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The Resilient Mind: Children’s Theory of Mind as a Protective Factor Against Social Emotional Problems during the Pandemic

DOI: 10.31038/PSYJ.2026813

Abstract

By March 2020, many governments closed schools and implemented “social distancing” to reduce COVID-19 spread. The current research examined a) the impact of reduced social interactions on children’s social-emotional health and b) whether children’s ‘theory of mind’ (i.e., their ability to understand others’ mental states) served as a protective factor against the potentially deleterious effects of reduced social interactions. Parents of 3–12-year-olds (n=130) reported on their child’s social-emotional health (Strengths & Difficulties Questionnaire; Social Skills Improvement System) and time spent in in-person interactions before and during the pandemic. They also completed a measure of their child’s theory of mind, and reported their own stress and loneliness. A subset of parents completed the child measures pre-pandemic (n=48), allowing for longitudinal analyses. Stepwise regressions showed that decreases in children’s in-person peer interactions significantly predicted increased social-emotional difficulties, even after accounting for other factors. Children’s theory of mind emerged as a significant predictor of fewer social-emotional difficulties, more prosocial behavior, and stronger social skills. Longitudinal data revealed that greater reductions in peer interaction predicted more negative changes in social-emotional functioning. However, children with more advanced theory of mind experienced fewer negative changes, suggesting their theory of mind buffered against the harmful effects of reduced interaction. These findings underscore the importance of peer interaction for children’s well-being and highlight theory of mind as a potential protective factor. Interventions aimed at strengthening children’s theory of mind may help minimize the deleterious effects of reduced social interaction.

The Resilient Mind: Children’s Theory of Mind as a Protective Factor Against Social Emotional Problems during the Pandemic

Humans have a primary need for social interaction and social connection [1-3]. Even moderate levels of social isolation can have detrimental effects on one’s physical and social-emotional health. For instance, moderate levels of social isolation have been linked to elevated blood pressure and stress hormones [4], immune system dysregulation [5,6], cardiovascular disease [7] as well as clinical depression and suicide ideation (see [8,9] for reviews). Experimental studies with humans and other animals suggest that social isolation is a major risk factor for mortality and morbidity, with the health risks associated with isolation at least as great as cigarette smoking [10,11]. Prospective studies controlling for baseline health status reveal an increased risk of death among people with fewer and poorer social relationships (e.g., [10]). Indeed, a meta-analysis of 148 studies [12] revealed a 50% increased likelihood of survival for participants with stronger social relationships. The magnitude of this effect did not differ based on age, gender, cause of death, or previous health status. Interestingly, the magnitude of the relationship between social relationships and mortality was greatest in studies that assessed the quality of the social connections, not only the quantity. Notably, even perceived social isolation (i.e., loneliness) has a similar effect on physical and mental health as actual social isolation (see [13] for a review).

Of particular interest to the current research are the lasting effects that reduced social interactions have on young children. Caspi et al. [7] followed over 1000 children at multiple timepoints from age 3 to age 26 assessing various indices of their physical health (e.g., weight, blood pressure, cholesterol) and level of social interaction revealing that those who were more socially isolated as children were at significant risk of poor adult health independent of other childhood risk factors for poor adult health (e.g., low SES, low IQ, obesity). Notably, this relationship between childhood social isolation and poor health 20 years later was not accounted for by exposure to stressful life events, smoking, alcohol abuse, or lack of exercise. This research also revealed that social isolation across multiple developmental time points had a cumulative negative effect on their health (see also [14]). Not surprisingly, the negative effects of social isolation in childhood are not limited to physical health. For instance, Marryat and colleagues [15] examined the social-emotional functioning of 10,000 preschoolers using the Strengths and Difficulties Questionnaire [16] which assesses Peer Relationship Problems, Emotional Symptoms, Hyperactivity/ inattention, Conduct Problems and Prosocial Behaviours. Their analyses revealed that various indices of social isolation predicted poorer overall social emotional functioning among preschoolers.

As it is well established that social interaction is especially critical for young children, several researchers expressed concern for children’s well-being due to the reductions in social interaction that many youth experienced during COVID-19 (eg., [17,18]). The current work examined how reductions in the number of in-person social interactions that they experienced during the pandemic affected children’s social-emotional well-being. Importantly, children’s social understanding, particularly their ability to reason about the mental states of others (sometimes called ‘theory of mind’ or ToM), is another key predictor of children’s social-emotional functioning and well-being (e.g., for recent reviews see [19,20]). Therefore, we also examined whether those children with more advanced theory of mind would experience fewer social emotional problems. Individual differences in theory of mind are present early and continue into adulthood [21,22] with more developed theory of mind predicting several positive outcomes for children’s development and well-being. For example, a meta-analysis of 20 studies on children ages 2-10 using measures of theory of mind and measures of peer popularity revealed that children with increased theory of mind tended to be more well-liked [23]. As another example, a meta-analysis of 76 studies examining theory of mind and prosocial behaviour (e.g., helping, comforting, and sharing) in children 2 to 12 years of age found that children with higher theory of mind scores were more likely to act prosocially [20,24,25]. Similarly, more advanced theory of mind has been associated with increased cooperation [26], reduced peer conflict [27] and improved communication skills [27-30]. Peterson and colleagues [31] also found that typically developing children’s theory of mind understanding independently predicted social skills above and beyond age, gender and verbal ability.

Conversely, deficits in theory of mind have been proposed as a characteristic feature of Autism Spectrum Disorder and are believed to play a central role in social-communication challenges [32,33]. Building on this early work, subsequent studies report that autistic children and adults demonstrate greater theory of mind difficulties relative to neurotypical peers (e.g., see [34-36] for a recent meta-analysis). Similar differences have also been observed among children with attention-deficit/hyperactivity disorder, who demonstrate weaker performance on certain theory of mind measures [37,38]. Individuals with conduct problems have likewise been shown to exhibit reduced theory of mind performance (e.g., [39-41]). Theory of mind understanding also predicts emotional symptoms (e.g., increased sadness) in adults and in adolescents and youth. For example, a meta-analysis of 18 studies with adults revealed that difficulties with theory of mind can be a risk factor for depression with the level of theory of mind impairment relating to the severity of the depressive symptoms and corresponding psychosocial impairments [42]. Similarly, Caputi and Schoenborn [43] examined theory of mind and internalizing symptoms during middle childhood and early adolescence and found that children with higher scores on theory of mind tasks demonstrated lower depressive symptoms and lower symptoms related to panic disorder and separation anxiety.

Of particular relevance to the current research is a small body of evidence that theory of mind may serve as a protective factor against some types of stress or adversity. For example, Hughes and Ensor [44] found that the adverse effects of harsh parenting on behavioural problems (e.g., hyperactivity, emotion regulation problems) were attenuated for two year olds with higher ToM scores. Moreover, after testing these same children two years later and controlling for their earlier behavioral problems, they found that theory of mind skills at age 2 predicted whether their behavioral problems persisted or diminished. Again, in a separate study, the negative effects that harsh parenting had on the child’s behavior were reduced in those with greater theory of mind [45]. Similarly, Cadamuro et al. [46] tested the role of theory of mind as a protective factor against the negative effects of parents’ stress on their child’s stress during the aftermath of a natural disaster. Their results revealed that mothers’ posttraumatic stress symptoms predicted their children’s posttraumatic stress symptoms–but only among children with low theory of mind abilities. In other words, strong theory of mind skills appears to help minimize at least some factors that adversely affect children’s social emotional well­being.

The Current Research

In sum, the primary research questions addressed in this manuscript were: 1) What impact did reductions in in-person social interactions during the pandemic have on children’s social-emotional well-being? And 2) Did children with more advanced theory of mind fare better than their peers with less advanced theory of mind? We hypothesized that reductions in in-person peer interactions that occurred during the COVID-19 pandemic would predict increases in social emotional difficulties (e.g., hyperactivity, conduct problems, emotional symptoms). We also predicted that children with more advanced theory of mind would experience fewer negative changes in their social-emotional functioning during the pandemic compared to their peers with less advanced theory of mind.

To address our research questions we asked parents of 3-12-year-old children to complete an online survey assessing their children’s social emotional functioning, theory of mind, and changes in their amount of social interactions during the pandemic (beginning in June 2020). Specifically, the survey included a measure of children’s social-emotional difficulties (Strengths & Difficulties Questionnaire [16], a measure of social skills (Social Skills Improvement System;SSIS [47]), and a measure of their ‘theory of mind’ (Children’s Social Understanding Scale; CSUS [48]). Parents also estimated the number of hours per day children engaged in interactions with peers and adults (in-person) before the pandemic versus currently. We also anticipated that parents’ stress and loneliness would increase during the pandemic, and wanted to control for that in our regression models. To that end we included two measures assessing the parent’s social-emotional health: a Perceived Stress Scale [49] and the UCLA Loneliness Scale [50]. Forty-seven of our participating families had visited our laboratory prior to the pandemic and completed the same child-specific measures. Therefore, in some of our analyses we can control for the children’s pre-pandemic level of social emotional functioning and specifically examine changes in their behavior.

Method

Participants

Full Sample

Of the 138 parents recruited, 8 were excluded for failing to complete at least 80% of the measures, resulting in a final sample of 130 participants with children ages 3-12 years old (MAge=87 months, SDAge,=30 months; 55% female children). Due to missing data on one or more variables included in the regression models, listwise deletion resulted in an analytic sample of 110 participants for those analyses. Parents participated online from anywhere in North America but were predominantly Canadian. The majority of the parent respondents were female (92%). The majority of the sample identified as European (38%) or Asian (36%). Approximately 80% of the sample reported completing at least some college education and a combined family income of $100,000/year or greater. All participants gave informed consent and were told they could skip any questions they did not wish to answer. Parents were compensated for their participation by choosing either a $5 gift card or a 1 in 25 chance of winning a $50.00 gift card.

Longitudinal Subsample

A subset of these parents had also completed the child-specific measures in our lab prior to the pandemic, allowing us to examine changes in their child’s behavior and specifically examine whether advanced theory of mind minimized any negative changes in social emotional health. The final longitudinal subsample consisted of data from parents for 48 children ages 2-12 years old (MAge=86 months, SDAge,=25 months; 60% female). Seventeen of these parents did not complete the SSIS measure but were included in the remaining analyses.

Measures

Parents completed the following measures in the following order (see Table 1):

Table 1: Description of Measures and Example Items.

Measure

Description

Example Items

Strengths and Difficulties Questionnaire (SDQ) •                Parent-report measure assessing children’s psychological and behavioural characteristics related to social emotional health

•                25-items on a 3-point scale: answer choices ranging from 0 (Not True) to 2 (Certainly True)

•        Often lies or cheats

•        Considerate of other people’s

feelings

The Children’s Social Understanding Scale (CSUS) •                Parent-report measure assessing individual differences in children’s theory of mind.

•                Shortened 18-item version on a 4-point scale: answer choices range from 1 (Definitely Untrue) to 4

(Definitely True)

•        Talks about differences in what people like or want
The Social Skills Improvement System Rating Scale (SSIS) •                Parent-report measure that assesses children’s social skills and problem behaviours

•                Shortened 46-item version on a 4-point scale: answer choices range from 0 (Never) to 3 (Almost Always)

•        Expresses feelings when wronged
Social Interaction Measure (SIM) •                Parents estimated the number of hours per day their child spent in in-person social interactions with peers versus parents.

•                Estimates were provided for during (i.e., between June and December 2020) and prior to the pandemic

•                Number of hours per day
Perceived Stress Scale (PSS) •                Self-report measure assessing the extent to which situations in one’s life are perceived as stressful in the last month

•                10-item on a 5-point scale: answer choices range from 0 (Not at all) to 4 (Very often)

•        In the last month, how often have you felt nervous and “stressed”?
The UCLA Loneliness Scale (UCLA Loneliness) •                Self-report measure assessing an individual’s subjective feelings of loneliness and feelings of social isolation

•                20-items on a 4-point scale: answer choices range from 1 (Rarely) to 4 (Often)

•        How often do you feel that you are no longer close to anyone?

Children’s Social Emotional Difficulties

Children’s social emotional difficulties were assessed using the Strengths and Difficulties Questionnaire (SDQ [16]), which is a widely used measured to examine individual differences in children’s social emotional competence (e.g., [15]). It consists of a 25-item scale focused on five different components of social-emotional health: emotional symptoms (e.g., often unhappy, depressed, or tearful), conduct problems (e.g., generally well behaved, usually does what adults request (reverse coded)), hyperactivity/impulsivity (e.g., constantly fidgeting or squirming), peer relationship problems (e.g., rather solitary, prefers to play alone), and prosocial behavior (e.g., considerate of other people’s feelings). Each subscale has 5 items and parents rated their child’s behavior over the previous 6 months on each item with answers ‘Not True’, ‘Somewhat True’, and ‘Certainly True’. The prosocial behaviors comprise the Strengths subscale. Higher scores on the prosocial subscale reflect greater levels of prosocial behavior. Cronbach’s α in the current sample was .758 for the 5-item Prosocial scale reflecting good internal reliability. The other four 5-item subscales—emotional symptoms, conduct problems, hyperactivity/impulsivity, and peer relationship problems—comprise the Difficulties scale. Higher scores on the difficulties scale reflect greater levels of difficulties. Cronbach’s α in the current sample was .843 for the 20-item Difficulties scale reflecting very good internal reliability.

Children’s Social Understanding Scale (Theory of Mind, or ToM)

The Children’s Social Understanding Scale (CSUS Short Form; [48]); is a parent-report measure of children’s understanding of mental states such as beliefs, desires, emotions, intentions, and knowledge, which is more generally referred to as theory of mind. The CSUS Short Form is a parent-report measure consisting of 18-items rated on a 4-point scale including ‘Definitely Untrue’ (1), ‘Somewhat Untrue’ (2), ‘Somewhat True’ (3), and ‘Definitely True’ (4). This measure has previously been shown to reliably predict individual differences in 3- to 12-year-olds social emotional competence [19]. Sample items include, “My child talks about differences in what people like or want (e.g., “you like coffee but I like juice”)”, “My child has trouble figuring out whether you are being serious or just joking” (reverse coded), and “My child talks about the difference between the way things look and how they really are (e.g., “It looks like a snake but it’s really a lizard”)”. Higher scores reflect greater levels of theory of mind or mental state understanding. In our sample, the internal consistency was very good (Cronbach’s α=.865) for this 18-item measure.

Children’s Social Skills

The Social Skills Improvement System Rating Scale (SSIS-RS; [47]) is a parent report measure comprising a social skills scale (46 items) and a problem behavior scale (30 items). For brevity in measurement, we only included the 46-item social skills scale (as a complement to the more limited 5-item “Strengths” scale in the SDQ). We did not include the problem behavior scale as we believed children’s problem behaviors were being adequately captured in the 4 “Difficulties” subscales of the SDQ. Answer choices range from 0 (Never) to 3 (Almost Always) and comprise 7 facets of social skills namely, Communication (e.g., Takes turns in conversations) , Cooperation, (e.g., follows your directions), Assertion (e.g. expresses feelings when wronged), Responsibility (e.g., is well behaved when unsupervised), Engagement (e.g., invites others to join in activities), and Self Control (e.g., stays calm when disagreeing with others). Higher scores reflect greater social skills. Cronbach’s α in the current sample was .950, reflecting excellent internal reliability.

Social Interaction Measure (SIM)

Parents were asked to estimate the number of hours per day their child was spending in in-person social interactions with their peers versus with adults for two time points: 1) Prior to the pandemic and 2) Currently (i.e., data were collected during the pandemic between June and December 2020).

Parental Stress

Stress was measured using The Perceived Stress Scale (PSS-10; [49]). It is composed of 10 items and examines the degree to which an individual perceives various life situations to be stressful in the last month. Answer choices on the scale range from 0 (Not at all) to 4 (Very Often) and example items include questions such as “In the last month, how often have you been upset because of something that happened unexpectedly?” and “In the last month, how often have you felt that you were on top of things?”. Higher scores reflect greater levels of perceived stress. Cronbach’s α in the current sample was .907 for this 10-item measure, reflecting excellent internal reliability.

Parental Loneliness

Parent’s subjective feelings of loneliness was assessed using The UCLA Loneliness Scale-Version 3 [50]; a 20-item self-report measure with answer choices ranging from 1 (Rarely) to 4 (Often). Example items include questions such as “How often do you feel that you lack companionship?” and “How often do you feel left out?”. Higher scores reflect greater feelings of loneliness. Cronbach’s α in the current sample was .936 for this 20-item measure, reflecting excellent internal reliability.

Procedure

Participants were recruited via social media ads and a University database of families interested in research. Data were collected between June and December 2020. The online survey took between 30-40 minutes to complete. Informed consent was obtained electronically prior to completion of the remaining survey which included demographic questions (e.g., age, gender, ethnicity, number of siblings, family income, education) followed by the aforementioned measures in the following order: SDQ, CSUS, SSIS, Social Interaction measure, PSS, UCLA Loneliness (See Table 1). Measures of the parents’ and children’s social substitution behaviors were also included in the survey as part of another research project. At the end of the survey all participants were provided with our contact information and a variety of wellness resources.

Analytic Plan

All data were entered into SPSS 26 software. Preliminary analyses included computing descriptive statistics for each variable (See Table 2) and paired samples t-tests to confirm whether there were significant reductions in the number of hours per day children were spending in in-person interactions during the pandemic. Two change scores for children’s social interactions (i.e., one with other children and one with adults) were computed by subtracting the number of hours per day children were spending in those interactions during the pandemic from the number of hours per day children were reportedly spending before the pandemic.

Table 2: Descriptive Statistics.

Variable

Mean Std. Deviation Min. Max.

N

SDQ_Difficulties

9.46

5.99 0 40 110

SDQ_ProsocialSubscale

7.87 2.55 0 10

110

SSIS_Scores

99.25

16.82 0 138 110

Child’s Age in Years

7.49 2.55 3

12

 
Total Perceived Stress

17.58

7.54 0 40 110

Total UCLA Loneliness

43.25 11.92 20 80

110

Change in in-person peer interactions

3.075

3.40     110

Change in in-person adult interactions

-.55 3.80    

110

Three Stepwise regression analyses were performed to identify which variables most strongly predicted 1) children’s social skills (Total SSIS scores), 2) children’s social emotional strengths (SDQ-Prosocial) and 3) difficulties (SDQ-Difficulties Total). Stepwise regression was selected because it enabled us to determine which of the variables was the most significant predictor of children’s social emotional health and identify how much additional variability in children’s social emotional health each variable contributed [51]. Predictor variables included the child’s age, the child’s gender, the child’s theory of mind, the parents’ loneliness and stress, and changes in the number of hours per day children were engaged in in-person interactions. The child’s theory of mind and changes in the child’s social interactions were the primary variables of interest. The child’s age and gender and the parent’s social emotional health indices (i.e, loneliness and stress) were included because these factors have been widely recognized to contribute to a child’s social emotional health (e.g., [52-54]).

Finally, we conducted analyses on our longitudinal sample. The parents of 48 children from our full sample had also completed the measures of children’s social emotional health (i.e. the SDQ, the SSIS) prior to the pandemic allowing us to control for pre-pandemic levels of their children’s difficulties. In this way we could expand upon the analyses above by specifically identifying which variables predicted the changes in the child’s social emotional health during the pandemic, albeit in a smaller sample. Preliminary analyses included computing change scores for each measure by taking the difference between their score before the pandemic and their score during the pandemic and conducting one-sample t-tests to identify whether there were significant changes in the children’s social emotional health from Time 1 to Time 2.

Results and Discussion

Assessing Changes in Social Interactions

As expected, paired samples t-test revealed a significant decrease in the number of hours children were spending in-person with other children per day during the pandemic (M=3.9, SD=4.2) compared to before the pandemic (M=6.7, SD=3.2), t(115)=9.522, p<.001. In contrast, there was a small, but non-significant, increase in the number of hours children were spending with adults during the pandemic (M=8.6, SD=5.2) compared to before the pandemic (M=7.9, SD=4.4), t(117)=-1.689, p=.094.

