BioPsychoSocial Medicine Psychological factors that promote behavior modification by obese patients

Hitomi Saito email@example.com
Center for Studies on Emotions, Stress, and Health
Doshisha University
Karasuma-Higashi Imadegawa, Kamigyo-ku Kyoto-shi602-8580KyotoJapan

Health Science Center
Kansai Medical University
3-1 Shinmachi 2-chome, Hirakata-shi573-1191OsakaJapan

Yutaka Kimura email@example.com
Health Science Center
Kansai Medical University
3-1 Shinmachi 2-chome, Hirakata-shi573-1191OsakaJapan

Sawako Tashima firstname.lastname@example.com
Health Science Center
Kansai Medical University
3-1 Shinmachi 2-chome, Hirakata-shi573-1191OsakaJapan

Nana Takao firstname.lastname@example.com
Health Science Center
Kansai Medical University
3-1 Shinmachi 2-chome, Hirakata-shi573-1191OsakaJapan

Akinori Nakagawa
Graduate School of Letters
Doshisha University
Karasuma-Higashi Imadegawa, Kamigyo-ku Kyoto-shi602-8580KyotoJapan

Takanobu Baba email@example.com
Otemon Gakuin University
1-15 Nishiai 2-chome567-8502IbarakiOsakaJapan

Suguru Sato firstname.lastname@example.com
Faculty of Psychology
Doshisha University
Karasuma-Higashi Imadegawa, Kamigyo-ku Kyoto-shi602-8580KyotoJapan

BioPsychoSocial Medicine Psychological factors that promote behavior modification by obese patients
10.1186/1751-0759-3-9BioMed Central Page 1 of 7 (page number not for citation purposes) Research * Corresponding author
Background:The weight-loss effect of team medical care in which counseling is provided by clinical psychologists was investigated in an university hospital obesity (OB) clinic. Nutritional and exercise therapy were also studied. In our previous study, we conducted a randomized, controlled trial with obese patients and confirmed that subjects who received counseling lost significantly more weight than those in a non-counseling group. The purpose of this study was to identify the psychological characteristics assessed by ego states that promote behavior modification by obese patients.Methods: 147 obese patients (116 females, 31 males; mean age: 45.9 ± 15.4 years) participated in a 6month weight-loss program in our OB clinic. Their psychosocial characteristics were assessed using the Tokyo University Egogram (TEG) before and after intervention. The Wilcoxon signed rank test was used to compare weight and psychological factors before and after intervention. Multiple regression analysis was used to identify factors affecting weight loss.Results:Overall, 101 subjects (68.7%) completed the program, and their data was analyzed. The subjects mean weight loss was 6.2 ± 7.3 kg (Z = 7.72, p < 0.01), and their mean BMI decreased by 2.4 ± 2.7 kg/m 2 (Z = 7.65, p < 0.01). Significant differences were observed for the Adult (A) ego state (0.68 ± 3.56, Z = 1.95, p < 0.05) and the Free Child (FC) ego state (0.59 ± 2.74, Z = 2.46, p < 0.01). The pre-FC ego state had a significant effect on weight loss (β = 0.33, p < 0.01), and a tendency for changes in the A ego state scores to affect weight loss (β = -0.20, p = 0.06) was observed.Conclusion:This study of a 6-month weight-loss program that included counseling by clinical psychologists confirmed that the A ego state of obese patients, which is related to their self-monitoring skill, and the FC ego state of them, which is related to their autonomy, were increased. Furthermore, the negative aspects of the FC ego state related to optimistic and instinctive characteristics inhibited the behavior modification, while the A ego state represented objective self-monitoring skills that may have contributed to weight loss.

Background

Behavior modification is essential for the prevention and treatment of obesity, which is one of the critical risk factors for lifestyle-related diseases. However, it is extremely difficult to encourage people to modify their behavior in order to achieve a healthier lifestyle because lifestyles largely depend on individual beliefs and values. For this reason, a behavioral scientific approach would be helpful [1]. It is also important to note that lifestyle-related diseases are closely associated with psychosocial stress [2]. Thus, it is necessary to assess obese patients' psychosocial status and to provide them with psychological support.

Given this background, we started an obesity clinic (OB clinic) in 1999. In the OB clinic, medical doctors, clinical psychologists, registered dietitians, and exercise trainers support obese people, providing team medical care [3,4]. Clinical psychologists assess the patients' psychosocial situation and identify factors that could prevent weight loss. We also try to encourage patients to change their lifestyles by themselves, by maintaining a dialogic relationship aimed at enhancing their self-effectiveness and autonomy. As part of this "team medical care", staff members share patient information and provide comprehensive treatment.

In our previous study, we conducted a randomized, controlled trial with obese patients between 1999 and 2001. In that study, weight was significantly reduced by patients who received counseling from clinical psychologists, as well as nutritional and exercise therapy, compared to patients who received no counseling from clinical psychologists but who received nutritional and exercise therapy. Above all, this study confirmed that subjects who received counseling lost significantly more weight than those in the control group [4].

Based on our previous findings, the purpose of this study was to identify the psychological factors that promoted behavior modification among the obese patients in this program. The psychological factors were assessed using the Tokyo University Egogram (TEG), which is based on transactional analysis theory.

Transactional analysis is a psychological perspective that emphasizes the study of ego states. An ego state is defined as "a coherent system of thoughts and feelings manifested by corresponding patterns of behavior" [5]. Berne defined three principal ego states, each with a specific origin and characteristics: Child (archaeopsyche), Parent (exteropsyche), and Adult (neopsyche) [6]. Further elaboration of ego state theory led to the recognition of two functional Parent ego states (Critical and Nurturing) and two functional Child ego states (Free and Adapted) ( Figure 1).

The transactional analysis theory as described above is an effective therapeutic intervention technique that provides an understanding of human behaviors based on observation and measurements.

Methods and Procedures

Subjects A total of 147 (116 female, 31 male) patients participated in a 6-month weight-loss program in our OB clinic between 2002 and 2006. At the start of the weight-loss program, the subjects' mean age was 45.9 ± 15.4 years, their mean weight was 85.1 ± 20.7 kg, and their mean BMI was 33.8 ± 7.0 kg/m 2 .

