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Volume 4 Issue 1 REview


JoHSCI 2021 Vol4(1) Download here the REview Issue

Dr Dean-David Holyoake, Developmental Editor

Knowing what and how to review relates to knowing value when you see it. For example, Wetherspoons, double denim and mindless theorising. Yet, if I am correct that reviewing and value share some type of equation then you need look no further than this edition of JoHSCI. It has packs of both and what’s more, it’s free to everyone of curious disposition (and any other come to that). But that’s the thing about ‘reviewing’ as well as being about value. It’s also a way of life for academics. We view and then review and then start again in a never-ending chasm of noticing. I’m tempted to say searching, but that would not necessarily be correct unless of course, it’s for the afore mentioned pub. Now go view, value, re-review and enjoy.


Romantic love is viewed as a cross-cultural and intense experience that influences multiple aspects of human life (Jankowiak & Fischer, 1992, p. 149). Relationship quality, stability and relationship satisfaction are all said to be correlated with romantic love (Riehl-Emde et al., 2003, p. 266). While romantic relationships can lead to greater well-being, euphoria and longer life expectancy (Drefahl, 2012, p. 472), relationship dissolvement can lead to depression, anxiety, pain and acute mental distress (Mearns, 1991, p. 328). Additionally, the Office for National Statistics in the UK, recorded the highest number of opposite- sex couple divorces in 2019, which was an increase of 18.4% compared to the 90,871 divorces that took place in 2018 (Ghosh, 2020). The most common grounds for divorce for opposite-sex couples was “unreasonable behaviour” with 49% of wives and 35% of husbands petitioning on these grounds (Ghosh, 2020). Consequently, Psychologists have an important role to play when counselling couples, as the effectiveness of therapy could impact not only the couples, but also their children and future partners. The more information Counselling Psychologists have regarding the way men and women understand and communicate love, the more effective therapy may become.

Some scientists argue that these divergences in behaviours and opinions may be due to gender differences in cognitive processing (Yin et al., 2013). Cognitive processes encompass almost all basic, as well as complex mental manipulation or storage of information (Spicer & Ahmad, 2006, p. 221). This includes memory, decision making, learning, language use, reasoning and problem solving (Smith & Kelly, 2015, p. 2). Over the years there have been many studies establishing gender differences in cognitive processing (Theofilidis et al., 2020, p. 269; Wehrwein et al., 2007, p. 156). Early studies found that men and women differed in their conceptualisation of love such that men are more likely to think about sexual commitment and intercourse satisfaction when thinking about love, while women are more likely to think of emotional commitment (Buss, 1988; 2000).

However, not many studies have explored the consequences of these cognitive differences in relation to romantic relationships. Yin et al., (2013) is one of the few studies which has sought to understand how romance is identified and assessed in a romantic relationship. The results of the study provide the first piece of evidence for gender differences in romance perception, proposing that it is more effortful for men to perceive and evaluate romance. Furthermore, results showed higher rating scores in males than females for low romance items, but not for high or medium romance items. This can explain how men might perceive simpler acts as romantic, while women see these same gestures or scenarios as low romance or normal day to day occurrences, leading women to feel like men are not romantic enough. In addition to the evidence of gender differences in romantic information processing, there is also evidence that the way love and romance is conceptualised and perceived can be influenced by gender. A further study by Yin et al, (2018) investigating romantic appraisals in male and female Chinese college students, found that men and women differed in the processing of romantic information and that it may be more effortful for men to perceive and evaluate romance degree (Yin et al., 2018).

Although both studies by Yin et al. (2013, 2018), provide unique evidence proposing gender differences in romance perception, the studies were conducted using only Chinese students. Cultural psychologists have already established that eastern and western cultures have significant differences in how romantic love is experienced and valued. Notably US couples are found to be significantly more passionate than Chinese couples (Gao, 2001). Therefore, it would be useful to conduct similar studies using western participants. Furthermore, although they show that there are indeed gender differences in the processing of romantic information and romance perception, it does not evaluate whether it influences how people experience felt love or the greater impact it may have in romantic relationships.

These limitations are explored by Oravecz et al., (2016), who not only produced a more westernised study, since it was based in the United States of America (US), but also interpreted love as a form of communication and explored specific scenarios that evoked felt love. Using cultural consensus theory to generate information, a group of lay participants were asked to generate descriptors of felt love situations, after which a second participant group rated these same situations according to what made them feel loved. Results proposed that there was a consensus on felt love. Furthermore, it was found that when women were faced with scenarios, they were uncertain of, they were more likely to judge those as indicators of felt love. This provides an area for potential exploration since perhaps it indicates that women are designed to maintain relationships which may have been a beneficial trait from an evolutionary perspective. Although the study was effective in conceptualising felt love as it occurs daily, and exploring whether there was a felt love consensus, the study was interested in all manifestations of felt love, not specifically romantic relationships. As such many items on the felt love questionnaire were irrelevant to romantic love (e.g., religion: does being closer to god make you feel loved?). Perhaps different results would be observed if the questionnaire was focused on felt romantic love. Furthermore, although the study was conducted in America, social norms are still different to the United Kingdom (UK) (e.g., people are said to be less religious that in America) (Furman et al., 2005).

Oravecz et al. (2016) study was further explored by Heshmati et al., (2017) and gained more detailed information on individual differences within the subject area. Results indicated that male participants lacked knowledge on experiences which elicited felt love compared to women. Meaning they were more uncertain about which actions evoked felt love. Therefore, it would be beneficial for future studies to consider gender differences while conducting cultural consensus analysis, before deciding which items should be used in a “felt love consensus” questionnaire. Hopefully, this will ensure greater understanding about what makes both men and women feel loved. Furthermore, there is a need for further investigation using people living in the UK, to provide a more representative consensus of felt love, since it is already known that there are major cultural differences when it comes to romance perception (Gao, 2001). Lastly the current felt love questionnaire created by Oravecz et al., (2016) is not specific to romantic relationships, indicating a need for a more accurate and valid measure, as well as being more targeted towards a UK sample.

Currently, there are several psychological therapies and interventions used to enhance relationship satisfaction and treat relational difficulties in romantic couples. Results from multiple studies have shown that integrative behavioural couples therapy, emotionally focused couples therapy, couples-focused cognitive behavioural therapy and behavioural couples therapy are particularly effective (Halford & Snyder, 2012; Sexton & Alexander, 2003). Nonetheless, effect sizes found in effectiveness studies are only moderate and effect-sizes in naturalistic, real-world settings are significantly lower than in controlled study conditions. In addition, it is still unknown how and why these therapies are useful, especially since there is no improvement in up to 50% of couples (Roesler, 2019). This indicates that more knowledge is needed to improve therapeutic outcomes and to understand why therapy works for some and not for others. Counselling psychologists adopt a pluralistic and integrative philosophy, meaning no single intervention is favoured. Therefore, further exploration in the field can allow counselling psychologists to identify the different components from various interventions, which led to improvements; thus, facilitating the integration of therapies. Hopefully, by identifying the effective components from these different therapies, therapy can be refined to contain more evidence-based practices and reduce non-beneficial interventions.


Buss, D. M. (1988). Love acts: The evolutionary biology of love. In R. J. Sternberg &M. L. Barnes (Eds.), The psychology of love (pp. 100–118). New Haven, CT: Yale University Press.

Buss, D. M. (2000). The evolution of happiness. American Psychologist, 55, 15.

Drefahl, S. (2012). Do the Married Really Live Longer? The Role of Cohabitation and Socioeconomic Status. Journal of Marriage and Family, 74(3), 462–475.

Furman, L. D., Benson, P., Canda, E., & Grimwood, C. (2005). A Comparative International Analysis of Religion and Spirituality in Social Work: A Survey of UK and US Social Workers. Social Work Education, 24(8), 813–839.

Gao, G. (2001.) Intimacy, passion and commitment in Chinese and US American romantic relationships. International Journal of Intercultural Relations 25: 329–342.

Ghosh, K. (2020, November 17). Divorces in England and Wales - Office for National Statistics [Dataset]. https: /

Halford, W. K., & Snyder, D. K. (2012). Universal processes and common factors in couple therapy and relationship education. Behavior Therapy, 43, 1 – 12.

Heshmati, S., Oravecz, Z., Pressman, S., Batchelder, W. H., Muth, C., & Vandekerckhove, J. (2017). What does it mean to feel loved: Cultural consensus and individual differences in felt love. Journal of Social and Personal Relationships, 36(1), 214–243.

Jankowiak, W. R., & Fischer, E. F. (1992). A Cross-Cultural Perspective on Romantic Love. Ethnology, 31(2), 149.

Mearns, J. (1991). Coping with a breakup: Negative mood regulation expectancies and depression following the end of a romantic relationship. Journal of Personality and Social Psychology, 60(2), 327–334. https://doi. org/10.1037/0022-3514.60.2.327

Roesler, C. (2019). Effectiveness of Couple Therapy in Practice Settings and Identification of Potential Predictors for Different Outcomes. Family Process, 59(2), 390–408. https: /

Sexton, T. L., & Alexander, J. F. (2003). Functional family therapy: A mature clinical model for working with

at-risk adolescents and their families. In T. L. Sexton, G. R. Weeks, & M. S. Robbins (Eds.), Handbook of fam- ily therapy: The science and practice of working with families and couples (pp. 323–348). Brunner-Routledge

Smith, A. D., & Kelly, A. (2015). Cognitive Processes. The Encyclopedia of Adulthood and Aging, 1–4. https://doi. org/10.1002/9781118521373.wbeaa213

Smith, A. D., & Kelly, A. (2015). Cognitive Processes. The Encyclopedia of Adulthood and Aging, 1–4. https://doi. org/10.1002/9781118521373.wbeaa213

Spicer, D. P., & Ahmad, R. (2006). Cognitive processing models in performance appraisal: evidence from the Malaysian education system. Human Resource Management Journal, 16(2), 214–230. 8583.2006.00007.x

Theofilidis, A., Karakasi, M.-V., Kevrekidis, D.-P., Pavlidis, P., Sofologi, M., Trypsiannis, G., & Nimatoudis, J. (2020). Gender Differences in Short-term Memory Related to Music Genres. Neuroscience, 448, 266–271.

Wehrwein, E. A., Lujan, H. L., & DiCarlo, S. E. (2007). Gender differences in learning style preferences among undergraduate physiology students. Advances in Physiology Education, 31(2), 153–157. advan.00060.2006

Yin, J., Zhang, J. X., Xie, J., Zou, Z., & Huang, X. (2013). Gender Differences in Perception of Romance in Chinese College Students. PLoS ONE, 8(10), e76294.

Yin, J., Zou, Z., Song, H., Zhang, Z., Yang, B., & Huang, X. (2018a). Cognition, emotion and reward networks associated with sex differences for romantic appraisals. Scientific Reports, 8(1), 1–8. https: / 018-21079-5


University of Wolverhampton

Health Information and Anxiety

It is common for children to undergo a clinical procedure at some point during their childhood (Lindsey et al., 2013). However, current literature demonstrates that children find minor procedures very distressing (Carmichael 2015). Research has demonstrated that half of five-million children who underwent surgery developed significant anxiety beforehand (Kain et al., 2006). Minimising anxiety has important benefits and one way that is proven to do this is through the provision of health information prior to a procedure.

Information about a procedure can reduce children’s anxiety around what is going to happen and facilitate realistic expectations (Bray et al., 2019a). Furthermore, literature suggests that children feel empowered when provided with this information (Ben Ari et al., 2019). Additionally, children are more likely to have poor experiences if they are not suitably prepared for procedures (Sheehan et al., 2015) and higher levels of anxiety (Carmichael et al., 2014) which can result in missed follow-up appointments (Shahnavaz et al., 2015), delays in recovery (Kerimoglu et al., 2013) and fear of medical professionals (Mahoney et al., 2010). This suggests that inadequate preparation can result in poor health outcomes and have other long-term psychological impacts, highlighting the importance of research in this area. Despite this, many children report that they have not accessed any health information prior to coming to hospital for a procedure. Additionally, limited time with professionals can act as a barrier to parents feeling adequately prepared (Bray et al., 2019a).

It is not only children who are negatively affected by feelings of anxiety when undergoing medical interventions, but parents also commonly experience anxiety (William Li et al., 2007). Furthermore, parent’s level of anxiety is positively correlated with their child’s level of anxiety (LaMontagne et al., 2001; Li & Lam, 2003) which suggests it may be important to support parents in managing their anxiety to help reduce children’s anxiety. The results of one study suggested parents derive benefits from child preparation programmes; parents who accompanied their child to a preoperative preparation group showed lower levels of anxiety compared to those who did not (Fincher et al., 2012). This highlights the importance of parental involvement in preoperative preparation for children and points towards a family-centred care approach (Li & Lopez, 2008).

Views of Parents and Children

Alongside the empirical evidence demonstrated, qualitative studies exploring the views of parents and children have shown that there is a desire for pre-procedural information. In a recent study, children explained that procedural information supports them to be aware of what is going to happen and feel less scared about a medical intervention (Bray et al., 2019b). Children also reported that they felt this information would enable them to practice coping strategies to help them to get through the procedure (Hockenberry et al., 2011). In addition, research states that both parents and health professionals feel that this information would be helpful for children. Despite this, parents report not sharing this information with their children (Bray et al., 2019a). Literature has suggested that future research is required to examine factors that influence parent’s decisions to share or withhold pre-procedural information (Ben Ari et al., 2019). 

Parents as Gatekeepers

Research shows that when accessing procedural information children are often reliant on their parents (Bray et al., 2019a). However, despite parents reporting that pre-procedural information would be helpful for children, a recent study explained that parents reported they had either not received information or had not read or communicated the information if they had received it, “When we are given leaflets they just go to the bottom of my bag and I forget about them” (Bray et al., 2019a, p.631). It is not clear why this information was not passed on to children (Bray et al., 2019a). However, parents are unintentionally disempowering their children when they limit access to this information (Birnie et al., 2014). It is clear that further research is needed in this area to support parents to share health information with their children, which could reduce anxiety prior to medical procedures.

Limitations of Current Research

Literature demonstrates that age influences perioperative anxiety in children (Ahmed et al., 2011) and suggests that participants in different age groups may express pain or anxiety differently (He et al., 2015). However, current research spans across different age ranges and does not appear to acknowledge the impact that age-related differences could have on findings. Therefore, future studies exploring pre and post-procedural information on anxiety should both examine and take into account age-related individual differences.

Another possible limitation of current research is that many outcome measures were based on subjective self-reports. Therefore, responses of children and parents could have been influenced by demand characteristics or subjective interpretation of questions. Future studies could incorporate reliable measures such as the State Trait Anxiety Inventory for Children which is considered the ‘gold standard’ in measuring anxiety in children over 5 years old (Ahmed et al., 2011) to increase the reliability and validity of results. In addition, more objective outcome measures such as blood pressure, cortisol levels and heart rate could also be used to verify self-report findings in future research (He et al., 2015). 

Research Gap

Positively, research has been conducted into the views of parents, children and professionals in regard to children accessing health information prior to a procedure. However, to the authors knowledge, there is a gap in research looking into why parents may be reluctant to share this information with their child despite parents explaining that pre-procedural information would be useful in reducing anxiety (Bray et al., 2019a). Therefore, further research is needed to explore why parents’ may not share this information with their children. Parents could act as either facilitators or barriers for their children in the receipt of information to help prepare them for health interventions. Therefore, identifying possible barriers and areas where further support is needed could facilitate access to health information for more children prior to a procedure and reduce anxiety and negative long-term effects.


Ahmed, M. I., Farrell, M. A., Parrish, K., & Karla, A. (2011). Preoperative anxiety in children risk factors and non- pharmacological management. Middle East Journal of Anesthesiology, 21(2), 153-164.

Ben Ari, A., Margalit, D., Roth, Y., Udassin, R., & Benarroch, F. (2019). Should parents share medical information with their young children? A prospective study. Comprehensive Psychiatry, 88, 52-56.

Birnie, K., Noel, M., Parker, J., Chambers, C., Uman, L., Kisely, S., & McGrath, P. (2014). Systematic Review and Meta- Analysis of Distraction and Hypnosis for Needle- Related Pain and Distress in Children and Adolescents. Journal Of Pediatric Psychology, 39(8), 783-808.

Bray, L., Appleton, V., & Sharpe, A. (2019a). ‘If I knew what was going to happen, it wouldn’t worry me so much’: Children’s, parents’ and health professionals’ perspectives on information for children undergoing a procedure. Journal Of Child Health Care, 23(4), 626-638.

Bray, L., Appleton, V., & Sharpe, A. (2019b). The information needs of children having clinical procedures in hospital: Will it hurt? Will I feel scared? What can I do to stay calm?. Child: Care, Health And Development, 45(5), 737-743. https://doi. org/10.1111/cch.12692

Carmichael, N., Tsipis, J., Windmueller, G., Mandel, L., & Estrella, E. (2015). “Is it Going to Hurt?”: The Impact of the Diagnostic Odyssey on Children and Their Families. Journal Of Genetic Counseling, 24(2), 325-335. https://doi. org/10.1007/s10897-014-9773-9

Fincher, W., Shaw, J., & Ramelet, A. (2012). The effectiveness of a standardised preoperative preparation in reducing child and parent anxiety: a single-blind randomised controlled trial. Journal Of Clinical Nursing, 21(7-8), 946-955. https://doi. org/10.1111/j.1365-2702.2011.03973.x

He, H., Zhu, L., Chan, S., Klainin-Yobas, P., & Wang, W. (2015). The Effectiveness of Therapeutic Play Intervention in Reducing Perioperative Anxiety, Negative Behaviors, and Postoperative Pain in Children Undergoing Elective Surgery: A

Systematic Review. Pain Management Nursing, 16(3), 425-439.

Hockenberry, M., McCarthy, K., Taylor, O., Scarberry, M., Franklin, Q., Louis, C., & Torres, L. (2011). Managing Painful Procedures in Children With Cancer. Journal Of Pediatric Hematology/Oncology, 33(2), 119-127. mph.0b013e3181f46a65

Kain, Z., Mayes, L., Caldwell-Andrews, A., Karas, D., & McClain, B. (2006). Preoperative Anxiety, Postoperative Pain, and Behavioral Recovery in Young Children Undergoing Surgery. Pediatrics, 118(2), 651-658. 2920

Kerimoglu, B., Neuman, A., Paul, J., Stefanov, D., & Twersky, R. (2013). Anesthesia Induction Using Video Glasses as a Distraction Tool for the Management of Preoperative Anxiety in Children. Anesthesia & Analgesia, 117(6), 1373-1379.