Predicting Children’s Social-Emotional Difficulties

The Stepwise Regression results revealed that 5 factors accounted for 35% of the variability in children’s social emotional difficulties (see Tables 3 and 4 for complete regression statistics). As illustrated in Table 3, parent loneliness was the most significant predictor, accounting for 18% of the variability in children’s social emotional difficulties. Notably, children’s theory of mind was the next most significant predictor. As hypothesized, children with higher theory of mind scores experienced fewer social emotional difficulties. With children’s theory of mind added to the model an additional 7.7% of the variance in children’s social emotional difficulties was explained. Gender accounted for an additional 5% of the variability in children’s social emotional difficulties, with male gender predicting greater social emotional difficulties than female gender. Parents’ stress accounted for an additional 4.6% of the variability, with greater parental stress predicting more social emotional difficulties in their child. Finally, the changes in the amount of time children were spending in person with other children during the pandemic compared to before the pandemic accounted for an additional 2.4% of the variability in their social emotional difficulties. That is, even after accounting for the four largest contributors to children’s social emotional difficulties, children who experienced greater reductions in their in-person peer interactions during the pandemic still had significantly greater social emotional difficulties than those who experienced fewer decreases or no changes in their peer interactions.

Table 3a: Stepwise regression analysis concerning predictors of social difficulties.

Model

R R2 Adjusted R2 Std. error of the estimate
1 .429a .184 .177

5.44

2

.512b .262 .248 5.20
3 .559c .312 .293

5.04

4

.599d .358 .334 4.89
5 .619e .383 .353

4.82

aPredictors: (Constant), Total UCLA Loneliness
bPredictors: (Constant), Total UCLA Loneliness, CSUS_Score
cPredictors: (Constant), Total UCLA Loneliness, CSUS_Score, Child’s Gender:
dPredictors: (Constant), Total UCLA Loneliness, CSUS_Score, Child’s Gender, Total Perceived Stress
ePredictors: (Constant), Total UCLA Loneliness, CSUS_Score, Child’s Gender, Total Perceived Stress, ChangeChild_InPersonChildren

The stepwise regression analyses excluded the child’s age and the change in the child’s in-person interactions with adults meaning these variables did not account for a significant amount of the variability in children’s social-emotional difficulties above and beyond the other variables. The lack of an effect from changes in adult interactions does not necessarily reflect an increased importance of peer interactions over adult interactions on children’s social emotional health, but instead, likely reflects the fact that the number of hours children spent with other children significantly decreased over the pandemic whereas their time with adults did not decrease (in fact it marginally increased).

Table 3b: Stepwise regression analysis concerning predictors of social difficulties: B and beta correlation and significance level of variables.

Model

Predictors B Std. error Standardized Coefficientsa t

p

1 (Constant)

.127

1.96   .065

.949

  Total UCLA Loneliness

.216

.044 .429 4.94

.000

2 (Constant)

18.51

5.80   3.19

.002

  Total UCLA Loneliness

.159

.045 .316 3.52

.001

  CSUS_Score

-.461

1.38 -.301 -3.35

.001

3 (Constant)

13.49

5.90   2.29

.024

  Total UCLA Loneliness

.156

.044 .309 3.55

.001

  CSUS_Score

-.422

1.34 -.276 -3.15

.002

  Child’s Gender

2.62

.937 .227 2.80

.006

4 (Constant)

12.92

5.73   2.25

.026

  Total UCLA Loneliness

.094

.048 .188 1.96

.052

  CSUS_Score

-4.24

1.30 -.277 -3.26

.002

  Child’s Gender

2.51

.910 .217 2.75

.007

  Total Perceived Stress

.196

.072 .247 2.74

.007

5 (Constant)

12.46

5.66   2.20

.03

  Total UCLA Loneliness

.086

.047 .171 1.82

.072

  CSUS_Score

-4.41

1.29 -.287 -3.43

.001

  Child’s Gender

2.68

.902 .232 2.98

.004

  Total Perceived Stress

.211

.071 .265 2.98

.004

  ChangeChild_InPersonChildren

.278

.138 .158 2.02

.046

aDependent Variable: SDQDifficulties

Predicting Children’s Prosocial Behavior

The Stepwise Regression predicting children’s current level of prosocial behavior (as measured by the SDQ), revealed that 3 factors accounted for 35% of the variability in children’s prosocial behavior. See Tables 4a and 4b for full regression statistics. Children’s theory of mind was the most significant predictor of children’s prosocial behavior accounting for 23% of the variability. The child’s gender accounted for an additional 8% of the variability in children’s prosocial behavior, and the parent’s loneliness accounted for an additional 3.8%. The stepwise regression analyses excluded the child’s age and the change in the child’s in-person interactions, with both children and adults, as well as the parent’s level of stress. That is, none of these variables accounted for a significant amount of the variability in children’s prosocial behavior above and beyond the other variables.

Table 4a: Stepwise regression analysis concerning predictors of prosocial behaviours.

Model

R R2 Adjusted R2 Std. error of the estimate
1 .478a .228 .221

1.58

2

.557b .310 .297 1.50
3 .590c .348 .329

1.46

aPredictors: (Constant), CSUS_Score
bPredictors: (Constant), CSUS_Score, Child’s Gender: – Selected Choice
cPredictors: (Constant), CSUS_Score, Child’s Gender: – Selected Choice, Total UCLA Loneliness

Table 4b: Stepwise regression analysis results concerning predictors of social skills: B and beta correlation and significance level of variables

Model

Predictors B Std. error Standardized Coefficientsa t

p

1 (Constant)

.328

1.34   .245

.807

  CSUS_Score

2.18

.386 .478 5.65

.000

2 (Constant)

2.33

1.39   1.67

.098

  CSUS_Score

2.02

.370 .443 5.48

.000

  Child’s Gender: – Selected Choice

-.99

.279 -.288 -3.56

.001

3 (Constant)

4.91

1.72   2.87

.005

  CSUS_Score

1.67

.389 .364 4.28

.000

  Child’s Gender

-.975

.271 -.283 -3.58

.001

  Total UCLA Loneliness

-.032

.013 -.210 -2.48

.015

aDependent Variable: SDQ_ProsocialSubscale

Predicting Children’s Social Skills

In the Stepwise Regression predicting children’s current level of social skills (as measured by the SSIS) 3 factors accounted for 49% of the variability in children’s social skills. Children’s theory of mind was the most significant predictor of children’s social skills, accounting for 38% of the variability. Parent’s stress accounted for an additional 9% of the variability in children’s social skills, while the child’s gender accounted for an additional 2.3%. The model excluded the child’s age, changes in the child’s in-person interactions, and parent’s level of loneliness, indicating that these variables did not account for a significant amount of the variability in children’s social skills above and beyond individual differences in theory of mind and the child’s gender. See Tables 5a and 5b for full regression statistics.

Table 5a: Stepwise regression analysis results concerning predictors of social skills.

Model

R R2 Adjusted R2 Std. error of the estimate
1 .615a .378 .372

13.34

2

.684b .468 .458 12.38
3 .700c .491 .476

12.17

aPredictors: (Constant), CSUS_Score
bPredictors: (Constant), CSUS_Score, Total Perceived Stress
cPredictors: (Constant), CSUS_Score, Total Perceived Stress, Child’s Gender

Table 5b: Stepwise regression analysis results concerning predictors of social skills: B and beta correlation and significance level of variables.

Model

Predictors B Std. error Standardized Coefficientsa t

p

1 (Constant)

7.94

11.35   .700

.486

  CSUS_Score

26.44

3.27 .615 8.10

.000

2 (Constant)

28.42

11.59   2.45

.016

  CSUS_Score

23.98

3.09 .557 7.77

.000

  Total Perceived Stress

-.682

.160 -.306 -4.26

.000

3 (Constant)

37.79

12.19   3.10

.002

  CSUS_Score

23.26

3.05 .541 7.62

.000

  Total Perceived Stress

-.664

.158 -.298 -4.21

.000

  Child’s Gender

-.4.91

2.27 -.152 -2.17

.032

aDependent Variable: SSIS_Scores

Longitudinal Analyses: Changes in Children’s Social-Emotional Health

One-sample t-tests revealed that there were significant changes in children’s social emotional difficulties, t(46)=-2.78, p=.008 from Time 1 to Time 2, but not in their prosocial behavior, t(46)=1.000, p=.323, ns, nor in their Social Skills, t(30)=.015, p=.989 ns. Therefore, regression analyses predicting changes in this subsample were only conducted for children’s social emotional difficulties.

Predicting Changes in Children’s Social-Emotional Difficulties During the Pandemic

The Stepwise Regression predicting changes in children’s social emotional difficulties revealed that the reductions in children’s in-person peer interactions was the most significant predictor, accounting for 18% of the variability in children’s social emotional difficulties. Children’s theory of mind was the next most significant predictor, accounting for an additional 15.3% of the variance in the changes in children’s social emotional difficulties. Neither age nor gender accounted for a significant amount of variance in the changes children experienced in their social emotional difficulties during the pandemic (ps > .20, ns). That is, as hypothesized, reductions in peer interactions during the pandemic predicted greater social emotional difficulties. Importantly, children with more advanced theory of mind were less likely to experience these negative changes in their social emotional health than those with less advanced theory of mind. That is, advanced theory of mind, or social understanding, appears to serve as a protective factor against the deleterious social emotional health effects encountered during the pandemic. See Tables 6a and 6b for full regression statistics.

Table 6a: Stepwise regression analysis results concerning predictors of change in total social difficulties.

Model

R R2 Adjusted R2 Std. error of the estimate
1 .421a .177 .156

4.28

2

.575c .330 .294

3.91

aPredictors: (Constant), Change in in-person peer interactions
bPredictors: (Constant), Change in in-person peer interactions, CSUS_Score

Table 6b: Stepwise regression analysis results concerning predictors of change in total social difficulties: B and beta correlation and significance level of variables.

Model

Predictors B Std. error Standardized Coefficientsa t

p

1 (Constant)

.215

.916   .235

.816

  Change in in-person peer interactions

-.518

.181 -.421 -2.86

.007

2 (Constant)

-15.93

5.62   -2.84

.007

  Change in in-person peer interactions

-.589

.167 -.478 -3.52

.001

  CSUS_Score

4.72

1.62 .395 2.91

.006

aDependent Variable: Change in total social difficulties

General Discussion

Childhood represents a foundational period during which social interactions play a central role in shaping children’s social-emotional health and development. Accordingly, it is vital to understand how even relatively short-term disruptions in these social interactions impact social-emotional health. This study examined the impact that COVID-19 related reductions in social interactions had on the social-emotional competence and health of children. We also examined whether children’s level of ‘theory of mind’ (i.e., how well they understand and reason about others’ mental states) provided protective benefits for their social emotional health.

As expected, we found that reductions in children’s in-person peer interactions during the pandemic predicted increased social-emotional difficulties, such as increased conduct problems, greater inattention and hyperactivity, and increased emotional symptoms. The negative impact of reduced social interactions was evident even after accounting for four other key predictors of their social emotional health, including parental loneliness, theory of mind, gender, and parental stress. That is, children who experienced greater reductions in their in-person peer interactions during the pandemic had significantly greater social emotional difficulties than those who experienced fewer decreases, or no changes, in their in person peer interactions. Our findings add to an important body of literature showing that social isolation or infrequent social interactions can have deleterious effects on children’s social-emotional skills and well-being (e.g., [7,14,15]) as well as corresponding effects on physical well-being [55-57]. Our results are consistent with a meta-analysis of children aged 5-13 that revealed that the COVID-19 lockdown measures were negatively associated with general mental health outcomes [58]. Notably, our findings highlight that deleterious effects from reduced social interactions can emerge within a few months—they do not require especially prolonged or extreme periods of social isolation.

Our second prediction was also supported: Children who were better at understanding others’ thoughts and feelings not only exhibited more prosocial behavior, greater social skills, and fewer social-emotional difficulties (consistent with the aforementioned body of literature), they also experienced fewer increases in social emotional problems during the pandemic. Notably, these results highlight the benefits of theory of mind as a protective factor for children’s well­being in times of adversity. These findings hold important implications for clinicians and researchers working with children who experience reductions in in-person social interactions, especially with their peers. This research suggests that interventions to improve children’s social understanding can offer a buffer against the negative effects of reduced in-person social interactions. This is especially important as experts predict humans will face future health crises similar to COVID-19 [59,60]. As such, anything that can be done to better prepare children and bolster their social-emotional well-being and resilience during times of hardship deserves special attention.

The benefits of improved theory of mind in children likely extends beyond the child’s social emotional well-being. The relationship between a parent’s social-emotional health and that of their child is seemingly bidirectional. That is, in much the same way that a parent’s health can affect their child, a child’s health can affect their parents (e.g., [61]). For example, research examining parents’ stress during the COVID-19 pandemic found that their child’s current level of social-emotional difficulties (e.g., hyperactivity, impulsivity, conduct problems) was a predictor of their parents’ perceived stress, even after controlling for their child’s pre-pandemic levels of difficulties [62]. Therefore, interventions aimed at fostering a child’s social-emotional health will have mutual benefits for the parent and child, with greater social understanding and well-being in children predicting similar benefits in their parents as well as reduced conflict within the parent-child relationship [63].

It is important to clarify the strengths and limitations of this research alongside their implications. First, it is important to acknowledge that the current study relied on correlational data. Therefore, while reductions in in-person peer interactions predicted increases in social-emotional difficulties, it does not mean that the reductions in social interactions caused these difficulties. That is, other factors associated with those reductions in social interactions, such as being absent from school, or not being able to participate in extracurricular activities, could at least partially account for the relationship. It is important to note as well that we asked parents to report on the number of hours children were spending in peer interactions. It would be an interesting objective for future research to also examine the number of social interaction partners and the quality of those interactions.

Identifying the causal nature of the relationship between theory of mind and social emotional health is also not possible with these data. Although children with more advanced theory of mind experienced less decline in their social emotional health over time, it is possible that at least part of the relationship between children’s theory of mind and better social emotional health outcomes in the current study can be accounted for by some ‘third’ variability associated with greater theory of mind or social emotional health, such as higher quality parenting. Importantly, a wealth of previous research suggests theory of mind can play a causal role in children’s social-emotional health. For instance, research shows that interventions designed to improve children’s theory of mind simultaneously enhance children’s social skills and social emotional development (e.g., [29], see [19] for a review, see also [64]).

The current results may also be influenced by the use of parent-report data and on parents’ memory of the changes in the number of hours per day their child spent interacting with others before the pandemic. On the one hand, parent-report data can be skewed, either positively or negatively, for a variety of reasons including the parents’ mood and their opportunity to observe certain behavior. For example, parents tend to underestimate their child’s internal and emotional states. If their child’s symptoms are more internalized (e.g., anxiety or sadness) than externalized (eg., conduct problems), they may not be as obvious to an outside observer [65-67]. Similarly, parent-reports may fail to capture a child’s behaviour outside of the home (e.g., at school, in the community; [68]).

On the other hand, parent-reports can allow for more comprehensive assessments with greater ecological validity of some constructs (e.g., ‘theory of mind’) than lab-based measures (e.g., [48]). One of the key strengths of this study was its use of multifaceted assessments. For instance, rather than examining only a single aspect of children’s social emotional health (e.g., anxiety) we examined a total of 12 different aspects of their social emotional health (both strengths and difficulties) using multiple previously-validated measures. We also selected a multifaceted measure of theory of mind (i.e., the CSUS) rather than relying on a single facet or dimension of theory of mind. According to a recent review [69], most previous work with young children has focused on one aspect of theory of mind, with 75% of studies with young children only including the false belief task (i.e., a binary pass/fail test of the ability to understand that others can hold beliefs that differ from reality)–a task that has been widely criticized for its limitations (e.g., [70-72]). Thus earlier results linking social emotional health and ‘theory of mind’ may be specific to their understanding of false beliefs and fail to account for children’s broader ability to understand and reason about other mental states such as their emotions, knowledge, intentions, and motivations [19,73]. Consequently, our measure of theory of mind and its predictive effects is relatively novel, capturing a more comprehensive and conceptually rich understanding of children’s mental state reasoning.

Finally, we believe that one of the most important contributions of this work is the finding that theory of mind appears to offer protective benefits against at least some factors that precipitate declines in social emotional health–in this case, the deleterious effects of reduced social interactions. This finding expands upon the three studies with children, discussed above, showing that having a more advanced theory of mind acted as a protective factor against harsh parenting [44-45] and parental post-traumatic stress transmission [46]). Together, these results suggest that a strong theory of mind may have relatively broad-sweeping protective, or resilience, benefits against many different types of stress and adversity.

An interesting question for future research to explore is precisely how theory of mind acts as a protective factor? The exact mechanism(s) by which better mental state reasoning buffers against adversity is somewhat unclear. However, the body of research linking theory of mind and different facets of social emotional competence highlights important elements. Of note, individuals with higher theory of mind abilities are better at predicting, interpreting, and influencing others’ behavior, which has a myriad of cascading benefits including stronger interpersonal relationships, and greater social emotional competence [20,23-31]. Moreover, it has been suggested, but not well tested, that those with greater theory of mind or ‘mentalization’ abilities may be better at seeking social support when needed, resulting in better stress management and greater resilience (e.g., [74]).

Anecdotal evidence offers some insight into why children with more advanced theory of mind may have fared better during the pandemic. One parent described asking her six-year-old daughter what she was drawing; the child replied that she was making a picture of their family to place in her grandmother’s window so her grandmother would not feel so alone during the social distancing. This example highlights two possible mechanisms through which theory of mind may have promoted resilience. First, children with stronger theory of mind may be more ‘other-oriented’ than ‘self-oriented’, which could support well-being. This idea aligns with research showing that excessive self-focused rumination can be detrimental to one’s mental health (for a review, see [75], and how spending money on others can make you happier than spending it on yourself [76]. Second, children with more advanced theory of mind may engage more readily in what we have termed “social substitution” behaviors (e.g., imagining conversations with others, talking to their pets or toys, or thinking about playing with their friends) that could partially compensate for reduced in-person interactions. This is consistent with findings that children with more advanced theory of mind tend to engage in more imaginative play [77].

Importantly, these potential resilience mechanisms are not mutually exclusive and may jointly contribute to more positive socioemotional outcomes during periods of stress or social isolation. Future research should aim to identify the specific pathways through which theory of mind promotes resilience, as well as the scope and timing of its protective effects. Even without clarity on the specific underlying mechanisms, interventions designed to foster theory of mind are likely to be beneficial, particularly if targeted at developmentally sensitive age groups or at the onset of stressors.

Acknowledgements

This research was supported by an Insight Grant from the Social Sciences and Humanities Research Council of Canada (SSHRC; Grant # 435-2025-0522) awarded to the first author.

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New Model for the Assistance to Frail Patients with Hematological Disease

DOI: 10.31038/IMROJ.20261111

Abstract

Haematological patients treated out-off hospital are more and more increasing due to use of new biological drugs. They have prolonged the patient survival and haematological disease prevalence. We do believe that an Internal Medicine ward where haematologists work together with hospitalists can improve quality of assistance and survival of frail haematological patients who need both Internal Medicine and Haematological competences. We report our experience in three years of such experimental assistance in agreement with Emergency Units and Haematological Department.

Keywords

Haematological frail patients, Emergency Department, Internal Medicine Department

Introduction

Due to appearance of new biological drugs. the prevalence of haematological patients is in continuous increasing. This epidemiological change is, at least partially, due to the efficacy of the new drugs “responsible” of more haematologic [1] cures and prolonged responses. According to this new scenario, when complications appear, the patients refers to family doctor or to hospital emergency departments [2,3]. News biological molecules can induce new side effects which, frequently, only haematologists are confident with. For this reason, we have implemented a network according to the town main Emergency Departments to admit frail haematological patients in our Internal Medical ward, where 4 internists cooperate with 2 hematologic specialists [4,5]. Since February 2022 to December 2024, 248 pts (116M, 132F), median age 76.4 yrs (range 30-98), were admitted to our ward, sent by Hematology or Emergency Departments of General Hospitals in Rome. The admittance procedure provided patient taken into our ward’s care in 12-72 h since the invoiced request by the proposing hospital [6].