In accordance with the Declaration of Helsinki and the ethical guidelines established by Kansai Medical University, all study objectives, as well as data protection and analysis methods, were explained to each subject prior to testing, and written informed consent was obtained. All study protocols were approved by the ethics review board of Kansai Medical University.

Outline of the OB program

In the OB program, patients first saw a physician for a medical consultation, and any patients with obesity attributable to endocrine abnormalities or psychiatric disorders were excluded. Subsequently, the patients under- Figure 1 Ego States. Berne defined three principal ego states, each with a specific origin and characteristics: Child (archaeopsyche), Parent (exteropsyche), and Adult (neopsyche). Further elaboration of ego state theory led to the recognition of two functional Parent ego states (Critical and Nurturing) and two functional Child ego states (Free and Adapted). CP stands for Critical Parent, with criticizing and regulating characteristics. NP stands for Nurturing Parent, with permitting and encouraging characteristics. A stands for Adult, focusing on gathering facts and considering alternatives and being objective. FC stands for Free Child, with self-orientation and optimistic characteristics. AC stands for Adapted Child, focusing on restraining one's emotions and with social characteristics.

Ego States

Adapted Child

Restr aining one's emotions Socializing went nutrition and exercise therapy as well as psychological counseling ( Figure 2).

As part of the nutrition therapy provided by registered dietitians, the Food Frequency Questionnaire (FFQ) was used to determine the subjects' daily food intake at the start of the program [7]. Subsequently, each subject received individual therapy monthly according to the transtheoretical model [8][9][10].

As part of the exercise therapy provided by exercise trainers, each subject underwent a cardiopulmonary exercise test as described in our previous report [11]. The anaerobic threshold (AT) was determined, an exercise prescription was made at AT intensity, and then the subjects had exercise therapy in the OB clinic two to three times a month. The exercise therapy lasted for 30 minutes and consisted of both aerobic exercise and stretching. In addition, the subjects were educated about home exercise and received instruction on how to exercise at home: Supervised exercise therapy or non-supervised exercise was performed at least three times a week.

All members of the staff exchanged information on each subject and examined their progress for effective support.

Intervention by clinical psychologists

First, the clinical psychologists conducted an intake interview for approximately 50 minutes. During the interview, the clinical psychologists listened and determined the patient's psychosocial status in order to better understand their environment and factors associated with obesity. Specifically, psychosocial status refers to the motivation for and expectation of weight loss, social support, and stress. Lifetime changes in weight were also confirmed. During this process, the clinical psychologists identified psychosocial factors that were related to gaining or losing weight.

As part of the subsequent counseling, transactional analysis therapy using the ego-state model and cognitive behavior therapy to improve self-monitoring skills was used. Specifically, the clinical psychologists integrated information about nutrition, exercise, and psychosocial situation, and they supported the subjects so that they could set objectives about diet, exercise, and lifestyle by themselves. The subjects were then instructed to monitor themselves by recording their weight, pedometer counts, and the degree of achievement based on their own objectives. During the psychological counseling, the clinical psychologists tried to focus on relationships among eating habits, physical activity level, psychosocial status, and changes in weight for each of the subjects, as well as focusing on how Obesity program Figure 2 Obesity program. The hospital has a 6-month weight-loss program known as the obesity program (OB program). In this program, physicians, clinical psychologists, registered dietitians, and exercise trainers support obese patients. During the 6month program, obese patients first consulted with a physician for blood and physical examinations. They then participated in intake interviews about their eating habits with a registered dietitian and about their current psychosocial condition with a clinical psychologist. At least once a month, the clinical psychologists met patients for individual face-to-face counseling. A meeting was held every month to discuss methods to support them and to improve their lifestyles. Internet much success the subject had in achieving their own objectives. It is important to enhance patients' self-effectiveness and self-control in order to reduce psychological stress and to maintain the weight loss. Therefore, the clinical psychologists respected the patients' autonomy and encouraged the patients to set their own objectives on the basis of the dialogic relationship. In addition, stress management techniques and a relaxation method were also adopted when necessary.

Psychological assessment

During the OB program, psychological characteristics were assessed using several psychological questionnaires. The psychological assessments included the revised NEO personality inventory (NEO-PI-R), which focuses on identifying healthy personality characteristics [12]; the TEG, which measures the ego states [13]; and the Profile of Mood State (POMS), which measures the present mood state [14]. The results from these assessments were then given to the subjects during psychological counseling and used as tools for the subjects to understand how their personalities and stress are related to their eating habits, exercise habits, and weight. Patients answered these questionnaires twice, once when they started the program and once when they completed the program.

In this study, the relationship between the psychological characteristics measured using TEG questionnaires and weight loss was examined. The TEG assessed the energy of each ego state, including Critical Parent (CP), Nurturing Parent (NP), Adult (A), Free Child (FC), and Adapted Child (AC), which are the concepts of the transactional analysis theory. Each ego state has 10 items, so there are 50 items in total.

Statistics

The data was analyzed using the SPSS12.0J software package. The Wilcoxon signed rank test was used for comparisons of weight and psychological factors before and after intervention. The Mann-Whitney test was used to com-pare the TEG scores at the start of the program between the subjects who discontinued and those who completed the program. Multiple regression analysis was used to identify factors affecting weight loss. The objective variable was the weight loss during the 6-month program. The explanatory variables were age, the number of sessions of nutrition therapy and counseling, TEG scores at the first session (pre-TEG), and the change in the TEG scores before and after intervention.

Results

Change in body weight

Overall, 101 subjects (68.7%) completed the 6-month program. A mean of 6.5 ± 2.3 sessions of nutrition therapy and a mean of 8.0 ± 4.5 counseling sessions were provided to each of the subjects during the program. Exercise therapy was provided at the OB clinic two to three times a month.

The mean weight and BMI at the start of the program of the subjects who completed the program were 83.9 ± 21.0 kg and 33.8 ± 6.9 kg/m 2 respectively. The subjects had a statistically significant mean weight loss of 6.2 ± 7.3 kg (Z = 7.72, p < 0.01), with weight loss ranging from -37.6 to 9.2 kg, and a statistically significant mean BMI decrease of 2.4 ± 2.7 kg/m 2 (Z = 7.65, p < 0.01), with a range from -12.5 to 3.7 kg/m 2 (Table 1).

