they copy it as you go (or scan and send it later—
see above for advice on how to do this with your phone),
 use a thick pen to draw diagrams (overcomes the problem of
low-resolution cameras).
Body image work. Some elements of body image work are rela-
tively easy to set for the patient to undertake outside of the therapy
session, so can be conducted as usual (e.g., psychoeducation; body
checking experiments, especially if the patient has now been asked to
buy scales—see above). However, others require greater adaptation to
be effective via telehealth. These include the following, which clini-
cians suggested based on their experiences:
• Use of surveys was reported to be relatively easy to maintain,
using video methods to screen-share the outcomes (whether col-
lated and presented by the patient or by the therapist). Whoever
is distributing the survey, clinicians reported that there was no
difficulty in recruiting people to deliver the ratings, as survey plat-
forms (e.g., Surveymonkey; Qualtrics) and social media
(e.g., Facebook) allow others (e.g., colleagues, friends) to be con-
tacted to do so.
• Comparison experiments can become much more difficult to con-
duct under conditions of social isolation, where one might not see
many people all day. Where such experiments (the impact of com-
paring your body to others' vs. not comparing your body to
others'), then it can be valuable to present this as a naturalistic
experiment (“how do you feel about your body now that you are
WALLER ET AL.
not comparing it all day vs. when you used to do so?”). If the
patient does a lot of body comparison on social media, then that
can still be used as the basis of a controlled experiment, of course.
• Mirror exposure remains possible when working with a video link,
though it requires careful positioning of the webcam without
becoming a distraction. It is even more important to get the patient
to do mirror exposure for homework between sessions, in order to
maximize the dose.
 An alternative approach that was suggested is for the patient to
use their computer screen to show their image, while the thera-
pist can also see it and can engage the patient in describing their
body, detailing anxiety levels, etc. This is possible with some
platforms (e.g., Google Meet) if the patient's image is “pinned”
to the main screen. While this method can be harder to set up
with a small screen, it is possible, and patients find it challenging
in the short term (as with in-person mirror exposure), but a good
launch base for repeated exposure for homework.
Working with core beliefs. Negative core beliefs often underpin
emotionally driven eating behaviors (e.g., binging to block emotions)
and body image (e.g., where there is a trauma history). The clinicians
note that:
• The majority of work with those core beliefs is cognitive, and the
necessary exploration, formulation, historical review and attribu-
tional work can still be carried out remotely, as long as the patient
is stable enough to tolerate the experience.
• Both imagery rescripting and chairwork/role play methods are still
possible online.
• Encouraging counter-schematic behaviors (e.g., mixing with other
people) can be more challenging, though some of it can be
achieved over the phone or online (e.g., addressing fears of aban-
donment by explaining true feelings to a friend).
• Environmental change might mean that there are fewer triggers to
these emotional states (though loneliness and frustration might be
more likely). This contextual difference gives clinicians the oppor-
tunity to stress that the core beliefs and emotions are situation-
specific, rather than being fundamental to the patient, thus helping
with re-attribution.
Group work. There were questions regarding whether group ther-
apy could work online (e.g., would the group connect and feel safe).
The experience of a large number of clinicians was that:
• Patients find that online groups are effective under these
conditions.
• Clinicians who were previously running groups online were finding
that such groups were no more or less effective than they had
been before the pandemic conditions set in.
• There were positive comments about the experience of running
online groups for binge-eating disorders and for low-weight
adolescents.
WALLER ET AL.
Post-session contact.
• Consider emailing a summary to the patient after the session, sum-
marizing what has been covered, what the plan is, and the broad
agenda for next time.
3.7 | Attention to local regulatory frameworks
Of course, all of the above should be considered within the regulatory
frameworks that apply to all telehealth and data sharing. These will be
set by employers (e.g., what platforms can be used), professional bod-
ies such as the American Psychological Association—see Appendix A,
and governments (e.g., data protection). These frameworks are there
to protect the therapist and patient alike, and all psychotherapists
should be observing them to ensure safe and good practice.
4 | DISCUSSION
This article is a summary of the ideas that emerged from clinicians
who took part in an online approach to CBT-ED in the context of the
Coronavirus on patients, clinicians and services. It is provided so that
we can respond helpfully to this pandemic. We note that some of the
ideas are specific to the restrictions inherent to the pandemic, which
has resulted in many therapists working from home, introducing
unique technical, logistical, and psychological challenges. Under more
normal circumstances, telehealth would normally be conducted from
the therapist's workplace. It is in no way a scientifically robust paper,
having been based on a limited sample and the ideas that were
expressed in the first 96 hr of sharing ideas and experiences. We
encourage clinicians to visit the relevant Google sheet to identify new
ideas that have been added since then, and to contribute their own.
We hope that these suggestions support clinicians in their innova-
tive use of CBT-ED, but we found that many of the suggestions could
be applied to all therapies. In future, it would be useful to undertake
similar studies of the application of other therapies for eating disor-
ders under such unusual circumstances, using more structured
methods (e.g., Delphi approaches) than were possible in this short
timeframe. Similarly, it will be valuable to compare these conclusions
about CBT-ED with recommendations that emerge for the treatment
of other disorders, to establish common lessons across disorders as
well as therapies. Of course, there are clinicians who are well-versed
in the delivery of telehealth, for whom these conclusions might be
seen as relatively obvious, and we welcome their supportive contribu-
tion to the suggestions outlined here. However, while there is some
recent preliminary evidence that telehealth can be effective in FBT for
adolescents with anorexia nervosa (Anderson et al., 2017), many clini-
cians have found this transition to be a new experience, and that has
led to the need to think about transitions and future practice.
Such work might be seen as running the risk of taking us away from
evidence-based protocols (e.g., Fairburn, 2008; Waller et al., 2019), but
we would argue that this approach is simply using the flexibility to the
1139
individual patient's needs that ought to be seen as inherent in such pro-
tocols (Wilson, 1996). Existing telehealth methods have already devel-
oped some evidence for this approach, though not under these
exceptional circumstances. The only way of knowing whether these
clinical recommendations are useful is to try them out and to evaluate
the outcome. We suggest that clinicians should use their existing data
collection methods to compare their patients' outcomes across cohorts
based on patients who were treated face-to-face before the current
COVID-19 pandemic, patients treated entirely by telehealth methods
during this period, and (possibly most interesting) those whose treat-
ment modality was forced to change during therapy as a result of the
changes in healthcare provision. We also recommend online supervision
to keep therapists on track with the delivery of protocols.
In the short term, we hope that therapists will learn enough from
these clinical recommendations to be potentially more flexible in their
delivery of evidence-based therapies, particularly in the context of
any future disruptions to normal service delivery. However, this exer-
cise in sharing information and developing consensus in a relatively
short time frame also has longer term benefits. At a later stage, it is
also possible that what we learn from these responses to the current
crisis might teach us to be more effective in delivering telehealth in
routine practice, enhancing the accessibility of effective treatment for
eating disorders when normal service is resumed.
CONFLIC T OF INT ER E ST
The authors declare no conflicts of interest.
DATA AVAILABILITY STAT EMEN T
The data used are available on the original online form: https://docs.
google.com/document/d/1n5X1zC_4lHMUH3V0JF8ZvEWhKFTZrjK
zUYo6DwxPrco/edit.
OR CID
Glenn Waller https://orcid.org/0000-0001-7794-9546
Tracey D. Wade https://orcid.org/0000-0003-4402-770X
Bronwyn Raykos https://orcid.org/0000-0003-3640-4229
Jennifer J. Thomas https://orcid.org/0000-0003-2601-581X
Hannah Turner https://orcid.org/0000-0003-4338-5476
Tom Hildebrandt https://orcid.org/0000-0001-7054-9590
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2018.06.010
Acierno, R., Gros, D. F., Ruggiero, K. J., Hernandez-Tejada, B. M., Knapp, R. G.,
Lejuez, C. W., … Tuerk, P. W. (2016). Behavioral activation and therapeu-
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Acierno, R., Knapp, R., Tuerk, P., Gilmore, A. K., Lejuez, C., Ruggiero, K., …
Foa, E. B. (2017). A non-inferiority trial of Prolonged Exposure for post
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Becker, C. B., Farrell, N., & Waller, G. (2019). Exposure therapy for eating
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Giel, K. E., Leehr, E. J., Becker, S., Herzog, W., Junne, F., Schmidt, U., &
Zipfel, S. (2015). Relapse prevention via videoconference for anorexia
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Parikh, S. V. (2017). A pilot study on telephone cognitive behavioral
therapy for patients six-months post-bariatric surgery. Obesity Surgery,
27, 670–675. https://doi.org/10.1007/s11695-016-2322-x
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Thomas, J. J., & Eddy, K. T. (2018). Cognitive-behavioral therapy for avoid-
ant/restrictive food intake disorder. Cambridge, England: Cambridge
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Mountford, V., & Russell, K. (2007). Cognitive-behavioral therapy for the
WALLER ET AL.
eating disorders: A comprehensive treatment guide. Cambridge, England:
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behavioural therapy for eating disorders: How, when and why. Behav-
iour Research and Therapy, 70, 1–10. https://doi.org/10.1016/j.brat.
2015.04.004
Waller, G., Turner, H. M., Tatham, M., Mountford, V. A., & Wade, T. D.
(2019). Brief cognitive behavioural therapy for non-underweight patients:
CBT-T for eating disorders. Hove, England: Routledge.
Wilson, G. T. (1996). Manual-based treatments: The clinical application of
research findings. Behaviour Research and Therapy, 34, 295–314.
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Yuen, E. K., Gros, D. F., Price, M., Zeigler, S., Tuerk, P. W., Foa, E. B., &
Acierno, R. (2015). Randomized controlled trial of home-based
telehealth versus in-person prolonged exposure for combat-related
PTSD in veterans: Preliminary results. Journal of Clinical Psychology, 71,
500–512. https://doi.org/10.1002/jclp.22168
How to cite this article: Waller G, Pugh M, Mulkens S, et al.
Cognitive-behavioral therapy in the time of coronavirus:
Clinician tips for working with eating disorders via telehealth
when face-to-face meetings are not possible. Int J Eat Disord.
2020;53:1132–1141. https://doi.org/10.1002/eat.23289
AP PE NDIX A: Resources identified to assist clinicians and patients
Google sheet detailing the topics raised and suggestions made:
https://docs.google.com/document/d/1n5X1zC_4lHMUH3V0JF8
ZvEWhKFTZrjKzUYo6DwxPrco/edit
Existing guidelines about delivering psychotherapy via telehealth:
https://www.apa.org/practice/guidelines/telepsychology
https://www.nationalregister.org/npc-telepsych-video/
https://www.crpo.ca/implementing-electronic-practice/
Online measures, diaries, psychoeducation materials, etc.:
Centre for Clinical Interventions—https://www.cci.health.wa.gov.
au/Resources/Looking-After-Yourself/Disordered-Eating (including
fillable pdf forms that can easily be returned online).
CREDO site—https://www.credo-oxford.com/4.4.html
BEAT—https://www.beateatingdisorders.org.uk/coronavirus
NEDIC—https://nedic.ca/covid-19-ed-faqs
CBT-T website—http://cbt-t.group.shef.ac.uk/
Eating to support the immune system:
https://www.eatright.org/health/wellness/preventing-illness/how-
to-keep-your-immune-system-healthy
COVID-19 specific dietary advice:
https://www.bda.uk.com/resource/covid-19-corona-virus-advice-
for-the-general-public.html
Example of quarantine food plans:
e.g., https://www.recipetineats.com/coronavirus-menu-plan-1
Professional bodies' toolkits and courses for newly remote workers
and the delivery of telehealth:
https://www.apa.org/news/apa/2020/03/newly-remote-workers
WALLER ET AL.
https://www.apa.org/education/ce/telehealth-001 (currently a free
course)
https://www.psychiatry.org/psychiatrists/practice/telepsychiatry/
toolkit
https://education.psychiatry.org/
https://education.smiadviser.org/Users/ProductDetails.aspx?
ActivityID=7257
APP E NDIX B : Information sheet for patients undertaking online
CBT-ED
Online therapy for eating disorders
Coronavirus has led to changes in the way that mental health services
deliver talking therapies. In order to limit face-to-face contact, many
services now provide therapy online (sometimes exclusively). This
information sheet explains how internet-based (cognitive behavioral
therapy for eating disorders [iCBT-ED]) (brief cognitive behavioral
therapy for eating disorders [iCBT-T]) is delivered and how you can
prepare for the start of your treatment.
We are aware that online therapy may not be your preferred
method of treatment or the treatment that you originally agreed
to. However, it is important that face-to-face contact is limited in
order to protect your health and the health of others. Given that the
process and content of [iCBT-ED/iCBT-T] is no different to face-to-
face therapy, there is no reason that it should be less effective than
therapy delivered in person.
Structure of iCBT-ED/CBT-T
iCBT-ED/T for [DIAGNOSIS] is provided over [NUMBER] sessions. Your
treatment will be reviewed [REGULARLY/AT SESSION x]. Sessions are
provided on a weekly basis and will last approximately 50 min. Attending
sessions consistently are vital to your treatment being effective.
Your therapist will contact you at the specified time using [PLAT-
FORM]. It is important that you are ready to meet at the agreed time.
Please be aware that your therapist cannot be contacted using
[PLATFORM] outside of your appointments.
Preparing for your sessions
What you will need:
You will need a pen and paper for each your sessions. Monitoring
your weight plays an important role in CBT-ED/T. For this reason, you
also need access to weighing scales during your appointments. Your ther-
apist will discuss this with you in more detail during your first meeting.
Software:
You will be using [PLATFORM] for your therapy sessions. It is a
good idea to practice using [PLATFORM] before your first session so
that you are familiar with how it works. This also ensures that your
software is up-to-date.
1141
Hardware:
It can be difficult to focus on therapy sessions if you are using a
small mobile phone screen which is easily moved. We recommend
using either a laptop or desktop computer. If you only have a phone
or tablet, please make sure it is on a stable stand.
Connectivity:
Poor internet connection can disrupt online therapy sessions.
Prior to your session, make sure that you are somewhere that your
access to the internet is strong and reliable. This may mean finding a
place that is close to your internet router.
Location:
It is important that you find a space that feels safe, comfortable,
and will not be disturbed during your therapy sessions. If possible, find
a place that you can use throughout the course of your treatment.
Public places and talking while driving are not recommended.
Privacy:
It is important that your sessions are private and confidential. Find
a location where you will not be interrupted, and you are able to speak
freely. If needed, let the individuals around you know that they should
not disturb you for the duration of your meeting. You may find it help-
ful to use headphones or a headset during your sessions if others are
nearby.
Distractions:
Try to limit things that might distract you during your sessions.
These might include the TV or radio, nearby conversations, phone calls,
noisy animals, drinking, or smoking. Remember that your therapist will
need to do the same if working from home.
Contact between appointments
Contact between your therapy sessions is limited. Your therapist
may email you between appointments for the following reasons:
• To summarize your session.
• To send you resources discussed during the appointment.
• To send appointment confirmations or notify you of appointment
changes.
Your contact with your therapist should focus on key tasks of
therapy, such as sending them copies of your homework prior to your
next session. Please remember that therapy for your eating disorder
should be going on all week, so the work you do between sessions is
really vital, and you should discuss problems and how you solved
them during your therapy sessions.
Matthew Pugh
With thanks and credit to Conor O'Brien, Lauren Antinoro, and Xi Liu
 pISSN: 0126-074X | eISSN: 2338-6223
RESEARCH ARTICLE MKB. 50(4):46–52
http://dx.doi.org/10.15395/mkb.v51n1.1577

Influence of Adolescents’ Smartphone Addiction on Mental and Emotional

Development in West Java, Indonesia

Meita Dhamayanti,1 Resti Gradia Dwiwina,2 Rubiah Adawiyah3

Department of Child Health Faculty of Medicine Universitas Padjadjaran/Dr. Hasan Sadikin General Hospital
1

Bandung, Indonesia, 2Department Biomedical Sciences, Faculty of Medicine, Universitas Padjadjaran, Indonesia,
3
Study Program of Undergraduate Medicine, Faculty of Medicine, Universitas Padjadjaran, Indonesia

Abstract

Smartphone use is widespread globally, including in Indonesia. The excessive use and ubiquity of smartphone
technology raise concerns on addiction and its effects on mental and emotional development of adolescents. This
study aimed to analyze the correlation between smartphone addiction and mental-emotional disorders in early
adolescents aged 11–12 years old in several primary schools in Bandung City and Sumedang District. This study
was performed October to December 2018. This was a cross-sectional study using convenient sampling technic
with unpaired categorical data for subject selection. Subjects were assessed with the Smartphone Addiction
Scale Short Version (SAS-SV) and Strength and Difficulties Questionnaire (SDQ) which were self-administered by
subjects. Subjects were classified into low level and high level smartphone user groups. Data were analyzed using
chi square test. Out of 206 subjects, only 178 met the inclusion criteria with 44.9% (n=80) and 55.10% (n=98)
were in high- and low-level of smartphone addiction. The percentage of mental and emotional problems based
on SDQ that was included in the normal, borderline, and abnormal category was 60.7, 21.9, 17.4, respectively.
Those with high-level smartphone addiction had mental and emotional problems with 1.425 prevalence ratio
and CI95% 1.141–1.779. In conclusion, there is correlation between smartphone addiction on mental emotional
problems of early adolescent.

Key words: Early adolescent, smartphone addiction, mental and emotional, West Java, Indonesia

Pengaruh Kecanduan Gawai pada Perkembangan Mental dan Emosional

Remaja di Jawa Barat, Indonesia

Abstrak

Pemakaian gawai sudah menyebar ke berbagai negara termasuk Indonesia. Pemakaian gawai sendiri memiliki
dampak positif serta negatif. Salah satu dampak negatif yaitu mengalami kecanduan gawai sehingga mempengaruhi
emosi dan perilaku dan juga dapat menurunkan produktifitas serta kualitas hidup. Tujuan penelitian ini adalah
untuk menganalisis hubungan pengaruh kecanduan gawai terhadap gangguan mental emosional pada remaja
awal usia 11–12 tahun. Metode penelitian menggunakan analitik pontong lintang dari beberapa Sekolah
Dasar Kota Bandung dan Kabupaten Sumedang pada Oktober sampai Desember 2018. Subjek dipilih dengan
metode convenient data kategori tidak berpasangan Subjek mengisi kuesioner yang berisi data sosiodemografi,
Strength Difficulties Questionnaire (SDQ) dan Smartphone Addiction Scale–Short Version (SAS-SV). Subjek dibagi
2 kelompok tingkat kecanduan rendah dan tinggi. Data yang diperoleh dianalisis dengan menggunakan uji chi
square. Dari 206 sebanyak 178 memenuhi kriteria. Subjek dengan tingkat kecanduan gawai tinggi sebanyak 80
(44,9%) dan rendah 98 (55,1%). Persentase gangguan mental emosional normal (60,7), borderline (21,9) dan
abnormal (17,4). sebanyak 31 responden atau 17,4%. Terdapat hubungan bermakna Tingkat kecanduan gawai
yang tinggi dan masalah mental emosi (rasio prevalens 1,45 (IK 1,141–1,779). Simpulan, terdapat hubungan
tingkat kecanduan gawai dan masalah mental emosio remaja awal usia 11–12 tahun.