Patient Characteristics

During the study period, our bed manager received by mail 248 requests for admitting in our ward patients affected by hematologic disease, complications of hematologic therapy, appearance or worsening of comorbidity as diabetes, cardiac failure, second primary neoplasm, sepsis or other infections, hemorrhages, etc. Patient’s characteristics are shown in Table 1. All admitted patients were assisted with appropriate therapies according to the specific complications or complaints (replacement or supportive therapy, antibiotics, hydration, etc.). The main reason for hospitalization were infections (36.3%) or cardio-vascular diseases (12.1%). Median time of hospitalization was 10 days (1-38). 196 out of 248 invoiced patients (80%) were referred back, cured or ameliorated, to their Hematological Center; 30 (21.1%) were sent to long-term or rehabilitation wards or others specialistic department; 9 pts (3.6%) were referred back to an emergency room for complications during hospitalization; 10 (4%) died in our ward and 3 (1.2%) were sent to the Palliative Cures. Infection was the principal reason of admission: 90 of them (36.3%) were admitted for this cause. Characteristics of patients with infections are reported in Table 2. The most frequent site of infection was lung or superior respiratory tract (54.4%). Sepsis with positive blood cultures were observed in 10 out of 90 pts (11.11%) and FUO in only 3 (3.3%). In all patients, antibiotic treatment lasted 5 days in lung infections or 7 days in case of sepsis, or 2 days after the disappearance of fever. In case of resistance of antibiotics, treatment was changed to alternative combination and/or following hemo-culture indications. Of all 90 pts 4 (1 Multiple Myeloma, 1 Chronic Lymphocytic Leukaemia, 1 Myelodysplastic Syndrome, 1 Acute Leukaemia) died, 6 were sent to the emergency room because complications that cannot be dealt with in our facility and lost at follow-up, 2 pts were sent to palliative care setting. The remaining 68 pts, after resolution of the acute complication, were referred, sometime after a follow-up visit after the discharge, to their reference haematologists for continuing specific treatment or follow-up.

Table 1: Main Characteristics of hematologic patients during period of observation 2022-2024.

Variables  
Gender, n (%) 248 (100%) Medical Complication     
  Male 116 47.8% Infection 90 36,29%  
  Female 132 53.2% Heart Disease 30 12,10%  
Median age, years (range) 76.4 (30-98) Pain 13 5.24%  
Median days hospitalization (range) 10 (1-38) Blood Disorders 23 9.27%  
Hematologic disease, n (%) Diabetes 12 4,84%  
  Multiple Myeloma (MM) 45 18,15% Anemia 26 10,48%  
  Chronic Lymphocytic Leukemia (CLL) 41 16,53% Hemorragy 9 3,63%  
  Myelodysplastic Syndrome (MDS) 43 17,34% Orthopedics 8 3,23%  
  Acute Leukemia (AL) 28 11,29% Respiratory Disease 14 5,65%  
  Non-Hodgkin Lymphoma (NHL) 32 12,90% Electrolyte Imbalance 11 4,44%  
  Myelofibrosis (MF) 8 3,23% Kidney Disease 8 3,23%  
  Myeloproliferative Neoplasm (MPN) Other Than MF 14 5,65% Solid Neoplasm 3 1,21%  
  Other 37 14,92% Hepatic Disorders 1 0,40%  

 

Discussion and Conclusions

Proper assistance and cure of haematological patients with their disease or treatment complications have become a true emergency because more and more frail pts are treated in ambulatory or day hospital setting and because the ageing of population. A local network for their care and the admission of these patients in multiskilfull ward to face different occurring complications, in our opinion, is crucial in order to accelerate their reception and prompt treatments of conditions possibly fatal. This network is appreciated to local Emergency and Haematology departments according to the progressive increase in the years of the patients addressed to our institute. On the other hand, close collaboration between hematologists and specialists in other fields such as internal medicine, cardiology, neurology, orthopedics, infectious diseases, and pain management allows for a comprehensive assessment of the patient to guide the continuation of specific treatment for their condition. While it is not possible to reach the target for all patients, it can still facilitate the process and help the family navigate the natural progression of the disease when treatment cannot be proposed. We think that the presence of a similar network can ameliorate the assistance of haematological patients and can allow the Hematology departments to dedicate to intensive care life-saving procedures. Moreover, this organization is certainly cheaper as it avoids the occupation of specialist beds.

Table 2: Main Characteristics of hematologic patients with infections.

Variables  
Gender, n (%) 90 (100%)    
  Male 51 56.67% Median age, years (range) 77 (30-94)  
  Female 39 43.33% Median days hospitalization (range) 9 (2-38)  
Type of Hematologic disease, n (%) Type of infection, n (%)
  MM 21 23,33% pneumonia 49 54,44%  
  CLL 12 13,33% sepsis 10 11,11%  
  MDS 17 18,89% infection of urinary tract 12 13,33%  
  AL 14 15,56% infection of GI tract 6 6,67%  
  NHL 12 13,33% FUO 3 3,33%  
  MF 7 7,77% skin 5 5,56%  
  Other 7 7,78% other 5 5,56%  

Acknowledgements

We thank Doct. Corrado Girmenia, head of the emergency room of the Department of Hematology of Policlinico Umberto I, and Doct. Maria Paola Saggese head of emergency department of Santo Spirito hospital for referring patients.

References

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Isolated Cardiac Cement Embolism Following Cement Vertebroplasty Presenting as Symptomatic Atrial Fibrillation

DOI: 10.31038/JCCP.2026913

 

An 86-year-old man presented to his cardiologist for regular follow up with chest pain and exertional intolerance with tachycardia and palpitations. The patient had further medical history of paroxysmal atrial fibrillation, chronic back pain with cement vertebroplasty, ischaemic heart disease with previous multivessel coronary stenting, hypertension, hypercholesterolaemia, type two diabetes mellitus, stage four diabetic kidney disease and previous upper GI bleed whilst on dual antiplatelets. His medications were apixaban 2.5 mg BD, metoprolol 25 mg BD, digoxin 62.5 mcg daily, irbesartan 300 mg daily, lercanidipine 10 mg daily, atorvastatin 40 mg daily, dapagliflozin 10 mg daily, metformin 1 g daily and pantoprazole 40 mg daily.

ECG showed atrial fibrillation with a heart rate of 57 bpm and no ischaemic changes. Subsequent Holter monitor showed atrial fibrillation throughout with a minimum heart rate of 41 and maximum of 141. Transthoracic echocardiogram showed normal left ventricular size and function with stable mild valvular disease.

The patient described his symptoms as being like a previous presentation which led to a diagnosis of obstructive left main coronary artery disease. The patient underwent invasive coronary angiography which illustrated only moderate non obstructive coronary artery disease with patent stents. There was the unexpected finding of radio-opaque masses in the right atrial appendage and the right ventricle. This was associated with new T12 cement vertebroplasty (Figure 1).

Figure 1: Coronary angiogram showing two radio-opaque masses in the right atrial appendage and the right ventricle.

Upon review of previous imaging, the radio opaque masses were not present on chest X-rays from prior to vertebroplasty but appeared on X-ray following vertebroplasty. A non-contrast CT chest confirmed the presence of high attenuation material in the right atrial appendage (Figure 2) and inferior right ventricle (Figure 3) and bone cement in the thoracic vertebrae that had extravasated to the region of the paravertebral venous plexus (Figure 4). This was consistent with cardiac embolism of vertebral bone cement.

Figure 2: Axial view of CT chest showing high attenuation material in the right atrial appendage.

Figure 3: Sagittal view of CT chest showing high attenuation material in the inferior right ventricle.

Figure 4: Sagittal view of CT chest showing cement in T12 vertebral body, extravasating into the paravertebral region.

Retrospective review of previous transthoracic echocardiogram showed a calcified area noted in the right ventricle near the moderator band and another in the right atrial appendage (Figure 5).

Figure 5: Transthoracic echocardiogram illustrating a bright, calcified area in the right ventricle.

The case was discussed at a cardiology multidisciplinary team meeting regarding invasive or medical management due to the risk of cement embolism erosion. The consensus was to manage the case conservatively with anticoagulation to prevent thrombus formation on the cement as the patient had not had any complications of the embolism to date and due to his advanced age and comorbidities. The patient’s apixaban was increased to 5 mg BD and his symptoms remained stable.

Discussion

Percutaneous vertebroplasty is used to treat osteoporotic fractures to reduce pain and provide stability to the spine [1]. The procedure involves injecting polymethylmethacrylate (PMMA) cement into the diseased vertebrae and the main risks are associated with the leakage of cement into the surrounding structures. With absorption into the iliolumbar and epidural veins, the cement can gain access to the central circulation.

The rate of extravasation into central veins during this procedure is estimated at 23% however usually particles of cement are small, and the patient remains asymptomatic. Symptomatic intracardiac embolism is estimated to occur in only 0.3% of cases [2]. Sequelae of embolism can involve arrhythmia, valve dysfunction, pulmonary embolism and rarely cardiac perforation resulting in tamponade.

If the suspicion for intracardiac cement embolism (ICE) is high, CT chest and TTE should be performed to confirm the diagnosis, location of the embolism and to assess for complications. The bone cement is high attenuation and has been described as 373-1600 Hounsfield units when embolised to the heart [3]. However as seen in this case other modalities including chest X ray and fluoroscopy can make the diagnosis.

Risk factors for embolism include higher number of segments, injection into the thoracic vertebrae, tumour related fractures, higher amounts of bone cement used and lower viscosity cement [4].

Prevention of ICE includes the use of high viscosity cement to reduce extravasation, avoiding over pressurisation and injecting under fluoroscopy to assess for embolization during the procedure [5].

Recommendation on management of ICE depends on the patient’s status. In asymptomatic patients, observation without intervention is most appropriate. Small cement emboli routinely do not cause symptoms so routine post procedural imagining is not recommended.

Symptomatic patients may require intervention. Patients with cardiac rupture and tamponade require urgent surgical intervention to remove the fragment and repair the myocardial defect. There have been case reports of percutaneous removal of fragments that are amenable to do so that are either high risk of causing cardiac rupture or impinging on the tricuspid valve apparatus [5].

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The TA Trial: A Long-Overdue Randomised Test of Total Arterial Revascularisation

DOI: 10.31038/JCCP.2026912

 

Coronary artery bypass grafting (CABG) remains the most durable revascularisation strategy for patients with multivessel coronary artery disease, with established long-term survival advantages over percutaneous coronary intervention in complex anatomical disease [1,2]. Yet despite decades of surgical refinement, one of the most consequential intraoperative decisions, conduit selection, remains insufficiently resolved by high-quality prospective evidence. The Total Arterial (TA) Trial, (clinical trial registry: ACTRN12623000864628) funded by the Australian Medical Research Future Fund, represents a serious and timely effort to address that gap.

The central question is simple: does the complete exclusion of saphenous vein grafts (SVGs) in favour of total arterial revascularisation (TAR) translate into superior graft patency and better clinical outcomes? The biological basis for expecting so is well-established. SVGs are anatomically and haemodynamically mismatched for the arterial circulation – subjected to pressures they were not designed to withstand – and the consequences are of reasonably predictable and progressive graft failure. Approximately 40–50% of SVGs occlude within 10 years, contributing significantly to postoperative myocardial infarction, repeat revascularisation, and premature mortality [3,4]. Arterial conduits appear to behave differently. Whether internal mammary arteries or radial arteries, they exhibit resistance to progressive atherosclerosis, adaptive remodelling, and durable angiographic patency over decades of follow-up [5,6]. Large registry analyses, including data from the Australian and New Zealand Society of Cardiac and Thoracic Surgeons (ANZSCTS) registries, have consistently associated TAR with a survival advantage [7,8].

The key question is whether this survival signal reflects the true biological superiority of arterial conduits or is substantially confounded by patient selection and operator expertise. Patients who receive TAR tend to be younger, less comorbid, and operated on by surgeons with higher procedural volumes. Observational analyses, however carefully risk-adjusted, cannot fully account for these confounders. Randomised allocation remains the only mechanism to isolate conduit biology from surgical selection – and prior trials have not achieved this adequately.

The Arterial Revascularisation Trial (ART) was undermined by a crossover rate exceeding 10% post-randomisation, diluting the treatment contrast and complicating interpretation of its insignificant result at 10 years [9]. Whether ART failed to show a benefit because none exists, or because insufficient patients received the assigned treatment, remains unresolved. However, it is also noteworthy that both arms could have received SVG. The ongoing ROMA trial, while more rigorously designed than the ART trial, addresses a related but distinct question: the number of arterial grafts, rather than the complete elimination of venous conduits [10]. Both arms of ROMA permit SVG use, which cannot therefore directly address whether abolishing venous grafting entirely – the strategy with the most consistent observational support, could improve survival.

The TA Trial is deliberately designed to address these limitations. By defining its intervention as zero SVGs versus at least one SVG, it isolates the specific variable that observational data most consistently associates with long-term outcome differences [7,11]. For clarity, unlike ART and ROMA, the focus of the investigation relates not to the arterial conduit use – but rather to the venous conduit use. The pragmatic surgical design –imposing no restrictions on conduit type, graft configuration, or reconstruction technique within the TAR arm – reflects clinical equipoise and preserves generalisability. This acknowledges that TAR is not a single operation but a surgical philosophy, executable through multiple technically sound configurations [12,13].

Equally important is the trial’s approach to protocol compliance. ART established that investigator non-compliance is a practical threat to trial validity, and not a theoretical one. The TA Trial approach mandates logbook review to confirm surgeon competence in TAR, requiring preoperative written confirmation of equipoise for every randomised patient, and instituting individual investigator follow-up after each protocol breach. These are the structural safeguards upon which the trial’s interpretability depends.

Selecting perfect graft patency as the primary endpoint at 24 months is scientifically well-justified. Simple patency captures graft survival but not graft health; a vein graft that is open but internally diseased will ultimately fail, and simple patency misses this trajectory. Perfect patency – a patent conduit with a smooth, regular lumen free of atherosclerotic change – provides an angiographic surrogate for long-term conduit durability validated against clinical outcomes.6 Assessment by CT coronary angiography with sensitivity and specificity exceeding 98% [14] allows non-invasive, reproducible assessment across all 18 sites. The additional CTCA at 3 months is a noteworthy design strength, offering a structured examination of early competitive flow effects on arterial graft function, a phenomenon that likely explains a proportion of early graft failures but remains poorly characterised prospectively [15].

Australia is uniquely positioned to conduct this trial. TAR utilisation rates across Australian centres substantially exceed those reported in North America and Europe [7], ensuring a sufficient pool of surgeons with established expertise in both TAR and non-TAR techniques. This mitigates a key methodological concern: differential technical proficiency across study arms could confound the treatment effect. The trial’s findings will therefore reflect outcomes achievable within a mature surgical environment, strengthening their external validity and translational relevance.

Conclusion

The TA Trial is the first prospective, randomised investigation designed to directly test whether complete elimination of venous conduits from CABG translates into measurable improvements in graft integrity and, through its comprehensive secondary outcome framework, patient survival and quality of life. If it confirms the observational literature, its implications for surgical practice and guideline development good be substantial and impactful. The cardiac surgery community has waited a long time for this evidence.

Authorship and Contributions

Justin Ren, writing and conceptualization of the manuscript. Alistair Royse, writing and conceptualization of the manuscript. Colin Royse, co-author and reviewer.

Acknowledgements

The author has acknowledged that this summary commentary is written on behalf of the TA Trial Steering Committee.

Conflicts

This manuscript has not been funded. The authors declare that they are the architects of the TA Trial study design and have written multiple supporting analyses for this trial.

Keywords

TA Trial, Total arterial revascularisation, TAR, Graft angiography

References

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Extracellular Ca2+ Influx is involved in Tip Growth of the Marine Red Alga Pyropia yezoensis

DOI: 10.31038/AFS.2026811

Abstract

The conchocelis, the filamentous sporophyte generation of Bangiales, proliferates through tip growth in which only the tips of branch initial cells elongate and subsequently divide perpendicularly to the apical–basal axis to form filamentous structures. As was found in terrestrial plants, the tip growth of conchocelis in the marine red alga Pyropia yezoensis is regulated by auxin, actin polymerization, and phosphatidylinositol signaling. Although extracellular Ca2+ influx is critical for tip growth in terrestrial plants, little is known about its involvement in the tip growth of algae. We therefore investigated whether extracellular Ca2+ influx is required for tip growth in P. yezoensis conchocelis. Treatment of isolated single-celled conchocelis with a Ca2+ chelator, ethylene glycol tetraacetic acid, inhibited both the formation of branch initials and the tip growth of branches in a dose-dependent manner. These findings indicate that extracellular Ca2+ influx is indeed involved in the tip growth of conchocelis, suggesting that the basic regulatory mechanisms governing tip growth may be conserved between marine red algae and terrestrial plants. Further confirmation of this possibility will require the characterization of the spatiotemporal patterns of Ca2+ oscillations and F-actin accumulation, as well as the subcellular localization of phosphoinositides and their catabolic enzymes in the P. yezoensis conchocelis.

Keywords

Branch initial, Ca2+, Conchocelis, Extracellular influx, Pyropia yezoensis, Red alga, Tip growth

Introduction

Patterns of anisotropic cell growth give rise to the body shapes of terrestrial plants and multicellular algae [1,2]. Diffuse growth, which results in the expansion of cell surfaces [3,4], produces planar or foliose shape, whereas tip growth [5-7], characterized by directional and highly localized expansion at the apex, produces a filamentous body architecture. Algal cells grow anisotropically through both diffuse and tip growth. We previously demonstrated that tip growth produces the filamentous structures of the conchocelis (sporophyte) and conchosporangium (conchosporophyte) of the red alga Pyropia yezoensis [8-12], although regulatory mechanisms of tip growth in P. yezoensis has not yet been fully elucidated. Moreover, how diffuse growth produces a foliose shape in the thallus (gametophyte) of P. yezoensis remains largely unknown. Therefore, characterizing the contrasting mechanisms that regulate patterns of diffuse and tip growth is necessary to understand the differences in growth–morphology relationships between the two life-cycle generations of Bangiales.

The mechanisms that regulate diffuse and tip growth systems have been studied extensively in terrestrial plants. Cortical microtubules (MTs), actin filament (F-actin), Rho GTPases, the histone variant H2A.Z, gibberellin, and brassinosteroids have all been implicated in the regulation of diffuse growth [1,3,13] likewise, MTs, F-actin, Rho GTPases, Ca2+ influx, reactive oxygen species, phosphatidylinositol signaling, auxin, and jasmonate have been shown to regulate tip growth [7,13-21]. Although research on the regulation of diffuse growth in macroalgae has shown little progress, recent studies have provided basic information about the mechanisms regulating tip growth in red and brown macroalgae [2,11,12,22]. Indeed, we demonstrated that auxin, phosphoinositide turnover, and actin polymerization are involved in the regulation of tip growth in P. yezoensis [11,12], consistent with findings in terrestrial plants [13,17,18,21]. Although extracellular Ca2+ influx is required for tip growth in terrestrial plants [17-19], little is known about its role in the tip growth of macroalgae. We therefore sought to determine whether extracellular Ca2+ influx is required for tip growth in P. yezoensis conchocelis.

Materials and Methods

Single-celled conchocelis of P. yezoensis strain U-51 were used for these experiments, enabling us to visualize and quantitatively analyze the initiation and progression of tip growth in detail [11]. Conchocelis were maintained in artificial seawater at 15°C under 60 µE/m²/s of light with a short-day cycle (10-h light/14-h dark) [23]. Single-celled conchocelis were prepared as described in [11]. In brief, aggregates of multicellular conchocelis were chopped with a razor blade, and small fragments of conchocelis were separated from larger pieces by filtration through a 10-μm nylon mesh. The separated conchocelis were then incubated in 30 mL of artificial seawater [23] at 15°C for 10 min. Unbranched single-celled conchocelis (Figure 1) were identified by observation under an Olympus IX73 light microscope equipped with an Olympus DP22 camera (Olympus Corporation, Tokyo, Japan), drawn into a micropipette, and transferred to 96-well plates (one cell per well containing 200 μL of artificial seawater). Ethylene glycol tetraacetic acid (EGTA; Dojindo Laboratories, Japan), an effective Ca2+ chelator, was dissolved in artificial seawater to create a 0.5 M stock solution (adjusted to pH 8.0 with NaOH) and stored at −30°C before use. Single-celled conchocelis were treated with 0, 500, or 750 μM EGTA for 3 days, and the growth and morphology of the side branches were observed using the microscope described above.