Psychological factors for weight loss

The subjects' scores on psychological testing were: CP, 9.78 ± 4.01; NP, 14.60 ± 4.17; A, 10.09 ± 4.49; FC, 12.00 ± 4.47; and AC, 9.52 ± 4.62. The Mann-Whitney test was used to compare the TEG scores at the start of the program between the subjects who discontinued and those who completed the program; however, no significant differences were observed. We also compared the pre-TEG scores and the change in the TEG scores over six months between men and women by the Mann-Whitney test; however, no significant differences were observed in this comparison either. The Wilcoxon signed rank test was used for comparisons of weight and psychological factors before and after intervention. The TEG scores from the first session (pre-TEG) were compared to those taken on completion (post-TEG) of the program in order to identify changes in these patients' psychological characteristics before and after intervention.

Next, the TEG scores from the first session (pre-TEG) were compared to those taken on completion (post-TEG) of the program in order to identify the changes in these patients' psychological characteristics before and after the intervention. Significant differences were observed for the A ego state (0.68 ± 3.56, Z = 1.95, p < 0.05) and the FC ego state (0.59 ± 2.74, Z = 2.46, p < 0.01) ( Table 1). The A ego state is associated with gathering facts and considering alternative characteristics objectively, and the FC ego state is associated with self-orientation and optimistic characteristics. Thus, these characteristics of these subjects appear to have been increased by team medical care intervention.

Furthermore, the multiple regression analysis was performed with weight change as the objective variable and age, the number of sessions of nutrition therapy and counseling, pre-TEG scores, and the change in the TEG scores over six months as explanatory variables. The pre-FC ego state had a positive effect on weight loss (β = 0.33, p < 0.01). Thus, the FC ego state, which is related to selforientation and optimistic characteristics, inhibits weight loss. The A ego state tended to affect weight loss (β = -0.20, p = 0.06). Thus, people who improved their A ego state, which is related to gathering facts and considering alternative characteristics, were able to lose more weight ( Table  2).

Discussion

Change in body weight

Over the 6-month period, the mean weight loss was 6.2 ± 7.3 kg, and the mean decrease in BMI was 2.4 ± 2.7 kg/m 2 . We previously reported that weight loss can be more easily achieved in a group in which the subjects received counseling in addition to nutrition therapy and exercise therapy [4]. The results of the present study confirmed that this intervention program for obesity resulted in effective weight loss.

The weight loss should be attributed not simply to the intervention of the clinical psychologists but to the total effect of the intervention of a holistic medical care team in which physicians, registered dietitians, exercise trainers, and clinical psychologists were involved as a team. While supporting the results that a comprehensive cognitive behavior modification method using social learning (group approach), self-monitoring, and exercise was most effective [15,16], the present study confirmed the importance of team medical care.

Psychological factors for weight loss

During the 6-month program, the FC ego state increased significantly; however, the changes in the scores of the FC ego state had no effect on weight loss and the pre-FC ego state was confirmed to prevent weight loss. We examined these results from the perspectives of ego states, each of which have positive and negative aspects. The positive aspects of the FC ego state involve controlling negative emotion and are related to the ability to look on the bright side and do things in one's own style [17], while the negative aspects are not caring about disease and giving in to temptation because of optimism, as well as instinctive and impulsive behaviors. In addition, other studies have reported that some negative emotion has a positive effect on the control of weight and blood sugar levels [4,18]. This study supports these previous findings regarding the relationship between optimism and carelessness in terms of disease prevention behavior modification. Considering the circumstances mentioned above, the negative aspects of the FC ego state prevented subjects from controlling their behavior, while the positive aspects of the FC ego state were increased by team medical care intervention, because the changes in the FC ego state during this program did not prevent weight loss.

The reports by Eysenk, Grossarth-Maticek, and Everitt, and also by Grossarth-Maticek and Eysenk [19,20] also point out that an "object-dependent" personality is a risk factor for disease, and they describe the importance of autonomy training. The enhancement of the patients' FC ego state as related to self-orientation as observed in this study is assumed to indicate that the patients could not only temporarily solve their problems and eliminate cer- The multiple regression analysis was used to identify factors affecting weight loss. The objective variable was the weight loss during the 6month program. The explanatory variables were age, number of sessions of nutrition therapy and counseling, TEG scores at the first session (pre-TEG), and the changes in TEG score from the first session to the completion of the program.

tain anxieties, but that they could also change their objectdependent behavior pattern into a more autonomous pattern. Berne [21] said that autonomy resulted from the attainment of three capacities: 1) awareness, 2) spontaneity, and 3) the capacity for intimacy. Joines [22] also stated that the goal of the therapists in transactional analysis is to work themselves out of a job, as the clients are helped to experience their own autonomy and learn to take charge of their own life. That is to say, the result in this study for patients who increased their autonomy shows that the possibility of regaining weight after the program was reduced, whereas the possibility of maintaining the healthy lifestyle obtained through the OB program was increased.

Furthermore, the A ego state increased during the 6month program and appears to have contributed to weight loss. The A ego state represents self-monitoring skill to get information and determine how well we can do things on the basis of facts. In previous studies, Devin and Reifschneider [15] and Padgett, Mumford, Hynes, and Carter [16] reported that self-monitoring is an important skill for lifestyle modification. In our previous studies, it was also suggested that the A ego state, which involves choosing behaviors suitable for the reality of "here and now," functioning appropriately according to the situation, is associated with improving self-esteem [23,24]. Hence, a person can be more confident in their ability to achieve a healthy lifestyle by taking an approach that allows the A ego state to function appropriately, so that improvement, as well as prevention, of lifestylerelated diseases can be promoted.

Limitations and future research

In the future, it will be necessary to investigate the factors associated with weight loss in a randomized, controlled trial. In our previous randomized, controlled trial, significant weight loss was observed in a counseling intervention group in which counseling was provided in addition to nutrition and exercise therapy. Therefore, the improvement of autonomy and self-monitoring skills by counseling may have contributed, albeit indirectly, to effectively achieving weight loss.

Moreover, there are other problems, such as the cost and time required to participate in a weight loss program based on a team medical care approach, that need to be resolved in order to reduce the burden on the patient. Given the fact that not all obese patients require counseling, it will also be necessary to establish a system for differentiating between patients who require psychological counseling and those who do not.