LaMontagne, L., Hepworth, J., & Salisbury, M. (2001). Anxiety and postoperative pain in children who undergo major orthopedic surgery. Applied Nursing Research, 14(3), 119-124.

Li, H., & Lam, H. (2003). Paediatric day surgery: impact on Hong Kong Chinese children and their parents. Journal Of Clinical Nursing, 12(6), 882-887.

Li, H., & Lopez, V. (2008). Effectiveness and Appropriateness of Therapeutic Play Intervention in Preparing Children for Surgery: A Randomized Controlled Trial Study. Journal For Specialists In Pediatric Nursing, 13(2), 63-73. https://doi. org/10.1111/j.1744-6155.2008.00138.x

Lindsey, M., Brandt, N., Becker, K., Lee, B., Barth, R., Daleiden, E., & Chorpita, B. (2013). Identifying the Common Elements of Treatment Engagement Interventions in Children’s Mental Health Services. Clinical Child And Family PsychologyReview, 17(3), 283-298.

Mahoney, L., Ayers, S., & Seddon, P. (2010). The Association Between Parent’s and Healthcare Professional’s Behavior and Children’s Coping and Distress During Venepuncture. Journal Of Pediatric Psychology, 35(9), 985-995. https://doi. org/10.1093/jpepsy/jsq009

Shahnavaz, S., Rutley, S., Larsson, K., & Dahllöf, G. (2015). Children and parents’ experiences of cognitive behavioral therapy for dental anxiety - a qualitative study. International Journal Of Paediatric Dentistry, 25(5), 317-326. https://doi. org/10.1111/ipd.12181

Sheehan, A., While, A., & Coyne, I. (2015). The experiences and impact of transition from child to adult healthcare services for young people with Type 1 diabetes: a systematic  review. Diabetic Medicine, 32(4), 440-458. me.12639

William Li, H., Lopez, V., & Lee, T. (2007). Effects of preoperative therapeutic play on outcomes of school-age children undergoing day surgery. Research In Nursing & Health, 30(3), 320-332.


University of Wolverhampton


In the UK, health care is the responsibility of the national government while social care is mediated by the local authority. Social care services oversee the running of residential and nursing homes, referred collectively from now on as care homes. It is estimated that there are over 416,000 residents living in

UK care homes (Laing, 2016) with this number set to rise (Bone et al., 2018). Care home residents are typically the most vulnerable and frail of the population and are often unable to live independently. It is also evidenced that these individuals have comorbid health problems and frequently need access to a wide range of health and social care services. It is therefore interesting that individuals living within a care home setting are actively excluded from research trials, making them a marginalised group (Backhouse et al., 2016).

Research in care home settings is ‘behind the curve’ compared to other populations (Moore et al., 2019). This is worrying as the literature suggests that care homes are generally underserved and under resourced (Paddock et al., 2019) and these issues cannot be resolved without research and a strong evidence base on which to ground change on. There have been numerous initiatives to integrate both health and social care, with limited success (Exworthy, Powell, and Glasby, 2017). From personal experience of working on the front line of the NHS to now conducting research within the health and social care sector, I believe the lack of research opportunities for care home residents and staff need to be addressed. As research drives practice, policy making and commissioning decisions, research projects need to stop excluding care home populations and justifications for exclusions should be scrutinised by Research Ethics Committees. Moreover, further research will increase our knowledge about the needs of care homes which may further elicit successful attempts for the integration of health and social care services.

One barrier for including care home residents and staff in research is the need for researchers to be extremely flexible. Care homes are busy environments and research will never be a main priority.

The current project I am working on is collaborating with care homes and it is challenging to organise meetings with keen senior care home staff due to the extreme pressures they are under. This experience is not an isolated incident and the National Institute of Health Research’s (NIHR) ENRICH toolkit offers guidance on how to overcome some of these common barriers.

The purpose of this opinion piece is to make researchers aware of the need to include care home residents and staff in health and social care research and to highlight the need for more education and guidance around this topic.


Backhouse, T. et al. (2016) ‘Older care-home residents as collaborators or advisors in research: a systematic review’, Age and Ageing, 45(3), pp. 337–345.

Bone, A. E. et al. (2018) ‘What is the impact of population ageing on the future provision of end-of-life care?

Population-based projections of place of death’, Palliative Medicine, 32(2), pp. 329–336.

Exworthy, M., Powell, M. and Glasby, J. (2017) ‘The governance of integrated health and social care in England since 2010: great expectations not met once again?’, Health Policy, 121(11), pp. 1124–1130.

Laing, W., (2016). Care of Older People. Market Report. 27th Edition. London: Laing and Buisson.

Moore, D. C. et al. (2019) ‘Research, recruitment and observational data collection in care homes: Lessons from the PACE study’, BMC Research Notes, 12(1), p. 508.

Paddock, K. et al. (2019) ‘Care Home Life and Identity: A Qualitative Case Study’, The Gerontologist, 59(4), pp.



Falmouth University



Introduction: As life expectancy worldwide is increasing, the prevalence of frailty is also on the rise. This scoping review aimed to identify and collate published information relating to frailty and spousal/partner bereavement in older people.

Method: A scoping review framework was used to identify papers that discussed frailty and spousal/partner bereavement. For example, the death of a life partner whether married or unmarried co-habiting, in community dwelling and individuals aged 60+ years old, were included.

Results: Four studies were included. Overall, spousal/partner bereavement was negatively associated with the incidence and level of frailty. All four studies reported that elderly widowed females had a higher prevalence of frailty compared to married females and widowed and/or married males. Males were also less likely to be widowed or living alone compared to females. Female longevity and the potential of living alone once bereaved increases the risk of frailty for this population.

Discussion: This review identifies the needs of ageing populations and the potential risk of frailty associated with spousal/partner bereavement.

Conclusion: This review helps make nurses more aware of the possible impact of bereavement on the development of frailty in older people and identify those most at risk, and/or in need of specific support/interventions. 

Key Words: Frailty, ageing, aging, widowhood, bereavement, risk


What is known and what this paper adds:
  1. This review summarises the sparse but existent evidence base on frailty in bereaved spouses/partners
  2. The review highlights the need to apply a clear operational definition for frailty
  3. The results help nurses gain an understanding of the physical and psychological signs of frailty in older adults
  4. This paper highlights the factors that may contribute to frailty following bereavement
  5. More research is needed to understand the factors which may mediate the development of frailty following bereavement
  6. The paucity of results highlights the need for further studies



Life expectancy is increasing (United Nations Department of Economic and Social Affairs Population Division, 2017), as data from the World Health Organisation indicate that 900 million people are aged over 60 (12% of global population) and this is predicted to increase to 2 billion (22% of the global population) by 2050 (The World Health Organisation, 2020). Typically, older age is correlated with increased health-related problems and becoming frailer (Kojima, Liljas and Iliffe, 2019). It is estimated that one quarter of people over 85 years are frail and have significantly increased risk of falls, disability, long-term care and death (Fried et al., 2001; Song, Mitnitski and Rockwood, 2011, Buckinx et al., 2015). In the United Kingdom (UK), it is projected that by 2036, over half of all local authorities will have 25% or more of their local population aged 65 and over (Office for National Statistics, 2017).

Growing interest in frailty research has attempted to provide an improved understanding of the heterogeneous factors that may contribute to the onset of frailty (Clegg et al., 2013). Currently, there is no agreed operational definition for the syndrome known as ‘frailty’ nor agreed diagnostic criteria (Hogan, 2006; Bergman et al., 2007; Buckinx et al., 2015). Frailty is an ambiguous term; however, it commonly refers to an increased vulnerability to adverse health outcomes when exposed to stressors (either internal or external) (Clegg et al., 2013).

In 2016, a WHO consortium defined frailty as “a clinically recognisable state in which the ability of older people to cope with everyday or acute stressors is compromised by an increased vulnerability brought by age-associated declines in physiological reserve and function across multiple organ systems” (WHO Clinical Consortium on Healthy Ageing, 2017). Frailty is also used as a prognostic indicator (RCP, 2020). For example, in the COVID-19 pandemic, frailty has been used to identify those at higher risk of poor outcomes (RCP, 2020).

The two most frequently used frailty definitions and assessment tools are the frailty phenotype (Kojima, Liljas and Iliffe, 2019) (also known as Fried’s definition or Cardiovascular Health Study (CHS) definition) and the frailty index (FI) (Jones, Song and Rockwood, 2004). The frailty phenotype classifies frailty as a syndrome that has three or more of five phenotypic criteria: weakness as measured by low grip strength, slowness by slowed walking speed, low level of physical activity, low energy or self-reported exhaustion, and unintentional weight loss. Pre-frailty is defined as having one or two criteria present. Non-frail older adults are classified as having none of the above five criteria. The frailty index is a measure of the number of ‘deficits’ identified during a comprehensive geriatric assessment, including diseases, physical and cognitive impairments, psychosocial risk factors, and common geriatric syndromes other than frailty (Jones, Song and Rockwood, 2004; Searle et al., 2008). Variables are identified as meeting the FI inclusion deficit criteria if the ‘deficit’ is acquired, is age-associated, is associated with an adverse outcome, and should not saturate too early (Jones, Song and Rockwood, 2004; Searle et al., 2008; Leng, Chen and Mao, 2014).

Due to the predicted increase of individuals

living into older age, and the potential subsequent increase of frail older adults, it is essential that the predictive characteristics of the syndrome, including factors that may impact onset, are better understood. For example, while frailty is most commonly identified in older adults, frailty is not determined by old age (Schuurmans et al., 2012). Frailty is a spectrum syndrome that can encompass a myriad of environmental, psychological and physiological impairments (Gobbens et al., 2010). Furthermore, several sociodemographic variables have been associated with frailty, including age and gender (Grden et al., 2017). Haapanen (2018) and colleagues reported that frailty is, in part, programmed in early life and is associated with lower socio-economic status in adulthood (Haapanen et al., 2018). Regarding later life, there is extensive research demonstrating a negative impact of widowhood on health outcomes. These impacts include a higher risk of disability (Goldman, Korenman and Weinstein, 1995), higher rates of depression and psychological distress (Gove, 1975; Pearlin and Johnson, 1977) and increased mortality rates in separated individuals compared to married individuals (Gove, 1975).

Research examining the relationship between marital status, specifically widowhood, and frailty is limited (Trevisan et al., 2016). Whilst a large body of research has examined the various psychological and physiological complications which may be associated with spousal loss, such as cardiovascular outcomes (e.g. Ennis and Majid, 2019), this scoping review focuses specifically on studies where a specific frailty definition was applied, in order to provide a more focused and clinically-informed review.

While frailty appears to affect females more than males, Trevisan and colleagues (2016) assessed a combined community dwelling and nursing home population sample, reporting that widowed or single males have a higher risk of developing frailty compared to married males, whereas widowed women carry a significantly lower risk of becoming frail compared to married women. The same authors identified unintentional weight loss, low daily energy expenditure, and exhaustion as factors associated with marital status and linked to related caring responsibilities which contributed to frailty (Trevisan et al., 2016). Studies have also identified gender-specific differences in marital- status, mortality and psychological wellbeing, showing an increased risk for divorced, single, widowed or never married males compared to females (Gove, 1975; Pearlin and Johnson, 1977; Hu and Goldman, 1990; Trevisan et al., 2016). Despite an association between marital status and healthy ageing being reported, little is known about the relationship between spousal/partner bereavement (i.e. the death of a life partner whether married or unmarried co-habiting) in community dwelling populations and frailty.

The aim of this review is to identify studies which examine the impact of partner/spousal bereavement on the development of frailty in older people living in community settings

Study design

A scoping method was used as initial searches revealed a paucity of pre-identified published studies, but nonetheless it was appropriate to identify and summarise this sparse literature (Arksey and O’Malley, 2005). It was anticipated that the current literature would be methodologically heterogenous and for this reason, the methodological framework proposed by Arksey and O’Malley (2005) and the guidelines for best practice provided by Colquhoun et al. (2014) were implemented, in addition to the PRISMA-ScR (Tricco et al., 2018) to support a more rigorous and systematic approach. The Arksey and O’Malley’s framework consists of six stages: (1) identifying the research question, (2) identifying relevant studies, (3) study selection, (4) charting the data, (5) collating, summarising and reporting results and (6) consultation with stakeholders. The optional final stage, consultation, was not included in the current scoping review, as this review was intended for publication to disseminate findings. Stages 1-5 are discussed below.

Stage 1: identifying the research question

This review aims to address the following questions:

  1. Is there a relationship between spousal/ partner bereavement and frailty?
  2. What factors influence frailty in bereaved older adults (60+) (protective or other)?
  3. What interventions are available, within the UK and internationally, that prevent any impact of spousal/partner bereavement, resulting in frailty?

Stage 2: identifying relevant studies

An initial exploratory online search using the electronic databases MEDLINE (PubMed) and CINAHL identified a paucity of articles and evaluation reports related to the topic of spousal/ partner bereavement and frailty. Next, the words in the title and abstract of relevant retrieved papers were then analysed in addition to the index terms used to describe the articles. These combined terms were used to form the keywords and index terms (see Appendix 1) for the systematic search strategy that was undertaken across all specified databases. Databases were searched from their start dates to April 2020 and searches were re-ran in June 2020 to make sure no new relevant new literature was overlooked.

Databases used were CINAHL, British Nursing Index, Web of Knowledge, Cochrane library, PsychInfo, SocIndex, University of York Centre for Reviews and Dissemination (DARE, NHS EED, HTA), JBI Database of Systematic Reviews and Implementation Reports, MEDLINE, EPPI, Epistemonikos, grey literature and references of included studies. Google Scholar citations of identified reports and articles were also searched for additional studies. The inclusion and exclusion criteria are shown in Table 1. The review was international in scope; however, only English language studies were included.

Stage 3: study selection

Initial screening selection (title and abstract screening) was distributed amongst four reviewers, divided into two groups. This was undertaken to measure inter-rater reliability using Cohen’s kappa coefficient (κ) in the study selection part of the review, aiming to add a new dimension to scoping reviews. Each group screened the full initial screening selection, with hits divided amongst both reviewers in each group. The screening selection for reviewer one from group A was paired with reviewer one from Group B and similarly for reviewer two from group A and reviewer two from Group B.

After eliminating the duplicates (studies that were identified more than once by the search engines), an initial screening of titles, abstracts, and summaries (if applicable) was undertaken to exclude records that clearly did not meet the inclusion criteria. Each record was classified as ‘include’ or ‘exclude’ to identify relevant, and exclude irrelevant, literature. The researchers were inclusive at this stage and, if uncertain about the relevance of a publication or report, it was left in. Any disagreements in studies shortlisted for full text screening were solved by consensus or by the decision of a fifth reviewer, where necessary.

Shortlisted study selection (full text screening) was then performed by four reviewers

  1. Any disagreements were solved by consensus or by the decision of a fifth reviewer where necessary. The agreement between the reviewers was again assessed with Cohen’s kappa coefficient (κ), for both sets of paired reviewers.
  2. Devkota and colleagues (2017), Grden et al. (2017) and Gross et al. (2018) found that living with a family member as opposed to a spouse can indicate greater frailty risk. On the other hand, Grden and colleagues (2017) argue that living with a family member can create a type of dependency, whether financial, physical and/or psychological, which may accelerate or contribute towards

The full text was obtained for all the records that potentially met the inclusion criteria (based on the title and abstract/summary only), as agreed by all reviewers. In this second step, all the full text papers were screened against the inclusion criteria, using a standardised tool. Studies that did not meet the inclusion criteria were listed with the reasons for exclusion. Multiple publications and reports on the same interventions were linked together and compared for completeness. The record containing the most complete data on any single intervention was identified as the primary article in the review, which was usually the original study or most recent evaluation report. A total of four studies met our inclusion criteria and were included in the review.

Stage 4: charting the data

Data (or study findings) for analysis were extracted from the included studies and managed in an Excel spread sheet. The data extraction sheet was tested on three included papers and, where necessary, it was revised to ensure it could be reliably interpreted and would capture all relevant data from different study designs. Extracted data included authors; year of study/report; aim/ purpose; type of paper (e.g. journal article, annual evaluation report etc); country/location; study population (e.g. age of participants, gender, marital status, living arrangements, health status pre- bereavement); average length of relationship (in years); average length of bereavement (in years); sample size; study design; frailty definition/ criteria; frailty rate; factors that impact on frailty rate (protective and negative factors); description of any interventions/support for study population; description of the interventions/support (if any); factors that facilitate and/or hinder access to interventions/support (if any) and any key findings that related to the review questions.

Stage 5: Collating, Summarising and Reporting the Results

A narrative synthesis was implemented to identify the main outcomes from the included studies, and findings were recorded using an Excel spreadsheet.


Initial screening (title and abstract) of 2812 records was completed independently by four reviewers (removed for review). Reviewers were divided into two groups, agreement was made between group 1 reviewers, assessed with the Cohen’s kappa (k)= 0.25 (fair agreement). The agreement between group 2 reviewers, assessed with the Cohen’s kappa (k)= 0.47 (moderate agreement). A fifth reviewer (JV) screened the initial shortlist of 91 records (title and abstract) and identified 21 records for possible inclusion. A full-text review of the 21 records was completed by all four reviewers (GB,KJ,RG,AM). Cohen’s kappa was not calculated at this stage, as three of the four reviewers could not access the full text of one or more papers. A fifth reviewer (JV) made the final decision regarding inclusion/exclusion where consensus could not be met. At the end of this review stage, eight records were identified that met the inclusion criteria (see Figure 1).

The citation lists (as reported using Google Scholar) of the eight shortlisted inclusion papers were then screened by the five reviewers independently. Of these 93 records screened, seven records were identified that met the inclusion criteria, with the fifth reviewer making the final decision regarding inclusion/exclusion where consensus could not be met. At the end of this review stage, 15 further records were shortlisted for data extraction and inclusion in the review.

During full-text data extraction, a further eleven papers were excluded as they did not meet the inclusion criteria when critically appraised.