Figure 1: Representative image of an isolated single-celled conchocelis. Nonbranched single-celled conchocelis were used for EGTA treatment experiments. Scale bar, 25 µm.

Results and Discussion

To evaluate the effects of EGTA on the initiation and elongation of side branches, we measured the branching rate (the percentage of observed cells that produced side branches) and branch length, respectively. Side branches were initiated and underwent elongation when treated with 0 (control) or 500 μM EGTA (Figure 2A and 2B), but 750 μM EGTA completely prevented both the initiation and growth of side branches (Figure 2C). The branching rate and branch length were affected by the presence of EGTA in a dose-dependent manner, being strongly inhibited at 750 μM (Figure 2D and 2E). These results demonstrate that extracellular Ca2+ influx is important for the production and tip growth of branch initials from differentiated conchocelis cells. It reminds to be elucidated whether washing out of EGTA and subsequent addition of CaCl2 in the medium recover branch initiation and branch growth and whether inhibition of channel-mediated Ca2+ influx by treatment with LaCl3 prevents tip growth.

Figure 2: Effects of EGTA treatment on the tip growth of side branches from single-celled conchocelis. (A–C) Photographs of single-celled conchocelis treated with 0 (A), 500 (B), or 750 μM EGTA (C) for 3 days, for which each treatment was employed total 16 isolated cells for observation. Arrows indicate tip-growing branches initiated from single-celled conchocelis. Scale bars, 25 μm. (D, E) Branching rate (D) and branch length (E) after treatment of single-celled conchocelis with 0, 500, or 750 μM EGTA for 3 days. Center line, median; cross, mean; box limits, interquartile range with upper and lower quartiles; points, individual data points; whiskers, range with maximum and minimum values. Lowercase letters in (D) and (E) denote significant differences between treatments based on three independent experiments (n = 3) as determined by the Tukey–Kramer test (p < 0.05).

There are two important steps in the tip growth of conchocelis: the formation of branch initials in non-dividing differentiated cells (initiation of tip growth) and the polar directional growth of these initials to form elongated branches [12]. Because the treatment of single-celled conchocelis with EGTA impaired both branch initiation and branch growth, we concluded that Ca2+ is required for both critical steps in tip growth. To confirm this proposal, measurements of the time-course of both production of branch initial and its growth in single-celled conchocelis are necessary for elucidation of a question which step requires extracellular Ca2+ influx. In addition, we previously demonstrated that these two steps are regulated by auxin, phosphoinositide turnover, and actin polymerization [11,12]. These findings are consistent with our understanding of tip-growth regulation in the pollen tubes and root hairs of terrestrial plants [13,14,16-18,21]. It is therefore possible that the basic regulatory mechanisms governing tip growth are conserved between aquatic red algae and terrestrial plants. Factors such as Ca2+, enzymes related to phosphoinositide turnover, and F-actin act at the cell apex to enable the polar growth of filamentous tissues such as root hairs and pollen tubes [14,16,18]; however, little is known about the spatial distribution of these factors during the initiation and elongation of branches in P. yezoensis conchocelis. Therefore, determining the specific regions where auxin and Ca2+ exert their effects and characterizing the subcellular distributions of F-actin and enzymes involved in phosphoinositide turnover will be critical for fully understanding tip-growth regulation in conchocelis branches. A live-imaging technique for conchocelis tip growth has recently been reported [10]. Improvements to this system are expected to enable the visualization of Ca2+ influx, F-actin distribution, and the localization of phosphoinositides and related enzymes, providing spatiotemporal details of polarity establishment and tip growth in P. yezoensis conchocelis.

Despite progress in understanding tip growth in the conchocelis, much less is known about the regulation of diffuse growth that gives rise to the foliose thallus of the gametophyte. It is remarkable that foliose and filamentous generations survive independently in P. yezoensis and other Bangiales [9], suggesting differences in the regulatory mechanisms governing these two growth patterns. However, the shared involvement of MTs, F-actin, and Rho GTPases in both diffuse and tip growth of terrestrial plants [1] raises the question of how common factors can regulate different types of growth. Characterizing the contrasting regulatory mechanisms that govern diffuse and tip growth will be essential for understanding the physiological and molecular bases of the distinct multicellular body plans of heteromorphic generations in P. yezoensis.

Author Contributions

RI: Methodology, Investigation, Data curation, Formal analysis, Validation, Visualization.

KM: Conceptualization, Methodology, Formal analysis, Validation, Visualization, Supervision, Writing—original draft preparation and reviewing and editing, Funding acquisition.

Conflict of Interest

The authors declare no conflicts of interest. No aspects of the study required informed consent, and the work did not involve human or animal subjects. All authors have read and agreed to authorship and to the submission of the manuscript for peer review.

Data Availability Statement

Data are contained within the article.

Funding

This research was supported in part by the designated research fund from Miyagi University.

Acknowledgments

We are grateful to the Marine Resources Research Center of Aichi Fisheries Research Institute for kindly providing P. yezoensis strain U51.

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Hantavirus Aptamer DNA Sequences with Therapeutic Potential According to 3-D Docking Models

DOI: 10.31038/IDT.2026711

Abstract

DNA aptamers were developed and sequenced against an envelope precursor polyprotein of Hantavirus (HV). The highest affinity aptamers from the final SELEX pool were determined by an enzyme-linked microplate assay against the recombinant envelope protein. Subsequent 3-D molecular models using two different docking platforms strongly suggest that the top aptamers will bind the exterior ectodomain of the envelope protein protruding from the viral lipid envelope and therefore could interfere with virus binding to host cell receptors, thus affording potential prophylaxis or therapy for Hanta-related hemorrhagic, pulmonary and renal syndromes.

Keywords

3-D Molecular modeling, Aptamer, Docking software, Hanta virus, Passive immunity

Introduction

Hanta viruses (HVs) including Sin Nombre virus are named after the Hantan river region in North and South Korea where an early outbreak occurred. HVs are spread mostly by rodent or rodent feces and urine exposure to humans, but not between humans. These viruses affect greater than 200,000 people worldwide although 90% of cases occur in China each year and can cause potentially lethal hantavirus pulmonary syndrome (HPS) and hemorrhagic fever with renal syndrome (HFRS) [1]. There are no effective government-approved treatments for HPS or HFRS except rest and treatment for the associated symptoms of fever, fatigue and severe muscle pain. However, at least two experimental monoclonal antibodies have demonstrated some efficacy by binding the external surface Gn and Gc viral proteins (cleavage products of the envelope polyprotein) to neutralize viral entry into host cells [2], thus opening the door for less expensive DNA aptamer-based passive immunity as well [3].

Materials and Methods

Recombinant Hanta Virus Envelope Polyprotein Target and Magnetic Bead Immobilization

The Hantavirus envelope recombinant polyprotein (Gn/Gc or G1/G2 precursor) target was produced by Bioclone Inc. (Dr. Peter Ding), San Diego, CA. It covered amino acids 50-450 from the Jurong TJK/06(RT50) Hantavirus strain (Swiss Protein number C7EMH7). Because the protein comes with a 6X histidine tail, the authors used NTA Nickel-coated magnetic beads from Thermo Fisher Inc. for immobilization of the target protein for SELEX aptamer development. By immobilizing at the tail end where the 6X histidine resides, most of the native protein was available to interact with the random DNA library to better select ectodomain aptamers versus randomly immobilizing the protein via tosyl leaving groups (common on magnetic microbeads) anywhere that a primary amine occurs in the protein. Figure 1 describes the SELEX template and PCR primers that were used for SELEX aptamer development. Otherwise, traditional magnetic bead-based SELEX methods as reported in the literature [3] were utilized and the final round 10 SELEX pool was sequenced using Illumina next generation sequencing by synthesis at Base Pair Biotechnologies Inc. (Pearland, TX, USA).

Figure 1: Schematic and DNA sequences of the 72 base SELEX template with randomized 36 bases (N36) region flanked by two fixed 18 base PCR primer binding ends and the Forward (F) and Reverse (R) primer sequences obtained from Integrated DNA Technologies (Coralville, IA, USA).

Results

Figure 2 documents successful 72 bp PCR amplicons from each of the final rounds of HV SELEX in an ethidium bromide-stained 2% agarose electrophoresis gel. The most frequent (i.e., top) 24 candidate aptamers that occurred at least 10 times or more in total (FCOUNT) in the final round 10 aptamer pool and greater than 6 times per million sequences (CPM) are reported in Table 1.

Figure 2: Ethidium bromide-stained 2% agarose electrophoretic gel image showing 72 bp aptamer amplicons from each of the final rounds of SELEX for HV envelope protein aptamer development.

The HV aptamer candidates were screened by ELISA-like (ELASA) assay as described previously [3] for affinity to the cognate HV envelope polyprotein. The ELASA relative affinity rankings by absorbance at 405 nm of each candidate aptamer from Table 1 are provided in Table 2 below and suggest the top aptamers to screen for inhibition of Hantavirus plaques in vitro [4], if that possibility ever exists. In particular, it appears that HV aptamers S2, S3, S7 and S9 with absorbance at 405 nm values greater than 2.0 are the best four candidates with which to start in vitro HV plaque inhibition studies in Vero cells [4].

Table 1: Top 24 Hantavirus Envelope Polyprotein Aptamer DNA Sequences and Frequency (Total Counts and Counts per Million Sequences).

Because Nanohmics developed a number of seemingly high affinity (Table 2) HV aptamers during this project, it followed that 3-D modeling of the top aptamer docking with the HV envelope polyprotein from the NCBI and Swiss Protein databases (number C7EMH7) was in order. The HV S1 aptamer emerged 115 times or 25 more total times than the nearest competitor in the NGS pool (Table 1) and was ranked in the top 7 aptamer candidates by ELISA-like assay vs. the envelope protein with an average absorbance at 405 nm of 1.9175 versus the top aptamer candidate (HV S7; A405 nm = 2.248) in terms of affinity. However, affinity is not always the best predictor of ability to block viral entry into host cells. So, HV S1 is also a logical candidate to begin modeling for future in vitro plaque assays.

Table 2: ELASA Plate Assay Rankings of the Top 24 Aptamers from NGS for Hantavirus Envelope Binding and Potential Inhibition (Average of Duplicate A405 nm Readings).

We were not able to find an established 3-D PDB model for the Hantavirus Jurong TJK/06(RT50) envelope protein, so we had to enter the amino acid sequence (cut and pasted) into a program within UniProt and then through a program called ModWeb from the Univ. of California at San Francisco (UCSF) to generate the 3-D envelope protein structure shown in Figure 3 below. Note the characteristic black “donut hole” in the middle of this envelope protein which helps to identify the polyprotein in 3-D docked images with candidate aptamers.

Figure 3: 3-D PBD model of the Hantavirus Jurong TJK/06(RT50) envelope protein generated by UniProt and ModWeb. Note the characteristic “donut hole” (black area in middle).

We utilized and compared results from HDock and ZDock internet programs as shown in Figures 4-6 below to determine where the HV S1 aptamer was preferentially binding on the HV envelope (E) polyprotein. From both the HDock and ZDock analyses, the HV S1 aptamer appears to prefer binding the thinner tapered segment of the HV E polyprotein. Unfortunately, according to Serris et al. [5], this end of the envelope protein may be inserted into the lipid envelope and not even available for aptamer binding, thus making the HV S1 aptamer potentially useless. However, some of the other top HV aptamer sequences subjected to 3-D docking analysis seemed to prefer binding the opposite end (ectodomain) of the HV envelope polyprotein making them better candidates (Figure 6).

Figure 4: Top 3-D docking ribbon structure for the HV1 aptamer (orange) with the yellow HV E polyprotein using HDock.

Figure 5: Top 3-D docking space-filled structure for the HV S1 aptamer (brown) with the green HV E polyprotein (green) using HDock software. Note again the “donut hole” in the E polyprotein and aptamer binding to the thinner end of the protein.

Figure 6: Top 3-D docking space-filled structure for the HV S1 aptamer binding the yellow ectodomain of the HV Envelope polyprotein using ZDock software rendered in RasMol software.

Discussion

Serris et al. [5] described the domain of Hantavirus (HV) envelope E polyprotein which is embedded in the viral envelope lipid membrane and the ectodomains that are outside of the viral coat and available for some particular aptamer binding. Figure 7 below illustrates how the 3-D ribbon structures of the HV envelope protein reported by Serris et al. [5] in panels A and B appear to match the general 3-D HV envelope structure that we used for aptamer docking studies. Note that Domain I in panels A and B appears to be the base domain that inserts into the viral lipid envelope and would be inaccessible to aptamers. However, the curved outer ectodomains appear to be accessible to aptamers and both of the top aptamer-HV E polyprotein docking models developed during this project show the S1 aptamer binding to these ectodomains as represented in panel D which could thus probably block binding to host cell receptors and inhibit or prevent plaque formation in vitro and infection in vivo. Naturally, all of this theoretical modeling needs to be tested empirically in vitro with plaque inhibition studies [4], but this publication provides a maximum of 24 candidate aptamers and some theoretical criteria for down selecting to the best ectodomain-binding candidates with HV neutralization potential in future studies.

Figure 7: A and B – 3-D ribbon structures of Hantavirus envelope protein borrowed from Serris et al. [5] showing the protein orientation and insertion in the envelope/membrane. C – The authors’ similar 3-D ribbon structure and D – the authors’ predicted blue aptamer docked with the accessible outer ectodomain which could enable blocking of host cell receptor binding and block viral entry.

Conclusions

A total of 24 new DNA aptamer sequences against HV envelope polyprotein were generated and studied by static 3-D docking models that suggest binding of the HV envelope polyprotein external ectodomain by some of the candidates. If true, one or more of the reported aptamer DNA sequences could block or inhibit Hantavirus entry into host cells in vitro and in vivo, thus providing HV neutralization and passive immunity.

Acknowledgements

Funding was provided by US DoD SBIR Contract No. W91SR22P0007.

References

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Self-Derivation through Memory Integration: A Unique Predictor of Semantic Knowledge in Children

DOI: 10.31038/PSYJ.2026812

Abstract

Developing a storehouse of semantic or world knowledge is an important developmental achievement. In addition to direct learning such as through books and lectures, semantic knowledge accumulates through so-called productive processes, which permit going beyond the given to generate new knowledge. In the present research, we tested whether the specific productive process of self-derivation through memory integration makes unique contributions to semantic knowledge, even when other known or hypothesized correlates of knowledge (i.e., verbal and visual abilities) are considered. One-hundred-forty- eight 8-12-year-old children participated in two waves of testing, one year apart. At Wave 1, latent constructs of self-derivation and fact recall and verbal and visual abilities each predicted unique and overlapping variance in the latent construct, knowledge; total variance in knowledge accounted for R2 = .56. At Wave 2, verbal and visual abilities predicted unique variance in knowledge, and self-derivation and fact recall contributed to additional shared variance; total variance in knowledge accounted for R2 = .70. Longitudinally, both self-derivation and fact recall and verbal and visual abilities from Wave 1 predicted unique and overlapping variance in the latent construct, knowledge at Wave 2; total variance in knowledge accounted for R2 = .63. The work establishes self-derivation through memory integration as a mechanism of semantic knowledge development.

Keywords

development, longitudinal, productive processes, self-derivation, semantic knowledge

Developing a storehouse of knowledge about the world—so-called semantic knowledge—is a critical developmental achievement. As such, it is important to establish the correlates of the development of semantic knowledge. One contributor to semantic content is memory for information that is directly taught or learned, such as provided through lectures, books, videos, and museum exhibits. Other contributors include productive processes such as analogy, transitive and associative inference, and induction, to name a few. Productive processes go beyond what is given through direct experience, and therefore have the potential to accelerate accumulation of knowledge [1-6]. From among the larger suite of productive processes, self- derivation through memory integration has emerged as a valid model of knowledge accumulation[7,8]. Self-derivation through memory integration involves combination of separate yet related episodes of new learning and use of the novel combination as a basis for inference of new knowledge. For example, a learner may be taught that the heart is the only muscle that never tires, and that the only muscle that never tires is powered by electricity. Combination of these facts supports derivation of the new knowledge that the heart is powered by electricity. This new information can be incorporated into semantic knowledge, even though it was not directly experienced [9].

Consistent with the suggestion that self-derivation through memory integration is a valid model of knowledge accumulation, the process is both a concurrent and longitudinal predictor of academic achievement among elementary-school children, even when other known correlates of academic achievement (e.g., working memory) are considered [10,11]. It also is a concurrent and longitudinal predictor of knowledge in a number of domains as tested by the Woodcock- Johnson measures of achievement[12,13]. However, beyond the classroom, self-derivation through integration has not been tested against other known correlates of domain knowledge, such as existing knowledge as measured by vocabulary, and working memory. As a result, it has not been established as a unique predictor of knowledge accumulation. Accordingly, in the present research, we tested self- derivation through memory integration along with measures of other cognitive abilities, as concurrent and longitudinal predictors of semantic knowledge. The major goal was to determine whether self- derivation makes unique contributions to prediction and thus can be considered a mechanism of semantic knowledge development.

Self-derivation through Memory Integration

Self-derivation through memory integration involves combination of separate yet related facts that have been directly taught, to support derivation of new knowledge. With some important exceptions, the task is structured like those that test associative inference [3]. In associative inference tasks, participants may learn arbitrarily-related pairs of images or symbols that have an overlapping element. For example, they learn the image pairs zucchini-bucket (i.e., notation: A [for zucchini], B [for bucket]) and bucket-truck (B, C [for truck]). They typically are informed that they can form an indirect relation between the two image pairs, based on the overlapping element (bucket). They then are tested for the indirect relation between zucchini-truck (AC; [14]). As suggested by the opening example (above), the test of self- derivation through memory integration is structured similarly to tests of associative inference, with the important exceptions that (a) the stimuli are true facts expected to be unfamiliar to participants, (b) participants are not made aware that the facts they are learning are related to one another, and (c) nor are they made aware that they can form an indirect relation based on an overlapping element. In these respects, the self-derivation through integration task mimics learning outside the laboratory.

Self-derivation through memory integration occurs across ages, venues, and domains. In children as young as 4 years, new information is taught in the context of brief narratives, in the laboratory [15,16]; in kindergarten and elementary school classrooms [17]; or in children’s homes, in the course of shared book reading [18] or visits to virtual museum exhibits[19]. Among children 8 years and older and adults, new information is taught in individual sentences (such as the opening example, above). Information is drawn from a range of domains, including arts and humanities, math, science, and elementary [7] and college [20] curricula. Developmental differences in self-derivation through integration are readily apparent in early childhood. By roughly 8 years of age, developmental differences are eclipsed by individual differences that persist at least into young adulthood [21].

Self-derivation through Memory Integration and Academic Achievement

As expected from a model of learning, performance on tasks of self-derivation through memory integration relates to measures of academic achievement. For example, among children in Grades 1-3 (roughly ages 7-10 years), self-derivation through integration was found to predict both math and reading achievement, as measured by end-of-year assessments. It explained up to 23% of the variance in math and 12% in reading [17]. Similar findings were reported in [10], among children in 2nd and 3rd grades. Self-derivation through memory integration also predicts math and reading achievement over one year, among children in 2nd and 3rd grade at Time 1 and 3rd and 4th grade at Time 2 ([11], Study 2). Self-derivation through memory integration performance at Time 1 predicted 18% and 21% of the variance in the Time 2 end-of-year math and end-of-year reading achievement, respectively.

Of course, self-derivation through memory integration is not the only predictor of academic achievement. For example, a consistent correlate of academic achievement is working memory [22, 23]. Children’s working memory skills predict math and reading achievement 6 years later, above measures of IQ [24]. Working memory in preschoolers predicts math and reading achievement in the first three years of primary school, and visual short term memory predicts math achievement in particular[25]. Further, visuospatial working memory predicts student’s math achievement from first grade to second grade [26].