Kata kunci: Gawai, mental emosional, remaja awal

Corresponding Author: Meita Dhamayanti, Department of Child Health Faculty of Medicine Universitas Padjadjaran/
Dr. Hasan Sadikin General Hospital Bandung, Jalan Pasteur No. 38 Bandung, 40161, West Java, Indonesia, Email: meita.
dhamayanti@unpad.ac.id

46 Majalah Kedokteran Bandung, Volume 51 No. 1, March 2019

M. Dhamayanti, et al: Influence of Adolescents’ Smartphone Addiction on Mental and Emotional Development in West Java,, Indonesia
Introduction
Smartphones are an instrument that has a
particular function, designed to be practical
and sufficiently advanced to be used in daily
activities. Smartphone usage has become
widespread globally. Indonesia is the 5th
highest smartphone user in the world that
takes 54% of total screen time.1 Smartphone
use in Indonesia has risen sharply since 2012;
91% of Indonesian have a mobile phone, with
all age groups using smartphones from pre-
schoolers to parents.2 Pre-schoolers are able
to operate the smartphones with or without
parental supervision. Smartphones can be used
for a variety of purposes ranging from playing
games, listening to music, watching videos,
and accessing information and social media via
internet. Previous studies indicated that the
majority of smartphone uses were related to
entertainment purposes (such as video games),
although there were other uses for smartphones,
such as study aid and for praying.3 The majority
of smartphones are used to access the internet.
Internet users in Indonesia in 2016 reach 132.7
million users from 256.7 million Indonesians,
which approximately 51.7% of all Indonesians
have access to internet; while in 2017, internet
users reach 143.26, which approximately
54.7% of the total population of Indonesia. The
majority of internet users live in Java island (86.3
million users or 65% of the total population of
Indonesia). The majority of internet users are
children and adolescents consisting of 79.5%
of all internet users in Indonesia, particularly in
5–12 year old age group. Internet users in urban
area are more than semi-urban area and rural
area.4
Smartphones may be used as tools to aid
learning and as entertainment media for
children. Although there are many positive
impacts of gadgets that facilitate teenagers,
excessive usage is always not a good thing.
Excessive smartphone usage may lead to dry
eyes due to inadequate blinking and may
significantly decrease social interactions of the
children. Social interaction is defined as social
relationship between individuals and is one
of many aspects of social life. Through social
interactions, children will learn how to live in a
society and to know better about themselves.3
Smartphone addiction may affect emotional and
behavioral development, and may also adversely
affect productivity and quality of life. Previous
studies have shown correlation between severity
of smartphone addiction and emotional and
Majalah Kedokteran Bandung, Volume 51 No. 1, March 2019
behavioral disorders.5,6
According to World Health Organization
(WHO), there are 20% children and adolescents
suffering from mental disorders. The prevalence
of mental disorders in Europe and United states
are 16.3%, 17.8%, 16%, and 18.4% for 8 years
old, 13 years old, 18 years old, and 25 years old,
respectively.7 There are approximately 12.5% of
children aged 6–12 years old with emotional and
behavioral disorders in Singapore8.
Mental and emotional disorders are a form
of psychological distress. According to the 2013
Indonesia Basic Health Research (IBHR), the
prevalence of mental and emotional disorders
in Indonesia is 6%, with the highest prevalence
rate found in Central Sulawesi, South Sulawesi,
West Java , Yogyakarta and East Nusa Tenggara.
The lowest prevalence of mental and emotional
disorders in Indonesia was found in Lampung
. The prevalence rate of mental and emotional
disorders in West Java is higher compared to the
national average(9.3% vs 6%).9
Psychosocial stressors may act as one
of many triggers to mental and emotional
disorders. Cognitive development of children
may be adversely affected by such disorders,
leading children to view their environs more
negatively and tend to have a more negative self
-perception. Parents may also complain about
lack of social interaction with their child, limiting
the communication between them. Children aged
9–13 years old are still significantly affected by
their interactions with their parents. Children
aged 12 years old have the highest prevalence of
emotional disturbance.8
According to prevalence data from the
2007 and 2013 IBHR, there are differences
of prevalence rate according to the location.
According to the 2007 IBHR , rural areas have
higher prevalence of mental and emotional
disorders, while according to the 2013 IBHR,
urban areas have higher prevalence of mental
emotional disorders compared to the rural
areas.9 A study by Firmansyah, et al., 2018 found
significant differences in prevalence of mental
and emotional disorders between urban and
semi-urban areas. Urban areas have significantly
higher prevalence of mental and emotional
disorders compared to semi-urban areas. The
patterns are corresponding to data from the
2013 IBHR, with the aforementioned study
found higher rates of mental and emotional
disorders in urban areas compared to rural
areas. Smartphone use may be one of many
factors that may correlate with higher rates of
mental disorders in urban areas.10
47
M. Dhamayanti, et al: Influence of Adolescents’ Smartphone Addiction on Mental and Emotional Development in West Java,, Indonesia
The aim of this study was to analyze the
correlation between smartphones on mental
and emotional development of early adolescents.
This study may improve the knowledge regarding
smartphone addiction and its relationship on
mental disorders on early adolescents. The
information acquired from this study may aid
educational institutions regarding students with
mental and emotional problems. Future studies
may be required to consolidate the findings of
this study, of which this study may provide the
groundwork necessary for future study of the
same topic.
Methods
The cross-sectional study with unpaired
categorical data was conducted from October to
December 2018. The selected study population
of this study was early adolescents aged 11–
12 years in primary schools of Bandung City
and Sumedang District. The primary schools
selected for this study was Sekolah Dasar Negeri
(SDN) Cibesi, SDN Hegarmanah, SDN Jatinangor,
SDN Cikuda, and SDN Sayang in Sumedang
District, and SDN 048 Sirnamanah and SDN 018
Sukagalih in Bandung city. The sampling method
used convenient sampling technique and the
minimum sample size for this study was 178
subjects. The inclusion criteria in this study were
students in primary school, aged 11–12 years
and smartphone users. The exclusion criteria
in this study were ill students and students
who were absent from school. The instruments
were informed consent, sociodemographic data,
Smartphone Addiction Scale Short Version (SAS-
SV) questionnaire, and Strength and Difficulties
Questionnaire (SDQ).
The severity of smartphone addiction was
assessed using SAS-SV,11 which was modified
to Indonesian version.12 Mental and emotional
disturbances were assessed with SDQ,13 which
was modified to Indonesian version as well.8
Mental emotional problems were measured
using self-reported SDQ, which consisted of 25
attributes in questions, assessing total difficulties
(emotional symptoms, conduct problems,
hyperactivity/inattention, peer relationship
problems), and assessing total strength or
prosocial behavior. The SDQ was categorized
as normal, borderline, and abnormal. SAS-SV
consists of 10 attributes, which had 6 factors
such as affect of daily activity, positive anticipate,
withdrawal effect, cyberspace relationship,
excessive and tolerance. The SAS-SV was
48
categorized into high and low.
The analyzed variables were distribution of
patient characteristics according to gender, age,
socioeconomic status, frequency of smartphone
use, family status, smoking or no smoking status,
duration of smartphone use and purposes of
smartphone use. The sociodemographic results
were presented in Table 1. Frequencies of mental
and emotional disturbances were presented in
Table 2. Analysis of effects of smartphone use
on mental and emotional disturbances were
presented in Table 3 for Bandung City and in Table
4 for Sumedang District. Analytical statistics for
correlation between smartphone use and mental
and emotional disturbances were presented in
Table 4. Data analysis wasperformed using IBM®
Statistical Program for Social Science (SPSS) ®
version 25.
Before the study was conducted, ethical
clearance had been received from Ethical
Committee of Health Research Faculty of Medicine
Universitas Padjadjaran No. 0118091273.
Results
Out of 206 students, there were 178 students
who had inclusion criteria. The students were
primary school students in Bandung City and
Sumedang District.
According to the study results above (Table
1), there were 91 female students (51.1%) more
than male students. There were 105 students
(59%) aged 11 years with mean + Standard
Deviation (SD) of 11.41+0.493. According to
parental income, there were most in low income,
spesificly in Sumedang District. The majority of
students still had two parents in their family (174
students, 97.8%) than single parent. According
to student smoking status, there were 17
smokers (9.6%), majority in Sumedang District
(11 students, 12.4%). Based on smartphone use
duration, most of the students were categorized
as low (80 students, 44.9%). According to
smartphone use intensity, the students were
mostly in high categories (64 students, 36.0%),
specifically in Bandung City. The students used
smartphone mostly to communicate and send
text message (102 students, 57.3%).
The current study found 31 students
(17.4%) with abnormal functioning. Students
in Sumedang were more frequently abnormal in
functioning compared to students in Bandung.
Smartphone addiction assessment using SAS-SV
consisted of 80 students (44.9%) with high SAS-
SV. Students in Bandung were more frequently
Majalah Kedokteran Bandung, Volume 51 No. 1, March 2019
M. Dhamayanti, et al: Influence of Adolescents’ Smartphone Addiction on Mental and Emotional Development in West Java,, Indonesia

Table1 Sociodemographic Characteristics of Study Subjects

Sumedang Bandung Total
Variable n=89 n=89 n=178
n (%) n (%) n (%)
Gender:
Male 41 (46.1) 46 (51.7) 87 (48.9)
Female 48 (53.9) 43 (48.3) 91 (51.1)
Age (years):
11 45 (50.6) 60 (67.4) 105 (59.0)
12 44 (49.4) 29 (32.6) 73 (41.0)
Parental income/month:
IDR <1,5million 42 (47.2) 37 (41.6) 79 (44.4)
IDR 1.5–2.5million 10 (11.2) 16 (18.0) 26 (14.6)
IDR 2.5–3.5 million 22 (24.7) 12 (13.5) 34 (19.1)
IDR >3.5 million 15 (16.9) 24 (27.0) 39 (21.9)
Parental status:
Two parents 87 (97.8) 87 (97.8) 174 (97.8)
Single parent 2 (2.2) 2 (2.2) 4 (2.2)
Smoking:
Yes 11 (12.4) 6 (6.7) 17 (9.6)
No 78 (87.6) 83 (93.3) 161 (90.4)
Level of smartphone use
Duration (minutes):
31 (34.8) 50 (56.2)
75–120 (high) 51 28.7
28 (31.5) 19 (21.3)
40–60 (moderate) 47 26.4
30 (33.7) 20 (22.5)
5–30 (low) 80 44.9
Intensity:
32 (36.0) 32 (36.0)
>3 x/day (high) 64 (36.0)
24 (27.0) 33 (37.1)
2–3 x/day (moderate) 57 (32.0)
33 (37.1) 24 (27.0)
<2 x/day (low) 57 (32.0)
Goals of smartphone use:
Text messaging and communication 56 (62.9) 46 (51.7) 102 (57.3)
Entertainment 33 (37.1) 44 (49.4) 77 (43.3)
Study 44 (49.4) 56 (62.9) 100 (56.2)
Playing games 34 (38.2) 46 (51.7) 80 (44.9)
Telephone 20 (22.5) 37 (41.6) 57 (32.0)
Others 14 (15.7) 24 (27.0) 38 (21.3)

Table 2 Frequencies of Mentalemotional Disorders and SAS-SV

Sumedang Bandung Total
Characteristics n=89 n=89 n=178
n (%) n (%) n (%)
Mental Emotional:
Normal 50 (56) 58 (65) 108 (61)
Borderline 23 (26) 16 (18) 39 (22)
Abnormal 16 (18) 15 (17) 31 (17)
SAS-SV:
Low 56 (63) 47 (53) 98 (55)
High 33 (37) 42 (47) 80 (45)

Majalah Kedokteran Bandung, Volume 51 No. 1, March 2019 49

M. Dhamayanti, et al: Influence of Adolescents’ Smartphone Addiction on Mental and Emotional Development in West Java,, Indonesia

Table 3 Effect of Smartphones on Mental-Emotional Disorders in Bandung City

Mental Emotional Disorders
Effect of PR
Normal Borderline Abnormal
Smartphones (95% CI)
n (%) n (%) n (%)
Low 36 (86) 5 (12) 1 (2)
1.592
High 22 (47) 11 (23) 14 (30)
(1.220–2.077)
TOTAL 58 (65) 16 (18) 15 (17)
PR=prevalence ratio; CI=confidence interval; p<0.05 with chi-square test

Table 4 Effect of Smartphones on Mental Emotional Disorders in Sumedang Regency

Mental Emotional Disorders
Effect of PR
Normal Borderline Abnormal
Smartphones (95% CI)
n (%) n (%) n (%)
Low 38 (68) 9 (16) 9 (16)
1.280
High 12 (37) 14 (42) 7 (22)
(0.884–1.854)
TOTAL 50 (56) 23 (26) 16 (18)
PR=prevalence ratio; CI=confidence interval; p=0.008 with chi-square test

highly addicted compared to students in Discussion

Sumedang (Table 2).
According to the study above (Table 3–5),
there were 21 students (26%) who had
mental emotional disorders with smartphone
addiction; 14 students (30%) in Bandung and 7
students (21%) in Sumedang. Through bivariate
analysis using chi-square test, the study found
that smartphone had a significant affect with
total difficulties particularly regarding mental
emotional disorders as shown in Table 5 for
early adolescents (p<0.05) with PR (normal/
abnormal) and 95% confidence interval (CI) of
1.592 (1.220–2.077); 1.280 (0.884–1.854); 1.425
(1.141–1.779), respectively. Moreover, using Chi
Square test, the study found that smartphone
did not significantly affect prosocial behaviour
(p=0.895)
Today’s generation Z adolescents (born from
1995 to the present) are millennials, internet
generation, or digital natives. This generation
tends to have some problems if they are separated
to their gadgets in this era of globalization. They
always want to get short, up-to-date, and real-
time information with picture attached.14
In previous study, it was found that
smartphone addiction is significantly correlated
with mental emotional disorder. The result is in
line with a study by Ahmad Ramadhan (2017)
which also found that smartphone addiction
significantly correlated with emotional and
behavioral disturbances of adolescents.12 The
other study also concluded that internet user
addiction is an association among psychiatric
symptoms such as somatization, sensitivity,

Table 5 Effect of Smartphones on Mental Emotional Disorders in Bandung City and Sumedang
Regency
Mental Emotional Disorders
Effect of PR
Normal Borderline Abnormal
Smartphones (95% CI)
n (%) n (%) n (%)
Low 74 (76) 14 (14) 10 (10)
High 34 (43) 25 (31) 21 (26) 1.425
TOTAL 108 (61) 39 (22) 31 (17) (1.141–1.779)
PR=prevalence ratio; CI=confidence interval; p<0.05 with chi-square test

50 Majalah Kedokteran Bandung, Volume 51 No. 1, March 2019

M. Dhamayanti, et al: Influence of Adolescents’ Smartphone Addiction on Mental and Emotional Development in West Java,, Indonesia
depression, anxiety, aggression, phobias, and
psychosis.6
This current study also found that 44.9% of
students had high-level smartphone addiction.
In a study in India, it was found that 33.3% out of
total 87% who are smartphone user are in high-
level addiction as well.15 Hence, this finding is
corresponding to other studies that smartphone
usage may carry disadvantage effect, with one
of the most significant drawbacks of excessive
smartphone usage that is being addicted to
smartphone and decrease productivity and
quality of life.3,16 Furthermore, the study is similar
to a study conducted by Arifin and Rahmadi17 that
concluding that severe smartphone addiction is
correlated with academic achivements.
The current study found that Sumedang
District had higher rates of mental and emotional
disorder compared to rates in Bandung City.
However, this study contradicted the previous
data form the 2013 IBHR and a study conducted
by Rizqy Firmansyah9 concluding that rates of
mental emotional disorders are higher in urban
areas compared to rates in semiurban and rural
areas.10 The contradiction may be caused by
different population and age categories. Thus,
it is suggested to obtain in depth detail age
categories and large population.
The students in Bandung City are highly
addicted to smartphone compared to students
in Sumedang District. The study is in line with
APJII 2018 stating that internet users are mostly
in urban areas compared to internet users in
semiurban and rural areas.4 In this current
study, it was found that smartphones were used
for sending text messages, studying, and playing
video games. Previous studies found that the
majority of pre-schoolers use smartphones,
tablets, iPad, or laptops to play video games3.In
addition, WHO concluded that gaming disorder
is defined in the 11th Revision of the International
Classification of Disease (ICD-11).18 The results
are also in line with previous study conducted
by Sundus19 in 2017, in which the majority of
children use smartphones to communicate with
parents, study, play games, and others.
In this study, duration of smartphone use
was more prevalent among low categories and
the intensity was more prevalent among high
categories. It was well established that the low
duration use of smartphone may have possibility
of having high intensity. The study was also
supported by UNICEF 2017 that non-use or
excessive use of smartphone has a small negative
impact and is not as relevant as other factors
known to be important to children’s mental well-
Majalah Kedokteran Bandung, Volume 51 No. 1, March 2019
being.20
The current study found that the majority of
students who smoke are in Sumedang District.
Another study found that adolescents with
mental emotional problems generally started
smoking at a younger age and this makes tobacco
control an important issue to be addressed
in young people as the number of cigarettes
smoked per day will likely be higher when the
habit becomes addition.13 It will be interesting
to obtain in depth detailed on how smoking
addiction relates to smartphone addiction.
A limitation of this study is that this cross-
sectional study design used self-reported data
and 178 sample sizes. The study may provide
additional information in researching the same
topic, perhaps, in other age groups, and in
observing other risk factors associated with
mental-emotional disorders in urban, semi-
urban, and rural areas with other designs and
large sample sizes.
There are correlations between smartphone
addictions associated with mental emotional
disorders in 11–12 year old adolescents. Further
studies are required to determine whether these
are precursors or sequelae.
References
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multiscreen world. 2014 [cited 2018
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4. Survei APJII: Penetrasi internet di
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BULETINAPJIIEDISI22Maret2018.pdf
5. Purnomo A. Hubungan antara kecanduan
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University students. J Res Med Sci. 2011;
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C, Rheza AM, Hapsari WA. Masalah emosi
dan perilaku pada anak dan remaja di
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Ciptomangunkusumo (RSCM), Jakarta. Sari
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Kesehatan Kementerian Kesehatan Republik
Indonesia. Jakarta: Kemenkes RI; 2013.
10. Dhamayanti M, Peryoga SU, Firmansyah
MR. Emotional mental problems among
adolescents: urban and semi-urban settings.
Althea Medical Journal. 2018;5(2):77–81.
11. Kwon M, Kim D-J, Cho H, Yang S. The
smartphone addiction scale: development
and validation of a short version for
adolescents. PLoS ONE. 2013;8(12):e83558.
12. Asif AR, Rahmadi FA. Hubungan tingkat
kecanduan gadget dengan gangguan emosi
dan perilaku remaja usia 11-12 tahun. Jurnal
Kedokteran Diponegoro. 2017;6(2):148–57.
13. Lawrence D, Mitrou F, Sawyer MG, Zubrick
SR. Smoking status, mental disorders
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Health and wellbeing. Aust N Z J Psychiatry.
2010;44(9):805–14.
14. Törocsik M, Szucs K, Kehl D. How generations
think: research on generation z. Acta Univ
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15. Soni R, Upadhyay R, Jain M. Prevalence
of smartphone addiction, sleep quality
and associated behaviour problems in
adolescents. Int J Res Med Sci. 2017;5(2):515–
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16. Radliya R, Apriliya S, Zakiyyah TR. Pengaruh
penggunaan gawai terhadap perkembangan
sosial emosional anak usia dini. Jurnal PAUD
Agapedia. 2017;1(1):1–12.
17. Arifin LA, Rahmadi FA. Hubungan tingkat
kecanduan gadget dengan prestasi belajar
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children. J Depress Anxiety. 2017;7(1):1–3.
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Majalah Kedokteran Bandung, Volume 51 No. 1, March 2019