The final review included four research papers (Devkota et al., 2017; Grden et al., 2017; Gross et al., 2018; Thompson et al., 2018) that met the inclusion criteria. The four studies were international in scope; Gardn et al (2017) and Gross and colleagues (2018) were conducted in Brazil, Devkota et al (2017) was undertaken in Nepal, and Thompson and colleagues (2018) was conducted in Australia. All four studies used cross- sectional designs, however, they implemented a variety of data collection methods, including survey (Gardn, et al, 2017), interviews (Gross, et al, 2018; Devkota, et al, 2017) and secondary analysis of quantitative data (Thompson, et al, 2018). All four papers had both male and female participants, although all studies had a higher number of female participants and the majority of participants were married, as opposed to being classified as a partner. Similarly, all four studies reported that the majority of participants were not living alone. The operational definition of frailty was varied across all four papers. Table 2 summarises the main characteristics and findings from the final included papers. 


The aim of this review was to identify studies which examine the impact of partner/spousal bereavement on the development of frailty in older people living in community settings. Specifically, the authors wanted to discern whether there was a relationship between bereavement and frailty, to identify what factors influence frailty in bereaved older adults and what interventions are available internationally (and in the UK) that may prevent the impact of partner bereavement resulting in frailty. All four studies (Devkota et al., 2017; Grden et al., 2017; Gross et al., 2018; Thompson et al., 2018) identified that older females who were widowed, divorced, never married and/or living alone were at a greater risk of frailty compared to women who were married or when compared to their male counterparts. Of note, Grden and colleagues (2017) reported an increased rate of frailty with female widowhood but did not report a significant association. Of course, it is known that females generally have a higher rate of frailty compared to males (Davidson, DiGiacomo and McGrath, 2008; Collard et al., 2012; Buttery et al., 2015; Duarte and Paúl, 2015). However, caution must be applied when interpreting the relationship between frailty and bereavement as reported in the included studies for several reasons, not least due to the heterogeneous definitions of frailty used.

Further comparison in respect to spousal/ partner status was also problematic, due to variance in the way the studies reported marital status. For example, Gross and colleagues (2018) categorise individuals as single/divorced/widowed compared to married, whereas Thompson and colleagues (2018) categorise individuals as divorced/widowed/never married, compared to married/living with a partner. Additionally, it is unclear if any studies identify instances whereby widowed or unmarried individuals had partners or not. Moreover, identification of specific interventions in preventing frailty was not explicit in the identified studies, however, implicit mediators were identified and are discussed later in this paper.

An important consideration when interpreting the findings is that all four studies, aforementioned, included significantly more females compared to males. However, this is a common occurrence in aging research due to women living longer than men. This phenomenon has been referred to as the feminisation of aging (Davidson, DiGiacomo and McGrath, 2008; Gross et al., 2018) and refers to women outliving men on average for one to seven years. Yet, longevity does not always correspond to healthy life expectancy.

For example, increased longevity can result in more women living alone with potentially reduced support and fewer resources (Davidson, DiGiacomo and McGrath, 2008). All four study populations included in this review showed fewer women were reported as living with a spouse compared to men (Devkota et al., 2017; Grden et al., 2017; Gross et al., 2018; Thompson et al., 2018).

In respect of factors that mediate frailty in older adults, the included papers found that women were more likely to live alone or with a family member, compared to men. Previous studies have reported that living with others can help maintain social relationships into older age resulting in better support networks, sustained health and the promotion of adaptive behaviour in stress the level of frailty experienced. Devkota and colleagues (2017) and Gross and colleagues (2018) note that the majority of their study participants were widowed females which may have resulted in this living arrangement. Similarly, Grden and colleagues’ (2017) found that 65% of participants were also widowed and 59% lived with a family member, as opposed to alone or with a spouse.

Furthermore, it should be noted that cultural practices of extended family living arrangements may also explain the findings of the included studies. Taken together, it is likely that marital status and living arrangements are interconnected, with marital status possibly influencing adjustments made to living arrangements following bereavement.

Inherent with the feminisation of aging is a greater prevalence of widowhood amongst women compared to men. This was reported in the studies included in the review, with more females being widowed, divorced or never married in all four studies (Devkota et al., 2017; Grden et al., 2017; Gross et al., 2018; Thompson et al., 2018)]. Gross and colleagues (2018) suggest that being married may have protective effects, lowering the risk of frailty. They do not provide further details. Thompson and colleagues (2018) argue that being married appears protective against the social vulnerability variables associated with frailty, however, they do not expand further on this point. Conversely, Grden and colleagues (2017) did not find a statistically significant association between marital status and frailty, but they highlighted the social and familial isolation associated with widowhood, particularly the potential for a self-care deficit which might otherwise be counterbalanced by the encouragement of a partner.

Strengths and Limitations

The review had several strengths. It was systematic in its approach and was international in its scope. To provide a measure of inter-rater agreement, the review reported Cohen’s kappa coefficient (k) throughout each key stage. The review also included two separate pairs of reviewers to ensure that no potential studies were missed or excluded, and a fifth reviewer was available for when consensus could not be achieved. Additionally, this is the first paper, to the authors’ knowledge, that collates literature on frailty and spousal/partner bereavement.

Nevertheless, this review also has some limitations. Only a small number of papers met the inclusion criteria, suggesting that the impact of bereavement on older spouses/partners has not been given sufficient consideration in empirical research. It is recommended that future studies consider assessing widowhood in frailty studies and include widowhood or loss of a partner as an independent demographic within marital status. It is also suggested that researchers report the duration of both the relationship and time of bereavement in addition to living situation as these details should be recorded in future research.

Further, matched case-controlled designs would be useful to accurately identify trends in frailty between males and females, which cannot be assessed due to the over-representation of females in this scoping review. Due to the heterogenous definitions used for frailty and partner status, consensus is required in future research. This may have resulted in papers being excluded from this review at the final ‘data extraction’ stage. Finally, no papers included in this review implemented a longitudinal methodology whereby the impact of bereavement on frailty was measured over time. This is recommended for future studies.


While there is existing research examining marital status and frailty, further research is required to better understand the association between the bereavement of a partner/spouse and the onset of frailty, including the physical and psychological dimensions. In particular, the

independent contribution of bereavement to frailty still needs to be identified. Based on the findings in this review, it is recommended that nurses

are aware of the characteristics of frailty in older populations and the possible factors influencing the development of frailty in same, including a spouse or partner’s bereavement. In doing so, they may be able to intervene early and prevent the condition

or reduce the level of severity. Considering the potential negative association between widowhood and being an older woman, it is suggested that nurses give particular consideration to how bereavement may affect the health status of older women who are now living alone. This may include directing them to community and voluntary organisations which provide bereavement support.


Ethics approval not required.

The authors declare that there are no competing interests.

This review was funded by the authors’ university.


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Rebecca Garcia1, Aoife Mahon2, Geraldine Boyle1, Kerry Jones1, Jitka Vseteckova1

1. Faculty of Wellbeing, Education and Language Studies, The Open University, Buckinghamshire, UK

2. Adelphi Values, Patient-Centered Outcomes, Cheshire, UK


Supplementary maetrials


Figure 1: Flow chart showing included/excluded papers

Table 2. Summary of findings from the four papers that met the inclusion criteria.*

*Average length of relationship and average length of bereavement was not detailed in any study. No studies implemented interventions/support programmes.


A mixed-methods study assessing the relationship satisfaction and the mental health outcomes of perpetration and victimisation in Cyber Dating Abuse (CDA) among 18–20-year-olds

Cyber Dating Abuse (CDA) is defined as a form of digital abuse which occurs within romantic relationships and is conceptualised as multiple abusive behaviours such as surveillance (Bennett et al., 2011), control, harassment, threats (Zweig et al., 2014), humiliation (Hinduja & Patchin, 2011), hacking (Lucero et al., 2014), and revenge porn (Flach & Deslandes, 2017). CDA has been described as a multidimensional construct as it involves various typologies of abuse (Bennett et al., 2011).

Due to the strenuous demands of modern life and a decrease in mobility, online dating has gained enormous popularity among 18-25-year- olds (Frazzetto, 2010). Individuals are moving away from traditional methods of socialisation and opting for more practical methods (Finkel et al., 2012) that allows both instant connections and personal mobility (Lutz & Ranzini, 2017).

These developments have formed new avenues for dating youth to socialise; Zweig et al. (2014) found a significant percentage of online daters have experienced or perpetrated cyber-monitoring, cyberstalking, and other abusive behaviours. Those who have been victim to Child Domestic Abuse (CDA) are at risk of developing mental health difficulties (Eshelman & Levendosky, 2012) and low self-esteem (Göncü & Sümer, 2011). There is a growing body of evidence that states victims have low-levels of relationship satisfaction, while perpetrators have higher levels (Lancaster et al., 2019). However, research has suggested, young people may be prone to misinterpret CDA because of the distorted perception they have of love (Sharpe & Taylor, 1999) and it is more discreet than physical abuse (Temple et al., 2016). These unique characteristics can cause a discrepancy in the levels of relationship satisfaction for both victims and perpetrators of CDA, making CDA more detrimental than other types of dating abuse. This literature review explores the levels of relationship satisfaction and mental health implications of victims and perpetrators in CDA within the existing literature, whilst highlighting the study’s rationale.

Several studies have found an alarming number of college students who have been involved in some form of CDA in their relationships. Burke et al. (2011) found 50% out of a sample of 804 college students, had experience of CDA. Caridade et al. (2020) conducted a systematic review and reported the rates of victimisation and perpetration within young adults are, 92% and 94%. Similar findings were reported by Stonard et al. (2015), Brown & Hegarty (2018), and Peskin et al. (2017). Although these studies present the worrying prevalence of CDA, it should be noted that all the studies that were reviewed were conducted in America. There is very little research discussing the rates and experiences of CDA in young adults within the UK. Though this research is crucial in understanding the impacts and likelihood of CDA amongst young adults, and there may be many similarities in the findings. It should be encouraged that a large body of the existing research cannot be exhaustively generalised to the young adults in the UK as Hobbs et al. (2016) reported that there are many differences in the dating cultures in the UK and USA. Introducing the first hypothesis, 18-20-year- olds with experienced CDA will have experience greater emotional distress than those who have no experience.

Additionally, the ages of American college students differs slightly to the university students in the UK. As some freshers tend to start college at the age of 17, which in the UK is described as adolescent. Studies reporting CDA in adolescences have found far lower prevalence rates, 23% than in university students, 73% (Marganski & Melander, 2015). Thus, the current study is looking at young adults because they have increased access to more advanced technology that offers a permanent connection to the internet, which may explain the difference in prevalence (Borrajo et al., 2015).

Couch et al. (2012) identified online daters are primarily worried about deception, privacy and anonymity risks, emotional vulnerability, and interpersonal intrusiveness (Burke et all., 2011). In spite of the dangers of online dating, a recent study found young adults still prefer online dating and find it safe (Flug, 2016). Research suggests that the level of relationship satisfaction and mental health implications may be moderated by the extent to which the CDA is acceptable to the victim (Schade et al., 2013). Barrajo et al. (2015) reported that most online daters are not aware of what CDA is, or that they are a victim to it, or even perpetrating it as some of the behaviours may not be perceived as abusive. Gámez-Guadix et al. (2018) pointed out some abusive acts are carried out in the context of play or humour that or acceptable signs of concern and love, (Sánchez-Hernández et al., 2020).This could cause numerous acts of CDA to remain hidden behind false justifications (Borrajo et al., 2015). Previously, higher levels of CDA has been associated with the victim experiencing lower levels of relationship satisfaction. However, recent research is highlighting how the perpetration of CDA is becoming less obvious, as there are a number of ways to invade a partner’s privacy or monitor their online activity without them knowing (Borajo et al., 2015). So, victims and perpetrators may present with falsely high levels of relationship satisfaction. Thus, a hypothesis of the current study is victims could present with high levels of relationship satisfaction despite experiencing abusive behaviours and perpetrators may present with lower levels of relationship satisfaction because they are perpetrating for mate retention reasons.

There is little research on the mental health outcomes or levels of relationship satisfactions in perpetrators. There are theories which discuss the onset of perpetration, but nothing on how facilitating CDA affects them. According to the Biopsychosocial perspective, aggressive behaviour is a result of the complex intertwining of the biological, psychological, interpersonal, and environmental components (Defoe et al., 2013).

Introducing the second hypothesis, perpetrators may present with similar mental health outcomes as victims. An increased focus has been placed on the prevalence rates of CDA, the predictive traits of perpetrators, the impact of CDA upon the victim, and their experience of CDA (Borajo et al., 2015). While there is evidence to suggest underlying issues can cause an individual to subconsciously facilitate CDA disguised as mate retention behaviours (Bhogal & Howman, 2018), limited research has been conducted on perpetrator’s experiences and their levels of relationship satisfaction and mental health outcome on a sample of young adults, within the UK. As recommended, more studies should further investigate the impacts of CDA in a British university population (Underwood & Findlay, 2004), inclusive of different ethnicities (Kaura & Lohman, 2007), and genders (Deans & Bhogal, 2017), and to investigate both partner’s experiences and perceptions of the phenomena’s of interest (Sidelinger & Booth-Butterfield, 2007).

Three research questions have been designed. Firstly, what is the role of biopsychosocial factors in the prevalence of perpetrating CDA? Secondly, how does the experience of CDA affect the mental health and relationship satisfaction of those with experience of CDA? Lastly, what are the experiences of 18-20-year-olds who have experienced CDA, in the UK?


Background: Infertility is a significant public health issue affecting many women in the reproductive age group; majority of these women are in the developing countries. In Nigeria, it is the most common gynaecological presentation in clinics. Beyond being a medical condition, women with infertility in Nigeria are confronted with socio-cultural challenges. Although, the evidence suggest that female factors contribute only a third to the causes of infertility in a couple, there is the stereotype that women are solely responsible. Consequently, they are disproportionately blamed for childlessness in a union. This has led to psychological and social impacts on these women. This study aims to explore the psychological and social experiences of women with infertility, the contributory and resilient factors.

Methods: Literature search for data was done using electronic databases which included CINAHL Plus, PubMed, Medline, Science Direct and google scholar. Relevant search terms were employed and articles retrieved were measured against a set of eligibility criteria. Articles were analysed using the Braun and Clark thematic framework.

Results: The study demonstrated that psychological effects of women with infertility in Nigeria included depression, anger, anxiety, self -guilt and poor self- esteem. The social impacts included marital instability, social stigma and discrimination, domestic violence, suicide, and economic deprivation.

Conclusion: Women with infertility in Nigeria have negative experiences which stem from their socio-cultural environment. Efforts should be geared toward proffering solutions that are holistic in nature at personal, community and governmental levels.

Key words: Infertility, females, Nigeria, Social, Psychological, Developed countries.



Infertility is a global public health issue that continues to be of concern (Kumar and Singh,2015). Clinically, it is defined as the inability to conceive after 12 months of frequent, unprotected sexual intercourse (Elhussein et al.,2019). Two types of infertility exist medically- Primary and Secondary (Vander Borght and Wyns, 2018). Primary infertility is the inability of a person to ever achieve a pregnancy whilst secondary infertility is the inability to conceive following a prior pregnancy. Epidemiologically, it is the inability of a woman in the reproductive age group to conceive for at least two years (Gurunath et al.,2011). The definition of infertility is also determined by the socio- cultural context. In some non-westernised settings, it has been defined as not getting pregnant very soon after marriage, having ‘few’ children and not having a male child (Whitehouse and Hollos,2014).

Infertility is named amongst the top six neglected maternal morbidities that occur in developing countries (Hardee, Gay, and Blanc, 2012). Arguably, it has been classified as a disability given its potential to restrict the activities of a woman and limit her participation in every area of life (Khetarpal and Singh,2012). The severity will depend on the socio-cultural environment she finds herself in (Khetarpal and Singh,2012).

Globally, it is said that between 60 and 80 million couples have infertility challenges (Katole and Saoji, 2019). Also, about 186 million women are said to struggle with infertility, with majority of them in developing countries (Dovom et al.,2014). High infertility rates have been reported to occur more in Sub-Sahara Africa; the prevalence is 20%- 46% compared to 10%-15% in developed nations (Panti and Sununu,2014). Consequently, it has been called the ‘infertility belt’, an area which includes West Africa, Central Africa and the eastern regions (Panti and Sununu,2014).This high infertility rates occur together with the high fertility rates in Sub-Saharan Africa, a phenomenon that has been described as “barrenness in the midst of plenty” (Inhorn and Patrizio,2015).

Nigeria is a country in West African with a population of 169 million with 30.8% of couples having infertility concerns (Olarinoye, and Ajiboye, 2019). It is the most common gynaecological presentation in clinics in Nigeria, accounting for 60%-70% of clinical cases (Omoaregba et al.,2011). Secondary infertility is the most prevalent type in women in Nigeria (Adegbola and Akindele, 2013). One of the causes of secondary infertility is infections from unsafe abortion procedures (Emmanuel, Olamijulo, and Ekanem, 2018). A structural problem exists in that abortion services are illegal and the laws restrictive (Emmanuel, Olamijulo, and Ekanem, 2018, p.249). As a result, women resort to visiting unskilled individuals in septic places, who performs procedures that lead to reproductive problems subsequently (Bankole et al.,2015, p.170).

Evidence in Nigeria has shown that the female factors contribute only 30%-40% to the causes of infertility (Odunvbun et al.,2018, p.224). However, women continue to disproportionately shoulder the blame for infertility in a couple (Omoaregba et al.,2011, p.21). With this stereotype that occurs in Nigeria that the infertility problem of a couple stems from the woman, it means that they will carry the psychological and social burdens even though they may not be responsible (Aiyenigba, Weeks and Rahhman,2019, p.77).

Previous researches exist on the psychological and social experiences of women with infertility in several regions of Nigeria (Zuraida,2010; Fehintola et al.,2017; Zubairu and Yohana,2017; Olarinoye and Ajiboye,2019). To the best of my knowledge, the evidence has not been previously compiled and synthesised. A compilation is imperative given the diverse nature of Nigeria with its various ethnic groups. Although, studies have been done on the psycho-social experiences of women with infertility, it is rather small compared to studies done for both male and female experiences. Only women studies are important given that they effects are more negative towards them than men (Deka and Sarma,2015).Evidence show infertility as a challenge yet, more projects are being done for fertility concerns such as the provision of free birth control measures (Hammarberg and Kirkman,2013).A study revealed that mental and behavioural problems are rarely detected during patient consultations at infertility clinics(Makanjuola et al., 2011). It may require that health care providers raise their indices of suspicion. The study will show the effects of infertility on women and enable holistic health care to be delivered. Infertility in women in Nigeria is a social problem and should not be solely ‘medicalised’ as it is been done (Greil et al.,2020).