Lastly, the present study investigated weight loss and psychological factors for only 6 months; therefore, it will also be useful to examine weight loss and the issue of regaining weight after program completion in a study that includes psychological differences between men and women.

Conclusion

As a result of the total effect of team medical care involving counseling by clinical psychologists, the A ego state and the FC ego state of obese patients were increased during the 6-month program. Weight loss was observed for patients who had less of an FC ego state at the start of the program and an increased an A ego state during the 6month program.

Table 1 :
1Pre and post weight, BMI, and TEG category scores (Wilcoxon signed rank test).Pre
Post
Mean
SD
Mean
SD
Z
p value

Table 2 :
2Factors affecting weight loss (Multiple regression
analysis).

Explanatory variables
β coefficient
p value

Pre weight
-0.58
< 0.01
Age
-0.97
0.37
Number of nutrition therapy sessions
0.01
0.93
Number of counseling sessions
0.08
0.37
Pre-Critical Parent score
-0.06
0.67
Pre-Nurturing Parent score
-0.15
0.25
Pre-Adult score
-0.05
0.75
Pre-Free Child score
0.33
0.01
Pre-Adapted Child score
-0.06
0.57
Change in Critical Parent score
0.18
0.09
Change in Nurturing Parent score
-0.15
0.15
Change in Adult score
-0.20
0.06
Change in Free Child score
0.14
0.18
Change in Adapted Child score
0.14
0.17

R(R 2 )
0.66 (0.43)

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AcknowledgementsThe authors would like to express their appreciation to the participants in this study and all members of the staff in the Obesity Clinic of Kansai Medical University Hospital. This study was supported by the Center for Studies on Emotions, Stress, and Health at Doshisha University.Competing interestsThe authors declare that they have no competing interests.Authors' contributionsHS conceptualized and designed the study, collected and analyzed the data, performed the statistical analysis, interpreted the results, and drafted the manuscript. YK participated in the design and coordination of the present study and provided clinical data regarding weight. ST contributed to the present study as a nutritionist and NT participated in the present study as an exercise trainer. TB and SS supervised the present study. All authors read and approved the final manuscript. http://www.bpsmedicine.com/content/3/1/9
Z Cooper, C G Fairburn, D M Hawker, Cognitive-behavioral treatment of obesity: A clinician's guide. New YorkGuilford PressCooper Z, Fairburn CG, Hawker DM: Cognitive-behavioral treatment of obesity: A clinician's guide New York: Guilford Press; 2003.

Preventive medicine of stress crisis -view from lifestyle Tokyo. K Morimoto, Japan Broadcast PublishingMorimoto K: Preventive medicine of stress crisis -view from lifestyle Tokyo: Japan Broadcast Publishing; 1997.

Effective psychological support for Obesity. T Baba, Y Kimura, S Sato, Japanese Society of Clinical Sports Medicine. 12Baba T, Kimura Y, Sato S: Effective psychological support for Obesity. Japanese Society of Clinical Sports Medicine 2004, 12:207-214.

Effectiveness of team medical care intervention for obese patients -relationship between personality and weight-loss. H Saito, T Baba, Y Kimura, S Tashima, S Sato, A Kosaki, K Ueta, Y Nakashima, T Iwasaka, Journal of Japan Society for the Study of Obesity. 13Saito H, Baba T, Kimura Y, Tashima S, Sato S, Kosaki A, Ueta K, Nakashima Y, Iwasaka T: Effectiveness of team medical care intervention for obese patients -relationship between per- sonality and weight-loss. Journal of Japan Society for the Study of Obesity 2007, 13:68-73.

What do you say after you say hello. E Berne, Grove PressNew YorkBerne E: What do you say after you say hello? New York: Grove Press; 1972.

E Berne, Transactional analysis in psychotherapy. New YorkGrove PressBerne E: Transactional analysis in psychotherapy New York: Grove Press; 1961.

Developing and evaluation of Food Frequency Questionnaire for estimation of nutrients and food groups. The Japanese. K Takahashi, Y Yoshimura, T Kaigen, D Kunii, R Komatsu, S Yamamoto, Journal of Nutrition and Dietetics. 59Takahashi K, Yoshimura Y, Kaigen T, Kunii D, Komatsu R, Yamamoto S: Developing and evaluation of Food Frequency Question- naire for estimation of nutrients and food groups. The Japa- nese Journal of Nutrition and Dietetics 2001, 59:221-232.

In search of howpeople change. Applications to addictive behaviors. J O Prochaska, C C Diclemente, J C Norcross, Am Psychol. 47Prochaska JO, DiClemente CC, Norcross JC: In search of howpeo- ple change. Applications to addictive behaviors. Am Psychol 1992, 47:1102-1114.

Introduction to Clinical Health Psychology Philadelphia. P Bennet, Open University PressBennet P: Introduction to Clinical Health Psychology Philadelphia: Open University Press; 2000.

Theories and intervention approaches to health-behavior change in primary care. J P Elder, G X Ayala, S Harris, Am J Prev Med. 17Elder JP, Ayala GX, Harris S: Theories and intervention approaches to health-behavior change in primary care. Am J Prev Med 1999, 17:275-284.

Vasodepressor effects of exercise are accompanied by reduced circulation ouabainlike immunoreactivity and normalization of nitric oxide synthesis. Y Komiyama, Y Kimura, N Nishimura, K Hara, T Mori, K Okuda, M Munakata, M Masuda, T Murakami, H Takahashi, Clinical and Experimental Hypertension. 19Komiyama Y, Kimura Y, Nishimura N, Hara K, Mori T, Okuda K, Munakata M, Masuda M, Murakami T, Takahashi H: Vasodepressor effects of exercise are accompanied by reduced circulation ouabainlike immunoreactivity and normalization of nitric oxide synthesis. Clinical and Experimental Hypertension 1997, 19:363-372.

. J Shimonaka, K Nakazato, Y Gondo, M Takayama, Neo-Ffi Manual Neo-Pi-R, Tokyo, Tokyo Psychological. Shimonaka J, Nakazato K, Gondo Y, Takayama M: NEO-PI-R, NEO-FFI manual Tokyo: Tokyo Psychological; 1999.