LITERATURE REVIEW
SPECIAL ISSUE
THE MENTAL HEALTH OF MEDICAL WORKERS DURING THE COVID19 PANDEMIC: HOW DO WE MANAGE
IT?
Devi Arine Kusumawardani1, Globila
Nurika2*, Nurul Ulya Luthfiyana3
Faculty of Public Health, University of Jember,
1,2,3
Jember 68121, Indonesia
Corresponding Author*:
nurikaglobila@unej.ac.id
Article Info
Submitted : 15 July 2020
In reviewed : 5 September 2020
Accepted : 22 September 2020
Available Online : 30 September 2020
Keywords : Mental health, medical workers,
Covid19 pandemic, mental health management
Published by Fakultas Kesehatan Masyarakat
Universitas Airlangga
Topics 10. Mental Health and Psychosocial Considerations during the Covid19 Outbreak
Vol. 12 No. 1 Special Issue
DOI: 10.20473/jkl.v12i1si.2020.21-28
ISSN: 1829 - 7285
E-ISSN: 2040 - 881X
Open Access
Abstract
Introduction: Covid19 pandemic has occurred in many countries and caused a world health crisis.
The morbidity dan mortality rate due to Covid19 still rising until now. The outbreak of Covid19 was not
only affected the mental health of the community but also affect the medical workers as the frontline.
Therefore, we present an overview of the mental health outcomes in medical workers and describe
the management at the organizational and personal level. Literature is obtained through searches
from the ScienceDirect, PubMed, and Google Scholar databases which are further classified and
summarized based on research questions. Discussion: The impact of the Covid19 pandemic on the
mental health of medical workers shows that the majority of workers experience anxiety, insomnia,
depression to severe stress. The risk of mental disorders in women is higher than men, nurses are
higher than doctors, and middle and junior positions are higher than senior degrees. Efforts that
have been made in controlling mental health problems for workers in health services include periodic
mental health monitoring, psychological support through self-care, mindfulness techniques, active
listening, music therapy, internal counseling, and problem-solving among ourselves. In addition,
workers in health services must also get social support such as instrumental support to emotional
support in the workplace. Conclusion: Medical workers in the health services have a very high risk
of experiencing mental health problems during the Covid19 pandemic so that the role of leaders in
every health care facility is required in carrying out stress management activities in the workplace.
21
 Vol. 12 No.1 Special Issue
Jurnal Kesehatan Lingkungan/10.20473/jkl.v12i1si.2020.21-28 September 2020 (21-28)

INTRODUCTION Distress psychological cause a negative impact not

only on the welfare of psychic health workers, but also
Since March 11, 2020, the World Health
have an impact on patient care and implementation of
Organization has set Covid19 as a pandemic. Pandemic
health systems in health care facilities (2). In addition,
Covid19 is a condition of the emergency international
the term impact such as the occurrence of mental health
public health that is unprecedented in modern history.
problems are also related to reduction in performance
Transmission of the virus occurs very massiv, resulting
efficiency, productivity decline, and absenteeism and
in levels of morbidity and mortality from Covid19 to be
even resignation of the health workers (7-8). Therefore,
increased. Current since July 12, 2020, the virus SARS-
it is necessary the existence of a literature review about
Cov-2 has infected 12.322.395 people and resulted in
how to impact and intervention efforts of mental health
556.335 of death worldwide (1). During the pandemic
on health personnel in health care facilities during a
Covid19, all countries in the world to implement a policy
pandemic Covid19?
of physical distancing in the activity of day-to-day and
Literature review is aimed to formulate the impact
every individual is encouraged to keep your distance
and the intervention efforts of mental health on health
and restrict activities that pose physical contact thereby
personnel in health care facilities. Activities literature
reducing the probability of occurrence of transmission
review is derived from 3 databases i.e. Pubmed,
Covid19. However, health workers during a pandemic is
Google Scholar, and Science direct with key words
actually a must do activity handling in a comprehensive
2 key words, namely: (1) Covid19 AND mental health
manner to patients Covid19, so that the application of
care AND mental health service; and (2) Covid19 AND
physical distancing is very difficult to do. This causes a
Manage* AND Mental Health AND Health worker. The
high risk to the health workers to directly exposed to the
inclusion criteria used in the search literature review are:
virus SARS-Cov-2 in health facilities. In addition to the
(1) published Articles; (2) Published in the year 2020;
high risk of exposure to the virus in the workplace, health
(3) Open access and full text. Based on the results of
workers are also particularly vulnerable to experiencing
the search, the number of literature review used in this
physical pressure and psychological pressure as a result
article, as many as 35 articles covering observasiobal
of the high activity and the need for health services in the
study, correspondence, commentary, and letter to the
care of patients during the pandemic Covid19 (2-3).
editor.
Limitations of resources such as infrastructure
DISCUSSION
and the comparison of the number of health workers
The Impact of the Pandemic Covid19 to the Mental
with patients Covid19 that is not balanced to be the main
Health of Health Workers
reason of the contact time of a health worker with the
Literature sources publications from various
patient Covid19 in health facilities become longer (4). In
different countries with geographical diversity, among
addition, the emergence of the virus SARS-Cov-2 during
others, China, Italy, and Brazil, shows that the pandemic
the pandemic in a relatively short time lead to health
Covid19 have an impact on the mental health of health
workers not yet ready in providing clinical intervention
workers in the Chinese territory as the center of the early
for patients Covid19 (5). Up to this time the duration of
transmission Covid19. One of the publications from
the pandemic Covid19 is still uncertain, not finding the
right therapy or vaccine to prevent virus infection, and China indicate that the prevalence of mental problems in
the potential of health resources including personal health workers who handle patients Covid19 is very high.
protective equipment that is limited can also be trigger Health workers experience mental problems ranging
factors of the psychological impact for health workers. from mild level such as irritability, fear, panic, anxiety to
Error information circulating in the virtual world can also mental issues of weight such as insomnia, depression,
worsen the psychological condition of the health workers and distress weight (9-11). The author also highlights
(6). Similarly, the stigma that exists in society against that female nurses on duty at installations that have a
health workers who handle patients Covid19 should be a high risk for physical contact with the patient such as the
concern to the mental health of health workers remains Emergency Room (ER) to the Installation of Outpatient
stable. (IRJ) is having mental problems more severe than other
Occurrence of stress or incidence of traumatic health professionals (3,12).
and other psychological problems experienced by the Studies conducted in the Country of China
health workers during a pandemic Covid19 (3) can and the country of Italy added that not only anxiety,
occur through direct contact with the patient Covid19, insomnia, and depression experienced by health
knowing someone who died as a result of exposure to workers. but Besides that, the health workers are also
Covid19, or know of a colleague quarantined or isolated. experiencing somatization even mental problems such

22

Jurnal Kesehatan Lingkungan/10.20473/jkl.v12i1si.2020.21-28
severe obsessive compulsive symptoms and post-
traumatic stress syndrome due to the difficulty of the
work safely during the pandemic Covid19. This can be
caused because of the lack of understanding about
the virus, knowledge about the prevention and control
of disease, working hours is longer, exposed to direct
patient Covid19, lack of personal protective equipment,
and lack of time off. The authors also identify that health
personnel work during a pandemic Covid19 experiencing
anxiety, disrupsi social, feel lonely, experience domestic
abuse, and conflict in the family. And even a higher
risk can occur mainly on the health workers who have
a history of degenerative disease and the time of work
overload or overload, female, and live in rural areas (3,13-
14). However, the mental disorders that occur in health
workers in the country of China including mild mental
disorders most of which occur in health workers men of
advanced age. A third study conducted in the Chinese
state that has limitations because of the absence of
follow-up and no comparison group so it is not able to
compare symptoms of mental disorders that happened a
long time ago or the symptoms of mental disorders that
have recently occurred due to the pandemic Covid19
(15).
The eight studies contained in the table (Table
1) indicates that there are many variables that affect
the mental health of health workers in the pandemic
Covid19 (3,5,9,13,15–18). A general overview of the
prevalence of symptoms of mental disorders that occur
in health workers in the pandemic Covid19 that exist
the symptoms of depression, anxiety, insomnia, and
distress. In addition also the occurrence of the symptoms
of the interpersonal sensitivity of health care personnel
who are exposed to direct patient Covid19. The rate of
mental health disorders varied from below the critical
point up to the weight, this disorder is more weight on
the most medical health, working on the front line or the
environment at risk any contact with the patient Covid19,
as well as Health workers who undergo quarantine
(3,9,13,15,17).
Based on population, gender women, nurse,
office work is low, the educational background is low
and long to work which is short of health personnel also
indicate a psychological disorder and / or depression
is high, and vice versa (5,13,16). The results of
other Studies also indicated that doctors and Health
professionals in position in the sphere of prevention and
control of Covid19 has the score of the sense of isolation
is high and social support is low compared to the staff
of medical technicians and not on the position within the
scope of the prevention and control of Covid19 (18). In
addition, health Personnel without the experience of care
23
Vol. 12 No.1 Special Issue
September 2020 (21-28)
public health emergency shows performance is worse in
mental health compared with health workers who have
experience of care public health emergency, for example
the experience when on the pandemic SARS was (16-17).
During the pandemic Covid19, health workers attempted
to access the material psychologically from a variety of
sources as well as follow counseling or psychotherapy
and crisis management as coping mechanisms (5,13).
The Management of the Mental Health of Health
Workers
Literature sources publications from various
different countries with geographical diversity, among
other countries China, the United Kingdom, and the
United States discuss about the strategy of management
problems at health professionals who focus on the
individual. The resilience of individuals during a pandemic
Covid19 can be built from self-care, self-efficacy, and
build social connections (19-20). Support psychic that
can be given on an individual can be a technique of
mindfulness, active listening, music therapy, internal
counselling and problem solving, as well as the adoption
of the attitude of altruism as health workers (6,21). The
author states that required an intervention in the form
of peer support models (Battle Buddies) for handle
exposure to stress be health by facilitating social support
from colleagues and peers and facilitate referral to
health facilities for advanced interference occurs when
the weight. The results of modeling the Battle Buddy
System this indicates that the intervention is very easily
implemented and very beneficial in addressing the issue
of mental health workers in the United States, but need
to be tested at the advanced level, namely the level of
the department (20). Another study in Wuhan, China
showed that health workers who have been given the
material a psychological form of manual handling mental
health and psychological counseling through the online
program for 24 hours showed a positive response, can
reduce the mental problems, and improve the perception
of their physical health (5,22).
Different with the above studies, some studies
stated that the interventions and strategies of mental
problems in the health workforce is not only done at
the individual level that needs to be done of the party
leaders and the organization (7,23). The leadership
of the organization needs to provide leadership that is
clear, honest, and open communication to all staff and
members to reduce the fear and uncertainty caused
by the pandemic Covid19 (2,24). Strategy is another
intervention that can be done at the organizational level
to deal with the impact of psychic due to the pandemic
Covid19, among others, provide the resources adequate
 Vol. 12 No.1 Special Issue
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Table 1. Literature Review

Name of Title Sample Method Instrumen Result Conclusion
Researcher
Rossi, et al. (3). Mental Health Health Workers Cross sectional, Italian version of the 49,38% of health workers are Health workers
Outcomes (n= 1379) web based study Global Psychotrauma experiencing PTSS; 24,7% experience
among Screen (GPS), experienced depression, 19,8% had mental Health
Frontline and the 9-item Patient anxiety, to 8.27% had insomnia, and disorders during
Second-Line Health Questionnaire 21,90% experienced severe stress. the pandemic
Health Care (PHQ-9), the 7-item Covid-19.
Workers Generalized Anxiety
during the Disorder scale
Coronavirus (GAD-7), the 7-item
Disease 2019 Insomnia Severity
(COVID-19) Index (ISI), dan the
Pandemic 10-item Perceived
Stress Scale (PSS).

Kang, et al. (5). Impact Medical and Studi cross Four scales to assess 36,9% of Health Workers are Mental Health
on mental nursing staff sectional the mental health experiencing mental Health disorders occur
health and working in status of medical and disorders below the critical point, in Health workers
perceptions of Wuhan (n= 994) nursing staff. The of 34.4% had mild disturbances, of in various level.
psychological 9-item Patient 22.4% impaired moderate, and 6.2% The majority of
care among Health Questionnaire Health workers
had severe disorders experienced
medical and (PHQ-9), the 7-item accessing
since the epidemic Covid-19.
nursing staff in Generalized Anxiety mental Health
Wuhan during Disorder (GAD-7), Health workers access the material services that are
the 2019 novel the 7-item Insomnia psychological (36,3%), the source available.
coronavirus Severity Index (ISI) of psychological information from
disease and the 22-item impact the media (50,4%), as well as attend
outbreak: A of Event Scale-Revised counseling or psychotherapy (to
cross-sectional (IES R) were used to 17.5%).
study evaluate depression,
anxiety, insomnia and
distress, respectively.

Lai, et al. (9). Factors Health Cross-sectional, Chinese versions of 50,4% had symptoms of depression, Nurse, women,
associated with personnel in 34 based on the the 9-item Patient to 44.6% experienced anxiety, especially those
mental health hospitals (n= survey Health Questionnaire, 34% had insomnia, and 71,5% who work in
outcomes 1257) the 7-item experienced distress. Nurse, female Wuhan, and
among health gender, Health professionals in directly involved
care workers Generalized Anxiety in the diagnosis,
position in the scope of the work
exposed to Disorder scale, the treatment, and
environment prevention and control
Coronavirus 7-item Insomnia patient care
Disease 2019 of Covid-19, and work in Wuhan, Covid-19 indicate
Severity Index, dan the
22-item Impact of China, shows the degree of severity the presence of
is higher on the measurement of all a psychological
Event Scale–Revised symptoms mental health of other disorder that is
health workers (p< 0.05) heavy.

Zhang, et al. Mental Medical Cross-sectional, Insomnia Severity Medical personnel have a higher During the plague
(13). health and personnel (n= Survey online Index (ISI), the prevalence in the insomnia (of COVID-19, the
psychosocial 927) and Health Symptom Check List- 38.4 vs. 30,5%), anxiety (13,0 most medical
problems of care Workers revised (SCL-90-R), vs. Of 8.5%, depression (12,2 health experience
medical health nonmedical (n= dan the Patient Health vs. To 9.5%), somatization (1,6 the problem of
workers during 1255) Questionnaire-4 psychosocial
vs. 0.4%), and symptoms of
the Covid-19 (PHQ-4) risk factors that
obsessive-compulsif (5,3 vs. 2.2%)
epidemic in influence it, so it
China compared with Health professionals
requires attention
nonmedical (p< 0.05). The female
and recovery
gender, and risky contact with the program.
patient COVID-19 is a factor of risk
of occurrence of insomnia, anxiety,
depression, somatisaso, and the
symptoms of obsessive-compulsif
(p< 0.05).

Sun, et al. (15). Psychological Health workers Cross-sectional, The 2019-nCoV Health workers undergo quarantine Health workers
impact of (n= 442); it questionnaire impact questionnaire has a score of IES is higher than that quarantined in
2019 novel consists of 53 system electronic and The Impact of is not a quarantine (p< 0.05) need of attention
coronavirus doctors, 348 Event Scale (IES) and counseling
(2019-nCoV) nurses, 18 staff s e r v i c e s
outbreak in administration psychological
health workers and logistics, more adequate.
in China and 23 other
health

24
 Vol. 12 No.1 Special Issue
Jurnal Kesehatan Lingkungan/10.20473/jkl.v12i1si.2020.21-28 September 2020 (21-28)

Name of Title Sample Method Instrumen Result Conclusion

Researcher
Xiao, et al. (16). Psychological Health workers multi-center Perceived Stress 55,1% of health workers are P a n d e m i c
impact of (n= 958) cross-sectional Scale (PSS-14) and experiencing psychological COVID-19
healthcare survey Hospital Anxiety stress that is higher than Health increase the
workers in / Depression scale professionals who have experience stress levels of
China during (HAD). working for SARS. The 54.2% health workers,
COVID-19 and 58% of health workers are especially
pneumonia
experiencing symptoms of anxiety anxiety and
epidemic: A
and depression. Stress levels of depression.
multi-center
health workers different based on The situation of
cross-sectional
position in the work and long work mental Health of
survey health workers
investigation experience
is alarming and
intervention
s e r v i c e s
psychological is
needed.

Cai, et al. (17). A cross- Health workers Studi cross- Symptom Check- As many as 1521 health workers, Training and
sectional study (n= 1521) sectional List-90 (SCL-90), of which 147 have the experience professional
on mental Chinese version of of a public health emergency, experience, high
health among Connor-Davidson while 1374 does not show that resilience and
health care resilience scale (CD- experience.Health workers without social support
workers during RISC) and Social required health
care experience public health
the outbreak of Support Rating Scale workers who
emergency shows bad performance
Corona Virus (SSRS). first participate
Disease 2019 in the mental health, resilience
and social support, and tend to in a public health
emergency.
experience a psychological disorder
in interpersonal sensitivity and
anxiety.