The aim of the study is to explore and synthesise the psychological and social experiences of women with infertility in Nigeria. The objectives are to determine the psychosocial effects of infertility in women, to examine the contributory effects to these experiences and the resilient factors. The study seeks to answer the following research question: How do the psychological and social experiences differ amongst the women with infertility in Nigeria?

Theoretical Perspective

This study is guided by a theoretical underpinning as developed by Daar and Merali (2002), which provides insights on the psychological and social experiences of women with infertility.Daar and Merali (2002) proposes six levels of the consequences of infertility (Figure 1), with level 1 being the least severe and level 6 the most severe. They argue that the consequences of infertility in westernised countries are never beyond level 2 while the severity of harm in developing countries are hardly as mild as level 3. This model attempts to bring forward the suffering women with infertility especially in Africa and Asia.


Searches were conducted for primary studies using a range of databases to provide a robust yield. The databases included CINAHL Plus, Pub Med, Medline, Science Direct and google scholar. Only articles between 2010 and 2020 were retrieved. Key words such as ‘psychological experiences’, ‘social experiences’, ‘infertility in women’ and ‘Nigeria’ were used to generate the relevant papers. Synonyms of these key words were sought and used as well. Key words were linked together for the search using Boolean operators- (Psychological OR Emotional OR Mental OR Depression) AND (Social) AND (Experiences OR Problems OR Impact OR Effect) AND (Women OR Female) AND (Infertility OR Barrenness OR Childlessness) AND (Nigeria).Also, the search was guided by a set of inclusion and exclusion criteria as seen in the table below . These criteria were made using the Population, Phenomenon of Interest, Context (PICo)strategy.

In addition to the electronic data bases search, hand searches were conducted on the reference list of relevant papers. Articles that were written in languages other than English and those that were not peer reviewed were excluded. Quality appraisal was conducted for each of the articles that were included using the Critical Appraisal Skills Programme (CASP) checklist as seen in appendix 1. The checklist includes questions that help to ensure the methodological rigour of each selected article.

The eligible primary studies were selected and compiled. The data extracted from each study contained the name of the author, year of publication, the title of the paper, study design, sample size and methodology and key findings (Ndarukwa, Chimbari, and Sibanda, 2019). The data analysis method employed was thematic analysis as proposed by Braun and Clark (2006). Recurrent themes from the data were analysed to bring out meanings that will facilitate understanding of the study.


The search result is summarised as shown in the Figure 2. The initial search yielded 30, 456 papers. 13 studies met the eligibility criteria. They include 6 quantitative,5 qualitative and 2 mixed-methods studies. The summary of the 13 included studies are shown in appendix 2.

The data were extracted and analysed using the Braun and Clark’s thematic analysis. Two main themes emerged from the analysis, which were psychological and social experiences. Several subthemes identified were depression, anxiety and stress, anger and frustration, guilt and self-blame, suicidal ideation and attempt, marital instability, social stigma and discrimination, and finally, domestic violence.

Depression was the most notable sub-theme discovered in the eligible studies. In one of the studies, it was higher in women with infertility visiting the gynaecology clinic than the other non-psychiatric units in the hospital (Mustapha et al.,2015). Some of the predictors for the depression were lack of support from their husband and from their husband’s relatives (Makanjuola, Elegbede and Abiodun,2010). Also, the severity of depression was observed to be associated with primary infertility, number of years of infertility and the financial cost of treatment (Mustapha et al.,2015).

The women were seen to express depression in several forms such as diminished appetite, weeping, insomnia, excessive thinking and poor libido (Naab, Lawali and Donkor,2019; Osayuki, Owofio and Osondi,2015). Another psychological impact were anxiety and stress among the participants. These feelings increased because of the uncertainty they had about sources of affection, respectable burial rites, matrimonial stability and continuity of their lineage (Mustapha et al.,2015). There was also apprehension about old age without children (Dimka and Dein,2013). Some of the women experienced pressure from members of the husbands’ family to have children, that also contributed to the stress (Fehintola et al.,2017).

Anger and frustration were strong psychological response by some women towards their infertility issues. As one study revealed, women had outburst of anger without any justifiable reason. Still in that same study, one of the reasons given for angry expressions were negative statements from husband’s relatives (Naab, Lawali and Donkor,2019). Some other respondents mentioned that pregnant women and children became the objects of their anger and frustration (Oluwole, Obadeji and Dada,2020).

In addition to anger and frustration, studies included also demonstrated guilt and self-blame as psychological impacts of infertility. In a study, one of the respondents came almost to the conclusion that she had a cursed lineage because the same thing happened to her mother before conceiving (Fehintola et al.,2017). Feelings of guilt and self- blame were also noted in women who had a prior history of abortion (Makanjuola, Elegbede and Abiodun,2010). This was how a woman expressed her guilt: ‘It is unfair for him to suffer because

I cannot give birth. You know that even if he is suffering and has pain in his heart, he will not show it. I didn’t want him to feel this so I went myself and got him another wife; When I found him a wife, I packed up my things and went back to my father’s house. What was I going to stay there and do?’(Dimka and Dein,2013).

Also, it was observed that most of the participants were ashamed of their inability to conceive. This had led to feelings of low self-esteem (Oluwole, Obadeji and Dada,2020). Furthermore, these feeling of low self- esteem and depression was the reason for the suicidal ideation and attempt, as one woman had ingested a petroleum product (Fehintola et al.,2017)

Marital instability was a sub-theme that emerged from the eligible studies. Marital instability involved spouses of these women having sexual relations outside of their marriages, with some resulting in children (Ojo, Oluwole and Obadeji,2017). Some other women had what was referred to as ‘co-wives’, as their husbands had married other women solely because of their inability to conceive. It was also reported that sometimes these new wives become the favourite after they might have borne children(Dimka and Dein,2013). There were constant threats of divorce and actual divorces. The initiators of these were mainly from the husband’s female relatives, especially his mother(Oluwole, Obadeji and Dada,2020)

Several of the studies that met the inclusion criteria documented that women with infertility in Nigeria are seen or perceived differently and are consequently treated in several negative ways. Stigma and discrimination were the reason some of the women were no longer being visited by members of the community; they were perceived to be cursed (Oluwole, Obadeji and Dada,2020). Not only that, they were presumed to have the ability to transfer the curse (Fehintola et al.,2017).

As a result, they were intentionally excluded from certain women meetings (Whitehouse and Hollos,2014). A female respondent with children justified these exclusions for ‘safety’ of her children. She said: ‘They usually maltreat other people’s children. It is better to avoid them; I can never allow them to carry or play with my children because they can poison them’ (Fehintola et al.,2017)  Lastly, domestic violence as a sub-theme also emerged. This was more likely to occur with women with infertility than in their fertile counterparts (Eka et al.,2019). The forms of violence experienced were physical, emotional, verbal, sexual and economic. The main perpetrators of these acts identified were mainly the spouses. The husbands’ female relatives were said to be also known culprits.


This study demonstrates the effect of infertility on women and the severity depends on the socio-cultural context. Daar and Merali (2002) proposed a model which highlights the some of the experiences of these women. They argue that women in developed countries barely have experiences that exceeds level 2. They also maintain that the women in developing settings do not usually have consequences as mild as level 3.

Depression which is a level 2 consequence was a common finding in both developed and developing nations. Isah et al. (2018) reported higher prevalence of depression in women with infertility compared to the fertile women. This is similar to studies conducted in the US and Portugal (Rooney and Domar,2018; Galhardo et al.,2011). However, lower prevalence was recorded in studies by Makanjuola, Elegbede and Abiodun (2010) and Adelosoye et al. (2020). The reason may be depression is often not discussed freely for fear of stigma (Sowore et al., 2021). Social desirability bias may have contributed to the findings in the studies (Latkin et al.,2017).

Makanjuola, Elegbede and Abiodun (2010) revealed that lack of husband’s support, lack of husband’s relatives support and discrimination were significantly associated with anxiety. Similar findings emerged in the Japanese study by Ogawa, Takamatsu and Horiguchi (2011). However, the study conducted in Europe revealed that poor maternal relationship and poor sexual relations with husband were factors which increased anxiety rather than social support from spouses and in laws (Lakatos et al.,2017).

Self-blame and guilt were level 1 psychological experiences seen in the primary studies compiled. Dimka and Dein(2013) revealed that a participant expressed a sense of guilt as she pointed out that her husband hides his feelings of pain and hurt to protect her. This is similar to a study conducted in Iran by Hasanpoor-Azghdy et al. (2014). It also demonstrates the disproportionate blame on women for infertility in developing countries.

Ojo, Oluwole and Obadeji (2017) and Dimka and Dein (2013) reported marital instability, which can be as severe as level 4. The spouses resorted to having extra-marital relations to have children. In addition, some men married other women without divorcing their first wives. This is similar to a study conducted in Ghana where the men explored polygamy to infertility issues in their marriages (Fledderjohann, 2012). Some marriages resulted in divorce. The initiators of these divorces were pressure from female relatives of the husbands.This is in contrast to studies conducted in western settings. Divorce may be a consequence of infertility but the decision is usually solely from the couple with a external influences.

Social stigma and discrimination which are level 3 to level 6 consequences of infertility. Isah et al. (2018) showed that a high percentage of women with infertility were socially excluded. This is similar to the study carried out in Ghana by Anokye et al. (2017). They were also called ‘witches’ and presumed to be cursed (Fehintola et al.,2017). A study conducted in Rwanda also revealed that they were referred to as ‘witches’ and brought bad luck to the community (Dhont et al.,2011). In contrast to developed countries, social taunts and abuse were not common findings. Lost dignity in death is the most severe consequence as argued by Daar and Merali (2002).

It was revealed that women without children were not given elaborate burials like other women (Whitehouse and Hollos, 2014). Similar findings were observed in the study conducted in Malawi where they were buried in manners to show their childless status (Chimbatata and Malimba ,2016). Domestic violence was a levels 3 and 4 consequences as noted by Eka et al. (2019) and Iliyasu et al. (2016). The predictors for domestic violence in both studies were women with no formal education, women involved in unskilled or semi-skilled work, an unemployed spouse and a spouse without tertiary education. This is similar to findings observed in a Pakistani study by Sami and Ali (2012) amongst other studies. Although the age at which a woman got married was not explored in the Nigerian studies included, however a study conducted in Iran demonstrated women who married at an early age experienced more domestic violence (Sheikhan et al.,2014)

Lastly, suicidal attempts were observed in the study by Fehintola et al. (2017, p.69). A female respondent had attempted to commit suicide because she was called a witch by individuals. However, the reason given for suicides and suicidal attempts were different in a Danish study (Kjaer et al., 2011, p.2401). The loss of a child with subsequent inability to give birth to children were a reason for suicidal ideations. This demonstrates the social abuse and taunts experienced by women with infertility in developing countries which could result in suicide.


This study answers the research question by synthesising existing literatures on the psychological and social experiences of women with infertility in Nigeria. This would have been difficult if only a single study was used. The thematic analysis employed provided an in-depth understanding based on its flexible approach. Despite the strengths, some limitations are noted. The results from this study are mostly dependent on the interpretation of the researcher, hence the possibility of introducing a researchers’ bias. Also, this review was only based on published papers; Grey literature were not sought. This study is therefore subject to publisher’s bias.


This study demonstrated that there is a gender disparity that exist against women in Nigeria concerning infertility. The study provided an extensive review of literature that exists on the psychological and social impacts of infertility in women in Nigeria. It is hoped that this study will influence policy formulation concerning the wellbeing of these women. Further research on the coping mechanisms and rural-urban women comparisons will add to the existing knowledge on the subject.


Supplementary maetrials


Figure 1: Continuum of the consequences of infertility (Daar and Merali, 2002)


Table 1: The Inclusion and Exclusion criteria


Figure 1: Prisma Flow Chart



Appendix 1: CASP Checklist for quality appraisal


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Deka, P.K. and Sarma, S., (2010). ‘Psychological aspects of infertility’. British Journal of Medical Practitioners, 3(3), pp.32-34.

Dhont, N., Van de Wijgert, J., Coene, G., Gasarabwe, A. and Temmerman, M. (2011) ‘Mama and papa nothing’: living with infertility among an urban population in Kigali, Rwanda’, Human Reproduction, 26(3), pp.623-629.

Dimka, R.A. and Dein, S.L., (2013). ‘The work of a woman is to give birth to children: Cultural constructions of infertility in Nigeria’. African journal of reproductive health, 17(2), pp.102-117.

Dovom, M.R., Tehrani, F.R., Abedini, M., Amirshekari, G., Hashemi, S. and Noroozzadeh, M. (2014) ‘A population- based study on infertility and its influencing factors in four selected provinces in Iran (2008-2010)’, Iranian journal of reproductive medicine, 12(8), p.561-566.

Eka, P.O., Swende, T.Z. and Hembah-Hilekaan, S.K., (2019). ‘Domestic Violence among Infertile Women in Makurdi, North-Central Nigeria’. Gynecol Reprod Health, 3(5), pp.1-4.

Elhussein, O.G., Ahmed, M.A., Suliman, S.O. and Adam, I. (2019) ‘Epidemiology of infertility and characteristics of infertile couples requesting assisted reproduction in a low-resource setting in Africa, Sudan’, Fertility Research and Practice, 5(1), p.7.

Emmanuel, M.O., Olamijulo, J.A. and Ekanem, E.E., (2018). ‘Risk factors associated with secondary infertility in women of childbearing age: A matched case–control study’. Tropical Journal of Obstetrics and Gynaecology, 35(3), pp.249-255.

Fehintola, A.O., Fehintola, F.O., Ogunlaja, O.A., Awotunde, T.O., Ogunlaja, I.P. and Onwudiegwu, U., (2017). ‘Social meaning and consequences of infertility in Ogbomoso, Nigeria’. Sudan Journal of Medical Sciences, 12(2), pp.63- 77.

Fledderjohann, J.J. (2012) ‘Zero is not good for me’: implications of infertility in Ghana, Human Reproduction, 27(5), pp.1383-1390.

Greil, A., McQuillan, J. and Slauson-Blevins, K. (2011) ‘The social construction of infertility’, Sociology Compass, 5(8), pp.736-746.

Gurunath, S., Pandian, Z., Anderson, R.A. and Bhattacharya, S. (2011) ‘Defining infertility—a systematic review of prevalence studies’, Human reproduction update, 17(5), pp.575-588.

Hammarberg, K. and Kirkman, M. (2013) ‘Infertility in resource-constrained settings: moving towards amelioration’, Reproductive Bio Medicine Online, 26(2), pp.189-195.

Hardee, K., Gay, J. and Blanc, A.K. (2012) ‘Maternal morbidity: neglected dimension of safe motherhood in the developing world’, Global public health, 7(6), pp.603-617.

Iliyasu, Z., Galadanci, H.S., Abubakar, S., Auwal, M.S., Odoh, C., Salihu, H.M. and Aliyu, M.H., (2016). ‘Phenotypes of intimate partner violence among women experiencing infertility in Kano, Northwest Nigeria’. International Journal of Gynecology & Obstetrics, 133(1), pp.32-36

Inhorn, M.C. and Patrizio, P. (2015) ‘Infertility around the globe: new thinking on gender, reproductive technologies and global movements in the 21st century’, Human reproduction update, 21(4), pp.411-426.

Isah, B.A., Yahayah, M., Panti, A.A., Abubakar, S., Shehu, A., Bello, A.S. and Abdulaziz, M.D., (2018). ‘Perceived Causes of Infertility and Its Psychosocial Effects among Women with Infertility Attending Gynaecology Clinic in Usmanu Danfodiyo University Teaching Hospital, Sokoto’. IOSR J. Dent. and Med. Sci, 17(11), pp.26-30.

Katole, A. and Saoji, A.V. (2019) ‘Prevalence of primary infertility and its associated risk factors in urban population of central India: A community-based cross-sectional study’, Indian Journal of Community Medicine: Official Publication of Indian Association of Preventive & Social Medicine, 44(4), pp.337-341.

Khetarpal, A. and Singh, S. (2012) ‘Infertility: why can’t we classify this inability as disability?’ The Australasian medical journal, 5(6), pp.334.

Kumar, N. and Singh, A.K., (2015). ‘Trends of male factor infertility, an important cause of infertility: A review of literature’. Journal of human reproductive sciences, 8(4), p.191.

Lakatos, E., Szigeti, J.F., Ujma, P.P., Sexty, R. and Balog, P. (2017) ‘Anxiety and depression among infertile women: a cross-sectional survey from Hungary’, BMC women’s health, 17(1), pp.48-57.

Latkin, C.A., Edwards, C., Davey-Rothwell, M.A. and Tobin, K.E. (2017) ‘The relationship between social desirability bias and self-reports of health, substance use, and social network factors among urban substance users in Baltimore, Maryland’, Addictive behaviors, 73, pp.133-136.

Makanjuola, A.B., Elegbede, A.O. and Abiodun, O.A., 2010. Predictive factors for psychiatric morbidity among women with infertility attending a gynaecology clinic in Nigeria. African Journal of psychiatry, 13(1), pp.36-41

Mohammed-Durosinlorun, A., Adze, J., Bature, S., Abubakar, A., Mohammed, C., Taingson, M. and Airede, L. (2019) ‘Use and pattern of previous care received by infertile Nigerian women’ Fertility Research and Practice, 5(1), p.1-8.

Naab, F., Lawali, Y. and Donkor, E.S., (2019). “My mother in-law forced my husband to divorce me”: Experiences of women with infertility in Zamfara State of Nigeria. PloS one, 14(12), pp.149-225.

Ndarukwa, P. Chimbari, M.J. and, Sibanda, E.N. (2019) ‘Protocol on a systematic review of qualitative studies on asthma treatment challenges experienced in Sub-Saharan Africa’, Systematic reviews, 8(1), pp.149-155.

Odunvbun, W.O., Oziga, D.V., Oyeye, L.O. and Ojeogwu, C.L. (2018) ‘Pattern of infertility among infertile couple in a secondary health facility in Delta State, South South Nigeria’, Tropical Journal of Obstetrics and Gynaecology, 35(3), pp.244-248.

Ogawa, M., Takamatsu, K. and Horiguchi, F. (2011) ‘Evaluation of factors associated with the anxiety and depression of female infertility patients’, Bio PsychoSocial medicine, 5(1), p.15-20.

Ojo, O., Oluwole, L.O. and Obadeji, A., (2017). A comparative study of depression among fertile and infertile women in a south-western Nigerian city. Medical Journal of Zambia, 44(2), pp.93-99.