Importantly, self-derivation through memory integration is predictive of academic performance even when other known correlates of achievement are considered. Specifically,[10] tested the concurrent predictive utility of self-derivation through integration when considered along with verbal comprehension, nonverbal intelligence, and working memory and other executive functions. End-of-year math performance was jointly predicted by self-derivation through integration, verbal comprehension, nonverbal intelligence, and working memory. The total variance in math achievement accounted for was 51% and 41% among children in 2nd and 3rd grades, respectively. Self-derivation through integration alone accounted for 31% and 25% of the total for children in 2nd and 3rd grades, respectively. In the models predicting end-of-year reading performance, for children in 2nd grade, self-derivation through integration was the only significant predictor, accounting for 32% of the variance in reading achievement. For children in the 3rd grade, self-derivation through integration was a significant predictor, along with verbal comprehension and nonverbal intelligence. The full mode accounted for 48% of the variance in reading achievement; self-derivation through integration alone accounted for 22% of the total variance. Longitudinally, as noted above, Esposito & Bauer [11], Study 2) found that self-derivation through memory integration performance at Time 1 predicted 18% of the variance in the Time 2 end-of-year math achievement. The addition of measures of vocabulary and parent education in the model did not result in significant improvement. Thus self-derivation through integration was the sole longitudinal predictor of math achievement. For the Time 2 end-of-year assessment of reading achievement, self- derivation through memory integration at Time 1 predicted 21% of the variance. The addition to the model of vocabulary and parent education increased the variance accounted for to 31%.

Self-derivation through Memory Integration and Semantic Knowledge

Just as self-derivation through integration is not the only predictor of academic achievement, so too is it the case that academic achievement is not the only measure of semantic knowledge. Indeed, end-of-year achievement tests are administered en-mass in sometimes noisy and crowded classrooms and thus may not reflect a given student’s actual achievement. As well, they do not provide information about the broader contents of semantic knowledge, beyond the skills of math and reading.

As expected from a model of learning more broadly, performance on tasks of self-derivation through memory integration relates to individually administered tests of knowledge in a larger number and variety of domains, thus providing converging evidence of relations between self-derivation through integration and semantic knowledge. Specifically, Bauer and colleagues [12] tested the predictive utility of self-derivation through integration to six domains assessed by the Woodcock-Johnson IV tests of achievement [27]. The sample was 8- to 12-year-old children tested individually, on a Zoom platform. The specific domains of achievement tested were humanities, math, sciences, and social studies, as well as general knowledge of what and where, and passage comprehension [12]. The battery thus provided a relatively comprehensive assessment of the status of semantic knowledge.

In tests of concurrent relations, self-derivation through integration predicted 15%-36% of the variance in 8- to 12-year-old children’s performance across the domains [12]. The exception was the domain of sciences, for which self-derivation through integration was not a significant predictor. [13] extended the sample to examine longitudinal relations between self-derivation through integration and the knowledge domains in the same sample of children, across one year’s time. They combined the six individual domains into one latent factor, knowledge. Self-derivation through integration at Time 1 was a significant predictor of Time 2 knowledge. Self-derivation through memory integration at Time 1 was a stronger predictor of Time 2 knowledge (β = .43) than either age (β = .33) or memory for directly taught facts (β = .30). To date, the predictive utility of the productive process of self-derivation through integration has not been tested in the context of a larger suite of cognitive abilities known to be or logical predictors of learning and semantic knowledge. This test is the subject of the present research.

The Present Research

The major goal of the present research was to determine whether self-derivation makes unique contributions to prediction of domain knowledge and thus can be considered a mechanism of semantic knowledge development in childhood. We addressed the question concurrently and longitudinally over one year, in a sample of 148 8- to 12-year-old children. The sample was the same as tested by Bauer and colleagues [12,13]. In the prior studies, self-derivation was found to predict semantic knowledge both concurrently [12] and longitudinally [13]. In those studies, self-derivation through integration—and its attendant measures of memory for the directly taught facts on which self-derivation depends—were the only measures in the predictive models. The extension provided by the present research was to include in predictive models measures of a number of cognitive abilities that have been found to relate to self-derivation itself, both concurrently and longitudinally [8].

The specific cognitive abilities measured in the present research were (a) verbal comprehension (vocabulary, synonyms, antonyms, analogies), which often is considered a measure of semantic knowledge and even as a proxy for intelligence [28]; (b) working memory, a known correlate of academic achievement in childhood [22]; (c) visual-auditory learning, which is a measure of encoding and retention of new information, such as on which self-derivation through integration depends; and (d) visualization, a potential predictor of knowledge of math and sciences in particular. The measure of verbal comprehension was from the WJ-III; the measures of working memory, visual-auditory learning, and visualization were from the WJ-IV. In [12], verbal comprehension, visual-auditory learning, and visualization were significantly positively correlated with self-derivation through integration; working memory was not. However, they were neither concurrently nor longitudinally predictive of self-derivation when measures of directly taught facts—such as on which self-derivation through integration depends—were included in the model.

Consideration of self-derivation through integration and measures of other cognitive abilities as predictors of semantic knowledge across a number and variety of domains permits test of the major question motivating the research, namely, whether self-derivation is a unique predictor, concurrently and/or longitudinally. Based on findings from elementary classroom-based studies [10, 11], we expected self-derivation through integration to make unique contributions to variance in semantic knowledge. To our knowledge, beyond the tests to evaluate the psychometric properties of the Woodcock-Johnson measures, there have not been assessments of relations between the measures of cognitive abilities and those of semantic knowledge. The present research thus presents a unique test of this question, as well as of the question of unique prediction of the measures. The work stands as an evaluation of the potential of self-derivation through integration as a mechanism of semantic knowledge development.

Method

Participants

Participants were 148 children ages 8 to 12 years (M=10.45, SD=1.37, range=8.13-12.91 years) at enrollment. Nominally, there were 30 8-year-olds, 27 9-year-olds, 42 10-year-olds, 20 11-year-olds, and 29 12-year-olds. Most participants were recruited from a database of families who had expressed interest in taking part in research in child development. The rest were recruited through a marketing firm or by referral by participants already recruited (i.e., snowballing). The sample was 76 female (51%) and 70 male (47%); 2 caregivers did not report their child’s assigned sex at birth. The racial and ethnic composition of the sample was 7% Asian, 15% Black/African American, 1% Middle Eastern or Arab, 65% White or Caucasian, 9% multi-racial, and 3% did not report on their children’s race; 7% of the sample self-identified as Hispanic or Latinx. Ninety-two percent of caregivers had received at least some college education, and 56% of caregivers had received at least some graduate level education; 7% did not report caregiver education. All demographic information is based on caregiver report provided at Year 1 (analyses of demographic information are provided [12], and are not repeated in the present report). An additional 25 children were recruited but their data were not included because of failure to complete all four sessions across the two years of data collection (18), technical failure (3), prior participation in a related study (1), parental report of a developmental disability (2), and child-initiated request to end the session before all tasks were administered (1).

The study involved two sessions in each of two consecutive years. Within each year, the two sessions took place an average of 7 days apart (Year 1 range=6-13 days; Year 2 range=5-14 days). Children participated in Year 2 Session 1 an average of 364 days after completing Year 1 Session 1 (range=341–435 days). This study was begun during the 2020 COVID-19 related shutdown, and all data were collected online via Zoom. Written informed consent for children’s participation was provided by the children’s caregivers; children provided verbal assent. Participants were compensated with $40.00 in an e-gift card at the end of the second session at Year 1, and with $50.00 in an e-gift card at the end of the final session at Year 2. The procedures were reviewed and approved by the university Institutional Review Board.

Stimuli and Materials

At both waves of data collection, the full protocol included tests of self-derivation through memory integration, recall of directly-taught and of self-derived facts, measures of candidate component cognitive abilities, and measures of domain knowledge. Concurrent and longitudinal relations between self-derivation through integration and measures of domain knowledge were reported [12,13], respectively. The unique contribution of the present report is to augment measures from the self-derivation through integration task with measures of candidate component cognitive abilities as concurrent and longitudinal predictors of measures of domain knowledge. The current analyses thus permit examination of the unique and combined predictive utility of the entire suite of potential predictors of domain knowledge. The exception is the measure of recall of self-derived facts. As reported in [12], it was not predictive of domain knowledge and for this reason, it is not included in the present report.

Outcome Measures: Tests of Achievement/Semantic Knowledge

The outcome variable of interest was domain knowledge/ semantic knowledge. Six tests from the Woodcock-Johnson® IV (WJ® IV) Tests of Achievement and Tests of Cognitive Abilities [27] were used to measure semantic knowledge. The tests assess content knowledge in a number of different domains: (a) Test 2, Applied problems (analyze and solve math problems); (b) Test 4, Passage comprehension (use syntactic and semantic cues to provide a missing word in a text passage); (c) Tests 8a and 8b, General knowledge-what and General knowledge-where (respond to questions of the form “What would you do with a                              ?” and “Where would you find a       ?”); (d) Test 18, Sciences (knowledge of anatomy, biology, geology, medicine, chemistry, and physics); (e) Test 19, Social Studies (knowledge of economics, psychology, government, history, and geography); and (f) Test 20, Humanities (knowledge of music, art, and literature). For children in the age range of 5 to 19 years, the tests have median reliability of .76 to .92. To accommodate online data collection, the tests were rendered as Qualtrics® surveys.

Predictor Variables

For both concurrent relations at each wave of testing, and for longitudinal prediction of semantic knowledge, there were two categories of predictors: measures from the self-derivation through memory integration task and measures from the Woodcock-Johnson III and IV tests of cognitive abilities.

Self-derivation through memory integration

The stimuli were 40 pairs of related facts (hereafter, stem facts) that could be used to self-derive new facts (hereafter, self-derivation facts). All facts were true and based on pilot testing with adults, were deemed unlikely to be familiar to children in the target age range. That is, adult testing demonstrated that the facts were unfamiliar to adults and that both members of the fact pairs were necessary to support high levels of production of the self-derivation facts. Specifically, for all 40 stimulus sets, adult performance was at least two-times as high when both members of the fact pair were presented (2-stem condition) relative to when only one member of the fact pair was presented (1- stem condition). Given these findings with adults, we may logically assume that the facts also would be unfamiliar to children, and that their production of the self-derivation facts would depend on exposure to both members of the fact pairs. Consistent with this assumption, at Wave 1, across the age range and for each nominal age group (8, 9, 10, 11, 12 years), performance in the 2-stem condition was reliably higher than performance in the 1-stem condition [12]. The same effect obtained at Wave 2 [13]. Because only 2-stem performance is indicative of self-derivation through integration, in the present manuscript, all analyses are of performance in the 2-stem condition only; 1-stem condition performance is not included in the present report ([12] for analysis of relative performance in the 1- and 2-stem conditions, and evidence that self-derivation depends on integration of separate yet related facts).

An example stimulus set is provided in Figure 1. The stimuli were obtained from the Bauer Lab Integration and Self-derivation Stimulus (BLISS) bank [29] , from which the stimuli are available upon request: (BLISS bank stimulus numbers S002, S051, S055-057, S066-67, S069, S084, S086, S093, S096-97, S108-111, S113, S126-147). The stimuli also included 24 “filler” facts (BLISS bank stimulus numbers F098-102, F104, F106-107, F109-110, F119-132). Filler facts were structurally similar to the stem facts yet could not be integrated with one another to derive new facts. For purposes of the present report, the purpose of the filler facts was to permit an independent test of fact recall (see below).

Figure 1: Example stimulus set, including a pair of related stem facts (Stem Facts 1 and 2), example open-ended test questions for self-derivation and stem-fact recall, and example forced-choice test question, with sample options.

Measures of cognitive abilities

Adapted versions of four tests from the Woodcock-Johnson Tests of Cognitive Abilities were used as candidate predictors of measures of domain knowledge: from the Woodcock Johnson III [30], (a) Test 1: Verbal Comprehension, which assesses comprehension of individual words and relations among words across the four subtests of Picture Vocabulary [1a], Synonyms [1b], Antonyms [1c] and Analogy [1d]; and from the Woodcock-Johnson IV [31]; (b) Test 7: Visualization, which is a two-part test of spatial relations, requiring visual-spatial recognition (Spatial Relations [Test 7a]) and mental manipulation of two- and three-dimensional visual representations (Block Rotation [Test 7b]); (c) Test 10: Numbers Reversed, which requires the participant to listen to and then recall a sequence of digits in reverse of the order of presentation. It is considered a measure of working memory; and (d) Test 13, Visual-Auditory Learning, which requires the participant to learn and recall pictographic representations of words. It assesses long-term storage and retrieval as well as associative memory. Verbal Comprehension is considered a measure of semantic memory and thus a “crystalized” ability, whereas Visualization, Numbers Reversed, and Visual-Auditory Learning are considered measures of “fluid” abilities. Due to the online format of data collection, the tests were rendered as Qualtrics® surveys.

Procedure

At each wave of testing, children took part in two sessions conducted and recorded via Zoom. Testing was conducted by one of six female experimenters. Within a wave, children were tested by the same experimenter for both sessions. Children were tested by different experimenters at Waves 1 and 2. The experimenters followed a detailed written protocol. Consistency was assessed by regular viewing of the session recordings by all experimenters. The protocols were the same at Wave 1 and Wave 2. Both within and between sessions, the order of the tasks and tests was the same for all participants. The order of administration was determined based on pilot testing with the goals of minimizing participant burden and maximizing participant engagement. Because the order was fixed, any general or specific carry-over effects are the same for all participants. A schematic of the testing protocol is provided in Figure 2, with Session 1 in the left panel and Session 2 in the right panel.

Figure 2: Schematic representation of the testing protocol. Tests in squared boxes are from the self-derivation through memory integration task; tests in rounded rectangles with broken/dashed outlines are measures of cognitive abilities; tests surrounded by ovoids are outcome measures.

Session 1

At each wave, in Session 1, participants engaged in the self- derivation through integration task, three tests of cognitive abilities, and one test of semantic knowledge.

Self-derivation through memory integratiaon

Learning phases. At each wave, in each of two learning phases, children were exposed to 21 novel facts, for a total of 42 facts. Of the 42 facts, 20 were in a 2-stem condition, 10 were in a 1-stem condition, and the remaining 12 were filler facts. Pairs of facts in the 2-stem condition could be integrated such that participants could self-derive new knowledge that had not been directly presented (i.e., self-derivation facts). The 10 facts presented in the 1-stem condition served as a control: each fact was one half of an integrable pair and thus there was no opportunity for integration and self-derivation. As noted above, because only 2-stem performance is indicative of self- derivation through integration, in the present manuscript, all analyses are of performance in the 2-stem condition only; 1-stem condition performance is not included in the report [12,13]. Each integrable fact pair was used approximately equally often in the 2-stem and 1-stem conditions across participants. The 12 filler facts provided the opportunity to examine recall of directly-taught facts, independent of the self-derivation task.

The 42 novel facts were presented across two learning phases. In Learning phase 1, children were presented with 21 facts: the first member of 10 pairs of facts in the 2-stem condition, 5 facts in the 1-stem condition, and 6 filler facts. Children were instructed to pay attention to the facts because they might be asked some questions about them later. Facts were presented individually on the experimenter’s screen, which was shared with the participant via Zoom. The experimenter first read the fact to the child and then the child read it back to the experimenter. After all 21 facts had been displayed and read aloud, children completed the Woodcock Johnson III [30] test of Verbal Comprehension (Test 1; see below for procedure). After the test for verbal comprehension, children engaged in Learning phase 2, during which they were presented with the remaining 21 facts: 10 facts in the 2-stem condition, 5 facts in the 1-stem condition, and 6 filler facts. Participants then completed Woodcock Johnson IV [27,30] Numbers Reversed test (Test 10), as a measure of auditory working memory (see below for procedure).

In total, there were 40 pairs of related stem facts, divided into two sets of 20 pairs of related facts. At each wave, half of the participants were tested on one set of related facts and half on the other. The stem-fact sets were used approximately equally often in each wave of testing, and participants were tested on different sets of facts at each wave. Within a stem-fact set, each stem-fact pair was used in the 2-stem and 1-stem conditions approximately equally often. In the 2-stem condition, each member of the stem-fact pair was presented in Learning phase 1 and Learning phase 2 approximately equally often. Each stem-fact set was presented in one of four different random orders, each used approximately equally often across participants. Participants were pseudo-randomly assigned to one of the four orders, constrained by the need to use each order approximately equally often.

Self-derivation through integration

Test phases. Following the Woodcock Johnson IV Numbers Reversed test (Test 10), children were presented with 20 open-ended questions testing for self-derivation through memory integration: 10 questions on facts from each of the 2-stem and 1-stem conditions. They then were presented with 15 open-ended stem-fact and 10 filler- fact recall questions. After tests for open-ended recall of stem and filler facts, children were tested on any self-derivation questions answered incorrectly in open-ended testing, this time in 3-alternative forced- choice format (see Figure 1 for example open-ended and forced- choice questions). Forced-choice testing of stem and filler facts was not conducted, in consideration of participant burden.

At each wave, the order of presentation of open-ended self- derivation through integration questions was randomized in Qualtrics. As well, the order of forced-choice testing of self-derivation questions not answered correctly in open-ended testing also was randomized in Qualtrics. Open-ended testing for recall of the stem and filler facts was conducted in one of eight pseudo-random orders each of which was used approximately equally often across participants. The constraint was that stem facts from the same fact set were not tested sequentially. Across participants, stem and filler facts were tested approximately equally often. After testing of self-derivation through integration and fact recall, children completed a test of domain knowledge (WJ-IV: Test 8a) and then were administered the third Woodcock-Johnson test: Test 7a: Visualization-Spatial Relations (see below for procedure).

Woodcock-Johnson tests of cognitive abilities

Between Learning phases 1 and 2, children were tested on the WJ- III test Verbal Comprehension (Test 1a-d). Between Learning phase 2 and the tests for self-derivation and fact recall, children were tested on the WJ-IV test of Numbers Reversed test (Test 10). As the final test of the session, children were tested on the WJ-IV test of Visualization- Spatial Relations (Test 7a). The tests were administered following the WJ protocols, with test items displayed on the Zoom screen. Children’s responses were recorded by the experimenter.

Woodcock-Johnson test of semantic knowledge

The pen-ultimate task of Session 1 was a test of academically- related content knowledge WJ-IV: General Information-where (Test 8a). The test was administered following the WJ protocols, with test items displayed on the Zoom screen. Children’s responses were recorded by the experimenter.

Session 2

Session 2 took place approximately 1 week after Session 1. Children were tested for retention of the self-derived facts from Session 1, six tests of academically-related content knowledge, and two tests of cognitive abilities (see Figure 2).

Retention of self-derivation facts

At each wave, children were tested for retention of the self- derivation facts from the 2-stem condition of Session 1. However, because retention of self-derived facts was not a significant predictor of semantic knowledge [12], we did not include measures of retention in analyses.

Woodcock-Johnson tests of semantic knowledge/achievement

Six tests of achievement were administered in the standard order as indicated: Test 19: Social Studies; Test 18: Sciences; Test 4: Passage comprehension; Test 20: Humanities; Test 2: Applied Problems; and Test 8b: General Information-what. All tests were administered following the WJ-IV protocol, with questions displayed on the Zoom screen.

Woodcock-Johnson tests of cognitive abilities

At Session 2, children completed two tests of cognitive abilities (see Figure 2). Between Tests 19 and 18, children completed WJ-IV test of Visualization—Block Rotation (Test 7b). As the final test of the session, children completed the WJ-IV test of Visual-Auditory Learning (Test 13). The tests were administered following the WJ protocols, with test items displayed on the Zoom screen. Children’s responses were recorded by the experimenter.

Scoring and Data Reduction

Scoring was conducted the same way for Waves 1 and 2. For open-ended self-derivation through integration and open-ended recall of stem and filler facts, 1 point was awarded for each correct response, for a total possible of 10 self-derivation facts in the 2-stem condition, 10 self-derivation facts in the 1-stem condition, 15 stem facts (5 stem-fact pairs from the 2-stem condition [10 facts] and 5 facts from the 1-stem condition), and 10 filler facts. Levels of self- derivation performance and of open-ended recall of the stem and filler facts at Session 1 were considered as potential predictors of semantic knowledge (along with measures from the Woodcock-Johnson tests; see below). Self-derivation also was tested in forced-choice. However, because open-ended performance provides stronger evidence of self- derivation, relative to performance that also includes selection of correct responses from among distracters, in subsequent analyses, we focus on open-ended self-derivation performance only ([12], for further justification for focus on open-ended performance only).