Medicine TEG Association: New edition TEG: manual and Egogram pattern Tokyo: Kaneko. Tokyo University PsychosomaticTokyo University Psychosomatic Medicine TEG Association: New edi- tion TEG: manual and Egogram pattern Tokyo: Kaneko; 2002.

A manual of POMS Japanese version Tokyo: Kaneko. K Yokoyama, S Araki, Yokoyama K, Araki S: A manual of POMS Japanese version Tokyo: Kaneko; 2002.

Meta-analysis of the effects of psychoeducational care in adults with hypertension. E C Devine, E Reifschneider, Nurs Res. 44Devine EC, Reifschneider E: Meta-analysis of the effects of psy- choeducational care in adults with hypertension. Nurs Res 1995, 44:237-245.

Meta-analysis of the effects of educational and psychosocial interventions on management of diabetes mellitus. D Padgett, E Mumford, M Hynes, R Carter, J Clin Epidemiol. 41Padgett D, Mumford E, Hynes M, Carter R: Meta-analysis of the effects of educational and psychosocial interventions on management of diabetes mellitus. J Clin Epidemiol 1988, 41:1007-1030.

Changing lives through redecision therapy Brunner New York: Manzal. M M Goulding, R L Goulding, Goulding MM, Goulding RL: Changing lives through redecision therapy Brunner New York: Manzal; 1979.

Diabetic Control of Patients with Diabetes in Relationship to Various Psychological Tests. R Shinzato, H Tamai, O Fukino, H Ishizu, T Nakagawa, Japanese Journal of Psychosomatic Medicine. 25Shinzato R, Tamai H, Fukino O, Ishizu H, Nakagawa T: Diabetic Control of Patients with Diabetes in Relationship to Various Psychological Tests. Japanese Journal of Psychosomatic Medicine 1985, 25:307-314.

Personality, stress, smoking, and genetic predisposition as synergistic risk factors for cancer and coronary heart disease. H J Eysenk, R Grossarth-Maticek, B Everitt, Integr Physiol Behav Sci. 26Eysenk HJ, Grossarth-Maticek R, Everitt B: Personality, stress, smoking, and genetic predisposition as synergistic risk fac- tors for cancer and coronary heart disease. Integr Physiol Behav Sci 1991, 26:309-322.

Creative novation behaviour therapy as a prophylactic treatment for cancer and coronary heart disease: Part I-Description of treatment. R Grossarth-Maticek, H J Eysenk, Behav Res Ther. 29Grossarth-Maticek R, Eysenk HJ: Creative novation behaviour therapy as a prophylactic treatment for cancer and coronary heart disease: Part I-Description of treatment. Behav Res Ther 1991, 29:1-16.

E Berne, Games People Play: The Psychology of Human Relationships. New YorkGrove PressBerne E: Games People Play: The Psychology of Human Relationships New York: Grove Press; 1964.

The Role and Function of Psychotherapy in the Future. V Joines, Transactional Analysis Journal. 31Joines V: The Role and Function of Psychotherapy in the Future. Transactional Analysis Journal 2006, 31:80-85.

A Study of the Relationship between Ego-Shift Pattern and Basic Position Based on Transactional Analysis Theory. H Saito, S Sato, Japanese Journal of Psychosomatic Medicine. 47Saito H, Sato S: A Study of the Relationship between Ego-Shift Pattern and Basic Position Based on Transactional Analysis Theory. Japanese Journal of Psychosomatic Medicine 2007, 47:931-937.

A Study of the Relationship between Ego-Shift Pattern and Basic Position Based on Transactional Analysis Theory-Cognitive and Behavioral System. H Saito, S Sato, Japanese Journal of Transactional Analysis. 32Saito H, Sato S: A Study of the Relationship between Ego-Shift Pattern and Basic Position Based on Transactional Analysis Theory-Cognitive and Behavioral System-. Japanese Journal of Transactional Analysis 2007, 32:134-141.


First evidence of sensory atypicality in mothers of children with Autism Spectrum Disorder (ASD)

Mirko Uljarević
Margot R Prior
Susan R Leekam
First evidence of sensory atypicality in mothers of children with Autism Spectrum Disorder (ASD)
S H O R T R E P O R T Open Access
Background: Atypical reactions to sensory stimuli show heritability in the general population and are a known risk factor for affective disorders. As sensory problems are highly prevalent in individuals with ASD and their siblings, and the occurrence of affective disorders is elevated in parents of children with ASD, investigating sensory symptoms in parents is important both from clinical and theoretical standpoints. Fifty mothers of children and adolescents with ASD completed the Adolescent and Adult Sensory Profile (AASP). The AASP is a norm-referenced questionnaire that provides scores for four types of responses to sensory stimuli (sensory quadrants): hypo-sensitivity, hyper-sensitivity, sensation seeking, and sensory avoiding. Findings: Mothers' scores were compared with AASP norms. Ninety eight percent of mothers had sensory scores at least one standard deviation (SD) above the normative mean and 44% were two or more SDs above the mean for at least one sensory quadrant. Conclusions: This study provides the first evidence for sensory atypicality in parents of children with ASD. Further research is needed to elucidate the contribution of genetic and environmental influences on the expression of sensory problems in ASD.

Introduction

Sensory systems provide pathways for the brain to receive, organize, and make sense of information about the world. These processes are foundational for learning and are necessary for enabling adaptive responses to the environment [1]. Atypical reactions to sensory stimuli are found in individuals with neurodevelopmental and psychiatric conditions including anxiety, Attention Deficit Hyperactivity Disorder (ADHD), Fragile X syndrome and schizophrenia [2]. Sensory atypicalities are particularly common in individuals with Autism Spectrum Disorders (ASD), with the majority of studies reporting prevalence of above 90% for both children and adults [3]. Sensory atypicalities have become increasingly recognised within the diagnostic criteria for ASD with 'hyperreactivity or hyporeactivity to sensory input, or unusual interests in sensory aspects of environment' now explicitly included as a symptom subdomain in the latest version of the Diagnostic and Statistical Manual of Mental Disorders (DSM) criteria for ASD (5 th edition; DSM-5; [4]).