Fang, et al. (18). Analysis on 511 health Survey Perceived Social 27,20% of Health workers are in a Psychological
mental health workers support scale (PSSS), position in the scope of the work problems of
status and Self-rating Depression environment prevention and control health workers,
needs of scale (SDS), ULCA of Covid-19. The level of depression, especially
health care loneliness scale scores feeling isolated, and social women, a
workers in nurse with a
support differ significantly on
designated background of
several variables based on gender,
medical low education,
institutions of occupation, position in employment, a professional
tuberculosis Educational background, and scope position that
during the of the work environment (p< 0.05). low, and staff in
epidemic The score of social support positions in scope
period of negatively correlated with of prevention and
COVID-19 depression and sense of isolation control of Covid-
(P < 0.001), while depression was 19 is relatively
positively correlated with the sense serious. This
of isolation (P < 0.001). population
requires attention
to the steps of the
intervention that
is adequate.

for the handling of patients Covid19, provides a guide
to triage the handling of cases according to priority and
handling problems, the addition of health workers and
administrative staff, providing a forum for discussion, the
reduction of criticism of the performance of staff and health
workers, and the formation of a team of psychologists to
deal with mental problems on health workers (4,8,25).
Literature other demonstrate intervention strategies that
health workers do not require psychological intervention
specifically in dealing with anxiety and psychological
problems other during the pandemic Covid19 health
professionals tend to be reluctant to participate in the
service of psychological intervention individual or group
and does not need a psychologist. However, the thing
that is most needed by health workers to maintain his
mental health is adequate rest without interruption, the
resources and tools to protect themselves from the virus
Covid-9 and training to deal with psychological problems
that occurred during the pandemic Covid19 (26).
The effort of handling mental health other health
workers who have been applied based on literature
(23,27–35) which are: (1) social Support post-trauma
and stressors (primary for example, the death of work
colleagues or a secondary such as labor relations or
the difficulty of the work) which is experienced during
recovery is the most powerful risk factors predict status
of mental health long-term; and (2) manager Support
to increase better mental health. Furthermore, there
are four key elements in recovery plans mental health
staff evidence-based, namely: (1) Grateful, whether
written or oral, which recognizes the challenging work
that is done, can foster the resilience of the individual.
(2) job Interview by the supervisor about mental health.
This interview allows a better understanding of the

25

Jurnal Kesehatan Lingkungan/10.20473/jkl.v12i1si.2020.21-28
experience of members of staff, while identifying the
stressors secondary to collaboratively design a plan
of recovery individual. (3) active Monitoring for anyone
exposed to a traumatic event, particularly the individuals
who are considered at risk of developing mental health
problems. (4) Discussion groups to help staff develop
the narrative means that reduce the risk of danger. Other
interventions that can be performed during the pandemic
which proved to be more effective, namely: (1) Self-
help interventions, because such interventions can be
delivered through a variety of media, and self-help has
been proven to be effective for a variety of mental health
problems. (2) Intervention self-help evidence-based
so-called Self-Help Plus (SH +) to manage stress and
overcome various difficulties.
So far, evidence-based intervention has been
done a lot but there are some barriers that exist because
of the way that used using conventional methods in
addressing health issues mental health workers during
a pandemic Covid19 this. These obstacles include: (1)
Psychotherapy raditional face-to-face difficult to apply
because the policy quarantine to minimize transmission
of the virus. (2) Not all healthcare workers willing to
participate in the psychological intervention group or
the individual. (3) In general, the targeting of mental
disorders single, whereas today most of the population
experienced a series of response to psychological and
mental disorders in the face of a pandemic Covid19. (4)
Covid19 has been spread to all over the world including
many low and middle income countries (LMICs) that
cause a significant impact on the gap in access to mental
health services, so that evidence-based intervention in
general in low and middle income countries need mental
health resources are substantial (23,27).
Based on the results of the literature review that
has been done, the efforts of the management of mental
health on health workers as the frontline in handling
pandemic Covid19 this can be mapped to 3 levels of
management i.e. the level of intrapersonal, interpersonal,
and management level. The level of interpersonal that
can be done is self-care, self-efficacy, and build social
connections. The level of intrapersonal that can be done
is peer support models (Battle Buddies). The Level of
management that can be done is to increase the role
of the leadership of the organization of the workplace
to have good leadership and communication skills in
handling the mental health of the staff.
CONCLUSION
Medical workers in the health service has a very
high risk to experience mental health problems during
26
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September 2020 (21-28)
the pandemic Covid19 start from the level of light such as
irritability, fear, panic, anxiety to mental issues of weight
such as insomnia, depression, and distress weight. The
efforts of the management of the mental health of health
workers this can be done by implementing interventions
Self-Help Plus (SH +) with the full support of leaders in
every health care facility in carrying out the activities of
stress management in the workplace, so that the mental
health of health workers during the pandemic can remain
stable.
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Received: 2 June 2017 | Revised: 11 December 2017 | Accepted: 24 January 2018

DOI: 10.1111/jasp.12506

ORIGINAL ARTICLE

The effects of “phubbing” on social interaction

Varoth Chotpitayasunondh | Karen M. Douglas

School of Psychology, University of Kent

Correspondence
Varoth Chotpitayasunondh, School of
Psychology, Keynes College, University Rd,
University of Kent, Canterbury CT2 7NP, UK.
Email: vc216@kent.ac.uk
Abstract
This research experimentally investigated the social consequences of “phubbing” – the act of snub-
bing someone in a social setting by concentrating on one’s mobile phone. Participants viewed a
three-minute animation in which they imagined themselves as part of a dyadic conversation. Their
communication partner either phubbed them extensively, partially, or not at all. Results revealed
that increased phubbing significantly and negatively affected perceived communication quality and
relationship satisfaction. These effects were mediated by reduced feelings of belongingness and
both positive and negative affect. This research underlines the importance of phubbing as a mod-
ern social phenomenon to be further investigated.

1 | THE EFFECTS OF “PHUBBING” ON
SOCIAL INTERACTION
Smartphones have recently overtaken personal computers and laptops
as the most common device that people use to access the Internet
(Buckle, 2016). They enable people to communicate with anyone any-
where, facilitating social interactions with people who are very close
by, or at the other side of the world. However, despite their obvious
advantages in bringing people together, smartphones may sometimes
pull people apart (Turkle, 2012). In particular, people often ignore
others with whom they are physically interacting in order to use their
smartphone instead. This phenomenon, called phubbing, seems to have
become normative in everyday communication (Chotpitayasunondh &
Douglas, 2016). One recent study reported that 90% of respondents
used their smartphones during their most recent social activity, and
also perceived that 86% of the others involved in the social interaction
did the same (Ranie & Zickuhr, 2015). Another recent study showed
that nearly half of adult respondents reported being phubbed by their
romantic partner (Roberts & David, 2016). Despite the apparent preva-
lence of this phenomenon, research into its social consequences is lim-
ited. The current study aimed to address this gap, focusing on the
effects that phubbing has on the perceived quality of communication
and relationship satisfaction, and the mechanisms that drive these
effects.
1.1 | Background
The term phubbing is a portmanteau of the words “phone” and “snub-
bing”, and describes the act of snubbing someone in a social setting by
paying attention to one’s phone instead of talking to the person
directly in one’s company (Haigh, 2012). This term was originally coined
in a campaign by the Macquarie Dictionary to represent a growing
problem of smartphone misuse in social situations (Pathak, 2013). In a
social interaction, a “phubber” can be defined as a person who starts
phubbing his or her companion(s), and a “phubbee” can be defined as a
person who is a recipient of phubbing behavior.
Some recent research has investigated the antecedents of phub-
bing behavior. The most important determinant appears to be smart-

et al.,
phone addiction (Chotpitayasunondh & Douglas, 2016; Karadag
2015). More distal predictors such as Internet addiction, fear of missing
out, and self-control have been found to predict smartphone addiction,
which in turn predicts phubbing behavior. Also, Chotpitayasunondh
and Douglas (2016) have demonstrated that phubbing behavior itself
predicts the extent to which people are phubbed, so that being a phub-
ber can result in a vicious, self-reinforcing cycle of phubbing that makes
the behavior become normative. Research on the effects of phubbing
suggests that it may create negative, resentful reactions such that peo-
ple perceive their interaction to be of poorer quality (Ranie & Zickuhr,
2015), are less satisfied with their interactions (Abeele, Antheunis, &
Schouten, 2016), trust their interaction partner less (Cameron &
Webster, 2011), feel less close to their interaction partner when a
phone is present (Misra, Cheng, Genevie, & Yuan, 2014), and experi-
ence jealousy (Krasnova, Abramova, Notter, & Baumann, 2016) and
deflated mood (Roberts & David, 2016).
Therefore, researchers have learned valuable information about
some of the factors that may cause phubbing behavior, and what some
of the effects of phubbing might be. However, research on this topic is
still in its infancy and there is much still to discover. In the current
research, we aim to complete another piece of the puzzle. Specifically,
although we know that phubbing has some negative social

J Appl Soc Psychol. 2018;1–13. wileyonlinelibrary.com/journal/jasp V

C 2018 Wiley Periodicals, Inc. | 1
2 |
consequences, it is not clear exactly why this is the case. For example,
what drives the relationship between phubbing behavior and decreased
relationship satisfaction? Why is phubbing associated with poor per-
ceived communication quality? To answer these questions, the current
reserch frames phubbing as a specific form of social exclusion that
threatens fundamental human needs and leads to deflated affect.
Social exclusion – or ostracism – is defined by Williams (2001) as
“being invisible and being excluded from the social interactions of those
around you” (p. 2). This experience of being a social outcast is critical to
an individual’s wellbeing (Baumeister, 2005). Social exclusion usually
leads to negative emotional disturbances such as aggression (Twenge,
Baumeister, Tice, & Stucke, 2001), anxiety (Baumeister & Tice, 1990),
depression (Leary, 1990), and loneliness (Stillman et al., 2009). More-
over, social exclusion can lead to detrimental effects on four funda-
mental human needs: the need to belong, the need for self-esteem, the
need for meaningful existence, and the need for control (Gerber &
Wheeler, 2009; Williams, 2001; Zadro, Williams, & Richardson, 2004),
which in turn lead to reactions such as immediate physiological arousal,
making self-affirmations in the short term, and self-imposed isolation in
the long-term (Williams, 2001).”
First, social exclusion threatens an individual’s need to belong, dem-
onstrating either explicitly or symbolically to a person that they are not
wanted or valued (Jamieson, Harkins, & Williams, 2010). Second, social
exclusion threatens the need to maintain high self-esteem since in some
situations it can act as a form of punishment, forcing the individual to
wonder what they did wrong (or what is wrong about them), or may
lead to the feeling that they are not worthy of attention (Ferris, Lian,
Brown, & Morrison, 2015; Williams, 1997). Third, an individual’s need
for meaningful existence is threatened by social exclusion because it
represents social “death” and creates the feeling of invisibility (Case &
Williams, 2004; Williams, 2007). Finally, social exclusion can threaten
the need for control as people attempt to work out the uncertain situa-
tion (i.e., why are they being ignored?) but are unable to influence the
situation, leading to feelings of hopelessness and helplessness
(Bandura, 2000).
Immediately after being socially excluded, rejected individuals
respond with threats to fundamental needs, physical and social pain,
and negative affect (Williams, 2009a). We propose that people will
respond to the experience of phubbing in a similar way. Specifically, we
argue that phubbing can be considered as a specific form of ostracism
or social exclusion that threatens the four fundamental needs and also
leads to negative emotional experiences. Phubbing has the crucial ele-
ment of social exclusion in that individuals are ignored by others –
whilst they remain in the physical presence of other people, they are
nevertheless shut out of social interaction. Like other forms of ostra-
cism (see Williams, 1997), people may phub others either deliberately
or without necessarily knowing they are doing so (Ranie & Zickuhr,
2015). Moreover, features and characteristics of phubbing, such as the
withdrawal of eye contact, may further be interpreted (or misinter-
preted) as being given the “silent treatment”, or being socially rejected
(Silk et al., 2012; Wirth, Sacco, Hugenberg, & Williams, 2010). Averted
gaze is a passive form of social exclusion (Wirth et al., 2010), and a sig-
nal of disinterest (Richmond, McCroskey, & Hickson, 2008), and
CHOTPITAYASUNONDH AND DOUGLAS
individuals on the receiving end tend to experience lower satisfaction
of the four fundamental human needs compared to those who receive
direct eye contact (Wirth et al., 2010). Phubbing therefore displays
many of the most common features of social exclusion and it is there-
fore plausible to suggest that phubbing could have similar detrimental
effects on the fulfillment of social needs, and how people feel.
While mobile-phone-induced ostracism has negative effects on
need-threats and moods (Gonzales & Wu, 2016), thwarted needs and
negative affect tend to have a corrosive effect on relational outcomes
at the same time. For example, targets who are deprived of the need
for control tend to terminate or change the pattern of the relationship
between source and target (Zadro, Arriaga, & Williams, 2008). Losing a
sense of belongingness can also be a symbolic message of losing a rela-
tionship or attachment to another individual or group. However, in
some cases, targets with threatened needs may attempt to regain them
by strengthening their bonds and relationships with others (Williams,
2001). Besides threatened needs, emotions aroused by being phubbed
may also play an integral role in the functioning of interpersonal rela-
tionships. According to the theory of attachment (Bowlby, 1969, 1988),
many emotions serve adaptive functions in human survival. Positive
affect brings people closer, which in turn helps individuals to form,
ensure, and maintain their relationships with others. In addition, posi-
tive emotions induce a greater likelihood of successful social interac-
tions (Waugh & Fredrickson, 2006). By contrast, studies have revealed
that negative affect does not lead to close relationships and relation-
ship satisfaction (Levenson & Gottman, 1983). Moreover, extreme neg-
ative emotions (e.g. anger) can lead to deleterious effects such as poor
relationship functioning and high interpersonal conflict (Sanford &
Rowatt, 2004).”
In addition to having a negative impact on fundamental needs and
affect, we further propose – following previous research – that phub-
bing will be associated with negative perceived interaction quality and
negative relationship satisfaction (e.g., Abeele et al., 2016; Ranie &
Zickuhr, 2015; Roberts & David, 2016). However, we more speficially
propose to test the hypothesis that phubbing indirectly influences per-
ceived interaction quality and relationship satisfaction, because it
threatens people’s fundamental needs to belong, have control, have
high self-esteem, experience meaningful existence, and it also dampens
their affect. In other words, the effects of phubbing on relationship sat-
isfaction and perceived interaction quality should be mediated by
threats to fundamental needs, and affect. We also consider some
potential moderators of these hypothesized effects. One of the possi-
ble moderators influencing the relationships between phubbing, threats
to fundamental needs, affect, and perceptions of interaction outcomes
is the extent to which people interpret phubbing behaviour as socially
normative (Chotpitayasunondh & Douglas, 2016). If people view phub-
bing as normative, they may not view it as a form of social rejection
and they may not find phubbing distressing or concerning. Further,
people’s experiences of phubbing may be moderated by their sensitiv-
ity to rejection (Kang & Chasteen, 2009). Phubbees who have lower
sensitivity to rejection may cope with phubbing better and maintain
their affect and fundamental needs satisfaction more easily than highly
CHOTPITAYASUNONDH AND DOUGLAS
FIGURE 1 Proposed model of the effects of being phubbed on the communication quality and relationship satisfaction
sensitive people. We therefore included these two potential moderat-
ing factors in the current study.
1.2 | The current research
Although phubbing has become a growing area of interest in recent
years, research on the social consequences of phubbing is limited.
Moreover, there is no research to our knowledge that investigates the
mechanisms underlying the effects of phubbing, except for factors
such as jealousy within romantic relationships (Krasnova et al., 2016).
In this study, we aimed to explore these mechanisms in detail. Specifi-
cally, we investigated (a) the effects of being phubbed on perceived
interaction quality and relationship satisfaction, and (b) the extent to
which phubbing functions similarly to social exclusion and these effects
are mediated by threats to fundamental needs, and affect. We also
explored whether these effects are moderated by the perceived nor-
mativity of phubbing and rejection sensitivity.
Participants were asked to view a three-minute animation depict-
ing a conversation between two people. They were asked to imagine
themselves as one of the people in the animation. There were three
conditions in which the participant’s conversation partner varied in
terms of their mobile phone use during the conversation: no phubbing,
partial phubbing, and extensive phubbing. After viewing the video, par-
ticipants responded to each of the dependent measures and potential
mediating and moderating variables. We have developed a research
model to explicate the mechanisms underlying the effects of phubbing.
The predicted model is depicted conceptually in Figure 1. Specifically,
we hypothesized that:
H1: Participants who were phubbed extensively would
experience greater threat to fundamental needs (belong-
ing, self-esteem, meaningful existence, and control),
would experience greater negative affect, and would
| 3
experience less positive affect, than those who were
phubbed partially, or were not phubbed.
H2: Participants who were phubbed extensively would
perceive their social interaction to be lower quality and
would experience lower relationship satisfaction, than
those who were phubbed partially, or not phubbed.
H3: Threat to fundamental needs and dampened mood
would mediate the effect of phubbing on relationship
satisfaction and the perceived quality of communication.
H4: We tentatively hypothesized that the perceived
social normativity of phubbing, and individuals’ rejection
sensitivity, would moderate the effect of phubbing on
fundamental human needs and affect.
2 | METHOD
2.1 | Participants
One hundred and fifty-three participants (19 men and 134 women)
ranging in age from 18 to 36 years of age (M 5 19.72, SD 5 2.23)
were undergraduate students at a British university who participated
for course credit. Twenty-five participants (16.34%) who failed to
answer attention check questions correctly were excluded (six from the
control group, six from the partial phubbing group, and 13 from the
extensive phubbing group; see explanation in next section).1 In total,
128 participants (14 men and 114 women) ranging in age from 18 to
34 (M 5 19.62, SD 5 1.79) remained in the study (45 from the control
group, 45 from the partial phubbing group, and 38 from the extensive
1
Including these participants in the analysis did not affect the pattern or sig-
nificance of any of the results.
4 | CHOTPITAYASUNONDH AND DOUGLAS

TA BL E 1 General characteristics of participants by gender

Male (n 5 14) Female (n 5 114) Total (n 5 128)

Characteristics % (n) % (n) % (n)

Age (years)
Mean 6 SD 19.50 6 1.29 19.63 6 1.85 19.62 6 1.79

Occupation
Attending university full-time 100.00 (14) 87.72 (100) 89.06 (114)
Attending university and working part-time 0.00 (0) 12.28 (14) 10.94 (14)

Ethnicity
White/Caucasian 57.14 (8) 62.28 (71) 61.72 (79)
Black British Caribbean 0.00 (0) 2.63 (3) 2.34 (3)
Black British African 14.29 (2) 5.26 (6) 6.25 (8)
Other black background 0.00 (0) 2.63 (3) 2.34 (3)
Asian British Indian 7.14 (1) 2.63 (3) 3.13 (4)
Asian British Pakistani 0.00 (0) 2.63 (3) 2.34 (3)
Asian British Bangladeshi 0.00 (0) 0.88 (1) 1.59 (1)
Chinese 0.00 (0) 1.75 (2) 0.78 (2)
Other Asian background 14.29 (2) 7.02 (8) 7.81 (10)
Other (including mixed ethnicity) 7.14 (1) 12.28 (14) 11.72 (15)