Olarinoye, A.O. and Ajiboye, P.O. (2019) ‘Psychosocial characteristics of infertile women in a Nigerian tertiary hospital’, Tropical Journal of Obstetrics and Gynaecology, 36(2), pp.252-257.

Oluwole, L.O., Obadeji, A. and Dada, M.U., 2020. Pains of the bane of infertile women in Southwest Nigeria: a qualitative approach. Fertility Science and Research, 7(1), p.99.

Omoaregba, J.O., James, B.O., Lawani, A.O. and Morakinyo, O. (2011) ‘Psychosocial characteristics of female infertility in a tertiary health institution in Nigeria’, Annals of African Medicine, 10(1).

Omosun AO, KofoworolaO. (2011) ‘Knowledge, attitude and practice towards child adoption amongst women attending infertility clinics in Lagos State, Nigeria’, African Journal of Primary Health Care & Family Medicine.;3(1).pp.1-8.

Osayuki, E.N., Owofio, C.J. and Osondi, V.F., 2015. A study of the experiences and coping strategies of barren elderly women, in Ondo State, Nigeria. African Journal of Nursing and Midwifery, 2(5), pp.156-162.

Panti, A.A. and Sununu, Y.T., (2014). ‘The profile of infertility in a teaching Hospital in North West Nigeria’. Sahel Medical Journal, 17(1), pp.7.

Sheikhan, Z., Ozgoli, G., Azar, M. and Alavimajd, H., (2014). Domestic violence in Iranian infertile women. Medical journal of the Islamic Republic of Iran, 28, pp.152.

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Whitehouse, B. and Hollos, M., (2014). ‘Definitions and the Experience of Fertility Problems: Infertile and Sub- fertile Women, Childless Mothers, and Honorary Mothers in Two Southern Nigerian Communities’. Medical anthropology quarterly, 28(1), pp.122-139.



Dr Tamunodiepiriye Jamabo, MBBS, MPH, MWACP
University of Wolverhampton


 Conceptualising bereavement relies heavily on the epistemological understanding of the person defying it with physical, emotional, social, and spiritual factors underpinning and shaping its constructs. The processes and experiences of bereavement, grief and loss have been widely researched and various theoretical frameworks have been proposed, with the direct application to practice, forming the therapeutic interventions (Davies, 2004). There is however, a theoretical debate whether accessing cooling facilities help or hinder the parental bereavement experience.

This literature review aims to explore two research questions: The impact of using cooling facilities (‘cold bedrooms’ and ‘cuddle cots’) on parental experiences of grief and the search question for the literature review: Does using the ‘cold bedrooms’ and ‘cuddle cots’ assist parental experiences of grief?

Data were obtained from the searches using the PICO tool and three articles were considered relevant and meeting the inclusion and exclusion criteria.

Findings have got direct practice implications for the palliative care providers who offer the cooling facilities as a recommended bereavement intervention and gaps in knowledge are explored and further recommendations made.

Key Words: parental grief, bereaved parents, death of a child, continuing bonds, cooling facilities



Theoretical perspectives on parental grief have changed over time, alongside the global societal transformations impacting on the understanding of death and life, as well as historical, cultural, medical, economical, and political factors influencing the delivery and accessibility of the children’s palliative care worldwide. The experiences of bereavement are seen as processes which are dynamic, hence various models have conceptualised stages of grief which suggest the anticipated steps with corresponding changes.

New understandings of parental grief have emerged highlighting the unique experience of each parent, and a need for holistic intervention models underpinned by a person-centred philosophy (Klass, 1993; Davies, 2004). Klass (1993) states that a concept of continuing bonds normalises the interactions with the deceased rather than pathologizing it. Its positive impact on the grief journey over traditionally suggested detachment, as in the model of Stroebe et al. (2003), has been highlighted and subsequently identified as a bereavement support intervention (National Institute for Health and Care Excellence, 2016, Together for Short Lives, 2018). Continuing bonds theoretical framework offers newly bereaved parents time to part with the deceased child by utilising cooling facilities. There are various technological solutions offered to bereaved parents that aim to preserve the bodies. Some of the most used solutions include cuddle cots, cooling blankets or the use of special (or cold) bedrooms in the children hospices. The amount of time that is available for bereaved parents varies depending on the local policies and procedures adopted by various palliative care providers as well as other factors, for example child’s diagnoses prior to death. However, it is recognised that this is a complex concept with some empirical contradictory findings (Root & Exline, 2013).

Review Methods

The aim of this review is to synthesize the best available evidence found which explores and assesses the bereaved parents’ experiences of using the cooling facilities, namely the cold bedrooms or the cuddle cots, on their experience of grief. This review addresses the following questions:

  1. What is known about the bereaved parents’ experiences of using cooling facilities for their children after death?
  2. Does using the ‘cold bedrooms’ and ‘cuddle cot’s assist parental experiences of grief?
Search strategy

This area of interest is novel; hence it has been anticipated that there are not many studies meeting the search criteria. Methley et al. (2014b) suggest that for searches where comprehensiveness is a key factor, the PICO tool should be the preferred option over PICOS and SPIDER. Key terms used were ‘parental grief’, ‘bereaved parents’, ‘death of a child’, ‘continuing bonds’, ‘cooling facilities’. All the searches were completed in March 2021. The search strategy included seven electronic databases: Medline, CINAHL, Nursing and Allied Health Source, Science Direct, Psychology and Behavioural Sciences Collection, PsycINFO, SOCindex and a further complimentary manual search of the reference lists of the identified publications. Three articles were considered relevant and meeting the inclusion and exclusion criteria.


Two studies were qualitatively reviewed, and one study was quantitatively reviewed. These studies provided primary data on the bereaved parents’ experiences of accessing the cooling facilities and their impact on the experiences of grief.

Two qualitative studies conducted by Davies (2005) and Norton (2018) used purposive sampling of the population of bereaved parents meeting the participants’ recruitment criteria, where ten bereaved mothers and seven bereaved parents (from five families using one hospice) were interviewed. In Norton (2018)’s study all children were under one year of age at the time of death, whereas Davies (2005) interviewed bereaved mothers of children ranging from three months to fourteen years of age at the time of death. All parents were English speaking. The studies provided an insight into the bereaved parents lived experience of using cooling facilities. Four themes were identified by Davies (2005) and eight by Norton (2018), where time, space, and privacy emerged in both studies and additionally, Norton (2018) recognised a need to be close to a baby, importance of mementoes, building a relationship with hospice staff and external perceptions of the use of the cooling facilities.

Forrester (2008) identified six themes like the other two studies: care for the child, care for the family, location of child’s body, the cold bedroom, funeral arrangements, and the spiritual needs. The identified themes are supported by theoretical concepts (Davies, 2003; Hackett and Beresford, 2021). However, there are limitations to the studies due to a small number of participants which limits the generalizability of findings. The participants were all English-speaking and were mainly mothers, therefore do not represent the population of parents of children with life limiting or life-threatened conditions (LLC) as the greatest prevalence is among those of Pakistani, other Asian, and Black ethnic minority groups (Fraser et al., 2020). Little is also known about fathers’ experiences. The qualitative design allowed an insight into the parents’ lived experiences; however, all positive experience of participants bias the interpretation. Parents who chose not to respond to the research request may have had a negative experience and hence decided not to take part in the studies. Moreover, Forrester (2008) suggests that bereaved parents who do not respond tend to be the most vulnerable.

Forrester (2008) attempted to interview all (thirty-four) bereaved families who used a cold bedroom in children’s hospices between January 2002 and March 2005. This approach offered opportunity for unbiased findings by capturing stories of all the parents who used the facilities regardless of their experience. However, only half (sixteen) of the respondents returned the questionnaire and further four declined their participation in the research.

It should also be noted that the study was based in one of the fifty-three children’s hospices in a particular geographical area of the South-East England so generalisations of findings should be with caution. There is a causal link between demographics and deprivation index and the prevalence of LLC (Fraser et al., 2020), hence findings from that area are unlikely to be reflective of the wider population.

Whilst the first question has been answered by the review to at last some extent, the second question remains unanswered due to the limitations and the small number of the research studies conducted to date exploring the parental experiences of using cooling facilities. All three studies have identified that further research of bereaved parents’ experiences of using the cooling facilities are needed to hypothesise causality between the cooling facilities and the experiences of grief. This would then support the evidence- based practice in offering cooling facilities’ provision by paediatric palliative care providers.


There have been no evaluative studies conducted to date exploring the bereaved parents’ experiences from the parents’ perspective. The research conducted to date does not reflect the wider population mainly due to small number of participants and research being locality based, hence findings are difficult to generalize. Accessibility and the practices of using the cooling facilities vary significantly across paediatric palliative care providers, therefore a further cross-sectional mapping study would enhance the understanding and would show what cooling facilities are available and where, what practices have been adopted as well as what support and training have been proposed for the healthcare professionals supporting bereaved parents with the use of the facilities in-house as well as in the community. Additionally, further research exploring specific cultural factors impacting on the access to cooling facilities as well as further studies with bereaved fathers are needed so that the healthcare professionals can meaningfully engage with the unrepresented parents and carers by adopting both evidence and practice based approach in their paediatric palliative care practices.



Davies, R. (2004). New understandings of parental grief: literature review. Journal of Advanced Nursing, 46(5), 506–513.

Davies, R. (2005). Mothers’ stories of loss: their need to be with their dying child and their child’s body after death. Jour- nal of Child Health Care, 9(4), 288–300.

Forrester, L. (2008). Bereaved parents’ experiences of the use of ‘cold bedrooms’ following the death of their child. Inter- national Journal of Palliative Nursing, 14(12), 578–585.

Fraser, L. K., Gibson-Smith, D., Jarvis, S., Norman, P., & Parslow, R. C. (2020). Estimating the current and future prevalence of life-limiting conditions in children in England. Palliative Medicine, 026921632097530. https://doi. org/10.1177/0269216320975308

Hackett, J., & Beresford, B. (2021). ‘Cold bedrooms’ and other cooling facilities in UK children’s hospices, how they are used and why they are offered: A mixed methods study. Palliative Medicine, 35(3), 603–610. https: /doi. org/10.1177/0269216320984335

Klass, D. (1993). Solace and immortality: Bereaved parents’ continuing bond with their children. Death Studies, 17(4), 343–368.

Methley, A. M., Campbell, S., Chew-Graham, C., McNally, R., & Cheraghi-Sohi, S. (2014b). PICO, PICOS and SPIDER: a comparison study of specificity and sensitivity in three search tools for qualitative systematic reviews. BMC Health Services Research, 14(1), 579.

National Institute for Health and Care Excellence. (2016, December). End of Life care for infants, children and young people with life-limiting conditions: planning and management.

Norton, E. A. (2018). Parents experience of using ‘cold’ facilitates at a children’s hospice after the death of their baby: A qualitative study (Thesis).

Root, B. L., & Exline, J. J. (2013). The Role of Continuing Bonds in Coping With Grief: Overview and Future Directions.

Death Studies, 38(1), 1–8.

Stroebe, W., Stroebe, M., & Schut, H. (2003). Does ‘grief work’ work? Bereavement Care, 22(1), 3–5. https://doi. org/10.1080/02682620308657561

Together for Short lives. (2018). A guide to children’s palliative care, supporting babies, children and young people with life-limiting and life-threatening conditions and their families. uploads/2018/03/TfSL-A-Guide-to-Children%E2%80%99s-Palliative-Care-Fourth-Edition-5.pdf



Monika Borchardt, MSc, MBPsS, DCounsPsych Trainee
University of Wolverhampton



Dr Anita Z Goldschmied, PhD, MRes, PgDip Mgmt, PgCert Ed, BA, SW, RNLD, FHEA
University of Wolverhampton

In 2020 the Office for National Statistics (2020) found that 1 in 5 children in England and Wales aged between 10 and 15 had experienced cyberbullying which is equivalent to around 764,000 children, with 72% of those also having experienced traditional bullying (face-to-face, usually within a school setting). Mental ill health has been rising in recent years within teenagers with such things as anxiety and depression, with mental health effecting physical wellbeing in terms of things like obesity and sleep deprivation (Patalay & Gage, 2019). With the rise of internet use online bullying has become a problem especially within adolescents who often spend a lot of time on social media and internet chatrooms; the focus is to use current literature to establish whether cyberbullying is a cause for mental health and if at all this differs from traditional face-to-face bullying.

The Barlett and Gentile cyberbullying model (BGCM, Barlett, 2017) attempts to explain cyberbullying by saying how perpetrators feel they have the autonomy online to be able to be and act however they feel without others knowing who they are, also regardless of physical power imbalance as across a screen it is irrelevant (Ansary, 2020). Studies have also shown that this theory positively predicts the chances of cyberbullying (Barlett, Chamberlin & Witkower, 2017). This theory also explains how cyberbullying is growing increasingly popular, due to the reasons listed above and how easy it is to do, the consequences are often less serious in the majority of cases and the ‘internet mob mentality’ (Norton, 2021).

Many studies have been done on finding an association between mental health and cyberbullying. The majority of the results show that there is a connection between the two. Fahy, et al (2016) found from their longitudinal study that cyberbullying is a direct cause of depressive symptoms, social anxiety and the well-being of adolescents being below average, however they did only use 12-13 year olds and interviewed them a year later so it may have been beneficial to include older participants or follow them for longer. Bottino, et al (2015) agreed with Fahy, et al (2016) within their systematic review, however they found further problems such as emotional stress and substance abuse; with a huge emphasis that as a result of cyberbullying teenagers are having increased suicidal thoughts as well as suicide attempts.

While Eyuboglu, et al (2021) found that there was ultimately a link between negative mental health traits and online bullying, they also found that females were more likely to be victims. Kaiser, Kyrrestad & Fossum (2020) discovered that as well as being more likely to be bullied, girls had a higher change of developing mental health problems when exposed to cyberbullying; they linked mental health to cyberbullying, but they found that those who had both been directly and indirectly exposed to online bullying were all more likely to suffer some form of negative mental health trait such as anxiety or depression. It was interesting that the victims themselves are not the only ones that are effected by this issue, however, neither Eyuboglu, et al (2021) and Kaiser, Kyrrestad & Fossum (2020) explained why females were more negatively affected; why they were more likely to be victims of cyberbullying and why they were more likely to develop mental health problems.

Lee (2021) conducted a study on university students to determine whether they had been affected by previous bullying from their childhood and teenage years; he found an increased risk of anxiety symptoms in those who have been cyberbullied. He also discovered that being cyberbullied or bullied  traditionally increased the risk of experiencing online bullying later in life. This may be explained by the victim precipitation theory; due to their personality traits and other characteristics it is thought that these individuals are ‘easier victims’ when previously bullied they are already a target for perpetrators (Peluchette, Karl, Wood & Williams, 2015).

Perret, et al (2020) carried out a longitudinal study of teenagers born in 1997-1998, they followed up with the participants when they were 13, 15 and 17 and wanted to explore suicide risk within victims of online bullying. Interestingly, they found that cybervictimisation alone did not cause a risk of suicide; however, a combination of traditional face-to-face bullying did. This shows that victims possibly felt that without an escape they had no other way out; they would have been bullied online at their educational setting. This is against the grain of studies such as Bottino, et al (2015) as other studies have found that cyberbullying alone can cause suicidal thoughts and attempts. While Perret, et al’s (2020) study gives context and critique to previous studies they could have added further variables as longitudinal studies are not as common as other methods; they have the ability to gather a lot of useful information so asking further questions would have been useful for the research on this subject.

The literature in this area is predominantly positively making links between adolescent mental health and cyberbullying, although with some differing results such as Perret, et al (2020) who found that cyberbullying only caused suicide risk when combined with traditional bullying; although this is a severe mental health problem and they unfortunately did not measure anxiety, depression and self-esteem issues. The research also clearly shows a need for gender to be a variant within future studies to back up claims of females being more likely to be victims and more likely to be negatively affected. From the literature it is clear that there is a lack of qualitative analysis in this area, and even more so mixed methods studies. 


Ansary, N. S. (2020) Cyberbullying: Concepts, theories, and correlates informing evidence-based best practices for prevention. Aggression and Violent behavior, 50, 101343

Barlett, C. (2017). From theory to practice: Cyberbullying theory and its application to intervention. Computer Human Behavior, 72, 269–275

Barlett, C., Chamberlin, K. & Witkower, Z. (2017) Predicting cyberbullying perpetration in emerging adults: A theoretical test of the Barlett Gentile Cyberbullying Model. Aggressive Behavior, 43(2), 147-154

Bottino, S. M. B., Bottino, C. M. C., Regina, C. G., Correia, A. V. L. & Ribeiro, W. S. (2015) Cyberbullying and adolescent mental health: systematic review. Cadernos de Saude Publica, 31(3), 463-475

Eyuboglu, M., Eyuboglu, D., Pala, S. C., Oktar, D., Demirtas, Z., Arslantas, D. & Unsal, A. (2021) Traditional school bullying and cyberbullying: Prevalence, the effect on mental health and self-harm behavior. Psychiatry Research, 297, (113730)

Fahy, A. E., Stansfeld, S. A., Smuk, M., Smith, N. R., Cummins, S. & Clark, C. (2016) Longitudal associations between cyberbully- ing involvement and adolescent mental health. The Journal of Adolescent Health, 59(5), 502-509

Kaiser, S., Kyrrestad, H. & Fossum, S. (2020) Cyberbullying and mental health in Norwegian adolescents. Scandinavian Journal of Psychology, 61(5), 707-713

Lee, J. (2021) Pathways from childhood bullying victimization to young adult depressive and anxiety symptoms. Child Psychiatry and Human Development, 52(1), 129-140

Norton (2020) Norton UK Blog. Available at:

Office for National Statistics (2020) Online bullying in England and Wales: year ending March 2020. Available at:https: /

Patalay, P. & Gage, S. H. (2019) Changes in millennial adolescent mental health and health-related behaviours over 10 years: a population cohort comparison study. International Journal of Episemiology, 48(5), 1650-1664

Peluchette, J. V., Karl, K., Wood, C. & Williams, J. (2015) Cyberbullying victimization: Do victims’ personality and risky social net- work behaviors contribute to the problem? Computers in Human Behavior, 52, 424-435

Perret, L. C., Orri, M., Boivin, M., Ouellet-Morin, I., Denault, A. S., Cote, S. M., Tremblay, R. E., Renaud, J., Turecki, G. & Geoffroy,


Lauren Potts, BSc (Hons), MSc Forensic and Investigative Psychology Student
University of Wolverhampton

Prior to the SARS-CoV-2 pandemic, it is estimated that an average 111 children suffered parental bereavement every day in the UK (Child Bereavement UK) While the direct impact of the pandemic on the number of bereaved children are currently unknown, there are some statistics that help to form a wider picture of the issue. As of the end of October 2020, the number of excess deaths has been counted at 56,313 and in the age range 15-64 stands at 9,813 while continuing to grow (PHE, 2020). For clarity, this is in addition to the 290,655 expected deaths. With the possibility that even more children are experiencing parental bereavement than at pre-pandemic times, it is important to understand the possible impacts on mental health and the best way to offer support and treatment to this vulnerable group. This literature review aims to look at the research into parentally bereaved children, in particular the children who would be classified as having post-traumatic stress syndrome (PTSD) and/or childhood traumatic grief (CTG), and the use of psychological interventions.