There is evidence for a genetic influence on sensory atypicalities [5,6]. Goldsmith et al. [7] estimated twin similarity on a perceptual sensitivity scale from the Children's Behavior Questionnaire finding that monozygotic and dizygotic twin correlations were .58 and .37, respectively. Given that ASD itself is a highly heritable disorder [8] with subclinical autistic traits found in parents [9], it is surprising that the presence of these problems has not been studied in parents of children with ASD.

Increased understanding of sensory atypicality in parents of children with ASD may contribute to knowledge about their clinical profile. Affective disorders are more frequent in parents of children with ASD than in parents of children with other developmental conditions [10]. Although the reasons for such a high prevalence of affective disorders are poorly understood, there is evidence that sensory atypicalities present a risk for affective disorders in the general population [11]. Therefore, the aim of this study was to assess the presence of sensory atypicalities in parents of children and adolescents with ASD.

Methods

Participants

Fifty mothers of children and adolescents with ASD (mean age of children = 10 years 7 months (10.7), standard deviation (SD) = 3.10; mean age of mothers = 44.4, SD = 6.3) living in South Wales, UK, were recruited to the study. All children had a community multidisciplinary team assessment leading to a best estimate clinical diagnosis of an ASD according to DSM-IV-TR [12] and International Classification of Diseases, version 10 (ICD-10) [13] criteria. In addition, data from the Social Communication Scale [SCQ; [14] were available for all children in the appropriate developmental range (N = 45) and all scored above 15 with the exception of two who scored 14. Data reported here were part of a larger study in which a set of questionnaires was sent to each family for completion by either parent. In all cases it was mothers who responded. None of the mothers had a diagnosis of ASD. Socioeconomic status (SES) data were not available but data on educational level showed that 32% of mothers had postgraduate qualifications, 30% had undergraduate or vocational qualifications and 25% did not have post-school qualifications (12.3% declined to give education information).

Procedures and measures

The study was approved by the Cardiff University School of Psychology Research Ethics Committee. Parents were recruited through local schools and parent support groups. Most mothers completed and returned the questionnaire by post. A small proportion (16%) chose to complete the questionnaire as part of the visit to the university.

The Adolescent/Adult Sensory Profile (AASP) [15]. is a 60-item self-report questionnaire containing statements about different responses to various sensory stimuli. Individuals rate the frequency of behaviour described in each statement on a five-point Likert Scale (score of five indicates higher endorsement of the item (that is, more atypicality). This is the opposite of the rating system on the Sensory Profile where a lower score indicates more atypicality). Sensory features are measured using Dunn's model [16] that classifies individuals on two dimensions: their neurological threshold (high/low) and behavioural response (active/passive). Based on the interaction between these dimensions, patterns of sensory processing are classified into four quadrants. A high threshold combined with a passive response is described as low registration (example item: 'I don't seem to notice when someone touches my arm or back'); a high threshold with an active response is described as sensation seeking ('I like to go to places that have bright lights and that are colourful'); a low threshold combined with passive response is described as sensory sensitivity ('I become bothered when I see lots of movement around me'); and a low threshold with an active response is described as sensation avoiding ('I stay away from noisy settings') quadrant. These quadrants reflect an individual's pattern of responding across modalities. AASP is a norm referenced questionnaire with cut off scores from a large normative sample. Each quadrant consists of 15 items. Based on those scores, an individual's performance on each of the quadrants can be classified in the five following categories: (1) Much Less Than Other People, (2) Less Than Other People, (3) Similar to Other People (Typical Performance), (4) More than Most People, or (5) Much More than Most People. It is possible for a single individual to have atypical scores in more than one sensory quadrant.

Findings

Descriptive statistics and internal consistency of AASP quadrants are presented in Table 1 together with mean raw scores for the AASP normative sample. Initial data screening revealed no outliers and no missing data.

In the original normative sample [15], 68% showed typical performance, with 28% having scores between one and two SDs outside of normative range and between 2% and 4% with scores of two or more SDs outside of the normative range. In contrast, 98% of mothers of children with ASD scored at least one SD above or below the normative mean for at least one sensory quadrant (32% for one, 18% for two and 48% for either three or four sensory quadrants). Moreover, 44% scored two or more SDs outside the normal range for at least one sensory quadrant (20% for one, 8% for two and 16% for three sensory quadrants). Table 2 provides the classification distributions of mothers for each of the four quadrants. In comparison with typically developing (TD) norms, 62% scored higher on sensory hypo-sensitivity (also known as the low registration) quadrant, 44% higher for the sensory sensitivity quadrant, 48% higher for the sensory avoidance quadrant and 60% of mothers had lower sensory seeking scores than the TD norms.

Discussion

This is the first study to provide evidence of sensory atypicality in parents of individuals with ASD. An exceptionally high number of mothers in this study (49 of 50 (98%) had AASP scores that were atypical; almost half of the sample (22 mothers) scored at least two SDs outside the normative range (only between 2% and 4% of the normative sample had scores in this range).

To date, only one study has looked at the presence of sensory atypicalities in non-twin siblings of ASD individuals who themselves do not have ASD [17]. The AASP was used to examine sensory processing in 80 ASD adolescents, their 56 non-affected adolescent siblings, and 33 adolescent controls. Results showed that compared with typical controls, non-affected autism siblings exhibited significantly fewer sensory seeking behaviours. The authors suggested, therefore, that sensory atypicalities might be a candidate endophenotype, since they meet some of the criteria proposed by Bearden and Freimer [18], namely, that the trait should co-occur with the condition of interest, should cosegregate with the disorder in families, and non-affected family members should express the trait more than the general population.

Since evidence of a positive correlation between the presence of sensory atypicalities and autistic traits in the general population has already been reported [19], it might be argued that our findings can be simply explained by ASD traits-sensory atypicalities association. However, none of the mothers in the study had an ASD diagnosis and we believe that a more complex explanation is likely. Sensory atypicalities are by no means specific to the ASD population and levels of atypicality beyond the general population have been reported in individuals with anxiety and depression, schizophrenia, ADHD and other neuropsychiatric and neurodevelopmental conditions [2]. This raises the question of specificity of the ASD traits-sensory atypicalities relationship. To understand further the role of sensory atypicalities, a large-scale systematic study examining the relationship between sensory atypicality, other ASD traits and co-morbid conditions in family members is needed. Sensory atypicalities are associated with affective disorders in both general [11] and clinical populations including ADHD and ASD [20,21]. Therefore, their contribution to anxiety in parents of children with ASD deserves further attention. The contribution may be direct as inability to tolerate sensory stimuli may impact directly on parental stress and anxiety. It may also be indirect as sensory problems can affect the type of coping strategies that individuals adopt in particular situations [22]. There is evidence that parents of children with ASD, when compared to parents of typically developing children and parents of children with other neurodevelopmental disorders, use more avoidant coping strategies and that a higher use of escape-avoidance is associated with higher levels of anxiety [23]. Future research should examine how sensory atypicalities in parents of children with ASD contribute to their level of anxiety and use of coping strategies, preferably using a longitudinal design.