phubbing group). The demographics of the sample are presented in first 30 seconds of the animation are similar to what can be seen in the
Table 1. control condition video, but then the conversation partner picks their
smartphone up from the table and starts phubbing for 30 seconds.
During this phubbing time, as shown in Figure 2, the conversation part-
2.2 | Manipulation
ner looks down to the smartphone, completely averts eye gaze from
The 3-dimensional (3D) animations used in this research were created the participant, swipes the screen on the device, and keeps smiling and
by a professional animator using Autodesk Maya software. The first laughing about something he/she has just read. The partial phubbing
step in building the animations was to design characters to suit the animation also repeats this sequence periodically in the second and the
research content, then create storyboards and discuss these with the third minute of the conversation. The final experimental animation rep-
authors to determine the direction and nature of the animations. Lastly, resents the “extensive phubbing” situation, in which the participant’s
these were developed into 3D animations. Participants watched a conversation partner comes and sits, then immediately starts phubbing
three-minute silent animation that depicted two people having a con- and continues this behavior throughout their conversation.
versation. Participants were asked to watch the animation carefully and
imagine themselves as the person closest to the screen (i.e., the person
2.3 | Measures
with their back turned to the screen). Participants were instructed to
imagine as vividly as they could that they were this person and that 2.3.1 | Needs satisfaction
they were engaged in this conversation with the other person. The The Need-Threat Measure (NTM), developed by Jamieson et al. (2010)
characters of the participant and conversation partner were designed contains 20 items measuring the extent to which an individual feels the
to be neutral in gender and ethnicity, which were thought to be possi- satisfaction/threat to the four fundamental needs following ostracism
ble confounding factors in this study. Voice was also removed from the (e.g., Williams, 2009b; e.g., “I felt I belonged to the group” and “I felt
animation, so the effect of being phubbed could not be influenced by powerful; 1 5 not at all, 5 5 extremely; a 5 .90, M 5 2.87, SD 5 1.20 for
the content of the conversation. However, the characters moved their
mouths when they were talking so that the conversation looked like
both people were speaking in turn, as they would in a typical face-to-
face interaction. Participants were randomly assigned to one of three
different animation conditions: (1) the conversation partner did not
phub at all, (2) they phubbed part of the time, and (3) they phubbed
most of the time. In the “no phubbing” condition (control condition),
the conversation partner, with smartphone in his/her left hand, comes
and sits opposite to the participant. The conversation partner immedi-
ately puts their smartphone on the table and does not pick it up
throughout the three-minute conversation. The first experimental ani-
mation created the “partial phubbing” situation, in which participants FIGURE 2 Screenshot from the partial phubbing situation
are phubbed by their conversation partner about half of the time. The animation
CHOTPITAYASUNONDH AND DOUGLAS
belonging, a 5 .90, M 5 2.70, SD 5 1.02 for self-esteem, a 5 .91,
M 5 2.93, SD 5 1.17 for meaningful existence, and a 5 .77, M 5 2.11,
SD 5 .82 for control). Items for each domain were reverse-coded as
appropriate. Since the NTM was originally designed to measure needs
satisfaction in the cyberball game experiment we modified some items
such as “I felt the other players interacted with me a lot” to “I felt that
the conversation partner interacted with me a lot”.
2.3.2 | Positive and negative affect schedule
This is a 20-item measure (Watson, Clark, & Tellegen, 1988) asking par-
ticipants to rate how well different feeling and emotions (e.g., “Inter-
ested”, “Distressed”, “Excited”, and “Upset”) describe them on a 5-point
scale (1 5 very slightly or not at all, 5 5 extremely; a 5 .92, M 5 18.77,
SD 5 8.03 for Positive Affect and a 5 .83, M 5 16.16, SD 5 5.52 for
Negative Affect).
2.3.3 | Quality of communication
The Iowa Communication Record (ICR), which assesses the quality and
impact of communications within specific conversational contexts
(Schwarz, 2008), is a 10-item questionnaire asking participants to read
10 bi-polar descriptors (e.g. “Attentive - Poor Listening”, “Formal -
Informal”, “Smooth - Difficult”; Duck, Rutt, Hoy, & Strejc, 1991) and
rate the conversation on each via a seven-point scale. Two additional
descriptors (Schwarz, 2008) were used to add meaningful dimensions
of communication quality that are not included in the original version
of the ICR (i.e., “Enjoyable – Not Enjoyable” and “High Quality – Low
Quality”; overall a 5 .82, M 5 5.47, SD 5 1.34). Reliability of the scale
which included the two additional items a 5 .88 for friends and a 5 .89
for intimate and family relationship (Schwarz, 2008). In our path analy-
sis, we reversed this score and labeled it as communication quality.
2.3.4 | Relationship satisfaction
The Relationship Assessment Scale (RAS; Hendrick, 1988) was devel-
oped to measure general satisfaction with romantic relationships and
consisted of seven items, which were modified here to measure satis-
faction with the animated conversation (e.g., “In general, how satisfied
were you with the conversation?” Participants responded on a five-
point scale (1 5 low satisfaction, 5 5 high satisfaction; a 5 .94, M 5 2.58,
SD 5 1.04).
2.3.5 | Perceived social norms of phubbing
The Perceived Social Norms of Phubbing Scale (PSNP; Chotpitayasu-
nondh & Douglas, 2016) contains three items measuring descriptive
norms, which are based on observations of others’ behavior such as
“Do you think that phubbing behavior is typical amongst people around
you?”, and two items measuring injunctive norms, which are related to
the inference of others’ approval of phubbing such as “Do you think
that other people view phubbing behavior as appropriate?” using a five-
point scale (1 5 not at all, 5 5 very much; a 5 .44, M 5 16.12, SD 5 2.63).
Both norms measurements were combined to a general measure of per-
ceived social norms of phubbing which was proposed as a moderator.
| 5
2.3.6 | Rejection sensitivity
The Adult Rejection Sensitivity Questionnaire (A-RSQ), is a modifica-
tion of the original RSQ (Downey & Feldman, 1996). Participants rated
the extent to which 18 statements accurately describe them on a six-
point scale (e.g., “How concerned or anxious would you be over
whether or not your family would want to help you?” and “I would
expect that they would agree to help me as much as they can”, 1 5 very
unconcerned/very unlikely, 6 5 very concerned/very likely), and coding
allows for a score between 1 and 36; a 5 .70, M 5 9.15, SD 5 2.55).
Rejection sensitivity was also proposed as a moderator in this study.
2.4 | Procedure
After giving their informed consent, participants were placed in individ-
ual cubicles, each with a personal computer, and completed an online
questionnaire designed via Qualtrics software. The study was a three-
group (phubbing: none/partial/extensive) between-participants experi-
mental design. The dependent measures were perceived communica-
tion quality and relationship satisfaction. Fundamental needs threat
(belonging, self-esteem, meaningful existence, and control) and affect
(negative and positive), were included in the model as potential media-
tors and perceived social norms of phubbing and rejection sensitivity
were included as potential moderators (see Figure 1).
Participants first completed the Adult Rejection Sensitivity Ques-
tionnaire. They then viewed the phubbing manipulation animation.
Next, participants were asked to answer two questions about what
they saw in the video in order to serve as an attention check. Specifi-
cally, we asked the participants to indicate the colour of the conversa-
tion partner’s shirt (the correct answer was white), and the name of the
object on the table (the correct answer was a bottle). Next, participants
were asked to complete the ICR, the RAS, the NTM, the positive and
negative affect schedule (PANAS), and the PSNP, respectively. Finally,
participants completed some basic demographic data. At the conclusion
of the study, they were thanked and debriefed.
3 | RESULTS
3.1 | Correlation analyses
All statistical tests were performed using SPSS Statistics version 24.0.
In order to test interaction effects of the moderators, we created inter-
action products from centered A-RSQ and centered PSNP variables.
Spearman’s rank-order correlations were computed to assess the non-
parametric relationship between phubbing intensity and dependent
variables, and Pearson product-moment correlations were used to
assess the relationship among other variables. All correlations between
the phubbing conditions and other variables, with the exception of
both proposed moderators and their interaction terms, were statisti-
cally significant in the expected directions. Intensity of being phubbed
in the dyadic conversation negatively correlated with RAS (r 5 2.72,
p < .001), positive affect (r 5 2.53, p < .001), and all NTM subscales
(r 5 2.39 to 2.74, p < .001), whereas intensity of being phubbed posi-
tively correlated with ICR (r 5 .71, p < .001) and negative affect
6 | CHOTPITAYASUNONDH AND DOUGLAS

TA BL E 2 Descriptive statistics and correlation coefficients among study variables (n 5 128)

Variables M SD 1 2 3 4 5 6 7 8 9 10 11 12 13

1. Phubbing intensity – – –

2. Belonging (NTM) 2.87 1.20 2.74* (.90)

3. Self-esteem (NTM) 2.70 1.02 2.62* .80* (.90)

4. Meaningful existence (NTM) 2.93 1.17 2.68* .85* .83* (.91)

5. Control (NTM) 2.11 .82 2.39* .63* .70* .68* (.77)

6. PANAS negative 16.16 5.52 .44* 2.62* 2.60* 2.60* 2.45* (.83)

7. PANAS positive 18.77 8.03 2.53* .61* .70* .68* .65* 2.30* (.92)

8. ICR 5.47 1.34 .71* 2.84* 2.74* 2.78* 2.58* .60* 2.55* (.82)

9. RAS 2.58 1.04 2.72* .87* .80* .83* .68* 2.54* .73* 2.85* (.94)

10. A-RSQ 9.15 2.55 .06 2.03 2.17 2.10 2.16 .11 2.07 .06 2.11 (.62)

11. PSNP 16.12 2.63 2.14 .07 .08 .03 2.02 .04 .12 2.04 .06 2.09 (.44)

12. Phubbing intensity* A-RSQ .13 5.32 2.03 2.01 2.15 2.07 2.11 .11 2.07 .06 2.08 .92* 2 .09 2

13. Phubbing intensity* PSNP 2.24 5.36 2.11 .08 .11 .03 .00 .04 .12 2.06 .08 2.09 .92* 2.12 2

Cronbach’s alphas are shown in the diagonal.

A-RSQ 5 adult rejection sensitivity questionnaire; ICR 5 iowa communication record; NTM 5 need-threat measure; PANAS 5 positive and negative
affect schedule; PSNP 5 perceived social norms of phubbing; RAS 5 relationship assessment scale.
*p < .001.

(r 5 .44, p < .001), as shown in Table 2. Neither of the proposed moder-
ators correlated with the dependent measures or potential mediators
(nor did the interactions between the proposed moderators and the
independent variable).
3.2 | Effect of moderators
We then explored the potential moderating effects of rejection sensitiv-
ity and perceived social norms of phubbing on the relationship between
phubbing intensity and fundamental needs, negative affect, and positive
affect, as seen in Figure 1. We used Hayes and Preacher’s (2013) PRO-
CESS procedure for SPSS (model 9, 20,000 resamples, bias corrected).
The result showed no moderating effects of rejection sensitivity and
perceived social norms of phubbing in our path model. The results
revealed no significant relationships between the phubbing intensity *
A-RSQ interaction term and fundamental needs; belonging (p 5 .96),
self-esteem (p 5 .86), meaningful existence (p 5 .72), and control
(p 5 .32). No significant relationship was found between this interaction
term and both PANAS scores; negative (p 5 .52) and positive (p 5 .07).
The results also showed no significant relationships between the phub-
bing intensity * PSNP interaction term and fundamental needs; belong-
ing (p 5 .71), self-esteem (p 5 .27), meaningful existence (p 5 .97), and
control (p 5 .44). Moreover, no significant relationship was found
between this interaction term and both PANAS scores; negative
(p 5 .96) and positive (p 5 .54). Due to this and the low reliability of the
PSNP, both moderators were therefore omitted from our path model.
3.3 | Effect of phubbing on communication outcomes
A one-way multivariate analysis of variance was conducted to
determine the effects of being phubbed on the combined
dependent variables. There were linear relationships, as assessed by
scatterplot, and no multicollinearity (r 5 2.85 2.87, p < .001).
Tabachnick and Fidell (2013) suggest that no correlation should be
above r 5 1/2.90. There was homogeneity of variance-covariances
matrices, as assessed by Box’s test of equality of covariance matri-
ces (p < .001). The difference between conditions on the combined
dependent variables was significant, F(16, 236) 5 9.91, p < .001;
Wilks’ K 5 .36; partial h2 5 .40.
The mean difference between groups of participants on the
dependent variables is presented in Table 3. Follow-up univariate anal-
ysis of variances (ANOVAs) showed that ICR scores (F(2, 125) 5 66.89,
p < .001; partial h2 5 .52) and RAS scores (F(2, 125) 5 68.95, p < .001;
partial h2 5 .53) were significantly different across the different phub-
bing conditions, using a Bonferroni adjusted a level of .025. These
were both medium-sized effects.
We investigated further with post hoc tests to determine where
exactly the differences lay between conditions. The Tukey post hoc
test was used to compare all possible combinations of group differen-
ces when the assumption of homogeneity of variances was met, as
assessed by Levene’s Test of Homogeneity of Variance (p > .05). The
Games-Howell post hoc test was used in this study when the assump-
tion of homogeneity of variances was violated. As predicted, partici-
pants in the control group showed significantly lower ICR than
participants who either were phubbed part of the time or most of the
time, as seen in Figure 3. Meanwhile, control group participants
showed significantly higher RAS mean scores than participants in either
the partial phubbing or extensive phubbing groups, as seen in Figure 4.
Post hoc test results of the dependent variables are shown in Table 4.
The Cohen’s d values ranging between 1.09 – 2.69 represented large
effects.
CHOTPITAYASUNONDH AND DOUGLAS | 7

TA BL E 3 Means and standard deviations of measures by groups of participants

No phubbing (n 5 45) Partial phubbing (n 5 45) Extensive phubbing (n 5 38)

Measures M SD M SD M SD

Iowa communication record 4.26 1.07 5.71 .90 6.62 .82

Relationship assessment scale 3.52 .85 2.40 .76 1.68 .47

Need-threat measure
Belonging 4.01 .83 2.62 .88 1.82 .65
Self-esteem 3.52 .92 2.52 .78 1.96 .65
Meaningful existence 3.95 .80 2.70 .88 1.99 .87
Control 2.58 .89 1.96 .72 1.75 .57

Positive and negative affect schedule

Negative 13.42 4.27 17.04 6.25 18.37 4.63
Positive 23.78 8.51 17.62 6.81 14.18 5.17

3.4 | Effect of phubbing on fundamental needs as showed significant differences with medium and large effects (Cohen’s
mediators d ranging between .76 – 2.93).

The mean difference between groups on the proposed mediators can be

seen in Table 3 and Figure 5. Using a Bonferroni adjusted a level of
.025, follow-up univariate ANOVAs showed that all domains of need sat-
isfaction following ostracism: belonging (F(2, 125) 5 80.75, p < .001; par-
tial h2 5 .56), self-esteem (F(2, 125) 5 41.17, p < .001; partial h2 5 .40),
meaningful existence (F(2, 125) 5 57.13, p < .001; partial h2 5 .48), and
control (F(2, 125) 5 14.26, p < .001; partial h 5 .19) were significantly
2
different across the different phubbing conditions. The partial h values
2
ranging between .19 – .56 revealed small to medium effects.
Further, we used post hoc tests to determine where the differen-
ces lay between conditions. As predicted, participants in the no phub-
bing group showed significantly higher overall needs satisfaction – and
also in each separate domain – than participants who either were
phubbed part of the time or most of the time. Post hoc test results of
the mediating variables are shown in Table 5. Post hoc tests revealed a
non-significant difference between the partial and extensive phubbing
groups in needs of control (p 5 .30). The other group differences
3.5 | Effect of phubbing on positive and negative
affect as mediators
The mean difference between groups on both mediators is pre-
sented in Table 3 and Figure 6. Using a Bonferroni adjusted a level of
.025, follow-up univariate ANOVAs showed that both domains of
affect: negative (F(2, 125) 5 10.52, p < .001; partial h2 5 .14), and
positive (F(2, 125) 5 20.00, p < .001; partial h2 5 .24) were signifi-
cantly different across the different phubbing conditions. Both par-
tial h2 values revealed small effects.
Further, we used Games-Howell post hoc tests to determine
where the differences lay between conditions. As predicted, partici-
pants in the no phubbing group showed significantly higher positive
affect and lower negative affect than participants who either were
phubbed part of the time or most of the time. Post hoc test results of
the mediating variables are shown in Table 6. Post hoc tests revealed a
non-significant difference only between the partial and extensive

FIGURE 3 Mean difference between groups of participants on FIGURE 4 Mean difference between groups of participants on
ICR RAS
8 | CHOTPITAYASUNONDH AND DOUGLAS

TA BL E 4 Post hoc tests of ICR and RAS

95% CI
Dependent (I) Phubbing (J) Phubbing Mean
variable Post hoc test condition condition diff (I-J) SE Sig. Upper Lower Cohen’s d

ICR Tukey HSD No phubbing Partial phubbing 21.45 .20 <.001 21.92 2.98 1.47
Extensive phubbing 22.36 .21 <.001 22.85 21.86 2.47
Partial phubbing No phubbing 1.45 .20 <.001 .98 1.92 1.47
Extensive phubbing 2.91 .21 <.001 21.40 2.42 1.09
Extensive phubbing No phubbing 2.36 .21 <.001 1.86 2.85 2.47
Partial phubbing .91 .21 <.001 .42 1.40 1.09

RAS Games2Howell No phubbing Partial phubbing 1.12 .17 <.001 .71 1.53 1.39
Extensive phubbing 1.85 .15 <.001 1.49 2.20 2.69
Partial phubbing No phubbing 21.12 .17 <.001 21.53 2.71 1.39
Extensive phubbing .73 .14 <.001 .40 1.05 1.15
Extensive phubbing No phubbing 21.85 .15 <.001 22.20 21.49 2.69
Partial phubbing 2.73 .14 <.001 21.05 2.40 1.15

phubbing groups in negative affect (p 5 .51). The other group differen-
ces showed significant differences with medium and large effects
(Cohen’s d ranging between. 60 – 1.36).
3.6 | Path analyses
We then tested the potential mediating effect of threats to fundamental
needs on the relationship between phubbing and both communication
outcomes, without moderators which were dropped at the previous
stage. The new model proposed in this study assumed that a significant
correlation existed between phubbing intensity, threats to four funda-
mental human needs (belonging, self-esteem, meaningful existence, and
control), affect (negative and positive), communication quality (reversed
ICR score), and relationship satisfaction. Analyses were conducted using
the AMOS version 24.0 program. Model fit was evaluated using the chi-
2
square test of model fit (v ), the root mean square error of approxima-
one path at a time on the basis of critical ratios and modification
indices in order to find the most parsimonious model. A perusal of
the model critical ratios showed that the paths between positive
affect and communication quality (p 5 .82), between self-esteem
and relationship satisfaction (p 5 .60), between control and commu-
nication quality (p 5 .52), between negative affect and relationship
satisfaction (p 5 .48), between meaningful existence and relation-
ship satisfaction (p 5 .37), between meaningful existence and com-
munication quality (p 5 .35), between self-esteem and
communication quality (p 5 .29), and between control and relation-
ship satisfaction (p 5 .13), should be dropped respectively. An exam-
ination of model modification indices indicated adding a covariance
path between communication quality and relationship satisfaction.
The results of structural path estimates of the proposed model and
final model are presented in Table 7. The modified model’s
goodness-of-fit was satisfactory, v2(128) 5 9.93, p 5 .27, CFI 5 1.00,

tion (RMSEA), and the comparative fit index (CFI). RMSEA 5 .04. The chi-square difference between the hypothesized
The model depicted in Figure 1 (minus the moderators), did not and final model was statistically significant (Dv2 5 15.96, p < .001).
adequately fit the data, v2(128) 5 25.89, p < .001, CFI 5 .98, The result of the path analysis with standardized regression coeffi-

RMSEA 5 .44. However, the model was re-specified by modifying
FIGURE 5 Mean difference between groups of participants on
NTM domains
cients and statistical significance is presented in Figure 7.
As seen in Table 7 and Figure 7, results from the path analysis pro-
vided support for H1, which posited significant negative relationships
between phubbing intensity and four fundamental needs satisfaction;
belonging (b 5 2.74, p < .001), self-esteem (b 5 2.62, p < .001), mean-
ingful existence (b 5 2.68, p < .001), and control (b 5 2.41, p < .001),
and affect, both negative (b 5 .37, p < .001) and positive (b 5 2.49,
p < .001). H2, which predicted that participants who were phubbed
extensively would perceive their communication to be lower quality
(b 5 2.24, p < .001) and would experience lower relationship satisfac-
tion (b 5 2.14, p 5 .01), was supported. H3 was partially supported. All
paths from self-esteem needs, meaningful existence needs, and needs
of control along with one path from negative affect and one from posi-
tive affect, were dropped following model-trimming process. However,
the results revealed that depletion of needs of belongingness mediates
the effect of phubbing on the perceived quality of communication
(b 5 .58, p < .001) and relationship satisfaction (b 5 .59, p < .001),
increase of negative affect mediates the effect of phubbing on the
CHOTPITAYASUNONDH AND DOUGLAS | 9

TA BL E 5 Post hoc tests of all need-threat measure domains

95% CI
Dependent variable Post hoc test (I) Phubbing condition (J) Phubbing condition Mean diff (I-J) SE Sig. Upper Lower Cohen’s d

Belonging Games-Howell No phubbing Partial phubbing 1.39 .17 <.001 .99 1.79 1.62
Extensive phubbing 2.19 .18 <.001 1.77 2.61 2.93
Partial phubbing No phubbing 21.39 .17 <.001 21.79 2.99 1.62
Extensive phubbing .80 .18 <.001 .38 1.22 1.04
Extensive phubbing No phubbing 22.19 .18 <.001 22.61 21.77 2.93
Partial phubbing 2.80 .18 <.001 21.22 2.38 1.04