In response to the early research on trauma and grief, childhood traumatic grief (CTG) is a construct which was first formulated to describe the situation in which a child or adolescent is experiencing prolonged grief due to the loss of a family member or friend to whom they were close and is unable to progress through the grieving process (Cohen et al., 2002; Cohen & Mannarino, 2004). Much of the early research linked to grief, loss and trauma within childhood focussed on what was described as a traumatic death. The studies would only include deaths that were objectively considered to be traumatic, including deaths caused by serious accidents, suicide, murder or other acts of violence including war and terrorism (Brown & Goodman, 2005; Cohen et al., 2006; Nader, 1997). However, later research has shown that because the experience of trauma is subjective, children who lose a parent through expected causes such as long-term illness, may also experience a degree of trauma. Therefore it has been argued that any parental death has the capability of causing trauma for a child (McClatchy et al., 2009). Furthermore, trauma is also found in addition to the events surrounding the death of the parent, who could be often regarded as a source of support and comfort. The child’s life now must continue without that caregiver which presents new challenges and difficulties, in addition to a potential change in circumstances, perhaps having to change school, move from the family home and new financial instability caused by the loss of the parent (Lin et al., 2004).

While CTG is strongly correlated with PTSD, the specific need for a new construct within mental health is justified by the link to bereavement and how this adds additional facets to the experience of the child (Alisic et al., 2014). It has been suggested that the trauma impedes what would be considered as a normal grieving process, with intrusive thoughts around the aspect of the death which is perceived as traumatic stopping the child from processing the loss and instead only being able to focus on the trauma (Cohen & Mannarino, 2004). Similar to PTSD, traumatic memories can be caused by external reminders triggered by stimuli. The stimuli can either be linked to the trauma itself, a trauma reminder, which is linked to the deceased or loss reminder, which may remind the child of the changes they have had to make to their life such as moving school (Pynoos, 1992). However, it is important to note that only a relatively small percentage (16%) of children who had been exposed to trauma will go on to develop PTSD as measured by the DSM IV criteria (Alisic et al., 2014).

As it has been shown that suffering a parental loss does not always lead to development of PTSD or CTG, it useful to understand the factors which increase the likelihood of more serious symptoms developing. A range of indicators have been found to be predictors. Perhaps the most obvious is the strength of the emotional connection that the child had to the deceased (Pfefferbaum et al., 1999, 2000). This would also include knowing whether the family had domestic abuse or substance abuse within it prior to the death. Other indicators include social support, level of coping skills and level of distress displayed by the remaining caregiver (Alisic et al., 2014; Godder, 2008; La Greca et al., 1998).

Even with knowing the predictors, it may not be possible to stop children from developing CTG so having a robust plan for treatment is imperative. The literature reviewed details a number of different approaches to treatment for parentally bereaved children including cognitive behavioural therapy (CBT), play therapy, psychodynamic and art therapy (Crenshaw, 2005; Dutil, 2019;

McClatchey & Wimmer, 2012; Rachamim & Yadin, 2013). Most of these treatments were offered alongside psychoeducation and all studies reported an improvement in the outcomes for the child participants. It has suggested that the reason most interventions will yield positive results is largely due to the recognition from the caregiver that a problem exists. Other research has indicated that if the primary caregiver did not identify that the child may have a mental health issue, this was a risk factor in determining if the child went on to develop more serious symptoms of PTSD and prolonged or complicated grief (Alisic et al., 2014). However, it is an important to avoid pathologizing grief, so finding a way for caregivers to understand the signs of a child struggling to process the bereavement is of utmost importance.

As research shows, a wide range of treatment options are available and display a degree of efficacy, there is yet to be a direct comparison between the different types of intervention. The most commonly used treatment by far is CBT in combination with psychoeducation. While it is important to acknowledge that there should not be only one provision for treatment as this implies that all cases will fit a standardised model, it would be useful to know if CBT is most commonly used because of its higher rate of efficacy or because it is easier to deliver within the current healthcare framework. Therefore, this review is proposing future research on a comparison of CBT with more person-centred methods that are age appropriate (e.g. play therapy for under 12s).


Alisic, E., Zalta, A. K., Van Wesel, F., Larsen, S. E., Hafstad, G. S., Hassanpour, K., & Smid, G. E. (2014). Rates of post-traumatic stress disorder in trauma-exposed children and adolescents: Meta-analysis. In British Journal of Psychiatry (Vol. 204, Issue 5).

Brown, E. J., & Goodman, R. F. (2005). Childhood traumatic grief: An exploration of the construct in children bereaved on September 11. Journal of Clinical Child and Adolescent Psychology, 34(2). s15374424jccp3402_4

Cohen, J. A., Mannarino, A. P., Greenberg, T., Padlo, S., & Shipley, C. (2002). Childhood Traumatic Grief: Concepts and Controversies. Trauma, Violence, & Abuse, 3(4).

Cohen, Judith A., & Mannarino, A. P. (2004). Treatment of childhood traumatic grief. In Journal of Clinical Child and Adolescent Psychology (Vol. 33, Issue 4).

Cohen, Judith A., Mannarino, A. P., Murray, L. K., & Igelman, R. (2006). Psychosocial interventions for maltreated and violence-exposed children. In Journal of Social Issues (Vol. 62, Issue 4). 4560.2006.00485.x

Dutil, S. (2019). Adolescent Traumatic and Disenfranchised Grief: Adapting an Evidence-Based Intervention for Black and Latinx Youths in Schools. Children & Schools. Crenshaw, D. A. (2005). Clinical tools to facilitate treatment of childhood traumatic grief. Omega: Journal of Death and Dying, 51(3).

Godder, G. (2008). Parental death and trauma from the attacks on the world trade center and psychological func- tioning in 8 to 12 year old children. In Dissertation Abstracts International: Section B: The Sciences and Engi- neering (Vol. 69, Issues 3-B).

La Greca, A. M., Silverman, W. K., & Wasserstein, S. B. (1998). Children’s predisaster functioning as a predictor of posttraumatic stress following Hurricane Andrew. Journal of Consulting and Clinical Psychology, 66(6). https://

Lin, K. K., Sandler, I. N., Ayers, T. S., Wolchik, S. A., & Luecken, L. J. (2004). Resilience in parentally bereaved chil- dren and adolescents seeking preventive services. Journal of Clinical Child and Adolescent Psychology, 33(4).

McClatchey, I., & Wimmer, J. (2012). Healing components of a bereavement camp: Children and adolescents give voice to their experiences. In Omega (United States) (Vol. 65, Issue 1).

McClatchy, I., Vonk, M., & Palardy, G. (2009). The prevalence of childhood traumatic grief - A comparison of vio- lent/sudden and expected loss. Omega: Journal of Death and Dying, 59(4).

Nader, K. O. (1997). Childhood traumatic loss: the interaction of trauma and grief. In Figley, Charles | Bride, Brian E | Mazza, Nicholas (ed.), Death and trauma: the traumatology of grieving.

Pfefferbaum, B., Gurwitch, R. H., McDonald, N. B., Leftwich, M. J. T., Sconzo, G. M., Messenbaugh, A. K., & Schultz, R. A. (2000). Posttraumatic stress among young children after the death of a friend or acquaintance in a terrorist bombing. Psychiatric Services, 51(3).

Pfefferbaum, B., Nixon, S. J., Tucker, P. M., Tivis, R. D., Moore, V. L., Gurwitch, R. H., Pynoos, R. S., & Geis, H. K. (1999). Posttraumatic stress responses in bereaved children after the Oklahoma City bombing. Journal of the American Academy of Child and Adolescent Psychiatry, 38(11). 00011

Pynoos, R. S. (1992). Grief and Trauma in Children and Adolescents. Bereavement Care, 11(1). https://doi. org/10.1080/02682629208657280

Rachamim, L., & Yadin, E. (2013). Treating child and adolescent traumatic grief. In Studies of Grief and Bereave- ment.


Sarah Lucas, ProfDoc Counselling Psychology Student
University of Wolverhampton


Avoidant Restrictive Food Intake Disorder (ARFID) is defined by an eating pattern characterised by a limited amount or variety of food (Thomas & Eddy, 2018). Literature states that children with ARFID often struggle to eat and drink well at school which can be due to a number of reasons, such as lack of availability of preferred food, changes in routine or sensory overload. These difficulties can affect growth, weight, concentration, energy and learning abilities. Additionally, school is an important factor in the success of ARFID interventions (Harris & Shea, 2018). Despite this, there is currently very little research around ARFID and schools.

What is ARFID

Avoidant Restrictive Food Intake Disorder (ARFID) is a relatively new diagnosis, added to the Diagnostic and Statistical Manual, Fifth Edition (DSM-5) in 2013 (Bourne et al., 2020). Prior to the introduction of this diagnosis patients were categorised into different presentations that did not fit the existing DSM-IV categories for example, selective eating or food-avoidance emotional disorder (Fisher et al., 2015). ARFID is characterised by persistent feeding difficulties that can result in a reliance on nutritional supplements or enteral feeding, weight loss or a failure to gain weight and significant interference with psychosocial functioning (Bourne et al., 2020). Defined by an eating pattern characterised by a limited amount or variety of food (Thomas & Eddy, 2018), people with ARFID may demonstrate avoidance towards new foods or the sensory characteristics of certain foods, show a lack of interest in eating and fail to meet their nutritional needs. In contrast to other eating disorders however, people with ARFID do not experience body image distortion or fear weight gain (de Souza et al., 2020).

Diagnostic Tools

Currently the main diagnostic tool for ARFID is known as the Pica, ARFID and Rumination Disorder Interview (PARDI; Bryant-Waugh et al., 2019). The PARDI involves a screening questionnaire, introduction and diagnostic and severity items for ARFID. It is aimed at ruling out the presence of other eating disorders such as anorexia nervosa, bulimia nervosa or binge eating disorder which may preclude a diagnosis of ARFID (APA, 2013). The PARDI is designed to support a multi-informant assessment and due to this there are four parallel versions; two parent/carer versions for different age ranges and two child versions for different age ranges. The vocabulary and response options have been adapted so that they are developmentally appropriate (Bryant- Waugh et al., 2019). Literature states that further research is needed, but initial studies suggest that this tool demonstrates acceptable validity and reliability in the diagnosis of ARFID and may even be able to be utilised to determine what type of treatment individuals may benefit from (Bryant- Waugh et al., 2019). 


Although more epidemiological research is needed, available studies suggest that ARFID is as prevalent as other eating disorders such as anorexia nervosa and bulimia nervosa (Thomas & Eddy, 2018). 22.5% of children visiting a hospital to participate in a day programme for eating disorders were found to have ARFID (Niceley et al., 2014) and a survey of schools in Switzerland reported a prevalence of 3.2% of children whose self-reported symptoms were consistent with a diagnosis of ARFID (Kurtz et al., 2015). Emerging research also demonstrates that in males and females in the general paediatric, adolescent and adult population, individuals with ARFID report to eating disorder services (Thomas & Eddy, 2018).

Psychosocial Impact

For some individuals, food aversion may arise following an episode of choking or vomiting. Children can experience fatigue, anxiety and irritability and mealtimes can be a source of difficulties for families of children with ARFID (de Souza et al., 2020). In addition, literature suggests that young people with ARFID may be at risk of impaired family and social functioning, particularly if mealtimes are highly stressful.

However, further long-term follow up studies are needed to corroborate this (Fisher et al., 2014). Children with ARFID also score lower on the Health-Related Quality of Life scale (HRQOL) than other children. Research shows that children aged 0-5 scored significantly lower on scales for motor functioning, appetite, stomach, lungs and liveliness compared to both healthy controls and chronically ill patients. In addition, they scored lower on the positive mood subscales compared to healthy children. Furthermore, children with ARFID aged 6-10 scored lower on school functioning compared to healthy controls (Krom et al., 2019). This suggests that children with ARFID have marked difficulties in many areas of psychosocial functioning and is in line with previous research that was conducted prior to the definition of ARFID demonstrating that children with feeding disorders have more emotional regulation problems, higher levels of anxiety and more social difficulties and difficulties at school (Chatoor et al., 2004; Bryant-Waugh et al., 2010; Rommel et al., 2003; Lukens & Silverman, 2014).

Literature states that children with a diagnosis of ARFID often struggle to eat and drink well at school which can be due to a number of reasons such as lack of availability of preferred food, changes in routine or sensory overload. These difficulties can affect a child’s growth, weight, concentration, energy and learning abilities. In addition, school is an important factor in the success of ARFID interventions; the environment around the child, including what happens at school are key and if difficulties aren’t addressed, they can inhibit the success of any intervention (Harris & Shea, 2018). Despite this, to the authors knowledge, there is currently very little research around ARFID and schools. 

Research Gap

ARFID is a relatively new diagnosis (Mammel & Ornstein, 2017). Positively, this area has a rapidly growing research base but there are many gaps within the literature that have not been explored. One such area that is currently under- researched is around the difficulties children with ARFID face at school and what can be done to support them within an educational setting.


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Bryant-Waugh, R., Markham, L., Kreipe, R., & Walsh, B. (2010). Feeding and eating disorders in childhood. International Journal Of Eating Disorders, NA-NA.

Bryant-Waugh, R., Micali, N., Cooke, L., Lawson, E., Eddy, K., & Thomas, J. (2019). Development of the Pica, ARFID, and Rumination Disorder Interview, a multi-nformant, semi-structured interview of feeding disorders across the lifespan:           A pilot study for ages 10–22. International Journal Of Eating Disorders, 52(4),                                                                                                                378-387.

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Hart, C., & Page, A. (2020). The capability approach and school food education and culture in England: ‘gingerbread men ain’t gonna get me very far’. Cambridge Journal Of Education, 50(6), 673-693. 10.1080/0305764x.2020.1764498

Krom, H., Sluijs Veer, L., Zundert, S., Otten, M., Benninga, M., Haverman, L., & Kindermann, A. (2019). Health related quality of life of infants and children with avoidant restrictive food intake disorder. International Journal Of Eating Disorders, 52(4), 410-418.

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Lukens, C., & Silverman, A. (2014). Systematic Review of Psychological Interventions for Pediatric Feeding Problems. Journal Of Pediatric Psychology, 39(8), 903-917.

Mammel, K., & Ornstein, R. (2017). Avoidant/restrictive food intake disorder: a new eating disorder diagnosis in the diagnostic and statistical manual 5. Current Opinion In Pediatrics, 29(4), 407-413. mop.000000000000050

Marcdante, K., & Kliegman, R. (2018). Nelson Essentials of Pediatrics E-Book. Elsevier.

Nicely, T., Lane-Loney, S., Masciulli, E., Hollenbeak, C., & Ornstein, R. (2014). Prevalence and characteristics of avoidant/restrictive food intake disorder in a cohort of young patients in day treatment for eating disorders. Journal Of Eating Disorders, 2(1).

Rodriguez, L. (2018). Methodological challenges of sensitive topic research with adolescents. Qualitative Research Journal, 18(1), 22-32.

Rommel, N., De Meyer, A., Feenstra, L., & Veereman-Wauters, G. (2003). The Complexity of Feeding Problems in 700 Infants and Young Children Presenting to a Tertiary Care Institution. Journal Of Pediatric Gastroenterology And Nutrition, 37(1), 75-84.

Thomas, J. J., & Eddy, K. T. (2018). Cognitive behavioural therapy for avoidant/restrictive food intake disorder: Children, adolescents and adults. Cambridge University Press.

Walsh, G., Druin, A., Guha, M. L., Foss, E., Golub, E., Hatley, L., & Franckel, S. (2010). Layered elaboration: A new technique for co-design with children. Proceedings of the SIGCHI Conference on Human Factors in Computing Systems, 1237-1240.

Zelenko, O., & Hamilton, J. (2008). Empowering children as participants in designing resilience strengthening online tools. EdMedia+ Innovate Learning, 574-584. Retrieved from publication/27476833_Empowering_children_as participants_in_de signing_resilience_strengthening_ online tools/references


Sarah E Halls, BSc, MSc, Trainee Counselling Psychologist
University of Wolverhampton


Introduction Field generated data indicates a racial disparity in police officers’ decisions to shoot suspects (Statista, 2021; The Washington Post, 2021). This study draws from procedural justice theory to summarise research surrounding the disparate treatment of minority ethnic civilians by law enforcement. This review develops recommendations for policy makers to promote fairness in shooting decisions.

Method A literature review was conducted on 30/01/2021 using the APA PsycInfo and PubMed databases. A total of 129 studies were received and ultimately five studies were deemed eligible for review. Findings of these studies were summarised within a review matrix and critically discussed.

Recommendations Reducing racial disparities in fatal shooting decisions requires an interactionist approach as minimising biased perceptions is insufficient. Policy makers must consider the impact of enclothed cognition, over- policing and community-police relationships when searching for long term solutions to reduce the unjust victimisation of minority ethnic groups.



On the 20th of April 2021, Derek Chauvin - a White police officer - was found guilty of manslaughter for using excessive, deadly force to restrain an unarmed African-American civilian (Bekiempis & Walters, 2021; Fox 9, 2020; McGreal et al., 2021). Footage of George Floyd’s death sparked global protests pertaining to the disparate treatment of minority ethnic groups by law enforcement, highlighting the need to understand and counteract discriminatory police practices. Police officer shooting decisions are especially concerning as data demonstrates a significant racial disparity in decisions to shoot Black suspects over White suspects in America (Statista, 2021; The Washington Post, 2021).

The present study aimed to contribute to the ongoing social commentary by employing a literature review to highlight factors which encourage officers to disproportionately shoot minority ethnic civilians. By summarising the key explanatory variables used by academics within this area, this review will provide recommendations for policy makers and law enforcement decision-makers to facilitate the implementation of fairer police practices.