The tests of cognitive abilities were scored as per the test protocol and standardized using WJ-III and WJ-IV proprietary software.

Results

The results are presented in four sections, starting with descriptive statistics and zero-order correlations among the variables in Section 1. Section 2 outlines the results of factor analyses to determine the number of latent factors among (a) the outcome measures of domain knowledge; and (b) the predictors of domain knowledge, namely, the (i) tests of cognitive abilities (verbal comprehension, visual-auditory learning, visualization, numbers reversed) and (ii) experimental measures of self-derivation through integration performance, and memory for stem and filler facts. In Section 3 we present the results of tests for concurrent relations among the outcome measures and the predictors at each of Waves 1 and 2. Finally, in Section 4, we present the results of longitudinal prediction of the outcome measures by the predictors from Wave 1 to Wave 2, one year later.

Section 1: Descriptive Statistics and Zero-order Correlations

Descriptive statistics for the measures of interest are provided in Table 1, Panels a and b for Wave 1 and Wave 2, respectively. For the outcome measure of domain knowledge, following [13], we report W Scores for each of the six Woodcock-Johnson Tests probing domain knowledge. W Scores represent the child’s performance on the task, based on the average performance of neuro-typical children of their age (in months). For every raw score, there is a W Score that is generated by Woodcock-Johnson Score Reports. W scores are centered on a value of 500, with a typical range on any given task of between 430 and 550. As discussed in [13], W scores represent an equal interval scale across tasks, making them particularly relevant for reporting participants’ actual growth in a measured trait [32]. For all other measures, we report proportion correct out of total trials. Initial skewness and kurtosis measures indicated that the data for all variables were normally distributed, with the exception of the Wave 2 measure of applied problems. One participant performed more than 5 standard deviations below the mean on this assessment. With the data from that participant removed, skewness and kurtosis values indicated normal distribution, as indicated in Table 1. Whether the data from this participant were or were not removed, overall results from subsequent analyses did not change.

Table 1: Descriptive statistics for outcome variables (domain knowledge) and predictor variables (cognitive abilities, self-derivation) at Wave 1 (Panel a) and Wave 2 (Panel b)

Category and Measure

Descriptive Statistics
Category Measure N Model Label Mean SD Skewness

Kurtosis

Panel a: Wave 1          
Domain knowledge Domain knowledge total

148

Total01 3020.42 80.74 -.16

.40

  General information

148

Gen01 503.51 14.19 -.274

-.214

  Passage comprehension

148

PC01 499.95 14.51 .022

-.154

  Sciences

148

Sci01 501.52 14.24 -.263

-.593

  Applied problems

148

App01 509.63 19.83 -.697

.958

  Social studies

148

Soc01 505.98 17.26 -.084

-.624

  Humanities

148

Hum01 499.83 15.75 .194

-.329

Cognitive abilities Verbal comprehension

143

VC01 107.90 10.755 .032

-.613

  Visual-Auditory learning

147

VisAud01 105.551 13.426 .007

.395

  Visualization

148

Vis01 104.541 13.543 -.029

.438

  Numbers Reversed

138

Num01 107.754 15.325 -.524

2.151

Self-derivation Open-ended self-derivation

148

SDI01 .329 .206 .354

-.423

  Stem fact recall

148

Stem01 .488 .186 .015

-.376

  Filler fact recall

148

Fill01 .567 .202 -.328

.137

Panel b: Wave 2          
Domain knowledge Domain knowledge total

148

Total02 3060.14 78.09 -.21

-.28

  General information

148

Gen02 509.19 13.13 -.075

-.158

  Passage comprehension

148

PC02 506.43 14.54 .067

.034

  Sciences

148

Sci02 507.80 13.25 -.481

-.355

  Applied problems

147

App02 517.57 16.69 -.54

.93

  Social studies

148

Soc02 513.35 16.54 -.378

-.676

  Humanities

148

Hum02 506.39 16.35 .200

-.453

Cognitive abilities Verbal comprehension

143

VC02 107.783 11.368 .066

.005

  Visual-Auditory learning

144

VisAud02 113.465 12.847 .64

.902

  Visualization

148

Vis02 105.653 14.583 .016

.056

  Numbers Reversed

143

Num02 108.329 16.369 -.109

-.31

Self-derivation Open-ended self-derivation

148

SDI02 .388 .209 .086

-.807

  Stem fact recall

148

Stem02 .533 .188 -.225

-.449

  Filler fact recall

148

Fill02 .592 .197 -.313

.011

Note. W Scores are used for all measures of domain knowledge (domain knowledge total, general information, passage comprehension, sciences, applied problems, social studies, humanities); proportion scores are used for measures of self-derivation, including stem-fact and filler-fact recall.

Zero-order correlations among the outcome variables (domain knowledge) and predictor variables (cognitive abilities, self- derivation), within and across waves, are provided in Table 2. Pearson’s product-moment correlations between the categories of predictor variables (cognitive abilities and self-derivation), within and across waves, are provided in Table 3. Pearson’s product-moment correlations within predictor variables (cognitive abilities, self-derivation), within and across waves, are provided in Table 4.

Table 2: Pearson’s product-moment correlations among outcome variables (domain knowledge) and predictor variables (cognitive abilities, self-derivation), within and across waves

Predictor Variables

Age Measures of Outcome Variables: Domain Knowledge
  Age 1 Total1 Gen1 PC1 Sci1 App1 SS1 Hu1 Total2 Gen2 PC2 Sci2 App2 SS2

Hu2

VC1

-.38 .39 .38 .37 .39 .20** .28 .40 .49 .46 .44 .41 .30 .37 .51
VA1 .01ns .42 .32 .36 .35 .32 .32 .47 .49 .42 .40 .40 .39 .35

.52

Vis1

-.09ns .24** .16* .26** .26 .22** .09ns .24** .31 .27 .24** .23** .30 .16ns .31
NR1 .09ns .20* .17* .22** .01ns .25** .13ns .20* .22** .19* .19* -.01ns .24** .18*

.22*

SDI1

.15ns .59 .54 .52 .45 .37 .52 .60 .61 .52 .50 .59 .46 .51 .61
Stm1 .20* .60 .55 .50 .49 .42 .54 .58 .62 .56 .48 .55 .47 .55

.61

Fill1

.16ns .53 .42 .50 .45 .35 .45 .56 .57 .47 .51 .56 .41 .44 .58
VC2 -.20* .55 .54 .57 .51 .30 .40 .54 .64 .61 .59 .56 .43 .47

.65

VA2

.05ns .42 .31 .38 .36 .37 .29 .43 .47 .41 .38 .44 .41 .30 .45
Vis2 0ns .30 .26** .29 .30 .27** .11ns .31 .36 .32 .28 .32 .32 .16ns

.40

NR2

.04ns .16ns .14ns .20* .02ns .22* .10ns .13ns .20* .15ns .18* .00ns .21* .19* .16ns
SDI2 .11ns .61 .46 .53 .56 .45 .55 .52 .63 .57 .49 .55 .48 .56

.62

Stm2

.06ns .55 .44 .48 .52 .38 .49 .48 .62 .57 .51 .60 .43 .50.61  
Fill2 -.01ns .52 .43 .44 .48 .31 .45 .54 .59 .54 .47 .57 .39 .48

.62

Note: Measures ending in “1” were collected at Wave 1; measures ending in “2” were collected at Wave 2. Age = participant age, Total = total domain knowledge, Gen = general information, PC = passage comprehension, Sci = sciences, App = applied problems, SS = social studies, and Hu = humanities. VC = verbal comprehension, VA = visual-auditory learning, Vis = visualization, NR = numbers reversed, SDI = self-derivation, Stm = stem-fact recall, and Fill = filler-fact recall. Unless otherwise indicated, all correlations are significant at p < .001. For other correlations, **= p < .01, * = p < .05, ns = not statistically significant.

Table 3: Pearson’s product-moment correlations between the categories of predictor variables (cognitive abilities, self-derivation), within and across waves

Measures of Self-derivation

Age Measures of Cognitive Abilities
  Age1 VC1 Vis-Aud1 Visual1 NR1 VC2 Vis-Aud2 Visual2

NR2

SDI1

.15ns .36** .30** .16* .13ns .51** .35** .27** .06ns
Stem1 .20* .35** .39** .18* .19* .42** .37** .34**

.22*

Fill1

.16ns .43** .33** .25** .12ns .49** .39** .30** .15ns
SDI2 .11ns .41** .34** .18* .14ns .48** .33** .26**

.14ns

Stem2

.06ns .45** .44** .23** .09ns .52** .42** .30** .12ns
Fill2 -.01ns .52** .42** .25** .13ns .56** .43** .31**

.11ns

Note: Measures ending in “1” were collected at Wave 1; measures ending in “2” were collected at Wave 2. Age = participant age, VC = verbal comprehension, Vis-Aud = visual-auditory learning, Visual = visualization, NR = numbers reversed, SDI = self-derivation, stem = stem-fact recall, and Fill = filler-fact recall. ** = p < .001, * = p < .05, ns = not statistically significant.

Table 4: Pearson’s product-moment correlations within predictor variables (cognitive abilities, self-derivation), within and across waves

Measures of Predictor Variables at Wave 2

Measures of Predictor Variables at Wave 1
  VC1 Vis-Aud1 Visual1 NR1 SDI1 Stem1

Filler1

VC2

.801** .48** .42** .15ns  

 

 

(See Table 3 for values in this quadrant)

Vis-Aud2 .35** .582** .32**

.14ns

Visual2

.30** .44** .71** .24**
NR2 .12ns .19* .21*

.66**

SDI2

 

 

(See Table 3 for values in this quadrant)

.537** .65** .50**
Stem2 .58** .632**

.60**

Filler2

.56**

.65**

.556**

Note: Measures ending in “1” were collected at Wave 1; measures ending in “2” were collected at Wave 2. Age = participant age, VC = verbal comprehension, Vis-Aud = visual-auditory learning, Visual = visualization, NR = numbers reversed, SDI = self-derivation, Stem = stem-fact recall, and Fill = filler-fact recall. ** = p < .001, * = p < .05, ns = not statistically significant.

Section 2: Factor Analyses

We conducted factor analyses to determine the number of latent factors among (a) the outcome measures of domain knowledge; and (b) the predictors of domain knowledge, namely, the (i) tests of cognitive abilities (verbal comprehension, visual-auditory learning, visualization, numbers reversed) and (ii) experimental measures of self-derivation through integration performance, and memory for stem and filler facts.

Outcome measures: Domain knowledge

Exploratory factor analysis (EFA) reported in [13] indicated that the six domains of knowledge formed one latent factor, thereafter referred to as knowledge. The specific procedures used to arrive at this solution are detailed in [13].

Predictors

For the Wave 1 variables, we used EFA to determine the number of latent factors formed by the tests of cognitive abilities (verbal comprehension, visual-auditory learning, visualization, numbers reversed) and the measures from the self-derivation through integration paradigm (open-ended self-derivation, stem-fact recall, filler-fact recall). The analysis was conducted using JASP software with the following settings: number of factors based on parallel analysis of factors, using the minimum residual estimation method, oblique rotation (promax), and with a factor loading cut off of .4. For Wave 2, given the absence of a theoretical expectation of a different factor structure, we conducted a confirmatory factor analysis (CFA) on the new data, using the factor structure discovered at Wave 1.

For the Wave 1 assessments, a Kaiser-Meyer-Olkin test indicated that the measures were suitable for factor analysis, with an overall MSA =.776. Bartlett’s test was significant, X2(21) = 322.33, p < .001, indicating that the data are a good fit to the factor analysis. As depicted in Table 5, two factors emerged: Factor 1 was comprised of the measures of stem-fact recall, open-ended self-derivation through integration, and filler-fact recall (hereafter self-derivation and fact recall). Factor 2 was comprised of the measures of the cognitive abilities of visual-auditory learning, verbal comprehension, and visualization (hereafter verbal and spatial abilities). The test of working memory (WJ-IV, Numbers Reversed) did not load on either factor. For the confirmatory factor analysis of the Wave 2 data, a Kaiser-Meyer- Olkin test indicated that the measures were suitable for factor analysis, with an overall MSA = .827. Bartlett’s test was significant, X2(15) = 338.269, p < .001, indicating good model fit. RMSEA = .069, indicating acceptable model fit. The parameter estimates are provided in Table 6.

Table 5: Results of exploratory factor analysis (EFA) for the predictor variables (self-derivation through integration, cognitive abilities) at Wave 1

Predictor Variables

Factor Structure
  Factor 1

(self-derivation and fact recall)

Factor 2

(verbal and spatial abilities)

Uniqueness

Stem-fact recall

0.906

 

0.215

Self-derivation

0.877

 

0.307

Filler-fact recall

0.642

 

0.468

       
Visual-Auditory Learning

0.703

0.484

VerbalComprehension

0.618

0.531

Visualization

0.614

0.687

       
Numbers Reversed

 

0.919

Note. Applied rotation method is promax.

Table 6: Parameter estimates for confirmatory factor analysis (CFA) for the predictor variables (self-derivation and fact recall, verbal and spatial abilities) at Wave 2: Factor loadings (Panel a) and residual variances (Panel b)

Factor and Indicator

Parameter Estimates
       

95% Confidence Interval

Factor

Indicator Estimate Std. Error z-value p Lower

Upper

Panel a: Factor loadings          
Self-derivation & fact recall Self-derivation

0.171

0.015 11.677 < .001 0.142

0.2

Filler-fact recall

0.143

0.015 9.695 < .001 0.114

0.172

  Stem-fact recall

0.169

0.013 13.211 < .001 0.144

0.194

Verbal & spatial abilities Verbal comprehension

8.543

0.955 8.942 < .001 6.671

10.416

  Visualization

7.008

1.297 5.404 < .001 4.466

9.55

  Visual-Auditory Learning

7.632

1.117 6.832 < .001 5.443

9.822

Panel b: Residual variances          
Self-derivation & fact recall Self-derivation

0.14

.002 6.233 < .001 0.010

0.018

Filler-fact recall

0.018

.003 7.134 < .001 0.013

0.023

  Stem-fact recall

0.007

.002 3.835 < .001 0.003

0.010

Verbal & spatial abilities Verbal comprehension

53.965

11.357 4.752 < .001 31.705

76.224

  Visualization

162.122

20.923 7.749 < .001 121.114

203.131

  Visual-Auditory Learning

105.082

15.182 6.921 < .001 75.325

134.838

Section 3: Concurrent Relations among Outcome Measures and Predictors

To examine concurrent relations among the outcome measures of knowledge and the predictors of self-derivation and fact recall and verbal and spatial abilities, we conducted Structural Equation Modeling (SEM) at each of Waves 1 and 2. At each wave, we used the two latent structures discovered using factor analyses (self- derivation and fact recall, verbal and spatial abilities) as predictors of the latent outcome variable of knowledge. We did not include the WJ-IV measure of Numbers Reversed (working memory) because, as discussed in Bauer et al. (2025), SEM modeling that included working memory was less than an ideal fit; the model without working memory was a better fitting model. Accordingly, in subsequent analyses, we used the model with only the latent constructs. At both waves, Chi-square goodness of fit tests indicated good model fit: X2(12) = 12.164, p = .433, X2(12) = 17.687, p = .126, for Waves 1 and 2, respectively. Model statistics are provided in Table 7, Panels a and b for Wave 1, and Panels c and d for Wave 2. Semi-partial R-squared values indicating the proportion of variance explained by each factor are provided in Table 8, Panel a.

Table 7: Parameter estimates for Structural Equation Modeling (SEM) of the outcome measure of knowledge with the predictor variables (verbal and spatial abilities, self-derivation and fact recall) at Wave 1: Factor loadings (Panel a) and regression coefficients (Panel b), and Wave 2: Factor loadings (Panel c) and regression coefficients (Panel d)

Factor and Indicator

Parameter Estimates

Panel a: Wave 1 Factor loadings        
       

95% Confidence Interval

Latent Indicator

Estimate

Std. Error z-value p Lower

Upper

Verbal & spatial abilities1 Verbal comprehension1

1.000

.000     1.000

1.000

  Visualization1

0.873

0.182 4.808 < .001 0.517

1.229

  Visual-Auditory Learning1

1.277

0.213 6.005 < .001 0.860

1.694

Self-derivation & fact recall1 Self-derivation1

1.000

.000     1.000

1.000

Filler-fact recall1

0.864

0.091 9.538 < .001 0.687

1.042

  Stem-fact recall1

0.959

0.082 11.650 < .001 0.798

1.121

Panel b: Wave 1 Regression coefficients      
     

95% Confidence ICnterval

Predictor Outcome

Estimate

Std. Error z-value p Lower

Upper

Verbal & spatial abilities1 Knowledge1

2.235

1.063 2.103 < .036 0.152

4.319

Self-derivation & fact recall1 Knowledge1

273.283

45.282 6.035 < .001 184.533

362.034

Panel c: Wave 2 Factor loadings          
           

95% Confidence Interval

Latent Indicator

Estimate

Std. Error z-value p Lower

Upper

Verbal & spatial abilities2 Verbal comprehension2

1.000

.000     1.000

1.000

  Visualization2

0.773

0.150 5.160 < .001 0.479

1.066

  Visual Auditory Learning2

0.852

0.133 6.400 < .001 0.591

1.112

Self-derivation & fact recall2 Open-ended self-derivation2

1.000

.000     1.000

1.000

Filler-fact recall2

0.827

0.085 9.778 < .001 0.661

0.993

  Stem-fact recall2

0.948

0.078 12.188 < .001 0.796

1.101

Panel d: Wave 2 Regression coefficients        
           

95% Confidence Interval

Predictor Outcome

Estimate

Std. Error z-value p Lower

Upper

Verbal & spatial abilities2 Knowledge2

5.284

1.609 3.284 < .001 2.130

8.437

Self-derivation & fact recall2 Knowledge2

121.647

69.387 1.753 0.080 -14.349

257.643

Note: Measures ending in “1” were collected at Wave 1; measures ending in “2” were collected at Wave 2.

At Wave 1, both self-derivation and fact recall and verbal and spatial abilities contributed significant unique variance in predicting knowledge: 33.3% and 4.5%, respectively (Table 8). Shared variance was 18.4%, bringing combined variance explained to R2 = .56. At Wave 2, verbal and spatial abilities once again contributed significant unique variance in knowledge (35.4%). However, the latent factor of self- derivation and fact recall merely approached significance, with 7.4% variance accounted for. The amount of shared variance was 27.3%, bringing combined variance explained to R2 = .70. Discussion of the most likely explanations for this pattern is reserved for the Discussion.

Table 8: Beta weights and semi-partial R2 values for concurrent predictors of knowledge at each of Waves 1 and 2 (Panel a) and longitudinal predictors of knowledge from Wave 1 to Wave 2 (Panel b)

Wave

Beta Weights   Variance Explained

Type of Variance

Wave

ß(VVA)

ß(SDI) r(VVA,SDI) R2 (total) Unique VVA% Unique SDI%

Shared%

Panel a: Concurrent prediction          
Wave 1

.212

.577 .754 .562 4.5% 33.3%

18.4%

Wave 2

.595

.272 .843 .701 35.4% 7.4%

27.3

Panel b: Longitudinal prediction        
Wave 1 to Wave 2

.379

.507 .635 .625 9.3% 15.8%

37.4%

Note: VVA = verbal and visual abilities, SDI = self-derivation and fact recall.

Section 4: Longitudinal Relations among Outcome Measures and Predictors

To examine longitudinal relations among the outcome measures of knowledge at Wave 2 and the predictors of self-derivation and fact recall and verbal and spatial abilities at Wave 1, we conducted SEM. We used the two latent structures of verbal and spatial abilities and self-derivation and fact recall from Wave 1 as predictors of the latent outcome variable of knowledge at Wave 2. A Chi-square goodness of fit test indicated good model fit: X2(12) = 12.088, p = .439. Model statistics are provided in Table 9. As reflected in Table 8, Panel b, both self-derivation and fact recall and verbal and spatial abilities at Wave 1 were significant predictors of knowledge one-year later, at Wave 2, explaining 15.8% and 9.3%, respectively. Shared variance was 37.4%, bringing the combined variance explained to R2 = .63.