Self-esteem Tukey HSD No phubbing Partial phubbing 1.00 .17 <.001 .60 1.40 1.17
Extensive phubbing 1.56 .18 <.001 1.14 1.97 1.96
Partial phubbing No phubbing 21.00 .17 <.001 21.40 2.60 1.17
Extensive phubbing .56 .18 .01 .14 .97 .78
Extensive phubbing No phubbing 21.56 .18 <.001 21.97 21.14 1.96
Partial phubbing 2.56 .18 .01 297 2.14 .78

Meaningful existence Tukey HSD No phubbing Partial phubbing 1.25 .18 <.001 .82 1.67 1.48
Extensive phubbing 1.96 .19 <.001 1.51 2.40 2.34
Partial phubbing No phubbing 21.25 .18 <.001 21.67 2.82 1.48
Extensive phubbing .71 .19 .01 .26 1.15 .81
Extensive phubbing No phubbing 21.96 .19 <.001 22.40 21.51 2.34
Partial phubbing 2.71 .19 .01 21.15 2.26 .81

Control Games-Howell No phubbing Partial phubbing .62 .17 .001 .21 1.02 .76
Extensive phubbing .83 .16 <.001 .44 1.22 1.11
Partial phubbing No phubbing 2.62 .17 .001 21.02 2.21 .76
Extensive phubbing .21 .14 .30 2.13 .55 .33
Extensive phubbing No phubbing 2.83 .16 <.001 21.22 2.44 1.11
Partial phubbing 2.21 .14 .30 2.55 .13 .33

perceived quality of communication (b 5 2.14, p 5 .01), and depletion
of positive affect mediates the effect of phubbing on relationship satis-
faction (b 5 .29, p < .001). Furthermore, this integrated model accounts
for 47% of the variance in communication quality and for 18% of the
variance in relationship satisfaction.
that the experience of phubbing in a controlled dyadic conversation
had a negative impact on perceived communication quality and rela-
tionship satisfaction. Theoretically, we proposed that these effects
would occur because phubbing lowers mood and threatens the four
fundamental needs of belongingness, self-esteem, meaningful exis-
tence, and control. We also found some support for this idea. Specifi-

4 | DISCUSSION cally, we found that people who had been phubbed experienced
greater threats to these needs, and one case, threat mediated the
The present research was conducted to further understand the effects effect of phubbing on communication outcomes. Specifically, the need
of phubbing on social interaction. As expected, our findings revealed for belongingness mediated the effect of phubbing on perceived com-
munication quality and relationship satisfaction. However, the need for
meaningful existence, self-esteem, and control did not mediate any of
these effects. Further, negative affect mediated the effect of phubbing
on perceived communication quality and positive affect mediated the
effect of phubbing on relationship satisfaction. In many cases therefore,
phubbing may negatively affect important social outcomes because it
threatens the same needs and affect that are threatened when people
are socially excluded. Concerns about the negative influence of smart-
phone use during conversations therefore appears to be warranted.
The current research makes an important contribution to the liter-
ature on ostracism. It shows that threats to fundamental needs can
occur as a result of an everyday communication phenomenon that a
significant majority of people report having experienced. Traditionally,
the effects of social exclusion have been studied in games such as the
cyberball paradigm (Hartgerink, van Beest, Wicherts, & Williams, 2015).
However, as people become more and more reliant on their smart-
FIGURE 6 Mean difference between groups of participants on phones, social exclusion has perhaps become a pervasive feature of
PANAS everyday social interaction. Unlike other more well-studied forms of
10 | CHOTPITAYASUNONDH AND DOUGLAS

TA BL E 6 Post hoc tests of PANAS negative and positive

95% CI
Dependent Post hoc (I) Phubbing (J) Phubbing Mean
variable test condition condition diff (I-J) SE Sig. Upper Lower Cohen’s d

PANAS negative Games-Howell No phubbing Partial phubbing 23.62 1.13 .01 26.32 2.93 .68
Extensive phubbing 24.95 .99 <.001 27.30 22.59 1.11
Partial phubbing No phubbing 3.62 1.13 .01 .93 6.32 .68
Extensive phubbing 21.32 1.20 <.001 24.18 1.53 .24
Extensive phubbing No phubbing 4.95 .99 .51 2.59 7.30 1.11
Partial phubbing 1.32 1.20 .51 21.53 4.18 .24

PANAS positive Games-Howell No phubbing Partial phubbing 6.16 1.62 .00 2.28 10.03 .80
Extensive phubbing 9.59 1.52 <.001 5.96 13.23 1.36
Partial phubbing No phubbing 26.16 1.62 .01 210.03 22.28 .80
Extensive phubbing 3.44 1.32 .03 .30 6.58 .60
Extensive phubbing No phubbing 29.59 1.52 <.001 213.23 25.96 1.36
Partial phubbing 23.44 1.32 .03 26.58 2.30 .60

social exclusion, phubbing can take place anywhere and at any time as
someone reaches for their phone and ignores their conversation part-
ner. People may therefore have their fundamental needs threatened
more regularly during the course of routine, everyday conversations,
providing new avenues for research on ostracism. This research repre-
sents an early attempt to understand the consequences of phubbing.
Therefore, it is important to consider its strengths, limitations, and
some directions for future research. First, the study has several
strengths. In particular, it contributes a novel method for studying
social exclusion in dyadic conversations by using animations. We know
from previous experiments using the cyberball paradigm that socially
excluded participants experience negative impact on fundamental
needs, affect, and various other constructs (Hartgerink et al., 2015). In
particular, individuals have an automatic mechanism detecting social
ostracism (Panksepp, 2003) and the ostracizers do not even need to be
real humans for targets to have reflexive responses (Zadro et al., 2004).
The current method therefore offers an additional controlled way of
studying social exclusion. A further advantage is that the animations
can also be easily adapted to study the effects of varying degrees of
phubbing, as well as features of the communication protagonists and
features of the communicative context. They are therefore easily
adaptable to different research purposes. However, the use of

TA BL E 7 Results of structural path estimates of study models

Proposed Model Final model

Dependent variable Independent variable B SE b p B SE b p

Phubbing intensity Belonging 21.10 .09 2.74 <.001 21.10 .09 2.74 <.001
Self-esteem 2.79 .09 2.62 <.001 2.79 .09 2.62 <.001
Meaningful existence 2.99 .09 2.68 <.001 2.99 .09 2.68 <.001
Control 2.42 .08 2.41 <.001 2.42 .08 2.41 <.001
Negative affect 2.51 .57 .37 <.001 2.51 .57 .37 <.001
Positive affect 24.84 .77 2.49 <.001 24.84 .77 2.49 <.001
Communication quality 2.38 .12 2.23 .00 2.39 .12 2.24 <.001
Relationship satisfaction 2.20 .07 2.15 .01 2.18 .07 2.14 .01

Belonging Communication quality .45 .12 .40 <.001 .64 .09 .58 <.001
Relationship satisfaction .38 .07 .44 <.001 .51 .05 .59 <.001

Self-esteem Communication quality .13 .12 .10 .29

Relationship satisfaction .04 .08 .04 .60

Meaningful existence Communication quality .11 .12 .10 .35

Relationship satisfaction .07 .07 .07 .38

Control Communication quality .07 .11 .04 .52

Relationship satisfaction .11 .07 .08 .13

Negative affect Communication quality 2.03 .02 2.14 .02 2.18 .07 2.14 .01
Relationship satisfaction 2.01 .01 2.03 .48

Positive affect Communication quality 2.01 .01 2.02 .82

Relationship satisfaction .03 .01 .25 <.001 .04 .01 .29 <.001

B 5 unstandardized coefficients; SE 5 standard error; b 5 standardized coefficients.

CHOTPITAYASUNONDH AND DOUGLAS
FIGURE 7 Path analysis of the final model
animations also comes with some limitations. For example, whilst they
ensure a rigorous level of experimental control, this may come at the
cost of external validity. The animations presented cartoon-like figures
on a screen (see Figure 2) and are therefore limited in the extent to
which they offer the opportunity to study real-life conversations
between strangers, acquaintances and friends. It may also be possible
that participants became aware of the purpose of the study and
responded in a socially desirable manner. Although we feel that this is
unlikely given the minimalness of the animation and manipulation, and
the privacy of participants’ responses, appropriate checks should be
made in future research.
The measures in our study present some other issues that need to
be considered. First, the proposed moderators (i.e., perceived social
norms of phubbing and rejection sensitivity) had no impact on any of
the effects we observed. Perhaps this can be explained by the nature
of people’s instant responses to ostracism. Individuals have immediate
indiscriminate reflexive reactions to social exclusion, then cope and
recover during a later reflective stage (Williams, 2009a). Immediate
responses to ostracism are robust and appear insensitive to moderation
by individual differences and situational factors (Williams, 2009b). A
further consideration is that meaningful existence predicted neither
perceived communication quality or relationship satisfaction. Further,
need for control only predicted relationship satisfaction. We can only
speculate about the reasons for these non-significant effects. The rela-
tively low reliability of the PSNP should also be addressed in future
research.
A further limitation of our research is that the sample size was rela-
tively small and not very diverse. Future research should address this
limitation. It is also possible that the mere presence of smartphones in
all animations can interfere with relationship outcomes (Misra et al.,
2014), which is something else that should be considered. Finally, the
| 11
current study only varied the extent to which participants were
phubbed during the dyadic conversation, and not the number of times
participants were phubbed. The frequency of being phubbed may have
an impact on relationship outcomes.
There are also other potential avenues for future research that we
would like to highlight here. First, to understand people’s coping and
longer term responses to phubbing behavior, we need to examine in
more detail the temporal need-threat model proposed by Williams
(2009b). This model suggested three stages of the ostracism effect: (1)
a reflexive (or immediate) stage, (2) a reflective (or coping) stage, and
(3) a resignation (or long-term) stage (Williams, 2009a). In this study,
we limited ourselves to examining only the initial and immediate
responses to being phubbed (i.e., the reflexive stage). Future research
should therefore investigate what happens in the second and third
phases of ostracism as a result of phubbing behaviour. For example, it
is interesting to note that the majority of our participants who failed
the attention checks were in the extensive phubbing condition, sug-
gesting that people may ‘tune out’ after some time being phubbed.
Studying the reflective stage will enable researchers to more fully
understand the longer term effects of phubbing.
Future research should also examine additional mechamisms to
explain the effects of phubbing on relationship outcomes. We have
focused on ostracism in the present study and our findings do support
the prediction that phubbing threatens at least one of the fundamental
needs and also dampens mood. However, another recent investigation
proposed and found evidence to support the idea that mobile phone
use during face-to-face interactions influences impression formation as
a result of conversational norm violation (Abeele et al., 2016). This
relates to the construct of expectancy violation more generally. Individ-
uals develop expectations about the behavior of communicators, and
as a result, they assign a positive or negative valence judgement when
12 | CHOTPITAYASUNONDH
they notice that their communication partner’s behavior deviates signif-
icantly from expectancies (Burgoon, 1993; Burgoon & Hale, 1988).
Miller-Ott & Kelly (2015) found that participants expected undivided
attention in some social contexts. Excessive mobile phone usage in
social interactions might therefore violate communicative expectations
and lead to negative relationship satisfaction (Kelly, Miller-Ott, &
Duran, 2017). Furthermore, “technostress”—or feelings of distress asso-
ciated with mobile phone use—may be another mechanism underlying
phubbing behavior (Gonzales & Wu, 2016). Further research exploring
the mechanisms underlying phubbing effects is therefore needed.
Further research should also examine phubbing effects in different
relationships contexts. For example, research could explore the effects
of phubbing by different individuals (e.g., friends/enemies) and groups
(ingroups/outgroups). Gonsalkorale and Williams (2007) found that
being ostracized even by a despised outgroup lowers mood and has a
negative impact on fundamental needs. Future research could examine
if similar effects occur for phubbing. For example, is it worse to be
phubbed by a friend than an enemy, or by someone from one’s ingroup
than by an outgroup member? Research such as this would allow schol-
ars to further align phubbing with the ostracism literature and investi-
gate possible differences between phubbing and other forms of social
exclusion.
Future research should also consider more naturalistic communi-
cation settings to increase external validity, actual behaviors of par-
ticipants on the receiving end of phubbing (e.g., nonverbal responses,
eye tracking responses), and the extent to which social exclusion in
the form of phubbing produces different outcomes to other types of
social exclusion such as cyberostracism. Finally, emerging findings on
the effects of phubbing and the mechanisms that drive these effects
may inform interventions to address the negative effects of
phubbing.
5 | CONCLUSIONS
This research breaks new ground by demonstrating that phubbing
violates fundamental human needs and reduces affect. In turn, a
sense of belonging, and both positive and negative affect lead to
negative communication outcomes. It extends upon research on the
antecedents and consequences of phubbing by further highlighting
some of the potentially negative consequences of mobile phone use
for social interactions. We anticipate this to be a fruitful line of
research as scholars further investigate the effects of modern tech-
nologies on social life.
AC KNOW LEDG MENT
The research was part of Varoth Chotpitayasunondh’s PhD research
project which was funded by the Royal Thai Government
Scholarship.
ORCI D
Varoth Chotpitayasunondh http://orcid.org/0000-0002-4253-4153
AND DOUGLAS
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NEW RESEARCH

Prevalence of Tourette Syndrome and

Chronic Tics in the Population-Based Avon
Longitudinal Study of Parents and
Children Cohort
Jeremiah M. Scharf, M.D., Ph.D.,
Laura L. Miller, M.Sc., Carol A. Mathews, M.D.,
Yoav Ben-Shlomo, M.B.B.S., Ph.D.

Objective: Recent epidemiologic studies have demonstrated that Tourette syndrome (TS) and
chronic tic disorder (CT) are more common than previously recognized. However, few
population-based studies have examined the prevalence of co-occurring neuropsychiatric
conditions such as obsessive-compulsive disorder (OCD) and attention-deficit/hyperactivity
disorder (ADHD). We evaluated the prevalence of TS, CT, and their overlap with OCD and
ADHD in the Avon Longitudinal Study of Parents and Children (ALSPAC) birth cohort.
Method: A total of 6,768 children were evaluated using longitudinal data from mother-
completed questionnaires. DSM-IV-TR diagnoses of TS and CT were derived using three levels
of diagnostic stringency (Narrow, Intermediate, and Broad). Validity of the case definitions
was assessed by comparing gender ratios and rates of co-occurring OCD and ADHD using
heterogeneity analyses. Results: Age 13 prevalence rates for TS (0.3% for Narrow; 0.7% for
Intermediate) and CT (0.5% for Narrow; 1.1% for Intermediate) were consistent with rates from
other population-based studies. Rates of co-occurring OCD and ADHD were higher in TS and
CT Narrow and Intermediate groups compared with controls but lower than has been
previously reported. Only 8.2% of TS Intermediate cases had both OCD and ADHD; 69% of TS
Intermediate cases did not have either co-occurring OCD or ADHD. Conclusions: This
study suggests that co-occurring OCD and ADHD is markedly lower in TS cases derived
from population-based samples than has been reported in clinically ascertained TS cases.
Further examination of the range of co-occurring neuropsychiatric disorders in
population-based TS samples may shed new perspective on the underlying shared
pathophysiology of these three neurodevelopmental conditions. J. Am. Acad. Child
Adolesc. Psychiatry, 2012;51(2):192–201. Key Words: Tourette syndrome, prevalence,
ALSPAC, obsessive-compulsive disorder, attention-deficit/hyperactivity disorder

T
ourette syndrome (TS) is a chronic, child-
hood-onset neuropsychiatric disorder char-
acterized by waxing and waning motor and
vocal tics that persist for more than 1 year.1 Tics
usually begin between 5 and 7 years of age, are
most severe in early adolescence, and then grad-
ually decrease in early adulthood.2,3 Chronic tic
disorder (CT), which is defined by the presence
of either motor or vocal tics (but not both), is
similar in clinical phenomenology and disease
Supplemental material cited in this article is available online.
course to TS, but is less frequently associated with
co-occurring neuropsychiatric conditions, such
as obsessive-compulsive disorder (OCD) and
attention-deficit/hyperactivity disorder (ADHD).4
TS and CT cause significant physical and psychos-
ocial morbidity, and in severe cases can produce
lifelong disability.2,5
TS was initially considered to be rare, with
early estimates of approximately 5 per 10,000
school-age children (0.05%).6 However, these
studies included only clinically ascertained cases,
an approach that greatly underestimates the true
prevalence of the disorder by excluding individ-
uals who do not seek treatment. In contrast, a

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192 www.jaacap.org VOLUME 51 NUMBER 2 FEBRUARY 2012

number of population-based studies have been
conducted over the past two decades that sug-
gest that TS is much more common, with most
prevalence estimates converging around a rate of
0.3% to 0.8% of the school-age population.7,8
Fewer studies have examined the prevalence of
CT, and estimates range from 1.3% to 3.7% of
children.9-11 Determination of accurate TS/CT
prevalence estimates is important for assessing
the overall burden of disease, allocating treat-
ment resources, and estimating the familial risk
in relatives of TS patients.
In addition, TS and CT are frequently associ-
ated with multiple co-occurring neuropsychiatric
conditions in clinically ascertained samples, par-
ticularly OCD and ADHD. In the largest clinical
study of 3,500 TS patients from 64 international
clinics, OCD was present in 27% (range 2%–
66%), whereas 60% had ADHD (range 33%–
91%).12 Furthermore, only 12% of TS patients
(range 2%–35%) had tics without any other
co-existing disorders.12 A more recent U.S.
telephone-based survey of clinician-diagnosed TS
found that 64% of children with TS had ADHD
and 79% had at least one co-occurring neuropsy-
chiatric condition.13 Although these clinic-based
estimates are important for informing clinical
practice, they may overestimate the true rates of
co-occurring disorders with TS in the general
population because of referral bias. Various stud-
ies have examined rates of TS-related OCD
and/or ADHD in the general population.4,14-20
Some of these studies suggest that community-
based TS subjects have lower rates of OCD4,17,19
(0%–19%) and ADHD15 (8%) than cases ascer-
tained through clinics, although others are consis-
tent with rates found in clinical populations (42%
for OCD15 and 36%–100% for ADHD).4,14,16,17,19,20
In addition, only one of these population-based
studies examined concurrent OCD and ADHD in
CT specifically,4 although other studies have exam-
ined rates of ADHD across the tic spectrum.7,21 A
more comprehensive understanding of the rela-
tionship and overlap between TS/CT, OCD, and
ADHD in the general population would provide a
framework for studies of the underlying genetics
and pathophysiology of these disorders.
Here, we determined the prevalence of TS
and CT, as well as the rates of co-occurring
OCD and ADHD, in the Avon Longitudinal
Study of Parents and Children (ALSPAC) sam-
ple, an ongoing, prospective, population-based
birth cohort study in which tic, OCD, and
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VOLUME 51 NUMBER 2 FEBRUARY 2012
TS/CT PREVALENCE IN THE ALSPAC COHORT
ADHD symptoms were assessed by maternal
screening questionnaires at multiple time points
throughout childhood.
METHOD
Subjects
A total of 14,541 pregnant women resident in Avon,
United Kingdom, with expected delivery dates be-
tween April 1, 1991, and December 31, 1992, were
enrolled in ALSPAC, representing 85% of the eligible
population.22,23 Of the 14,472 pregnancies with known
birth outcomes, 13,988 infants were alive at 1 year.
Mothers completed self-administered questionnaires
about themselves and their child’s development, envi-
ronmental exposures, and health outcomes approxi-
mately every 6 months from birth to age 7 years and
every year thereafter, with data available for 7,152
children at age 13. 99% of children were between 13
years 1 month and 13 years 11 months of age at the
time the age 13 questionnaire was answered (full
range: 12 years 10 months to 16 years 1 month). Ethical
approval for the study was obtained from the ALSPAC
Law and Ethics Committee and Local Research Ethics
Committees. The characteristics of this population-
based sample and its generalizability have been previ-
ously reported.22 Briefly, children in Avon had parents
with a similar racial distribution as the general UK
population (5.1% versus 6.4% nonwhite, in Avon and
the entire United Kingdom, respectively), level of
education (14.0 % vs 13.7% with university degrees),
and the rate of single parent households at age 5 (4%
versus 5%), although children in Avon were signifi-
cantly less likely to have a father working in manual
labor (51.6% versus 65.1%).
Disease Definitions
ALSPAC children were evaluated for the presence of a tic
disorder in nine mother-completed questionnaires from age
1.5 to 13 years (questionnaires are available at the ALSPAC
Web site at http://www.bristol.ac.uk/alspac/sci-com/
quests/). At yearly intervals from age 1.5 to 7.5 years and at
age 10, mothers were asked a single screening question
about the presence and frequency of “tics or twitches” in
their child. Rates of positive response to this single tic
question at each age are provided online (Table S1, available
online). At age 13 years, a more detailed tic assessment was
administered, including a section with five questions about
specific motor and vocal tics: (C1: In the past year, has your
child had any repeated movements of parts of the face and
head (e.g., eye blinking, grimacing, sticking tongue out,
licking lips, spitting)?; C2: Has your child had repeated
movements of the neck, shoulder or trunk (e.g., twisting
around, shoulder shrugging, bending over, nodding)?); C3:
Has your child had repeated movements of arms, hands,
legs, feet?; C4: Has your child had repeated noises and
sounds (e.g., coughing, clearing throat, grunting, gurgling,
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SCHARF et al.