A literature review was conducted on 30/01/2021 using the APA PsycInfo and PubMed databases. APA PsycInfo was selected as it hosts over 2,200 journals, many of which are relevant to criminological research. PubMed was selected as its focus on medical research was believed to increase the holism of studies selected for review. The search terms used are presented below. “racial disparit*” OR “police officers dilemma” OR “first person shooter task” AND “shoot” OR “force” OR “brutality” English peer reviewed, journal articles were included if they used quantitative data to demonstrate race-specific trends in policing decisions. The researcher believes primary and secondary data offer unique perspectives when exploring discriminatory police practices, thus both were deemed eligible for review. The database search aimed to include research from all countries to improve this review’s generalisability, however, an initial scoping review demonstrated most relevant studies were US specific. Contemporary research was of interest given the prevalence of the ongoing social dialogue thus parameters were set to 2016 and 2021 inclusive. A total of 129 studies were generated: 20 from PsycInfo and 95 from PubMed. After review, 87 studies were removed based on relevance. Of the remaining studies, the five most pertinent articles were selected for this student paper and were summarised using a synthesis matrix (Appendix A).

Investigating disparities using crime statistics

In 2019, Johnson and colleagues analysed fatal officer-involved shooting (FOIS) data from the American National Violent Death Reporting System. Both officers and victims involved in fatal shootings were investigated - a novel approach, given research typically avoids reporting officer characteristics (Siegel et al., 2019; Streeter, 2019). Their findings demonstrate ethnic minority officers involved in fatal shootings positively correlated with Black and Hispanic deaths, but not White deaths. This occurred because of an increase in demographic rates within different districts and not an in-group bias.

Comparatively, Streeter (2019) compiled an original data set which included over 1,200 FOIS reported by the US media. Data was analysed using the Random Forest and Lasso Regression machine learning techniques which enabled the researcher to predict Black and White mortality rates using 126 different situational variables. Streeter’s (2019) unique analysis corroborated Johnson and colleagues’ (2019) indicating race only marginally predicts Black and White FOIS incidents. This suggests race alone does not predict fatal encounters (Statista, 2021; The Washington Post, 2021) thus policy makers must recognise reducing racial biases in police officers is not wholly effective for minimising disparate police use of force.

Findings from Streeter’s (2019) machine learning approach suggests higher frequencies of interactions between police officers and Black suspects may explain the disparity in shooting decisions. To explore this, Siegel and colleagues (2019) compared racial residential segregation (the level of physical separation within a neighbourhood), with the ratio of Black and White victims of FOIS. Findings show racial residential segregation significantly correlated with shootings of minority civilians from 2013-2017, indicating areas of less physical separation observed less disparate incidences of FOIS. Siegel and colleagues’ (2019) inclusion of racial residential segregation suggests police officers’ force decisions are moderated by socioeconomic and situational factors thus decisions to shoot are highly contextual. Despite using the same methodology as the previous studies, Siegel and colleagues (2019) created a numerical ratio to represent the victims’ race (Black÷White victims). This allowed the researchers to measure racial disparities in frequencies of fatal shots and not just their likelihoods – a superior and holistic variable, recommended for future research. In any case, their findings demonstrate Black civilians are at an increased risk of victimisation due to over policing in Black-centric neighbourhoods. Law enforcement decision-makers are therefore advised to identify solutions to the over-policing of minority ethnic communities (such as rapport building: Sheppard & Stowell, 2021) to minimise the racially disparate occurrences of FOIS.

Investigating disparities using experimental research

Correll and colleagues (2002) devised a first-person shooter task (FPST) in which participants rapidly decide to ‘shoot’ or ‘not shoot’ images of Black and White suspects holding guns or inanimate objects. The images are randomised, represent real-world scenarios and are presented using a within participants design. Whilst this task provides more experimental control than crime statistics for exploring racial disparities in shooting decisions, a key conceptual limitation of the FPST (Correll et al., 2002) is it does not consider shooter characteristics. To combat this Mendoza and Parks-Stamm (2020) used a large student sample to investigate the impact of wearing police uniforms on shooting behaviour. Firstly, the expected disparities were observed; Black suspects were significantly more likely to be shot than White suspects in both the armed and unarmed conditions. Critically, the study demonstrated students dressed in police uniforms were significantly more likely to shoot an unarmed suspect, than students dressed in their own clothes (p=.006). The enclothed cognition theory (Adam & Galinsky, 2012) states wearing specific articles of clothing triggers behavioural tendencies relative to the clothing’s symbolic meaning, suggesting uniformed officers are more risk tolerant. However, whilst the shooter’s clothing caused more false alarms, clothing did not exasperate racial disparities in shooting decisions thus, perceived power through clothing solely increases action orientation, not specific implicit stereotypes. This implies the risk of FOIS scenarios disparately victimising minority ethnic civilians can be minimised by developing police training programmes which reduce officers’ perceptions of invulnerability/power whilst wearing their uniforms.

Classic research suggests cognitive load, which is exasperated by poor sleep (Alger, et al., 2020), can increase biased decision-making (Kleider et al., 2010). Scullin and colleagues (2020) investigated the mediating impact of sleep deprivation on disparate shooting performance in the FPST (Correll et al., 2002). Volunteers from a large civilian sample were randomly allocated to a restricted sleep schedule (1:30am - 7:30am) or neutral sleep schedule (10:30pm – 7:30am) for four consecutive nights. Similar to Mendoza and Parks-Stamm (2020), the expected racial disparities were observed across sleep conditions, indicating Black suspects were consistently more likely to be shot than their White counterparts irrespective of sleep quality. Interestingly, the researcher’s signal detection approach demonstrated shooting decisions were moderated by sleep quality when observing White suspects (p<.001) but not Black suspects (p=.79), suggesting improved sleep quality may actually exasperate racial disparities in officers’ shooting decisions. Further research is required to investigate the impact of cognitive load on shooting decisions before policy makers promote better sleep to reduce disparate FOIS incidents.


Field generated data indicates racial disparities exist in the prevalence of fatal shooting incidents in the US (Statista, 2021; The Washington Post, 2021). A review of secondary (Johnson et al., 2019; Siegel et al., 2019; Streeter, 2019) and experimental research (Mendoza & Parks-Stamm, 2020; Scullin et al., 2020) illuminate key considerations for policy makers to reduce the disparate victimisation of minority ethnic civilians.

  1. Reducing racial bias in police officers will not eliminate the disparity in police use of force alone. An interactionist approach is requiredReducing racial bias in police officers will not eliminate the disparity in police use of force alone. An interactionist approach is required

  2. Police resources must be deployed proportionately in areas of high crime whilst not over-policing impoverished minority ethnic communities.Reducing racial bias in police officers will not eliminate the disparity in police use of force alone. An interactionist approach is required.Reducing racial bias in police officers will not eliminate the disparity in police use of force alone. An interactionist approach is required.
  3. Officers’ perceptions of their powers and responsibilities whilst wearing their uniforms must be appropriately managed and reorientated.

Adam, H., & Galinsky, A. D. (2012). Enclothed cognition. Journal of Experimental Social Psychology, 48(4), 918- 925.

Alger, S. E., Brager, A. J., Balkin, T. J., Capaldi, V. F., Simonelli, G. (2020). Effect of cognitive load and emotional valence of distractors on performance during sleep extension and subsequent sleep deprivation. Sleep, 43(8), 1-10.

Bekiempis, V., & Walters, J. (2021, April 21). Derek Chauvin guilty verdict: Biden says ‘systemic racism is a stain on our nation’s soul’ – as it happened. The Guardian. live/2021/apr/20/derek-chauvin-verdict-trial-jury-returns-george-floyd-death?page=with:block- 607f42a88f08a84aa5918f29#block-607f42a88f08a84aa5918f29

Buvik, K. (2014). The hole in the doughnut: A study of police discretion in a nightlife setting. Policing and Society, 26(1), 1-18.

Correll, J., Park, B., Judd, C. M., & Wittenbrink, B (2002). The police officer’s dilemma: Using ethnicity to disambiguate potentially threatening individuals. Journal of Personality and Social Psychology, 83(6), 1314- 1329.

Fox 9 (2020, June 6). Hennepin County Medical Examiner declares George Floyd death homicide. https://www.

Greenwald, A. G., McGhee, D. E., & Schwartz, J. L. K. (1998). Measuring individual differences in implicit cognition: The implicit association test. Journal of Personality and Social Psychology, 74(6), 1464–1480. https://

Johnson, D. J., Tress, T., Burkel, N., Taylor, C., & Cesario, J. (2019). Officer characteristics and racial disparities in fatal officer-involved shootings. Proceedings of the National Academy of Sciences of the United States of America, 116(32), 15877-15882.

Kleider, H. M., Parrott, D. J., & King, T. Z. (2010). Shooting behaviour: How working memory and negative emotionality influence police officer shoot decisions. Applied Cognitive Psychology, 24(5), 707–717. https: /doi. org/10.1002/acp.1580

McGreal, C., Beckett, L., Laughland, O., & Ajasa, A. (2021, April 21). Derek Chauvin found guilty of murder of George Floyd. The Guardian. guilty-murder-george-floyd

Mendoza, S. A., & Parks-Stamm, E. J. (2020). Embodying the police: The effects of enclothed cognition on shooting decisions. Psychological Reports, 123(6), 2353-2371.

Moffett, B. L. Jr. (2021). Influence of implicit racial bias on police officers’ decision to use force [Doctoral Dissertation, Walden University]. ProQuest Information & Learning.

Scullin, M. K., Hebl, M. R., Corrington, A., & Nguyen, S. (2020). Experimental sleep loss, racial bias, and the decision criterion to shoot in the Police Officer’s Dilemma task. Scientific Reports, 10(1), 1-8. https: /doi. org/10.1038/s41598-020-77522-z

Sheppard, K. G., & Stowell, J. I. (2021). Police fatal force and crime reporting: A test of community responses to fatal police-civilian encounters. Journal of Interpersonal Violence.

Siegel, M., Sherman, R., Li, C., & Knopov, A. (2019). The relationship between racial residential segregation and black-white disparities in fatal police shootings at the city level, 2013-2017. Journal of the National Medical Association, 111(6), 580-587. (2021, January 5). People shot to death by U.S. police, by race 2017-2020. statistics/585152/people-shot-to-death-by-us-police-by-race/

Streeter, S. (2019). Lethal force in black and white: Assessing racial disparities in the circumstances of police killings. The Journal of Politics, 81(3), 1124-1132.

The Washington Post. (2021, January 27). Fatal Force. police-shootings-database/


Chand Dhot, MBPsS, BSc, MSc Forensic and Investigative Psychology Student
University of Wolverhampton



Background: McDaniel & Coyne (2016) define interference in our interactions from technology as technoference.A further term; phubbing, (Roberts & David, 2016) adopted by others, refers to phone snubbing. Thus, is it possible that the ubiquitous technology people often revere, may be distracting from relationships and causing detrimental consequences? 

Purpose: Mobile digital devices have been in our lives for over 20 years now. However, this is still a relatively new area of study with potential life-long negative implications on our relationships.

Search Method: literature search was conducted on 27th April 2021, using; PsycINFO Database, BrowZine Journal Library, BASE (Bielefeld Academic Search Engine), and Psychology and Behavioral Sciences Collection. Peer reviewed, full articles, available online from the last 6 years were included. Age of participants; young children, adolescents and adults, were considered. Studies regarding; children’s overuse of digital devices and possible links to attention were excluded.

Findings: Qualitative, quantitative and mixed methods studies were found. There may be potential implications for; child behaviour and level of consequences, self-esteem of children, Depression, attachment, parental overuse of digital devices and links to child behaviour, and parenting strategies for digital device use in front of children. Aspects studied included; eye contact, listening, responding, escaping boredom/conflict, and prompting.

Conclusions: Disruption to relationships from technology may

Key Words: Technoference, phubbing, parent*, child*, *phone, behaviour.


Digital technological devices are so comprehensively integrated into daily life and human behaviour.

Time spent on such devices, however supplementary or life encompassing, is time subtracted from relationships occurring in the same physical spatiality as us. McDaniel & Coyne (2016) describe persistent interferences from technology, as technoference. Furthermore, Braune-Krickau et al. (2021) refer to; immersion or absorption, whereby people are immersed in their device, or their attention is absorbed into digital devices instead of being fully present in social interactions with people physically there in person. This can refer to friends, family and romantic partners, a gloomy picture for any relationship, however possibly the most damaging maybe technology interrupting relationships at the most vulnerable stage in life, childhood when human development is crucially and rapidly progressing, hence the parent-child relationship is in focus here.

Braune-Krickau et al. (2021) begin to investigate the issue of whether technoference and absorption, are involved in impacting parental responsiveness and sensitivity to young children, through using a smartphone in the presence of the child. They review 12 studies whereby the literature overwhelmingly indicates that smartphone use negatively impacts the responsiveness and sensitivity of parents towards their children, whilst being distracted by their smartphones. Furthermore, in the observational and experimental studies they review, parents use their smartphones through mealtimes, at playgrounds and in mock waiting room settings. Overall, this was to the detriment of their children, as many missed opportunities for communication, signs of a child’s distress or achievement, and safety aspects went unnoticed (Braune-Krickau et al., 2021).

Stockdale et al. (2018) consider the parent- adolescent relationship regarding technoference, citing that other literature focuses on the parent- child relationship, however young children do not have their own access to digital devices like older children do. This adds a further dynamic of technoference due to the adolescent’s own use. The important point here is the possible consequences of technoference. Stockdale et al. (2018) discuss the potential negative behaviour outcomes for children, whether exhibited internally or externally, often revealed differently in young children as opposed to adolescents. Adolescent children acting out or withdrawing can sometimes be expressed through; anxiety, depression, cyberbullying or risky behaviours. Furthermore, it seems that when the parent-child relationship suffers interruptions often, and social cues have potentially been missed, possibly on both sides of the relationship for older children due to attention being focused on digital devices rather than on the person in front of them, thus over time this may lead to a decrease in the warmth of the relationship.

Gugushvili et al. (2020) looked at adults’ problematic smartphone use (PSU), the connection with fear of missing out (FoMO) and negative wellbeing. Interestingly, finding two significant aspects of the possible negative effect on wellbeing from PSU; a preference for online over offline relationships, and physical symptoms of PSU. If we relate this to the parent-child relationship, it is possible that a decrease in adult or parental wellbeing from excessively using a smartphone, could possibly also affect a child present. If a parent chooses to spend time engaging in an online relationship, for example, through social media, rather than offline with the child physically present who is relying on them for attention, what message could this be relaying to the child? Furthermore, how may this affect self-esteem, if possibly appearing less important than a virtual entity?

Indeed, a young baby demands a different kind of parental attention than an adolescent, but to what extent could a parent being absorbed in a device rather than the child they are caring for, by looking into the device rather than at the child, have on wellbeing and the child’s developing self-worth? Raudaskoski et al. (2017) consider whether the ability for parents and children to gauge emotions and share, can be affected if the parent’s gaze is often directed away from the child.

McDaniel (2019) details that evidence has not yet addressed the following issue directly, although anxieties are accumulating suggesting parental smartphone use may be distracting parents away from their child/ren so much so it could lead to children forming a less secure attachment to their caregivers. The importance of secure attachment of children to their caregivers (Bowlby, 1958) is well documented and inherent in children’s social care work today. Hence if parental smartphone use is subtracting from the quality of children’s attachment to their caregivers, and smartphones, social media and Internet use is prevalent in our lives today (Kemp, 2021) this issue is a pertinent one. Moreover, McDaniel (2019) discusses the impact of smartphone use for parent and child wellbeing, as possibly being at a significant level.

An experimental study by Kushlev & Dunn

(2019) studied parental smartphone use and social connectedness during a museum visit. One group used their phones frequently and the other infrequently. The group who used their phones more frequently whilst with their children, felt less social connectedness. Kushlev & Dunn (2019) carried out a second study asking parents to complete daily online diary surveys and found the quality of attention parents paid to their children seemed to be affected negatively by increased smartphone use. Limitations of both studies can be seen in that smartphone use was assessed using self-reporting methods only.

Accordingly, the literature available does not make for a significant link yet to attachment, however does seem to be mounting, depicting a reality where parental smartphone use in front of children, can make for; negative differences in parental responsiveness and sensitivity to their children (Braune-Krickau et al., 2021), possible internal and external negative behaviour outcomes for children (Stockdale et al., 2018), feasibly experiencing less social connectedness when distracted by a smartphone (Kushlev & Dunn, 2019), and reduced opportunities for sharing emotional connections through eye contact and understanding facial expression (Raudaskoski et al., 2017).

The research topic is certainly necessary to investigate, for understanding disruption to family relationships may not only be negative for the individuals concerned presently, but also for future relationships and hence society to function optimally, given the omnipresence of smartphones. The value of research being conducted in this area will hopefully aid the development of practicable theory, and advice to be shared with parents and professionals working with parents, for a better understanding of the consequences of smartphone use behaviour in front of children, or how best to manage unavoidable use to minimise any possible detrimental effects to children’s development, relationship quality and whole family wellbeing. Future studies could include a mixed methods approach, to effectively address the research question and hypothesis: Parents abstaining from smartphone use in front of their child/ren, will see an improvement in the child/ren’s behaviour. 


Bowlby, J. (1958). A note on mother-child separation as a mental health hazard. British Journal of Medical Psychol- ogy, 31(3-4), 247-248.

Braune-Krickau, K., Schneebeli, L., Pehlke-Milde, J., Gemperle, M., Koch, R. & Von Wyl, A. (2021). Smartphones in the nursery: Parental smartphone use and parental sensitivity and responsiveness within parent–child interac- tion in early childhood (0–5 years): A scoping review. Infant Mental Health Journal, 42(2), 161–175.

Gugushvili, N.,Täht,K., Rozgonjuk, D., Raudlam, M., Ruiter, R. & Verduyn, P. (2020). Two dimensions of prob- lematic smartphone use mediate the relationship between fear of missing out and emotional well-being. Cyber- psychology: Journal of Psychosocial Research on Cyberspace, 14(2), Article 3.

Kemp, S. (2021). Digital 2021, Global Overview Report.

Kushlev, K., & Dunn, E. W. (2018). Smartphones distract parents from cultivating feelings of connection when spending time with their children. Journal of Social and Personal Relationships. https://doi-org.ezproxy.wlv.