Table 9: Parameter estimates for Structural Equation Modeling (SEM) of the outcome measure of knowledge at Wave 2 with the predictor variables (verbal and spatial abilities, self-derivation and fact recall) from Wave 1: Factor loadings (Panel a) and regression coefficients (Panel b)

Factor and Indicator

Parameter Estimates

Panel a: Wave 1 to Wave 2 factor loadings      
       

95% Confidence Interval

Latent Indicator

Estimate

Std. Error z-value p Lower

Upper

Verbal & spatial abilities1 Verbal comprehension1

1.000

.000     1.000

1.000

  Visualization1

0.865

0.174 4.967 < .001 0.524

1.206

  Visual Auditory Learning1

1.251

0.193 6.486 < .001 0.873

1.629

Self-derivation & fact recall1 Self-derivation1

1.000

.000     1.000

1.000

Filler-fact recall1

0.863

0.090 9.608 < .001 0.687

1.039

  Stem-fact recall1

0.949

0.081 11.675 < .001 0.790

1.109

Panel b: Wave 1 to Wave 2 Regression coefficients        
           

95% Confidence Interval

Predictor Outcome

Estimate

Std. Error z-value p Lower

Upper

Verbal & spatial abilities1 Knowledge2

3.829

1.014 3.774 < .001 1.841

5.817

Self-derivation & fact recall1 Knowledge2

231.203

40.682 5.683 < .001 151.467

310.939

Note: Measures ending in “1” were collected at Wave 1; measures ending in “2” were collected at Wave 2.

Discussion

The major purpose of the present research was to determine whether self-derivation through memory integration makes unique contributions to prediction of domain knowledge and thus can be considered a mechanism of semantic knowledge development in childhood. The question was tested in a sample of 148 children, ages 8 to 12 years at the time of enrollment. The outcome measure of semantic knowledge was based on six domains that were treated as one latent factor, knowledge: applied problems (math), humanities, sciences, social studies, general knowledge of what and where, and passage comprehension. The predictors were (a) tests of self- derivation through memory integration and memory for directly taught facts (stem facts and filler facts); and (b) measures of four cognitive abilities, namely, verbal comprehension, visual-auditory learning, visualization, and working memory. The predictors formed two latent factors: self-derivation and fact recall and verbal and spatial abilities. Working memory was not included in either factor. Children participated in two waves of testing, separated by one year.

In prior research on the same sample, self-derivation through memory integration was found to predict semantic knowledge for five of the six individual domains assessed; the exception was the domain of sciences (Bauer et al., 2024). In a subsequent test of longitudinal relations, the six individual domains were treated as one latent factor, knowledge. Self-derivation through integration predicted knowledge both concurrently, at each of Waves 1 and 2, and longitudinally over one year [13]. In a separate evaluation, measures of memory for directly taught facts (stem and filler facts) were found to be both concurrently related and longitudinally predictive of self-derivation, whereas the measures of cognitive abilities were not [8]. Based on this pattern of findings, in the present research, we expected to observe (a) separate latent factors for self-derivation and fact recall and visual and spatial abilities; and (b) that both latent factors would be predictive of knowledge, concurrently and over one year.

Consistent with expectations, at Wave 1, the latent constructs of self-derivation and fact recall and verbal and spatial abilities both were uniquely predictive of semantic knowledge. The amount of unique and shared variance in semantic knowledge explained by the factors was 56%. At Wave 2, only verbal and spatial abilities was uniquely predictive. Self-derivation and fact recall predicted a nonsignificant 7.4% of the variance in semantic knowledge. Considering the amount of unique and shared variance, the total variance explained by the factors was 70%. Notably, semantic knowledge at Wave 2 was predicted by Wave 1 self-derivation and fact recall and Wave 1 verbal and spatial abilities. Both latent factors made unique contributions to prediction of semantic knowledge at Wave 2. The amount of unique and shared variance in semantic knowledge explained by the factors was 63%.

Overall, the findings of the present research were as expected, with the exception of the concurrent test at Wave 2, in which only verbal and spatial abilities emerged as a statistically significant predictor of semantic knowledge; self-derivation and fact recall only approached significance. We attribute this pattern to the strong correlations among the various Woodcock-Johnson tests at Wave 2 (see Table 2), and to the nominal increase in shared variance of the factors at Wave 2 (27.3%), relative to Wave 1 (18.4%; see Table 8). The result was relatively less variance to be explained by the experimental measures of self- derivation. The pattern of relatively stronger correlations among the Woodcock-Johnson tests at Wave 2, relative to Wave 1 was especially apparent for the measure of verbal comprehension: at Wave 1, the correlations with the individual semantic domains ranged from rs = .20-.40, whereas at Wave 2, they ranged from rs = .43-.65. This finding is understandable in light of the fact that the Woodcock-Johnson tests were essentially identical at the two waves: the same questions were asked in the same format. The only differences were in one or possibly two additional questions posed to establish ceiling performance. Given this feature of the instrument, there was substantial shared task variance at Wave 2, likely inflating the proportion of variance in semantic knowledge accounted for by verbal and spatial abilities. In contrast, whereas the format of the tests for self-derivation and fact recall were the same at both waves, the specific items were unique at each wave.

An unexpected—yet explicable—finding in the present research was of the substantial amount of variance in longitudinal prediction shared by the latent factors of self-derivation and fact recall and verbal and spatial abilities. Whereas each factor contributed unique variance, the amount of shared variance in knowledge explained approached 40%. We interpret this pattern as a reflection of the tight relation between existing knowledge and the ability to add to it. In the present research, existing knowledge was reflected in the latent construct of verbal and spatial abilities, which included a measure often used as a proxy for existing knowledge, namely verbal comprehension. The ability to add new knowledge was reflected in the latent construct of self-derivation and fact recall, which included both memory for directly taught facts and the productive process of generating new knowledge from them. Critically, each individual construct at Wave 1 was a unique predictor of semantic knowledge at Wave 2, over and above the variance they shared. Self-derivation and fact recall accounted for a nominally greater proportion of variance relative to verbal and spatial abilities (15.8% and 9.3%, respectively)

The present research makes a substantial contribution to the literature in establishing self-derivation through memory integration as a unique predictor of semantic knowledge, at least among children ages 8 to 12 years. It is not without limitations, however. One limitation is that, based on the present research, it is not known whether the same pattern of findings would be apparent among children younger than age 8 years or among participants older than 12 years. The structure of cognitive abilities changes across the late elementary school years, with increasing differentiation of cognitive abilities from one another [33]. As such, different patterns may be expected at younger and older ages. It will be left to future research to address this possibility.

A second potential limitation is that the children were tested online, as opposed to in person. The online format may have resulted in lower performance than might be expected from in-person testing. Importantly, given that all tasks and all participants were tested in the same way, any general or specific effects of online testing would be equally distributed over the entire battery and sample.

A third potential limitation of the present research is that only one productive process was tested as a predictor of semantic knowledge. As noted earlier, self-derivation through memory integration is but one among many productive processes, including (but not limited to) analogy, induction, and associative and transitive inference [1,4, 34]. It is possible that one or more of these processes also may account for unique variance in semantic knowledge. This question has yet to be tested empirically in children. Among adults, self-derivation through integration has been found to be uniquely related to academic achievement relative to other paradigms that test productive processes [35]. Importantly, finding that other productive processes also predict semantic knowledge would not undermine the importance of self- derivation through memory integration as a mechanism of semantic knowledge development. Rather, it would establish a larger suite of productive processes on which knowledge expansion depends.

In conclusion, in the present research, we tested self-derivation through memory integration along with measures of other cognitive abilities, as concurrent and longitudinal predictors of semantic knowledge. Both factors were found to be concurrent predictors at Wave 1. Critically, both factors as measured at Wave 1 predicted semantic knowledge at Wave 2. The work thus establishes self- derivation through memory integration as a unique longitudinal predictor of semantic knowledge in childhood. As such, it can be considered a mechanism of semantic knowledge development.

Acknowledgement

Support for this research was provided by NICHD R01 HD094716 to Patricia J. Bauer. The authors also thank Britney Del Solar, Jessica Dugan, Melanie Hanft, and Alissa Miller, for their help with data collection and reduction, and other members of the Memory at Emory laboratory group for their help at various stages of this research, and the children and families who so generously gave of their time to take part in this research.

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Gender, Care, and Mobility: A Practice Approach

DOI: 10.31038/AWHC.2026912

Introduction

Mobility practices have been understood as practices that consume distance [1]. This research note investigates the gender dimensions of mobility practices and their components, as well as their links with sustainability issues. Particular focus is given to car commuting. The context studied is Belgium, a federal country comprising three regions – Flanders, Wallonia, and Brussels – each of which has competence in housing, mobility, and other socio-economic matters. Regarding mobility, rules, signs and even city names can vary between regions, meaning commuters effectively commute between different mobility systems.

In Belgium, most people are mobile (making at least one trip on the reference day): in 2024–25, the average number of trips per day is 3.53 for men aged 18 and over and 3.30 for women of the same ages, with 85% and 82% of men and women respectively making at least one trip on the reference day (Service Public Fédéral Mobilité et Transports, 2025a: 6–7). Most round trips are made mainly by car, with little difference by gender (61% for men and 59% for women). However, women walk slightly more often (23% versus 20% for men) and use local public transport (bus, tramway, or metro) more frequently (6% versus 4%). Meanwhile, men cycle more often (12% versus 10%) and use the train slightly more frequently (3% versus 2%) (Ibidem: 11). Almost four-fifths (78%) of the total daily distance is travelled by car for both men and women (Ibidem: 12). This figure has remained stable for 25 years, despite the increase in cycling (Ibidem: 28). However, men spend more time on daily travel (69 minutes) than women (60 minutes) (Ibidem: 13).

Conceptual Framework: The Social Theory of Practice

As car is the main mode of transport, let us focus on the practice of commuting by car, with reference to the sociological theory of practice. Its main author ([2]: 89) defines a practice as both a performance and a coordinated entity. For him, practice as performance ‘denotes the doing, the actual activity or energization, at the heart of action […] and reminds us that existence is a happening taking the form of a ceaseless performing and carrying out’ ([2], 90). As coordinated entities, practices are ‘open spatial-temporal nexuses of doings and sayings that are linked by arrays of understandings, rules and end-task-action combinations (also emotions and even moods) that are acceptable for or enjoined of participants’ ([3], 15). A practice as a coordinated entity is thus a pattern for action. Understandings refer to the know-how and competences needed to carry out the practice, as well as the mental and bodily routines involved. Rules are explicit, such as ‘principles, precepts, instructions, and the like [which] means that people take account of and adhere to these formulations when participating in the practice’ ([2], 100). Previously, rather than ‘end-task-action combinations’, Schatzki writes about ‘teleo-affective structures’, which he defines as ‘embracing ends, projects, tasks, purposes, beliefs, emotions and moods’ ([2], 89). [4,5], and the same later together with Watson ([6], 82) define materials as a component of a practice. As material arrangements and infrastructures are of special interest for mobility studies based on practice theory, they are included in this research.

When applying the practice theory framework, the practice under study – in this case, commuting by car – is considered the unit of analysis rather than the commuters themselves and their individual characteristics that could explain their behaviour. To understand the difference between a practice and behaviour (as studied in economics, psychology, and geography), it is helpful to make a comparison: behaviour (such as a car journey) is like the visible part of an iceberg, whereas the components of a practice – the understandings, rules, teleo-affective structure, and material arrangements – are the submerged part of the iceberg. Therefore, to understand and possibly change a practice, these components must be studied. The components of the car commuting practice are described in section 4 below. The data and methods used are presented in the following section.

Data and Methods

Along with published statistics, data come from two dozen in-depth interviews conducted with car commuters during the spring of 2022 and 2023. In spring 2022, fuel prices were high. The interviewees represented a variety of ages, genders, locations and car types, whether private or company-owned.

In-depth interviews resemble a conversation between familiar acquaintances, but the interviewer should not know the interviewee beforehand [7]. Open-ended questions allow the interviewee to express themselves, and many follow-up questions help to create empathy. Most interviews were conducted face-to-face, with only a few conducted online by my appropriately trained students. The interviews lasted between 35 and 75 minutes. To ensure comparability between the interviews, a common, detailed interview guide was developed.

All interviews were recorded and then fully transcribed. Based on a content analysis, they were analysed using a common framework based on the concepts of practice theories, particularly to describe and compare the four components that underpin commuting to Brussels by car, whether private or company. Parts of the analysis are derived from [8].

Results

Rules

The company car system replaces part of an employee’s salary by providing them with a car as a form of payment in kind, which they can use for work-related reasons or otherwise [9]. The system has existed in Belgium since the 1970s, and since the 1990s, the company car has often simply been a ‘wage car’. In practice, the company car system is a legal tax avoidance scheme from which both the employer and the employee benefit [9,10]. This form of remuneration is unfair, particularly from a distributional perspective, as neither the employee nor the employer pays tax on this portion of their wages, resulting in the state losing out on tax revenue. In 2007, 272,000 company cars were granted to 7.4% of employees, and this figure increased by around 5% each year, reaching 627,600 cars granted to 14.9% of employees by 2025. However, both figures remained stable between 2024 and 2025 ([11]: 3).

Company cars were more often provided to men in 2010 [9] and 2021 [12]. Among employees with the right to alternative financial benefits in 2023, 16.67% of women have a company car for private use, compared to 27.99% of men ([13]: 34). However, these figures should be adjusted for other factors. For example, it is well established that company cars mainly benefit higher earners (Ibidem, 36), raising issues of social justice [14]. Additionally, women tend to earn less than men. Controlling for income decile, sector of activity, age group, number of workers, and status (white- versus blue-collar), men are 1.85 times more likely than women to have a company car for private use ([13]: 77).

Since 2019, the mobility budget has set new rules to correct the fiscal advantages of company cars. It proposes alternatives to employees in the form of in-kind benefits, such as a budget for public transport, electric scooters or bicycles, smaller and less expensive company cars, and, under certain conditions, a housing cost contribution. The mobility budget can also be used as a wage supplement for the remaining part, if any [15]. Although the adoption of the mobility budget has been slow, it is increasing. Most beneficiaries choose other benefits over a company car. In 2022, there were 4,865 beneficiaries of a mobility budget who did not receive a company car. This figure increased to 9,592 in 2023 and 17,157 in 2024 ([11]: 4). In 2023, 60% of all beneficiaries of a mobility budget were men, enjoying an average financial advantage of €7,263, while 40% were women, enjoying a lower advantage of €6,660 [13]: 46). Thus, among employees granted a company car or a mobility budget, women are more likely to choose a more environmentally friendly option.

Material Arrangements

As [8] describe in detail, there are some significant material differences between commuting by private car and commuting by company car: the characteristics of the car used – company cars are generally larger and more powerful than private cars ([16]: 8), places for refuelling and repairs (specific garages for company cars). Although the same network of highways and roads is used, commuting with a company car involves longer journeys. Company cars are often granted a ‘free’ petrol or diesel card. To the best of my knowledge, there are no gender-specific statistics for any of these aspects.

Company cars offer better protection in the event of a road accident [17]. Women are less likely to be involved in road accidents than men at all ages below 65. As ([16]: 15) shows, men driving company cars are much more often involved in road accidents than men driving private cars, especially between the ages of 25 and 59. The figures are more similar and lower for women, except after the age of 55, when there is a higher incidence of road accidents involving women driving private cars. Regarding accidents involving bodily injury, 3.8 deaths occur among occupants of company cars compared to 8.8 in private cars. However, company cars cause more serious damage to third parties: 6.8 deaths as opposed to 5.0 deaths caused by private cars ([16]: 16). There are no gender-specific statistics regarding injuries.

Understandings

No difference in driving or navigation skills was found among our interviewees of different genders. Among those who commute by private car, men may have more knowledge and practice of economical driving, although our sample is too small to be conclusive in this respect. Those commuting by private car are more familiar with public transport alternatives than those travelling by company car, but there is no gender difference in this regard.

Some pragmatic versatility – taking the train once in a while for example – is shown by several women of all ages among our interviewees and by a few young men, whether they use their private car or a company car. Women thus seem to have more environmentally friendly practices than men, but this should be confirmed, or not, with a larger sample size.

Teleo-affective Structure

Autonomy, social success, efficiency, and safety are the four values structuring the practice of commuting by car. All are enhanced if commuting by company car.

Women place greater importance on flexibility and time-saving when using a car. In particular, the mothers in the sample consider the car to be essential for fulfilling their responsibilities, such as taking the children to school or their activities. [18] also highlight the dependence of mothers on cars for childcare-related tasks. Therefore, gender roles also structure mobility practices.

In addition, women attach greater importance than men to the fact that the car provides a sense of security, particularly at night and/or in areas deemed insecure, such as near large train stations.

Concluding Discussion: Gender and Environmentally Friendly Practices

As this research shows, women are less likely to have powerful vehicles or SUVs than men because they are less likely to benefit from a company car. Furthermore, when given the option of a mobility budget, women are more likely to choose this than men. Additionally, women appear to demonstrate greater pragmatic versatility, such as occasionally taking the train, than men, although this result requires confirmation with a larger sample size. Thus, women appear to engage in more environmentally friendly practices than men. However, in order to fulfil their gender role as mothers, women rely on cars, which are seen as a necessity. According to [19], representations of gender roles relating to obligations towards children and family are stronger for mothers than for fathers.

MacGregor analyses the increased gender differentiation in institutional and individual responses to climate change both as ‘a masculinization of environmentalism’ and what she calls ‘ecomaternalism’ ([20]: 128, 136). For her, “[i]n so far as consumption is a private sphere activity, and women tend to be principally responsible for household consumption, it is likely that exhortations to ‘live green’ are directed at (and will be received primarily by) women. Men may hear them, but expect women to do the work” ([20]: 134). Her examples are conserving energy, taking public transportation, recycling waste and avoiding flights.

[21] in the UK and [22] in Belgium found that women engaged in more ‘green’ practices than men. Men use more energy than women, particularly in terms of mobility and meat consumption [23]. When it comes to changing practices, [24] notes that ‘the lifestyle changes were gender-biased, with the women as driving forces but also bearing most of the extra workload’.

More sustainable mobility practices, by train or by cycling for example, were also found to be ‘compensatory practices’: some mothers reported that they could only compensate the lack of environmentally friendlier actions of their family members by changing their own practices, here for their daily trips. [25].

Overall, a practice-based approach to car commuting, combined with a gender analysis, has yielded significant findings. While women may exhibit certain mobility practices that are slightly more sustainable than men, even in the case of car commuting, for care-taking trips, cars remain a crucial necessity. The apparent conflict between caring for children and caring for the environment is thus a salient concern.

In the future, more statistics on mobility should be published by gender. Further research on a larger sample would be necessary to investigate knowledge of and practice in economical driving, pragmatic versatility, and the material arrangements and policies governing compatibility between caring for others (namely children) and caring for the environment [26,27].

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Planning for Women’s Health and Wellbeing in the City: the Birmingham for People Women’s Group

DOI: 10.31038/AWHC.2026911

Abstract

The impact of the built environment on health outcomes has been long recognised [1,2], however the gender dimensions of this remain underexplored. This article uncovers the hidden history of a group of women who came together in Birmingham (England) in the 1990s to campaign for a city that would suit the needs of women. This summary of the women’s work highlights the need, then and now, for women’s views to be taken into account in the planning process. This experience shows that including women’s voices in the planning system is not only vital to ensure women’s equal access to public space, city resources and opportunities, but also has potential health benefits. We highlight two aspects of their work relevant to health: the importance of safety in urban planning, and the importance of women’s collective involvement in decision-making for positively reinforcing their self- confidence, well-being and mental health.