TABLE 1 Definitions of Tourette Syndrome (TS) and Chronic Tics (CT) Based on Mother-Completed Questionnaires
From the Avon Longitudinal Study of Parents and Children (ALSPAC)
TS CT

Narrow Definition
Intermediate Definition
(same as Narrow except
“Probably” allowed in
response to tic questions
and frequency expanded
to include daily-weekly)
Broad Definition
(Relaxed to remove
chronicity requirements;
designed to capture
subjects with onset after
Age 10 or missed in
early screens)
1) Motor and Vocal Tics: Response of
“Definitely” to motor AND vocal tic
questions at Age 13
2) Frequency: Daily
3) Chronicity: Positive response to tic
screening question at 1 other time
point
4) Exclusions: IQ ⬍80 or autism
1) Motor AND Vocal Tics: Response of
“Definitely” or “Probably” to motor
AND vocal tic questions at age 13
2) Frequency: Daily or ⬎once per week
3) and 4) Chronicity and Exclusions:
Same criteria as for Narrow
Definition
1) Motor AND Vocal Tics: Response of
“Definitely” or “Probably” to motor
AND vocal tic questions at age 13
2) Frequency: Daily or ⬎once per week
3) Chronicity: No chronicity requirement
4) Exclusions: IQ ⬍80 or autism
1) Motor OR Vocal Tics: Response of “Definitely”
to motor OR vocal tic questions (not both) at
Age 13
2) Frequency: Daily
3) Chronicity: Positive response to tic screening
question at 1 other time point
4) Exclusions: IQ ⬍80 or autism
1) Motor OR Vocal Tics: Response of “Definitely”
or “Probably” to motor OR vocal tic questions
at age 13
2) Frequency: Daily or ⬎once per week
3) and 4) Chronicity and Exclusions: Same
criteria as for Narrow Definition
1) Motor OR Vocal Tics: Response of “Definitely”
or “Probably” to motor AND vocal tic
questions at age 13
2) Frequency: Daily or ⬎once per week
3) Chronicity: No chronicity requirement
4) Exclusions: IQ ⬍80 or autism

Note: Diagnoses of probable TS and CT were derived based on three levels of diagnostic stringency (Narrow, Intermediate, and Broad) to define TS and
CT using DSM-IV-TR criteria. Specific tic symptom questions are provided in the text and on the ALSPAC Web site (http://www.bristol.
ac.uk/alspac/sci-com/quests/).

hissing)? C5: Has your child had repeated words or
phrases?). Each question was answered as “definitely”,
“probably” or “not at all” present. An additional item
queried the frequency of the repeated movements.
Diagnoses of TS and CT were defined by applying
DSM-IV-TR criteria to the questionnaire responses
based on three levels of stringency (Narrow, Interme-
diate, and Broad) (Table 1). Positive responses regard-
ing the presence and frequency of specific motor
and/or vocal tics in the Age 13 questionnaire were
required for all definitions (Table 1). Positive responses
at an additional time point between ages 1.5 and 10
years were required to meet DSM-IV-TR chronicity
criteria of tic persistence for more than 1 year for the
Narrow and Intermediate definitions. No chronicity
criteria were required for the TS Broad definition. All
assessments were performed before age 18 and thus
met DSM-IV-TR age of onset criteria. Subjects who
endorsed only repeated movements of the arms,
hands, legs or feet (Question C3) or repeated words or
phrases (Question C5) in the absence of a positive
response to other tic questions (C1, C2, C4) were
excluded from all case definitions to remove non-tic
movements such as stereotypy or isolated echolalia.
Response rates to each of the age 13 tic-related ques-
tions are provided online (Table S2, available online).
Subjects with intellectual disability (ID) or autism
were excluded to remove individuals with persevera-
tive behaviors and stereotypies that might mimic tics.
Autism and ID were defined based on a review of
medical and school records as described previously.24
As record-review data for ID were only available for a
subset of ⬃900 subjects, ID was also defined based on
the results of age-appropriate standard neuropsycho-
logical assessments administered at ages 4 and 8
(Wisconsin Preschool and Primary Scale of Intelligence
[WPPSI] and WISC-IV, respectively). Age 4 data were
examined only if age 8 data were unavailable. Subjects
with full-scale IQ ⱕ80 were excluded. When IQ data
were not available at either age (n ⫽ 1,437), the
presence of a Special Educational Needs (SEN) state-
ment for any reason other than “sensory or physical
needs” was used as a proxy for low IQ; as a result, an
additional six subjects were excluded (Figure 1). A
total of 267 subjects had no IQ, autism, ID, or SEN
statement data available. These subjects were no more
likely to receive subsequent tic diagnoses compared
with subjects in the main sample and thus were
included in the overall analysis (data not shown).
Controls were defined as subjects who were eligible
for analysis (data available at age 13 and not excluded
based on the presence of ID, autism, IQ ⬍80 or an SEN

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 TS/CT PREVALENCE IN THE ALSPAC COHORT

FIGURE 1 Study flow diagram. CT ⫽ chronic tics; SEN ⫽ Special Educational Needs statement; TS ⫽ Tourette
syndrome.

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SCHARF et al.
TABLE 2 Prevalence of Tourette Syndrome (TS) and Chronic Tics (CT) Using Narrow, Intermediate and
Broad Definitions
TS
Definition n Prevalence, %
Narrow 23 0.3
Intermediate 50 0.7
Broad 217 3.2
Note: Prevalence rates were calculated from the number of children whose mothers completed the age 13 questionnaire and who did not have autism or
intellectual disability (n ⫽ 6,768). CI ⫽ confidence interval.
statement in the absence of available IQ data), but did
not meet any of the tic case definitions.
Lifetime diagnoses of DSM-IV-TR OCD and ADHD
were derived using a self-report version of the Devel-
opment and Well Being Assessment (DAWBA) parent
interview that was completed by ALSPAC mothers
about their children as part of the age 7, 10, and 14
questionnaires.25 The presence of recurrent obsessions
or compulsions (response of “sometimes” or “often” to
1 or more of 7 questions about contamination, clean-
ing, checking, repeating, touching, arranging, or
counting symptoms) that were severe enough either to
last ⬎1 hour a day, “waste a lot of time,” cause
significant distress (“upset a great deal”), or cause
interference or impairment (answers of “Quite a lot” or
“A great deal” to five questions about interference with
family, friends, school, or hobbies) at one of the three
time points was required for a diagnosis of OCD. Recog-
nition of these thoughts as excessive or unreasonable was
not required per DSM-IV-TR guidelines for diagnosing
OCD in children. Similarly, the presence of six of nine
inattentive and/or six of nine hyperactive/impulsive
symptoms, starting before age 7 years and causing inter-
ference in at least two of four settings (family, friends,
school, leisure activities) were required to meet criteria
for ADHD.
Statistical Analyses
All statistical analyses were performed in Stata v.11.
The Poisson option was used to calculate exact confi-
dence intervals for prevalence estimates. Gender ratios
and rates of co-occurring OCD and ADHD in subjects
with TS and CT were compared with unaffected con-
trols using ␹2 statistics with Yates’ adjustment for
small sample sizes; exact confidence intervals were
also calculated. Heterogeneity analyses between dif-
ferent TS/CT disease definitions were performed us-
ing Cochran’s Q and I2 statistics. Because these TS/CT
disease definitions are nested, heterogeneity was ex-
amined by comparing subjects in the more narrowly
defined group (for example, TS Narrow) to the addi-
tional subjects which comprised the broader definition
(e.g., TS Intermediate subjects excluding those who
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196 www.jaacap.org
CT
95% CI n Prevalence, % 95% CI
0.2–0.5 35 0.5 0.4–0.7
0.5–1.0 72 1.1 0.8–1.3
2.8–3.7 583 8.6 7.9–9.3
met criteria for TS Narrow). All statistical tests were
two-tailed.
RESULTS
TS and CT Prevalence Rates in the ALSPAC Cohort
Figure 1 documents the flow of subjects through
the study. Of 14,472 subjects with known birth
outcomes, mothers of 7,152 subjects completed
the age 13 questionnaire containing the detailed
tic-related questions. Of these, 384 were excluded
for ID, autism, IQ⬍80, or an SEN statement as
described above, leaving 6,768 subjects for anal-
ysis (Figure 1). Point prevalence estimates of TS
and CT at age 13 were calculated for the Narrow,
Intermediate, and Broad definitions (Table 2).
The prevalence rates for TS Narrow and TS
Intermediate (0.3% and 0.7%, respectively), as
well as CT Narrow and CT Intermediate (0.5%
and 1.1%) were consistent with those reported in
previous community-based samples.7,8 In con-
trast, the TS Broad and CT Broad prevalence
estimates (3.2% and 8.6%, respectively), which
did not require that tics be chronic, were signif-
icantly higher than would be expected based on
prior studies; for this reason, only the TS/CT
Narrow and Intermediate definitions were in-
cluded in subsequent analyses.
CT Narrow and Intermediate cases were also
subdivided into those with chronic motor tics
only (CMT) and chronic vocal tics only (CVT).
The prevalence rates of CMT and CVT Narrow
were 0.3% and 0.2%, respectively, whereas CMT
and CVT Intermediate were 0.7% and 0.4% (Ta-
ble S3, available online).
Gender Ratios and Rates of Co-occurring OCD
and ADHD in TS/CT Definitions
To assess the validity of the TS/CT Narrow and
Intermediate disease definitions, gender ratios
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VOLUME 51 NUMBER 2 FEBRUARY 2012

and rates of OCD and ADHD were compared
across different TS/CT disease groups and tested
formally for heterogeneity (Table 3). As expected,
male-to-female gender ratios were significantly
higher in both TS case definitions (TS Narrow,
3.6:1; TS Intermediate, 2.3:1) compared with con-
trols (0.9:1; p ⫽ .006 and p ⫽ .002, respectively). A
low-to-moderate degree of heterogeneity26 was
present between the two TS definitions (I2 ⫽
32.8%, p ⫽ .22). Similarly, CT Narrow and CT
Intermediate groups had a higher proportion of
males than controls (CT Narrow, 1.9:1; CT Inter-
mediate, 2.4:1; p ⫽ .047 and p ⬍ .001, respec-
tively) with no heterogeneity between the two
CT definitions (I2 ⫽ 0%, p ⫽ .64). The gender
ratios for the CMT and CVT case definitions were
similar to those for overall CT with no heteroge-
neity between the Narrow and Intermediate
groups (Table S3, available online).
Rates of OCD and ADHD were elevated in all
four TS/CT disease definitions relative to con-
trols (Table 3). OCD was present in 22% of TS
Narrow and 20% of TS Intermediate subjects
compared with 2% of controls (p ⬍ .001 for both
groups), whereas 9% of CT Narrow and 10% of
CT Intermediate subjects had OCD (p ⫽ .039 and
p ⬍ .001, respectively). The frequency of ADHD
was 17% in TS Narrow and 18% in TS Interme-
diate, 14% in CT Narrow and 11% in CT Inter-
mediate, compared with 2% in controls (p ⬍ .001
for all comparisons). There was no evidence of
heterogeneity between the Narrow and Interme-
diate definitions for either TS or CT with respect
to OCD or ADHD (I2 ⫽ 0% to 2.5%). Rates of
OCD and ADHD were also elevated compared
with controls in the CMT Narrow/Intermediate
and CVT Narrow/Intermediate groups, with a
slightly higher rate of OCD in CVT Narrow and
Intermediate (17% and 12%, respectively) relative
to CMT Narrow (4%) and CMT Intermediate (9%)
(Table S3, available online). Rates of co-occurring
ADHD were 13% in both CMT definitions; the rate
of ADHD was higher in CVT Narrow (17%) com-
pared with CMT, but lower in CVT Intermediate
(8%) (Table S3, available online).
The overlap between TS/CT, OCD and ADHD
were also examined for all subjects who com-
pleted both the tic and OCD/ADHD question-
naires (n ⫽ 6,607) (Figure 2). 8.2% of TS Interme-
diate cases had both ADHD and OCD, whereas
only 2.2% of all OCD cases and 2.5% of all ADHD
cases had all three disorders (Figure 2a). In
addition, 69% of TS Intermediate cases and ap-
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VOLUME 51 NUMBER 2 FEBRUARY 2012
TS/CT PREVALENCE IN THE ALSPAC COHORT
proximately 80% of all OCD or ADHD cases had
an isolated disorder without either of the other
two diagnoses. This relatively low rate of over-
lapping TS, OCD, and ADHD was present even
when considering all chronic tic disorders (TS or
CT Intermediate) or when restricting the sample
to the more stringent TS Narrow definition (Fig-
ure 2b and Figure S1, available online).
Sensitivity Analysis of Tic Frequency Criterion
To assess the effect of applying strict DSM-IV-TR
frequency criteria requiring that tics be present
daily or nearly every day, a sensitivity analysis
was conducted to relax the frequency criterion in
TS/CT Intermediate to include children with tics
occurring “about once a week.” This analysis
increased the TS and CT Intermediate sample by
10% (five TS and seven CT cases), but resulted in
no substantial change in prevalence, gender ra-
tios, or rates of co-occurring OCD or ADHD
(Table S4, available online).
Examination of Attrition Bias
Because parents of children who left the study
before age 13 years consistently endorsed higher
rates of tics than those who remained at age 13
(Table S1, available online), we examined the
factors related to attrition in the sample (Table S5,
available online). Female gender, nonwhite eth-
nicity, lower maternal age, and markers of lower
socio-economic status such as housing tenure
and maternal education were all associated with
loss to follow-up before age 13.
DISCUSSION
This study examined the point prevalence of TS
and CT as well as rates of co-occurring OCD and
ADHD in the population-based ALSPAC birth
cohort. Both the TS Narrow and TS Intermediate
definitions produced prevalence estimates (0.3%
and 0.7%, respectively) that fall within the range
of 0.3% to 0.8% reported by most population-
based TS prevalence studies of school-age chil-
dren over the past decade.8,10,11,17,18,20 Although
some recent studies reported significantly higher
TS rates (3%27 and 3.8%28), these studies were
confounded by small sample size and low par-
ticipation rates, respectively.7 Similarly, the only
prior population-based study to report a mark-
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SCHARF et al.
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TABLE 3 Gender Ratios and Rates of Co-occurring Obsessive-Compulsive Disorder and Attention-Deficit/Hyperactivity Disorder Across the Two Definitions of Tourette
Syndrome and Chronic Tics
Gender OCD ADHD
2 2
M:F Male OR I Total OR I Total OR I2
Ratio % (n) (95% CI) p-Value (p-het) % (n) (95% CI) p-Value (p-het) % (n) (95% CI) p-Value (p-het)

Controls 0.9:1 47 (2,833) 2 (122) 2 (106)

TS Narrow 3.6:1 78 (18) 4.0 0.006 — 22 (5) 13.0 ⬍0.001 — 17 (4) 11.4 ⬍0.001 —
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(1.4, 13.7) (3.7, 37.1) (2.8, 35.0)

TS Intermediate 2.3:1 70 (35) 2.6 0.002 32.8%a 20 (10) 12.0 ⬍0.001 0%a 18 (9) 12.2 ⬍0.001 0%a
(1.4, 5.1) (p ⫽ 0.22) (5.2, 25.2) (p ⫽ 0.83) (5.1, 26.2) (p ⫽ 0.87)
OF THE

CT Narrow 1.9:1 66 (23) 2.1 0.047 — 9 (3) 4.4 0.039 — 14 (5) 9.0 ⬍0.001 —
(1.0, 4.7) (0.9, 14.3) (2.7, 24.1)
AMERICAN ACADEMY OF CHILD & ADOLESCENT PSYCHIATRY

CT Intermediate 2.4:1 71 (51) 2.7 ⬍0.001 0%a 10 (7) 5.0 ⬍0.001 0%a 11 (8) 6.8 ⬍0.001 2.5%a
(1.6, 4.7) (p ⫽ 0.64) (1.9, 11.3) (p ⫽ 0.86) (2.7, 14.6) (p ⫽ 0.31)
VOLUME 51 NUMBER 2 FEBRUARY 2012

Note: I2 is the percent variation due to heterogeneity rather than chance with I2⫽25%, 50%, and 75% suggesting low, moderate, and high heterogeneity, respectively.26 ADHD ⫽ attention-deficit/hyperactivity disorder;
M:F ⫽ male:female ratio; OCD ⫽ obsessive compulsive disorder; OR ⫽ odds ratio; p-het ⫽ p value for Cochran’s Q heterogeneity test (p ⬎0.05 suggests lack of heterogeneity).
a
heterogeneity comparison between narrow and intermediate groups. Controls were defined as subjects who were eligible for analysis at age 13 years but did not meet any of the tic case definitions.