This study had a number of limitations. Results are limited by the sample size and by the use of a self-report questionnaire. We were also able to only recruit mothers of children with ASD. Difficulties related to engaging fathers in research of this kind are not specific to this study and are also found in research on parents of ASD children, typically developing children and children with other neurodevelopmental and psychiatric conditions [24]. Inclusion of fathers in future research is important as research with typically developing children [25] and ASD adults [26] indicates that sensory problems are more prevalent in females and it would be important to explore whether the same trend is present in parents of children with ASD. Future work should include replication of these results with a larger sample and the use of carefully designed experimental protocols to disentangle the neurophysiological mechanisms underlying sensory atypicalities. Furthermore, comparing sensory atypicalities in parents of children with ASD with parents of children with other neurodevelopmental conditions is important. Finally, this study did not include a control group. As this was the pilot study and the first time that sensory atypicalities were assessed in parents of children with ASD, norms from the AASP were considered a good comparison as these are based on a large, representative sample of individuals without any co-morbid conditions in the

Conclusions

This study is the first to demonstrate that sensory atypicalities are prevalent in mothers of children and adolescents with ASD.

AASP: Adolescent and Adult Sensory Profile; ADHD: Attention Deficit Hyperactivity Disorder; ASD: Autism Spectrum Disorder; DSM: Diagnostic and Statistical Manual of Mental Disorders; ICD: International Classification of Diseases; SCQ: Social Communication Questionnaire; SD: standard deviation; SES: socioeconomic status; TD: typically developing.

Table 1
1Descriptive statistics Table 2Performance of parents across four sensory quadrants Typical performance (less than 1 SD above or below the mean) appropriate age range. However, in future it will be important to compare sensory problems in parents of children with ASD with parents of children with other neurodevelopmental conditions.Variables
Mothers of children with ASD
Normative sample

Mean (SD)
Range
Cronbach's alpha
Mean (SD)
Cronbach's alpha

Low registration
38.84 (10.24)
19 to 58
.796
30.29 (6.25)
.82

Sensory seeking
40.32 (8.65)
24 to 67
.701
49.91 (6.83)
.79

Sensory sensitivity
41.60 (11.70)
15 to 65
.795
33.71 (7.63)
.81

Sensory avoidance
41.35 (12.08)
19 to 63
.866
34.57 (7.34)
.66

http://www.molecularautism.com/content/5/1/26
AcknowledgmentsThis research was supported by PhD funding to MU and SL from the Wales Office of Research and Development for Health and Social Care, National Institute for Social Care and Health Research and the School of Psychology, Cardiff University. We deeply appreciate the support and time given by the parents who were involved in the research. We thank Dr Sarah Carrington for helpful comments. We also thank Lynda Morgan and Bev Winn for their help with recruitment.Competing interestsThe authors declare that they have no competing interests.Authors' contributions MU participated in the conception, design, data collection and analysis, draft, revision and final approval of the manuscript. SL contributed to the design, draft, revision and final approval of the manuscript, and financial support for dissemination. MP participated in the revision and final approval of the manuscript. All authors read and approved the final manuscript.
E Kandel, J Schwartz, T Jessell, S Siegelbaum, A J Hudspeth, Principles of Neural Science. New YorkMcGraw-Hill5th editionKandel E, Schwartz J, Jessell T, Siegelbaum S, Hudspeth AJ: Principles of Neural Science. 5th edition. New York: McGraw-Hill; 2012.

Diagnostic validity of sensory over-responsivity: a review of the literature and case reports. S Reynolds, S J Lane, J Autism Dev Disord. 38Reynolds S, Lane SJ: Diagnostic validity of sensory over-responsivity: a review of the literature and case reports. J Autism Dev Disord 2007, 38:516-529.

Describing the sensory abnormalities of children and adults with autism. S R Leekam, C Nieto, S J Libby, L Wing, J Gould, J Autism Dev Disord. 37Leekam SR, Nieto C, Libby SJ, Wing L, Gould J: Describing the sensory abnormalities of children and adults with autism. J Autism Dev Disord 2007, 37:894-910.

American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders. American Psychiatric PublishingArlington, VA5th editionAmerican Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders. 5th edition. Arlington, VA: American Psychiatric Publishing; 2013.

Somatosensory and sensorimotor consequences associated with the heterozygous disruption of the autism candidate gene, Gabrb3. T M Delorey, P Sahbaie, E Hashemi, W W Li, A Salehi, D J Clark, Behav Brain Res. 216DeLorey TM, Sahbaie P, Hashemi E, Li WW, Salehi A, Clark DJ: Somatosensory and sensorimotor consequences associated with the heterozygous disruption of the autism candidate gene, Gabrb3. Behav Brain Res 2011, 216:36-45.

Variation in the autism candidate gene GABRB3 modulates tactile sensitivity in typically developing children. T Tavassoli, B Auyeung, L C Murphy, S Baron-Cohen, B Chakrabarti, Mol Autism. 36Tavassoli T, Auyeung B, Murphy LC, Baron-Cohen S, Chakrabarti B: Variation in the autism candidate gene GABRB3 modulates tactile sensitivity in typically developing children. Mol Autism 2012, 3:6.

Toddler and childhood temperament: expanded content, stronger genetic evidence, new evidence for the importance of environment. H H Goldsmith, K A Buss, K S Lemery, Dev Psychol. 33Goldsmith HH, Buss KA, Lemery KS: Toddler and childhood temperament: expanded content, stronger genetic evidence, new evidence for the importance of environment. Dev Psychol 1997, 33:891-905.