McDaniel, B. T. & Coyne, S. M. (2016). Technology interference in the parenting of young children: Implications for mothers’ perceptions of coparenting. The Social Science Journal, 53, 435–443.

McDaniel, B. T. (2019). Parent distraction with phones, reasons for use, and impacts on parenting and child out- comes: A review of the emerging research. Human Behaviour & Emerging Technology, 1(2), 72– 80.

Raudaskoski, S., Mantere, E., & Valkonen, S. (2017). The influence of parental smartphone use, eye contact and “bystander ignorance” on child development. In A. R. Lahikainen, T. Mälkiä, & K. Repo (Eds.), Media, family interaction and the digitalization of childhood. (173–184). Cheltenham, UK: Edward Elgar Publishing.

Roberts, J. A. & David, M. E. (2016). My life has become a major distraction from my cell phone: Partner phubbing and relationship satisfaction among romantic partners, Computers in Human Behavior, 54, 134-141.

Stockdale, L. A., Coyne, S. M. & Padilla-Walker, L. M. (2018). Parent and Child Technoference and socioemotional behavioral outcomes: A nationally representative study of 10- to 20-year-old adolescents. Computers in Human Behavior, 88, 219-226.


Caroline Lowe, BA(Hons), MBPsS Dip, MSc in Cyberpsychology, Student
University of Wolverhampton


We were the first to translate the works of Gannushkin and Suhareva from Russian
into English and the only gap we found was that in our heads….
Goldschmied AZ (2021 personal correspondence)
Among [the autistic] we can find people occupying positions at the tops of the realm 
of ideas, in the thin air which is difficult to breathe for an ordinary man: this includes
the aesthetic artists whose work is mostly formal, the profound metaphysicist and finally
the talented schematic scientists and brilliant revolutionaries in science…
Gannushkin (1933) (trans. Goldschmied AZ & Zumpalov LG 2017)



Throughout our education and beyond, we keep on hearing how literature reviews are an essential and, as such inevitable part of academia. So far, we agree. Literature reviews fulfil many pragmatic roles in science, research and teaching. In addition, many academics go as far as to say that searching literature has the purpose of finding a gap in knowledge. This is where we take a different view on the role of literature reviews, the nature of knowledge and their presentation in the 21st Century. This article aims to rethink what we researchers understand by the ubiquitous term ‘gap’ when reviewing the literature. It introduces the unchartered works of two psychiatrists (Pyotr Borisovich Gannushkin 1875-1933 and Grunya Efimovna Suhareva 1891-1981) who primarily published in Russian and therefore remained hidden from the English-speaking literature and as such demonstrate how the notion of ‘the gap’ is not all it appears to be. Principally, if the ‘gap’ is a question of presence and absence of evidence, as is the view of the gap-hunter then, we offer the metaphor of the boat builder and the activity of noticing literature. We will summarise in 10 points (see Table 1 and the 10 description cards) how our boat building as a genealogical model shares many similarities to translating texts from Russian, we learnt from Gannushkin’s and Suhareva’s work in autism.

Genealogy & Translation as Alternative Method to Locating ‘Best Fits’ 

Thanks to literature, the history of autism, like most others in medicine, is well-known in scientific circles. In 1943 Kanner published his article “Autistic disturbances of affective contact”, describing for the first time autistic presentations which were revolutionary but destined to be superseded by Asperger Syndrome in 1981 in English. This symbolises the manner of gap hunting in which literature is seen to chronologically stand on the shoulders of a few noted scientists by following the logic of deduction and progression and also with what it means to generate knowledge1.

… just like translations, boats come in all shapes and sizes… 

But for those who do not speak German or prefer to build boats, the process of translating is a literary form which reveal that words on a same article to decipher and expect 100 different returns), but so is the response of the intended audience. Translating shows how literature and our relationship with it are more than one of truth, correspondence and objectivity (the so-called high values of deductive and inductive science). It is also one of abduction, best fits and the art of page do not act like the data they serve to communicate. Far from providing the certainty demanded of consistent results, systematic ordering and quantifiable symbolism, the literature review in the eyes of boat building translators is at best about ‘best fits’ because every translation justification. Thus, when building boats, especially at sea, it can become nautically disorientating to rely on singular truth or voice in finding, translating or reading literature. Every choice now offers multiple possibilities that Captains need to notice is about choices, moods and any number of very human qualities. Or better still, the boat builder who has no choice but to build his ship at sea remaining adaptable and flexible rather than deciding in advance what ship will suit best.

This abductive (rather than deductive or inductive2) admission is at loggerheads with the scientific tradition of attempting to be objective and gap hunting in literature. Boat builders in the form of translations, semantics and generally other opinions. We may not appreciate this range of choice and attempt to plug holes, wind in sails and tug ropes to make their research appear more certain and conclusive. But boat builders recognise how communities of truths generate alternative methods of value, use, historical context and textual ordering. So, from a story of how two of the authors (AZG & LGZ) laboured for months translating original text from Russian to Bulgarian to Hungarian and eventually to English, we now introduce you to how their genealogical method of deciding on the best semantic fit was aided very little by ‘finding gaps’ but helped along the way by building their ship at sea.

        …translating assembles knowledge rather than finds it…

Such workmanship requires hours of tedious scholarliness pawing over paragraphs, sentence by sentence not too dissimilar to researchers combing literature. This systematic assembly of manipulating language points up what the authors will go onto discuss in terms of their 10 points because in rough seas words are always semantically slippery. That is, all translations, be they between languages, literal claims or squiggles of math on a page, are arbitrary, mediated and therefore open to many different interpretations. Not only is translation just as much an art as it is a science (you could give 100 translators the know that building your boat at sea is anything but certain. In particular, no matter how many deductively induced writing courses the average researcher attends in an effort to make each corresponding paragraph appear ‘a thing’ (reliable, credible, trustworthy, independent, systematic, objective), it is ‘not a thing’ but that: one choice and description of many truths, literal appearances, necessitated mediation and as such compromise which, even the most steadfast language of math must also contend. In terms of translating, our genealogical connecting found that instead of ‘the gap’, we can never avoid making choices. For every corresponding gap, there are more than enough leaks to surmise. Such is the methodological nature of literature reviews. It demands attention to detail and noticing the way things connect chronologically. It is through that process of being active in the interpretation that translators generate crazy observations and best fits.

For example, Suhareva’s paper is never included in the story of autism because it was not translated into English until 19963. In 2015 Silberman noticed the work but then decided to follow other choices and, as such, rendered a right to sail a preferred course. One that is about active roles in translation, of presence, absence and noticing, which does not only affect the writing of the text but the reading of it. An example being that although the German translation of Suhareva’s paper was available in English since 1996 and her brilliant and foreseen observations on autism available to ‘fill gaps’, countless articles have still been written under the pretence that no gap actually existed because Kanner and Asperger are the ‘fathers’ of autism (Corbier 2004, Fellows 2005, Lyons and Fitzgerald 2007, Schopler and Mesibov 2013). So, the notion of ‘the gap’ is no doubt attractive, especially when the existence of it is either pragmatically or theoretically celebrated, but the debate does offer up a new type of map and compass with which to sail and nautically orientate. 

Suhareva and Gannushkin: what they teach us about gaps and best fit knowledges

As far as the authors can tell, only a few sources reference the name and work of Suhareva or Gannushkin into their literature. In traditional terms, this would suggest ‘a gap’, not necessarily in the literature, but rather the authors’ personal knowledge. To put this bluntly, our experience of translating these two works taught us that gap hunting is only as good as the relationship forged by the gap hunter. We also learnt at least another 10 things about literature reviews as a result of our fumbling with compass and sails. Table 1 summarises, compares and contrasts boat builders (on the sea) and gap hunters (in the library) views on literature. Whilst such simplification always causes controversy and needs to be handled with a degree of scepticism, it offers our contribution to how literature reviews built at sea are carved in a manner similar to translators making sense of meaning.

Our 10 points for aspiring boat builders on how literature reviews act emerged when we started translating Suhareva’s book chapter. To our surprise, we learnt that actors like terminologies produced assemblages about autism4. We started to surmise how Suhareva’s and Gannushkin’s work challenged notions of progress and chronology and wondered how many others are still hidden on shelves, on the cloud and easily accessible for a willing reviewer? These potential omissions kick- started our theorising about boat building and gap hunting and promoted us to do an experiment in the spirit of the live method.

We put up our ores and instead did what every researcher does and typed ‘gap in literature’ into and got “723,000,000 results (0.57 seconds) 14 Sept 2021 12:55.” Reading through the first few dozen hits, we were smacked in our sea weather-beaten faces with the typical definition: Gap in literature means Missing pieces or insufficient information in the research literature. The most popular stance proposed that Research is a tool to fill the knowledge gaps in a particular field or Otherwise, it is not novel research and is therefore not contributing to the overall goals of science. Thus, the sentiments of the gap hunter firmly exonerated in that it would take 200 years to read the first 50 words of each hit and still not find a source denying the existence of ‘the gap’. Such is the potency of scientific discourse that the relevance of building one’s ship at sea, like the work of Suhareva and Gannushkin, is largely absent. So, it was here that the authors allowed the translating process to emerge a list of 10 alternatives (not to refute gap hunting per se) but rather, to help us describe what usually happens in our experience of reviewing and boat building. Translating assembles knowledge rather than finds it.

10 points Suhareva and Gannushkin taught us about literatures, reviews and knowledges

For the authors, the idea of communities of knowledge rather than stand-alone literature has become a way of negotiating gaps. Instead of being things-in-themselves that come into existence by the authority of the authors, we acknowledge through our translating of Suhareva and Gannushkin how the ideas inform one another. Our models consider how literature mediates, connects and mixes in the raging seas that metaphorically go to make up what it means to review topical literature. We did not discover but instead assembled our knowledge, our new relationship with autism and negotiated all 10 of the points that now symbolise our boat building rather than gap hunting approach. We remain steadfast that both are useful whilst in awe that our creativity and, as such, enthusiasm for inventing links, surmising connection and even reinventing knowledge is an exciting alternative to finding it. Besides, translation demands such bravery because any number of versions can be more correct, rhetorical, pragmatic or simply get the message across better. Not too dissimilar to the poetics of a heart-warming play or the claims of statistical analysis, the translator, like an audience, is Captain of their boat who at times has to make analytical decisions, defend choices and be prepared to revise, reinvent and review.

Discussion on the role of contemporary literature reviews

The first thing we noticed was that this article could not be the result of finding a gap in knowledge, specifically in the literature on autism. Neither could it be an attempt to fill gaps in autism with our two ‘newly discovered’ Russian psychiatrists. As a result of our translating, we are more pragmatic and realist. We hoped to reassemble autism and tell another (hi)story with the works of Gannushkin and Suhareva (Goldschmied ZA & Zumpalov LG, 2017). We started to conclude that there could be no gaps per se in autism but rather, terrains to be explored and ships to be built so that absence, presence and the role of the mediating effect of translation could be rethought. Our translating stoked our curiosity to explore unchartered terrains to reassemble, tell and retell further (hi)stories and knowledges of autism. Reviews are assemblages, the effect of noticing to offer multiple possibilities. No matter what methodology we choose, which database we access, how systematic we are, at the end of the day, our literature review will be just an experiment of many possibilities. Students, scientists and academics need to do good enough work (see 10 points of boat builders) as a means to negotiate, compromise, and make judgements about their choices as they sail along the sea to inform policies and practices. For there is no doubt that sooner or later, the next translations change the terrain and reassemble what we think we know.

… be prepared to reinvent, revise and review … 

Traditional gap hunters like Silberman question Kanner’s authenticity, whilst Manoluenko, Bejerot and Wolf inquire whether Asperger or Kanner knew about each other or the work of Suhareva. Others try to figure out who was really the first who made the ground-breaking discovery (Chown 2012, Chown and Hughes 2016). None of them goes as far as to notice the presence of others. Translating taught us that sometimes new actors enter the scene like Gannushkin’s and Suhareva’s book chapter. Researchers constantly de- assemble and re-assemble prior theories and knowledge, like our articles. None of this happens overnight and certainly not as the result of one single person as the literature so often implies. Furthermore, the role and dominance of particular languages in the scientific world cannot be overlooked. Naturally, the history and relationship of Europe, Russia and the United States of America need to be added to the assemblage. Moreover, with the digital, it is not only our local interactions (books, education, family, papers) that provide us with information but also the virtual translating of faraway actors. Mostly freely. Mostly instantly. Something that was unimaginable just 20 years ago. We can reassemble our knowledge within seconds at the touch of a button.


Boatbuilders put into practice ideas of genealogies aiming to re-assemble knowledge rather than providing the reader with one objective account. Therefore, we summarise what we learnt through a genealogical method of literary scholarship - something necessary when translating the semantic nuances of one language to another. First, knowledge, including literature reviews, does not exist in and by itself. They are assembled. Second, literature reviews are composed by the noticing of many actors, their connections and translations, the dynamics they emerge: observations, written papers, clinics, computers, algorithms, search engines, languages, lights, dictionaries, qualifications, caffeine level and the audience like supervisors, editors, translators, publishers, readers and other gatekeepers. Third, literature reviews are pragmatic endeavours to meet various goals, experiment, map the terrain and build a ship on the sea. Fourth, literature reviews show the processes openly and transparently with all their imperfections. It is no longer good enough to stick a passive and detached paragraph named limitations to the end of an article covering a few of those surprises and uncertainties we have uncovered and sail over in this article. Fifth, and possibly the main point we would like to get across, is that literature reviews should inspire curious minds, offering many possibilities and not one objective truth.

… we can reassemble our knowledge within seconds at the touch of a button … 

This article also aimed to inspire others to reach out to materials other than the usual scientific narratives. Every time we present our literature, we need to show how it is only one of many realities and descriptions. By sticking to the language of gap finding and filling, it is usually the people in need of support who will suffer at the expense of aspiring researchers’ career progress and similar activities. In this case, people like the authors, who are often misunderstood and misinterpreted. Autism did not start with Kanner and Asperger and will not end with Suhareva and Gannushkin. We started this article by noticing how literature and traditional gap hunters tend to name two people as fathers of autism. We finish with arguing that boat builders and explorers trace a whole community of knowledge mothers like Grunya Efimovna Suhareva, grandfathers like Pyotr Borisovich Gannushkin and many more that we hope future articles will include by translating those works that have never been accessible in English. They could be an invaluable addition to our understanding of not autism per se but everyday affairs like knowledge, joy and hope.


Luka Georgiev Zumpalov is related to Dr Anita Z Goldschmied. The works were translated from Russian to English between 2016-2017. Luka, aka Bebo, is not a linguist, medically trained professional or licensed translator. He is a mathematician who studied engineering at the Azerbaijan State University of Oil and Industry. He has years of experience translating from Russian and working with academics, including his wife (Dr Maria Kenessey), a Turkologist5.The use of a non-medically trained translator and someone  related was purposeful and convenient. Such a decision provided a layperson and common-sense approach to the topic through an informal relationship held together by those very human qualities like love, trust and hope instead of financial or other career induced remunerations. Such arrangement, however, bring on sacrifices such as the specialist knowledge of early 20th Century Russian psychiatry and Russian medical language. Dr Anita Z Goldschmied is a dually trained nurse and social worker who provided the autism-specific aspects. Hungarian (Anita’s mother tongue) and Bulgarian (Bebo’s mother tongue) link the original Russian text and English. Dr Dean-David Holyoake (mother tongue caustic street-slang Brummie) added to the assemblage of translation and writing by being a specialist in both the topic and the English language. Luka Georgiev Zumpalov, Bebo, could not see the published version of the works as he passed away unexpectedly in 2019 October. This article pays tribute to his contribution and the nameless majority of our scientific communities who made us reflexively re-assemble our teaching and practices of literature and their reviews.


1 (translated into English by Uta Frith in 1981, Asperger in 1944 published his article (“Die ‘Autistischen Psychopathen’ im Kindersalter” - “Autistic Psychopathy in childhood”). Numerous articles and books were written about these two professionals (fathers of autism) in the past 30 years, some even investigating the near identical discovery (Silberman 2015; Robison 2016). Silberman claims: "Long before the internet or email, the transmission of scientific ideas could nevertheless flow from one lab to another through a doctor working in both". Silberman’s investigation is one of the few accounts that notices a few more actors that assemble the (hi)story of autism (scientists, articles, histories, laboratories, ranks, language, politics) than average literature reviews do.

2 Most scientific research (fixed and flexible designs) is carried out by the inductive method to explain what is seen in the data to accumulate evidence so science can arrive at a believable or adequate certainty confirmed finally by deduction. Abductive reasoning, on the other hand, establishes the likely case based on a premiss and a performance. Abduction requires no complete observations, can be creative, intuitive, and even revolutionary in finding the most likely case as they are not limited by apparent objective and universal structures, facts and gaps.

3 In 1996, Wolf translated G.E. Suhareva “Die Schizoiden Psychopathien im Kindersalter” article published in 1926 in German. Incidentally, Suhareva published the original paper in 1925 in Russian, which is still not accessible in English (as far as the authors can tell). The authors (AZG LGZ) translated Suhareva’s book chapter on autism [2nd edition in press 2022]. Manoluenko and Bejerot published a further article: “Sukhareva — Prior to Asperger and Kanner” (2015). They compare Suhareva original descriptions with the DSM-5 (American diagnostic manual of mental health conditions), showing the brilliance of her observations and a clear picture of autism.

4 Commonly used terminologies and their effect of translation: ‘eccentrics’, ‘schizoid’, ‘schizophrenic constitution’, ‘group schizoid’, pathologi- cally closed’, ‘autistic’. The ‘milder’ form of autism and the term Asperger Syndrome was absent in the English-speaking world until the late 20th Century.

5 Turkology is a complex of humanities sciences studying languages, history, literature, folklore, culture, and ethnology of people speaking Turkic languages and Turkic peoples in chronological and comparative context (Wikipedia 2021).

Supplementary materials
10 points of boat builders and gap hunters


10 points about literatures, reviews and knowledges 


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Wolff S (1996) The first account of the syndrome Asperger described? translation of a paper entitled Die schizoiden Psychopathien im Kindesalter by Dr. G. E. Ssucharewa; scientific assistant, which appeared in 1926 in the Monatsschrift für Psychiatrie und Neurologie 60:235–261. Eur Child Adolesc Psychiatry 5:119–132 .


Dr Anita Z Goldschmied, PhD
University of Wolverhampton

Dr Dean-David Holyoake, PhD
University of Wolverhampton