FIGURE 2 Overlap of Tourette syndrome (TS)/chronic
tics (CT), obsessive-compulsive disorder (OCD) and
attention-deficit/hyperactivity disorder (ADHD)
diagnoses in the Avon Longitudinal Study of Parents and
Children. (a) Comparison of overlap among TS, OCD,
and ADHD cases using the TS Intermediate (TSi)
definition. Note: Percentages indicate the fraction of
subjects in each subgroup. Percentages on either side of
the dotted line indicate the different fractional percent of
individuals with overlapping conditions relative to the
disorder of reference. For example, the five cases of
TS⫹ADHD without OCD represent 10.2% of the total TS
sample but only 3.1% of the ADHD sample. Similarly,
the four TS⫹OCD⫹ADHD cases at the center of the
diagram represent 8.2% of the TS sample but only 2.2%
of the OCD and 2.5% of the ADHD samples,
respectively. (b) Comparison of overlapping conditions
between any chronic tic disorder (TS or CT), OCD and
ADHD using the Intermediate case definitions of TS or
CT (TSCTi).
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VOLUME 51 NUMBER 2 FEBRUARY 2012
TS/CT PREVALENCE IN THE ALSPAC COHORT
edly lower TS prevalence rate (0.04%) assessed
subjects in late adolescence when tics often di-
minish or disappear.2,15 Thus, the rates observed
in the current study, combined with the minimal
heterogeneity observed between TS Narrow and
TS Intermediate, suggest that either definition
could serve as a reasonable proxy for TS in future
studies.
In contrast, the prevalence estimates for CT
Narrow (0.5%) and CT Intermediate (1.1%) were
somewhat lower than the rates of 1.3% to 3.7%
reported in prior population-based studies.9-11
Both CT definitions had lower male-to-female
ratios and rates of co-occurring OCD and ADHD
compared with the TS groups (Table 3), a finding
that is consistent with the one previous popu-
lation-based study that examined rates of co-
occurring conditions in both TS and CT in the
same cohort.4 In that study, most of the CT-
associated OCD and ADHD arose from sub-
jects with chronic vocal tics (CVT) (8% with
OCD, 33% with ADHD) rather than subjects
with chronic motor tics (CMT) (0% with OCD
and 12% with ADHD). Although a trend to-
ward higher rates of OCD was observed in the
ALSPAC sample in CVT relative to CMT, the
small sample size of these subgroups, particu-
larly in the Narrow definitions, limit the inter-
pretability of these results (Table S3, available
online).
The rates of concurrent TS and OCD in the
current study are consistent with those of two
prior, school-based studies that identified OCD
in 16%19 and 19%4 of children with TS. A third,
smaller school-based study identified only seven
children with TS, none of whom had OCD,
placing their point estimate of co-occurring
OCD at an upper limit of 14% (⬍1 in seven).17
Together, these data suggest that co-occurring
OCD is less common in TS cases derived from
population-based studies compared with those
from clinically ascertained samples. Although
one community-based study of 17-year-old Is-
raeli army recruits identified OCD in 42% of TS
subjects,15 this rate is not necessarily comparable
to those in other studies, as OCD may be more
prevalent in adolescent TS patients compared
with school-age children.3,29
The rate of co-occurring ADHD in the
ALSPAC TS sample is substantially lower than those
reported in other population-based studies (36%–
100%),4,14,17,19,20,30 although it is higher than the
8% ADHD rate reported in the Israeli TS study.15
www.jaacap.org 199
SCHARF et al.
This finding may be attributable to the instrument
used to diagnose ADHD in ALSPAC, as previous
studies have demonstrated that the DAWBA parent-
form alone underestimates the true rate of ADHD
in the population.25,31 Thus, our estimate of co-
occurring ADHD should be considered a mini-
mum prevalence in this sample.
Our study also offers the opportunity to ex-
amine the rates of overlap among TS, OCD and
ADHD cases, a comparison that has not been
previously reported in a population-based sam-
ple (Figure 2 and Figure S1, available online).
Only 8% to 9% of ALSPAC TS cases had all three
disorders (TS⫹OCD⫹ADHD) compared with
18% to 34% of clinically ascertained TS pa-
tients.29,32 Similarly, although fewer than 30% of
TS clinic patients have TS without co-occurring
OCD or ADHD,29,32 nearly 70% of ALSPAC TS
cases did not have either of these two major
co-existing conditions. These data suggest that
TS individuals in the general population, com-
pared with those seen in specialty clinics, may
be more likely to have an isolated tic disorder
without OCD or ADHD. This observation, if
validated in future studies, would be important
for community psychiatrists and pediatricians
to consider when counseling patients with new
diagnoses and their families. However, it is
important to note that many other neuropsy-
chiatric conditions can be associated with TS
that were not examined in this study. Other
population-based studies have reported high
rates of disruptive behaviors in children with
tics,21,33 and a recent population-based study
found that 92% of community-based TS cases
had at least one additional neuropsychiatric
condition including OCD, ADHD, depression,
conduct disorder, developmental coordination
disorder, learning disability, sleep disorder, or
mental retardation.4
We have taken a number of steps to minimize
the impact of the study’s primary limitations, the
likely bias in our prevalence estimates resulting
from differential attrition, and the reliance on
maternal questionnaires rather than direct clini-
cal assessments. With regard to attrition bias, it is
important to note that any cross-sectional study
in a school-age population inherently represents
a biased sample of children compared with their
original “birth cohort,” although in most cases
the attrition rate is unmeasured. Here, because
ALSPAC is a longitudinal study, we were able to
examine the factors related to attrition and take
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200 www.jaacap.org
note of potential bias, turning an inherent weak-
ness into a strength of the study. Although the
identified attrition bias might reduce the gener-
alizability of our findings to some degree, the
factors that we identified as being associated
with attrition (female gender, nonwhite ethnic-
ity, lower maternal age, and lower socio-
economic status) are likely to predict nonpar-
ticipation in most epidemiologic studies. We
may also have missed some subjects who had
chronic tics that abated before age 13, the time
point for which we have the most reliable
tic-related data; however, because TS generally
begins early in childhood and peaks in early
adolescence, we believe that we have success-
fully captured most subjects.2 In addition, we
deliberately chose rigorous disease definitions
and sought to exclude subjects with likely
non-tic movement disorders (e.g., stereotypies
in autism or intellectual disability, repetitive
arm/leg movements that could be better ex-
plained by tremor or motor restlessness) to
minimize the potential impact of our necessary
reliance on maternal questionnaires.
Although these potential limitations may lead
to an underestimate of the prevalence of TS and
CT in the ALSPAC sample, our results are con-
sistent with other prevalence estimates of TS and
CT in the general population, and this study is
one of few to report the overlapping rates of
co-occurring TS/CT, OCD, and ADHD in a
population-based sample. Furthermore, this is
the first study to examine the rates of TS and CT
in the ALSPAC cohort, in which detailed longi-
tudinal data about child development are avail-
able for more than 7,000 children. Through our
strict inclusion/exclusion criteria and heteroge-
neity analyses, we believe that we have identified
optimal disease definitions that both meet
DSM-IV criteria and maintain face validity.
Therefore, these definitions should prove ex-
tremely useful for future studies of TS and CT in
this cohort. &
Accepted November 15, 2011.
Dr. Scharf and Ms. Miller contributed equally to this article.
Dr. Scharf is with the Psychiatric and Neurodevelopmental Genetics
Unit, Center for Human Genetics Research, Massachusetts General
Hospital, and the Division of Cognitive and Behavioral Neurology,
Brigham and Women’s Hospital. Dr. Ben-Shlomo and Ms. Miller are
with the School of Social and Community Medicine, University of
Bristol, UK. Dr. Mathews is in the University of California at San
Francisco.
This research was specifically funded by a grant from the Tourette
Syndrome Association. The UK Medical Research Council and the
OF THE AMERICAN ACADEMY OF CHILD & ADOLESCENT PSYCHIATRY
VOLUME 51 NUMBER 2 FEBRUARY 2012

Wellcome Trust (grant ref: 092731) and the University of Bristol
provide core support for the Avon Longitudinal Study of Parents and
Children (ALSPAC).
This publication is the work of the authors and Drs. Scharf, Mathews,
and Ben-Shlomo will serve as guarantors for the contents of this paper.
Ms. Miller served as the study statistician.
We are extremely grateful to all the families who took part in this
study, the midwives for their help in recruiting them, and the whole
Avon Longitudinal Study of Parents and Children (ALSPAC) team,
which includes interviewers, computer and laboratory technicians,
clerical workers, research scientists, volunteers, managers, recep-
tionists, and nurses.
Disclosure: Dr. Scharf has received research grant funding from the
National Institutes of Health (NIH) and from the TSA. He has received
honoraria from the TSA and the Center for Disease Control. Dr. Mathews
has received research grant funding from the NIH and from
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TS/CT PREVALENCE IN THE ALSPAC COHORT
TSA. She has served on the TSA Medical Advisory Board. She has
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Dr. Ben-Shlomo has received grant funding from the British Heart
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Correspondence to Jeremiah M. Scharf, M.D., Ph.D., Psychiatric
and Neurodevelopmental Genetics Unit, Center for Human
Genetics Research, Massachusetts General Hospital, 185
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SCHARF et al.

TABLE S1 Proportion of Children in the Avon Longitudinal Study of Parents and Children (ALSPAC) Cohort Whose
Parents Endorsed the Presence of “Tics or Twitches” in Their Son/Daughter at Each Age-Specific Questionnaire
Child’s Age at Time of
Completion of Children with Data Children with Data
Maternal Available at Age 13 Not Available at
Questionnaire Years Age 13 Years Overall Sample

1 Year 6 months 0.42% (26/6,155) 0.96% (41/4,280) 0.64% (67/10,435)

2 Years 6 months 0.54% (32/5,973) 0.73% (27/3,678) 0.61% (59/9,651)
3 Years 6 months 1.39% (84/6,048) 1.78% (62/3,476) 1.53% (146/9,524)
4 Years 9 months 0.80% (47/5,909) 1.25% (37/2,961) 0.95% (84/8,870)
5 Years 9 months 1.18% (68/5,740) 1.72% (41/2,379) 1.34% (109/8,119)
6 Years 5 months 1.37% (79/5,751) 2.22% (49/2,210) 1.61% (128/7,961)
7 Years 7 months 1.64% (93/5,681) 2.65% (51/1,922) 1.89% (144/7,603)
10 Years 8 months 2.29% (135/5,903) 3.32% (43/1,296) 2.47% (178/7,199)
13 Years 17.9% (1211/6,768) NA 17.9% (1211/6,768)

Note: Rates of positive response to the single question about tics at each age are separated into children who had data available at age 13 years (eligible
for inclusion in the current study) and children who were lost to follow-up before age 13 years (not eligible for inclusion in the current study due to absence
of detailed tic questionnaire data only available at age 13). Rates of positive responses in the overall sample are also provided. These data do not
include subjects with intellectual disability, autism, or IQ ⬍80 as described in the main text.

TABLE S2 Response Rates in the Avon Longitudinal Study of Parents and Children (ALSPAC) Age 13 Mother-
Completed Questionnaires to Each of the Detailed Questions about Specific Tics and Their Frequencies
C1: Repeated C2: Repeated C4: Repeated
Movements of Movements of Neck, Noises and Sounds C6b: Frequency of
Response Face and Head Shoulder, or Trunk in Past Year Response These Habits

Definitely 327 (4.8%) 125 (1.9%) 308 (4.6%) ⬍ Once a month 150 (2.2%)
Probably 303 (4.5%) 203 (3.0%) 479 (6.6%) 1–3 Times a month 164 (2.4%)
Not at all 6,063 (89.6%) 6,336 (93.6%) 5,910 (87.3%) About once a week 151 (2.2%)
Missing 75 (1.1%) 104 (1.5%) 106 (1.6%) ⬎ Once a week 501 (7.4%)
Every day 667 (9.9%)
Missing/NA 5,135 (75.9%)

Note: Exclusions for ID, autism, IQ ⬍80 were conducted before these variables were tabulated.

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VOLUME 51 NUMBER 2 FEBRUARY 2012
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TABLE S3 Prevalence Rates, Gender Ratios, and Rates of Co-occurring Obsessive-Compulsive Disorder (OCD) and Attention-Deficit/Hyperactivity Disorder (ADHD) in
the Two Definitions of Chronic Motor Tics (CMT) and Chronic Vocal Tics (CVT)
Gender OCD ADHD

Prevalence M:F Male OR p Total OR p Total OR

Rate Ratio % (n) (95% CI) Value I2 (p-het) % (n) (95% CI) Value I2 (p-het) % (n) (95% CI) p Value I2 (p-het)

Controls 0.9:1 47 (2,833) 2 (122) 2 (106)

CMT Narrow 0.3% 1.9:1 65 (15) 2.1 .14 — 4 (1) 2.1 .98 — 13 (3) 8.1 .001 —
(n ⫽ 23) (0.8, 5.7) (0.1, 13.4) (1.5, 27.9)
CMT Intermediate 0.2% 2.1:1 68 (32) 2.4 .008 0%a 9 (4) 4.4 .012 75%a 13 (6) 7.9 ⬍.001 0%a
(n ⫽ 47) (1.2, 4.7) (p ⫽ .90) (1.1, 12.3) (p ⫽ .045) (2.7, 19.3) (p ⫽ .73)
CVT Narrow 0.7% 2.0:1 67 (8) 2.2 .30 — 17 (2) 9.4 .013 — 17 (2) 10.8 .006 —
(n ⫽ 12) (0.6, 10.1) (0.99, 44.6) (1.1, 51.5)
CVT Intermediate 0.4% 3.2:1 76 (19) 3.50 .008 0%a 12 (3) 6.4 .006 0%a 8 (2) 4.7 .12 0%a
(n ⫽ 25) (1.34, 10.73) (1.2, 21.7) (p ⫽ .83) (0.53, 19.4) (p ⫽ .75)

TS/CT PREVALENCE IN THE ALSPAC COHORT

Note: I2 is the percent variation due to heterogeneity rather than chance with I2 ⫽ 25%, 50%, and 75% suggesting low, moderate, and high heterogeneity, respectively.1 CI ⫽ confidence interval; M:F ⫽ male:female
ratio; OR ⫽ odds ratio; p-het ⫽ p value for Cochran’s Q heterogeneity test (p ⬎ 0.05 suggests lack of heterogeneity). Controls were defined as subjects who were eligible for analysis at age 13 years but did not
meet any of the tic case definitions (see Figure 1).
a
heterogeneity comparison between narrow and intermediate groups.
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SCHARF et al.
TABLE S4 Sensitivity Analysis of Tourette Syndrome (TS) and Chronic Tic (CT) Intermediate Definitions
Gender OCD ADHD

Prevalence Rate M:F Male OR p Total OR Total OR p

(95% CI) Ratio % (n) (95% CI) Value % (n) (95% CI) p Value % (n) (95% CI) Value

Controls 0.9:1 47 2 (122) 2 (106)

TS Intermediate 0.7% (0.5%–1.0%) 2.3:1 70 (35) 2.6 (1.4, 5.1) .002 20 (10) 12.0 (5.2, 25.2) ⬍.001 18 (9) 12.2 (5.1, 26.2) ⬍.001
(n ⫽ 50)
TS Intermediate 0.8% (0.6%–1.1%) 2.2:1 69 (38) 2.5 (1.4, 4.7) .002 19 (10) 10.6 (4.7, 22.0) ⬍.001 19 (10) 12.4 (5.4, 25.8) ⬍.001
Plus
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(n ⫽ 55)
CT Intermediate 1.1% (0.8%–1.3%) 2.4:1 71 (51) 2.7 (1.6, 4.7) ⬍.001 10 (7) 5.0 (1.9, 11.3) ⬍.001 11 (8) 6.8 (2.7, 14.6) ⬍.001
(n ⫽ 72)
OF THE

CT Intermediate 1.2% (0.9%–1.5%) 2.2:1 68 (54) 2.4 (1.5, 4.0) ⬍.001 9 (7) 4.5 (1.7, 10.1) ⬍.001 10 (8) 6.1 (2.5, 13.2) ⬍.001
Plus
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(n ⫽ 79)
VOLUME 51 NUMBER 2 FEBRUARY 2012

Note: TS Intermediate and CT Intermediate disease definitions were derived as described in the Method section of the text. A sensitivity analysis was performed by relaxing the tic frequency criterion to include children
whose parents reported the presence of tics “about once a week” in addition to the two higher frequency responses “daily” and “more than once a week” (Table 1 and Table S2, available online). This analysis increased
the TS Intermediate sample by five cases (TS Intermediate Plus) and the CT Intermediate sample by seven cases (CT Intermediate Plus). Prevalence rates based on the original definitions and relaxed definitions are
provided along with gender ratios, and rates of co-occurring obsessive-compulsive disorder (OCD) and attention-deficit/hyperactivity disorder (ADHD). p values indicate comparisons between each definition and the
control population. Controls were defined as subjects who were eligible for analysis at age 13 years but did not meet any of the tic case definitions (Figure 1). CI ⫽ confidence interval; OR ⫽ odds ratio.
 TS/CT PREVALENCE IN THE ALSPAC COHORT

TABLE S5 Comparison of Avon Longitudinal Study of Parents and Children (ALSPAC) Cohort Attendees of the Age
13 Assessment With Nonattendees
Attendees n (%) Nonattendees n (%) p Value

Gender
Male 3,351 (49.5) 3,743 (52.7) ⬍.001
Female 3,417 (50.5) 3,363 (47.3)
Maternal education
⬍ O’level 1,276 (20.2) 2,195 (39.7) ⬍.001
O ‘level 2,204 (34.9) 1,903 (34.4)
⬎ O’level 2,834 (44.9) 1,437 (26.0)
Housing tenure
Mortgaged/owned 5,301 (83.9) 4,131 (63.8) ⬍.001
Rented/other 1,015 (16.1) 2,346 (36.2)
Ethnicity of child
White 5,982 (96.3) 4,972 (93.5) ⬍.001
Nonwhite 228 (3.7) 345 (6.5)
Maternal age (mean) 29.2 (4.6) 26.9 (5.1) ⬍.001

Note: Attendees at age 13 (n ⫽ 7,152) represent the subset of the ALSPAC sample whose mothers completed the Age 13 Questionnaire and thus were
eligible for the present study. Nonattendees (n ⫽ 7,381) indicate subjects from the original ALSPAC birth cohort who were lost to follow-up before the
Age 13 tic screening questionnaire.

JOURNAL OF THE AMERICAN ACADEMY OF CHILD & ADOLESCENT PSYCHIATRY

VOLUME 51 NUMBER 2 FEBRUARY 2012 www.jaacap.org 201.e4
SCHARF et al.

REFERENCE FIGURE S1 Overlap of Tourette syndrome

1. Higgins JP, Thompson SG, Deeks JJ, Altman DG. Measuring
inconsistency in meta-analyses. Br Med J. 2003;327:557-560.
(TS)/chronic tics (CT), obsessive-compulsive disorder
(OCD) and attention-deficit/hyperactivity disorder
(ADHD) diagnoses in the Avon Longitudinal Study of
Parents and Children (ALSPAC) using the TS and CT
narrow case definitions. (a) TS Narrow (TSn).
Comparison of overlap between TS, OCD, and ADHD
cases using the TSn case definition. Note: Percentages
indicate the fraction of subjects in each subgroup.
Percentages on either side of the dotted line indicate the
different fractional percent of individuals with
overlapping (co-occurring) conditions relative to the
disorder of reference. For example, the two cases of
TS⫹OCD⫹ADHD at the center of the diagram represent
8.7% of the total TS sample, but only 1.1% of the OCD
and 1.3% of the ADHD samples, respectively. (b) TS or
CT Narrow (TSCTn). Comparison of overlapping
conditions between any chronic tic disorder (TS or CT),
OCD, and ADHD.

JOURNAL OF THE AMERICAN ACADEMY OF CHILD & ADOLESCENT PSYCHIATRY

201.e5 www.jaacap.org VOLUME 51 NUMBER 2 FEBRUARY 2012
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