Genetics of autistic disorders: review and clinical implications. C M Freitag, W Staal, S M Klauck, E Duketis, R Waltes, Eur J Child Adolesc Psychiatry. 19Freitag CM, Staal W, Klauck SM, Duketis E, Waltes R: Genetics of autistic disorders: review and clinical implications. Eur J Child Adolesc Psychiatry 2010, 19:169-178.

The broader autism phenotype and its implications on the etiology and treatment of autism spectrum disorders. J Gerdts, R Bernier, Autism Res Treat. Gerdts J, Bernier R: The broader autism phenotype and its implications on the etiology and treatment of autism spectrum disorders. Autism Res Treat 2011, 2011:1-19.

AV: Parent and family impact of autism spectrum disorders: a review and proposed model for intervention evaluation. J S Karst, Van Hecke, Clin Child Fam Psychol Rev. 15Karst JS, Van Hecke AV: Parent and family impact of autism spectrum disorders: a review and proposed model for intervention evaluation. Clin Child Fam Psychol Rev 2012, 15:247-277.

Sensory processing sensitivity: a review in the light of the evolution of biological responsivity. E N Aron, Aron A Jagiellowicz, J , Pers Soc Psychol Rev. 16Aron EN, Aron A, Jagiellowicz J: Sensory processing sensitivity: a review in the light of the evolution of biological responsivity. Pers Soc Psychol Rev 2012, 16:262-282.

American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders. American Psychiatric AssociationWashington DC4th editionAmerican Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders. 4th edition. Washington DC: American Psychiatric Association; 1994.

World Health Organisation: Manual of the International Statistical Classification of Diseases, and Related Health Problems. 1Geneva, SwitzerlandWorld Health OrganisationWorld Health Organisation: Manual of the International Statistical Classification of Diseases, and Related Health Problems, 10th revision (Vol. 1, pp. 375-377). Geneva, Switzerland: World Health Organisation; 1992.

Western Psychological Services: Los Angeles. M Rutter, A Bailey, C Lord, Social Communication Questionnaire (SCQ)Rutter M, Bailey A, Lord C: Social Communication Questionnaire (SCQ). Western Psychological Services: Los Angeles; 2003.

C Brown, W Dunn, Adolescent/Adult Sensory Profile. Pearson; San Antonio, TXBrown C, Dunn W: Adolescent/Adult Sensory Profile. Pearson: San Antonio, TX; 2002.

The sensations of everyday life: empirical, theoretical, and pragmatic considerations. W Dunn, Am J Occup Ther. 556Dunn W: The sensations of everyday life: empirical, theoretical, and pragmatic considerations. Am J Occup Ther 2001, 55(6):608-620.

Atypical sensory processing in adolescents with an autism spectrum disorder and their non-affected siblings. W De La Marche, J Steyaert, I Noens, Res Autism Spectrum Disord. 6De La Marche W, Steyaert J, Noens I: Atypical sensory processing in adolescents with an autism spectrum disorder and their non-affected siblings. Res Autism Spectrum Disord 2012, 6:639-645.

Endophenotypes for psychiatric disorders: ready for primetime?. C E Bearden, N B Freimer, Trends Genet. 22Bearden CE, Freimer NB: Endophenotypes for psychiatric disorders: ready for primetime? Trends Genet 2006, 22:306-313.

The relationship between sensory sensitivity and autistic traits in the general population. A E Robertson, D R Simmons, J Autism Dev Disord. 43Robertson AE, Simmons DR: The relationship between sensory sensitivity and autistic traits in the general population. J Autism Dev Disord 2013, 43:775-784.

Sensory over-responsivity and anxiety in children with ADHD. S Reynolds, S J Lane, Am J Occup Ther. 63Reynolds S, Lane SJ: Sensory over-responsivity and anxiety in children with ADHD. Am J Occup Ther 2009, 63:433-440.

Sensory overresponsivity and anxiety in typically developing children and children with autism and attention deficit hyperactivity disorder: cause or coexistence?. S J Lane, S Reynolds, L Dumenci, Am J Occup Ther. 66Lane SJ, Reynolds S, Dumenci L: Sensory overresponsivity and anxiety in typically developing children and children with autism and attention deficit hyperactivity disorder: cause or coexistence? Am J Occup Ther 2012, 66:595-603.

A phenomenological study of sensory defensiveness in adults. M Kinnealey, B Oliver, P Wilbarger, Am J Occup Ther. 49Kinnealey M, Oliver B, Wilbarger P: A phenomenological study of sensory defensiveness in adults. Am J Occup Ther 1995, 49:444-451.

Parenting stress and coping styles in mothers and fathers of pre-school children with autism and Down syndrome. A Dabrowska, E Pisula, J Intellect Disabil Res. 54Dabrowska A, Pisula E: Parenting stress and coping styles in mothers and fathers of pre-school children with autism and Down syndrome. J Intellect Disabil Res 2010, 54:266-280.

Father involvement and child well-being. K R Wilson, M R Prior, J Paediatr Child Health. 47Wilson KR, Prior MR: Father involvement and child well-being. J Paediatr Child Health 2011, 47:405-407.

A population-based twin study of parentally reported tactile and auditory defensiveness in young children. H H Goldsmith, C A Van Hulle, C L Arneson, J E Schreiber, M A Gernsbacher, J Abnorm Child Psychol. 34Goldsmith HH, Van Hulle CA, Arneson CL, Schreiber JE, Gernsbacher MA: A population-based twin study of parentally reported tactile and auditory defensiveness in young children. J Abnorm Child Psychol 2006, 34:393-407.

T Tavassoli, L J Miller, S A Schoen, D M Nielsen, S Baron-Cohen, 10.1186/2040-2392-5-26Sensory over-responsivity in adults with autism spectrum conditions. Autism. in press. Tavassoli T, Miller LJ, Schoen SA, Nielsen DM, Baron-Cohen S: Sensory over-responsivity in adults with autism spectrum conditions. Autism. in press. doi:10.1186/2040-2392-5-26

First evidence of sensory atypicality in mothers of children with Autism Spectrum Disorder (ASD). Uljarević, Molecular Autism. 526Cite this article asCite this article as: Uljarević et al.: First evidence of sensory atypicality in mothers of children with Autism Spectrum Disorder (ASD). Molecular Autism 2014 5:26.