Keywords

Community-led planning, Women’s histories, Urban planning, Feminist planning, Health, Wellbeing; Participation

The impact of the built environment on health outcomes has long been recognised. As long ago as 1898, with the founding of the Garden City movement, Ebenezer Howard was advocating for an antidote to the ‘dark satanic mills’. Fast forward to this century and the Marmot review reinforced the role of the built environment in promoting or restricting healthy lifestyles [2]. However, the gender dimensions of the impact of planning and the environment on health and wellbeing remained underexplored (Brennan undated;[3]). This is despite research which highlights the differential experience of the built environment between men and women [4-6] and despite decades of action by women to improve urban spaces [7,8]. This piece reveals the hidden history of one such group and the relationship between two aspects of their work and public health impacts.

In the 1990s a group of women came together in Birmingham (England) to campaign for a city that would suit the needs of women. Central to their work was an emphasis on safety, in the context of the city that had been redeveloped in the 1970s on the model of the male commuting businessman, rather than to meet the everyday needs of the women who lived and worked there. This was manifested most prominently in the dangerous and disorienting subways that pedestrians had to access up and down steps in order to reach the city centre, going under the urban motorway Ring Road that encircled it. Recent reports have highlighted the impact of unsafe spaces on women’s physical and mental health [9,10], but women have been aware of this for decades. From 2022-2024 we conducted historical and archival participatory research unearthing the work in the 1990s of Birmingham for People (BfP) Women’s Group, as part of the Spaces of Hope project that explored the hidden histories of community-led planning across the four nations of the UK [11,12]. The built environment is an upstream determinant of health and this summary of the women’s work highlights the need, then and now, for women’s views to be taken into account in the planning process. It also highlights the importance, further downstream, of women being given a voice in the context of collective activism for their health and wellbeing.

BfP Women’s Group emerged from a broader community campaign called Birmingham for People who were campaigning for a more people-friendly redevelopment in Birmingham City centre. Whilst this brought together a committed group of planners, architects, market traders and community organisers, the women in the group realised at the very first meeting in 1989 that their voices and needs were not being heard. In response they set up a sister group which for the next five years worked relentlessly to push for women’s needs to be recognised and met by the city planners. Women across the UK had already begun to fight for women’s voices and needs to be included in a planning system that was typically gender blind, with a negative impact on women’s access to and experience of public space [4-6,13]. This led to the emergence of a Women in Planning movement in the mid 1980s, was manifested in the establishment of bodies such as the Women’s Design Service (WDS) in London in 1987, and the inclusion of Women’s Committees and Women’s Units in the more progressive Local Authority planning departments, including in Birmingham.

Right from the beginning women’s health and wellbeing were central to BfP Women’s Group’s work, which was evident in their key focus on safety campaigns, as well as pushing for the spaces that women needed. So, on the one hand they focused on making the city’s public spaces and transport safer for women, such as calling for the subways, multi-storey car parks and bus stops to be better lit; and on the other hand they attended to the embodied needs of women, pushing for more breast feeding areas and more public toilets (see Figures 1 and 2).

Figure 1: Cover of BfP Women’s Group’s report on women’s public toilets in Birmingham. Courtesy of BfP Women’s Group.

Figure 2: Birmingham for People News promotes the women’s group’s work. Courtesy of Birmingham for People Group.

One BfP Women’s Group member, Tonia Clark, explains how the focus on safety incorporated both the physical and emotional, and was connected to women’s typical role as carers,

“We did a lot of work on community safety – both feelings of safety and the changes needed to the built environment to make them actually safer. This was central to health in terms of a lower risk of attack or rape. We looked at physical space in terms of safety and I think feelings of wellbeing were part of this. When women have a voice in planning and in urban design they will design spaces that improve wellbeing – partly I think because of their need to create positive spaces for their children and dependent elders.”

From the start it was apparent that as well as making demands for a more women -friendly built environment, the processes of involvement and advocacy brought other benefits, both with potential health impacts. Karen Garry was the first paid worker for the group, and the central remit of her job was to build relationships with the City Council and influence council policies,

“it was a fabulous first job out of university for me… here was a chance to be right in the middle of my city. You know, I was really, really very passionate about it.”

At the time the City Council was pedestrianising the main streets in Birmingham, and BfP Women’s Group looked at women’s physical access around Birmingham city centre, particularly thinking about women with children and push chairs, which also worked to improve access for people using wheelchairs.

Karen worked with the council’s Community Safety Unit and the planning and architecture department, supported by the council’s newly-established Women’s Unit. Through this she made contact with Jeanette Arregger, who was seconded from the council as a community architect, and together they worked on the Bloomsbury estate in Nechells, a housing estate undergoing regeneration. Karen describes it as,

“a typical 1960s estate. Lots of dead end alleys, lots of overhanging bushes. Lots of lighting that’s not working. Lots of steps, lots of underpasses”

The estate already had a resident-led management board, but again dominated by men, so Karen and Jeanette pulled together a group of women residents on the estate, which became the Safe Estates for Women (SEW) group,

“We walked around the estate, and the women mapped it, and they said these are areas that we go to, these are areas that we don’t go to. This is where we’ll let our children play. And they did it from their point of view. They also identified their desire paths” (Karen).

To ensure the women’s views translated into action, Karen and Jeanette built strong relationships between SEW and the City planning department, as well as with local service providers such as the police, the council’s Community Safety Unit, Highways, Lighting and Maintenance teams and with Councillors, who they showed round the estate, “going around with clipboards, finding all the nasty areas on the estate that were just unsafe basically” (Jeanette). The relationships were built over several years and the women had a hotline to the relevant bodies to report issues, “they used to report lights going out and uneven paving slabs and all that tasking kind of thing. And they did get changes on the estate as a result of their work” (Karen) (see Figures 3 and 4).

Figure 3: Women residents auditing the Bloomsbury estate. Photo courtesy of Jeanette Arregger.

Figure 4: The Bloomsbury estate women residents and BfP Women’s Group photographed unsafe areas of the estate. Photo courtesy of Jeanette Arregger.

The methods used on the estate were developed into a Safety Audit tool that was then used by women across the city to gather evidence about their environment and lobby for change. The work of SEW on the estate also led to the setting up a more strategic city-wide body called the Women’s Safety Initiative (WSI). Karen convened its Women and Safety in the Built Environment Task Group, which brought women representing various bodies across the city together, including the City Planning Department, the voluntary sector, the Police Community Safety Unit, BfP Women’s Group, SEW and the West Midlands Passenger Transport Executive. This cross-sectoral group was able to effectively push for women’s perspectives to be taken on board in policy decision-making. Thus they had influence on city-wide issues such as anti-social behaviour, police safety initiatives and planning issues such as improved design and pedestrianisation, ultimately contributing to the break up of the Inner City Ring Road with surface-level crossings. BfP Women’s Group also benefited from a grant from the Home Office Safer Cities project, set up in 1988 by the Conservative government and launched in Birmingham with a £250,000 budget for three years to fund crime prevention schemes, a multi-agency approach and to work with existing locally-run schemes (see Figure 5).

Figure 5: Birmingham for People News, publicising the women’s work for the Forum on Women’s Safety and SEW, supported by the Home Office Safer Cities project. Courtesy of Birmingham for People Group.

The building of relationships, between BfP Women’s Group and the residents, between residents and the relevant authorities, and between the city partners, took time, which was in part about building trust and confidence. Karen says of the women residents in Nechells, “It took time for that to build up really, for the women to have confidence”. BfP Women’s Group even fundraised for one of the residents, Jo Townsend, to present their estate work as a case study at a conference in San Francisco. Jo describes how important this was for her self-confidence,

“I’ve never flown before…For me personally, it was quite amazing. It was another building of confidence moment because of getting up and speaking in front of people… it was a really big step for me… quite nerve wracking. But it definitely helped build my confidence”

The BfP Women’s Group members also spoke of how important their work was for positively reinforcing their self-confidence and well-being, and indeed how important community activism is for women’s health in general. Polly Feather, a volunteer, says

“My over-riding belief is that most forms of community and grass-roots engagement and activism, where people who perceive themselves as being ‘without a voice’ do actually acquire a voice and make themselves heard, are health-giving to those involved. By ‘health’ in this context I mean mostly mental health. Any improvement in self- esteem and self-confidence is by definition a strengthening process, even leaving aside the possible beneficial outcomes that the activism has been aiming for. These ideas apply particularly to women’s activism. Hence I believe that for myself, getting involved in campaigning for change in the attitudes and practice of the world of Planning and the Built Environment was a much healthier behaviour than not engaging and feeling frustrated, ignored & dismissed. I think others in the BfP Women’s Group would subscribe to this view too.”

Through her experiences as a community architect on the Bloomsbury estate, Jeanette Arregger joined BfP Women’s Group as a volunteer, and she reflects on the importance of being part of a women-only group for her health. Throughout her career she had undiagnosed ADHD and says she struggled to make her voice heard, especially in groups and committees, and in the context of a male- dominated patriarchal society,

“I was terrified of saying the ‘wrong thing’ and found those situations extremely stressful. Birmingham for People Women’s group offered a supportive group where my ideas were listened to and taken seriously. Knowing that the group supported my ideas gave me the confidence to set up the Women’s Safety Group in Nechells with their help, and to promote the Women’s Safety Group at the Bloomsbury Estate Management Board and the Heartlands Development Corporation. With both organisations, I had to attend all male or male dominated meetings and raise issues that were not necessarily prioritised. So having a supportive group behind me encouraged me to promote other women too. My mental health must have benefitted from their support as my role as Community Architect was quite an isolated one. As the BFP Women’s Group grew in stature we were able to attract interest from the planning department and West Midlands transport and were included in consultation. We interviewed Les Sparks, head of Planning at Birmingham City Council, for a video and were able to influence the renewal of the City Centre that all added to the strength and status of the group and individuals in it. The support of the group extended to long term friendships and Karen Garry was a really great and supportive friend to me. I think that having a “cause” to fight for brought us closer as a group.”

This highlights the affective dimension of being part of a supportive group, particularly important to consider in the context where a person’s identity (in this case as a woman) is not the model upon which decisions are made. It also has crucial impacts where your positionality (such as being a woman, living in poverty or suffering a health condition) can erode your mental health and confidence to speak out. This was evident as Jeanette describes how the Bloomsbury women residents who joined SEW also benefitted from the support of a local group where they felt safe to express their feelings and personal situations, as well as their opinions about the public good,

“where they could discuss their fears and problems with negotiating the immediate environment and their frustrations with getting their voices heard by the local authority. One woman who was disabled could not use a bath and the local authority didn’t want to remove the bath as a future tenant may need it. We were able to negotiate with them to get her a shower. Some of the women who joined the group struggled with poverty and ill health and the isolation of living on a large housing estate, but gained confidence and optimism from being listened to and seeing small improvements being made to their environment. One woman volunteered to take the minutes of the meetings and as a result grew in confidence enough to apply for and get a job at the Development Corporation.”

Several of the women went on to take what they had learned with BfP Women’s Group into other workplaces, some specifically in health, such as Karen,

“it was a fantastic opportunity, it opened my eyes to all sorts of possibilities around people having a voice and being able to influence things and that’s never gone away for me. After Birmingham for People, I worked on a regeneration project in inner city Birmingham, City Challenge, on the health side of one of those massive area regenerations that happened in the early ‘90s. And currently I am working in an NHS environment on still the same topics, really”

The work that Birmingham for People Women’s Group did clearly centres safety in urban planning as a crucial upstream determinant of women’s health, and the importance of understanding health inequities in relation to gender, as well as to disability and class. Further downstream, the importance of women having a voice, being involved in activism and decision-making, and being part of a women’s group in order to further such participation, is also crucial for positively reinforcing self-confidence, mental health and wellbeing. Creating the conditions to enable participation as a way to address health inequities is increasingly being recognised by both researchers and public health agencies [2,14]. And, as the women’s work here indicates, integral to creating those conditions is understanding the ways in which gendered and other marginalised identities can be better enabled to participate. We need to learn the lessons from these types of projects and carry them forward, as well as continuing to engage in more research focusing on the relationship between women’s health and the built environment, and women’s health and their participation in community activism and public-health decision-making.

Acknowledgements

The Spaces of Hope research was funded by an AHRC grant number AH/T00729X/1

Thanks to all the women who participated in the Spaces of Hope research, including Jeanette Arregger, Tonia Clark, Polly Feather, Mary Fielding and Jo Townsend. And special thanks to Karen Garry who made a crucial and exceptional contribution to the BfP Women’s Group. Karen sadly died last year.

No conflict of interest.

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Parents, Individual, Teachers and Others (PITO) Theory of Human Development, Attachment and Overall Well-Being/Ill-Being

DOI: 10.31038/PSYJ.2026811

Abstract

Generally, theories of wellbeing exert that people desire what they value and are happy when they achieve it. In Parents, Individual, Teachers and Others (PITO), it may be difficult for one to have a desire not connected to the person’s early and present attachment and what happens throughout the various stages of development. Thus, most people desires are linked to their yearning to satisfy others based on the attachment shared by them and their intended satisfaction which may yield a positive or a negative outcome to them and others at the long run. Positive outcomes promotes healthy/happy (PITO positive) whereas, negative outcomes aid unhealthy/unhappy (PITO negative) individual.

Keywords

Overall wellbeing, Human Development, Attachment and PITO.

Introuction

The theory focused on every facet of human development in relation to early attachment through parents/primary caregivers and children and their interaction with others and teachers to energize well-being or emotional/mental disorder (ill-being). Before the author proceed, it is pertinent to acknowledge that many theorists have done noble in the field of human development, attachment and overall wellbeing as demonstrated below: Piaget [1] demonstrated that people move from one stage of development to another just like many other human development theorists. In addition, this new theory exerts that people move from one facet of development to another in upward (stages) movement as indicated by Piaget and others, although there are presence of PITO at every stage of development. For instance, at birth there are presence of parents/caregivers, the individual in question, teachers and others who contribute to one’s development irrespective of the stage. Some theories of attachment were reviewed hence, most of them suggest three main types of attachment: anxious, avoidant and secure. Erikson [2] opined that during the first year to a year and a half of life the most important goal is the development of a basic sense of trust in one’s caregivers. In addition, Bowlby [3] an evolutionary theorist of attachment suggests that children come into the world biologically pre-programmed to form attachments with others because this will help them to survive. One thing that is common among the attachment theorists is that the early interaction with caregivers forms a continuum for emotional regulation to be secure, anxious or avoidant. Thus, being secure may amount to wellbeing while being anxious and avoidant may suggest ill-being.

Further, the concept of overall wellbeing is a composite mix of a person’s economic, mental, emotional, physical, spiritual and social health factors. Wellbeing is how one feels about his/herself and life. Wellbeing is seen from the stance of hedonism, desire satisfaction views and objective list views. Parfit [4] holds that we intend to desire what we regard objectively as worthwhile and intend to be happier when we achieve it. Maslow [5] described “wellbeing” with his characteristics of a self-actualized person. The author looked at some modern theories of overall well-being such as: Ryff [6] who opined that psychological wellbeing consists of self-acceptance, positive relationships with others, autonomy, environmental mastery, a feeling of purpose and meaning in life, and personal growth and development. Positive Emotions, Engagement, Relationships, Meaning and Accomplishment (PERMA) Theory of Well-Being [7]: A prominent model in positive psychology that identifies five essential, measurable elements for human flourishing:

  • Positive Emotions: Experiencing feelings like joy, hope, and inspiration.
  • Engagement: Being completely absorbed in activities that draw on one’s interests and skills (the “flow” state).
  • Relationships: Having strong, positive social connections and support systems.
  • Meaning: Serving a purpose or cause perceived to be greater than oneself.
  • Accomplishment: Pursuing success, mastery, and achievement for its own sake.

Also “Having, Loving, Doing, Being” Theory [8]: A needs-based theory that integrates psychological, sociological, and philosophical traditions by proposing four fundamental dimensions to human existence and well-being:

  • Having: Meeting physical and material needs (e.g., health, income, safety).
  • Loving: Fulfilling social needs, relatedness, and inclusion.
  • Doing: Exercising agency, autonomy, and competence through goal-oriented action.
  • Being: The subjective experience of life, including positive affect and overall life satisfaction.

Homeostasis Theory of Well-Being [9]: This biological and psychological theory posits that subjective well-being is a homeostatic process, where internal psychological mechanisms work to maintain well-being within a normal, stable range despite external life events. Despite the fact that existing theories of overall well-being as enumerated above have done a lot in the above discourse, the present theory has identified another shift in understanding overall well-being. Hence, below is PITO fully demonstrated:

Oeuvre-The Body of Work

This theory: Parents, Individual, Teachers and Others (PITO), proposed four main dimensions of human development, attachment and overall well-being namely:

  1. The parents or the primary caregivers (P).
  2. The individual in question from conception through birth to adulthood/death (I).
  3. The teachers at different stages and levels of the individual’s development (T).
  4. The other players which involve the society, religious affiliations, schools, peers, family, social media, etc, (O).

The figures below illustrate rectangular inter-related structure of human development, attachment and overall well- being (Figures 1-3):

With the above diagrams the following combinations are possible which further buttress overall well-being/ill-being however, the theory focuses on 1st combination PITO (PITO/PIOT = 1/2, IPTO/IPOT =3/4, TOPI/TOIP = 5/6 and OTPI/OTIP = 7/8).

Figure 1: A diagram demonstrating how PITO forms a rectangular shape Which either brings PITO positive or PITO negative.

Figure 2: A diagram showing the parallel nature of parents and individuals and also how attached they seem to be without the influence of T and O.

Figure 3: A diagram illustrating the parallel nature of teachers and others and how close they seem to be without P and I.

Parents

The first line in the above diagram in Figure 1 symbolically represents the parents (P) of a child because even before any individual is conscious of his or her existence, the parent(s) has identified a growing being which is expected to be nurtured right from the moment of conception till death. This is a unique and core role in developmental process. The P is the first lengthy line which equally represents the enormous roles being shouldered by parents/primary care givers toward their children or wards. Most of these roles are meant to be positive in order to nurture a well developed, bonded and well nurtured individual. This can be achieved through P’s inter-relationship with the other dimensions (I, T, and O) of the rectangular shape. From the time of conception onward, the parents have a parallel association with their offspring. But because of the relative absence of line T (Teachers) and line O (Family, School, social media, etc) in the rectangular shape at very early stages of development, line P(Parents) and I (Individual) are very close which prove the existence of bonding (attachment between parents and children). However, owing to the choices of the parents/caregivers, the bond experiences pressures from lines T and line O which widens the attachment. The parents/primary caregivers’ choices of the kind of environment to bring up the child, invariably houses the kind of schools, teachers, peers, social media links, etc the child will interact with. These choices have a lot to do with the child development, attachment and overall well-being. When these choices are right they improve the development, attachment and overall well-being despite their weight on the early attachment between parent(s) and children. Conversely, when these choices are wrong, they will hamper the development, attachment and overall well-being of the individuals owing to the gap orchestrated by Teachers and Others which may weaken the attachment established very early in life between parent(s) and children. The parents (P) symbolically represented by the first lengthy line of a rectangle have enormous roles in the development, attachment and overall well-being of their children even before these children realize it. The choices the parents make toward their children in terms of Teachers and Others may make or mar the children development, parent to child attachment and overall well-being.

Individual

Line I in the diagram in Figure 1 symbolically represents the individual. Human development starts from conception but along the line, the individual through innate tendencies and learning gain consciousness and insight into his/her existence. First, the child feels warmth being provided for by the parents/primary caregivers. The individual represent the second lengthy line of the rectangle, which suggests that the child has enormous roles in what he or she becomes in life. Again, these two lengthy lines of a rectangle (P and I) in the absence of the two short lines (T and O) are adjacent to each other and without any gap felt in between yet they are parallel which means they cannot meet. The closeness suggests that bonding is taking place between parents and children, starting from conception till the moment the choices of the parents in terms of T and O begin to exert their influences on the existing attachment which then widen the gap between parents and the individual. Being exposed to these influences from P, T and O, the child is then what he or she makes of the interactions with his/her environment.

Teachers

The first short line T in Figure 1 of the rectangle symbolically represents Teachers. In human development, attachment and overall well-being, P and I seem to have bigger influence because they direct T and O. However, in this discourse, teachers were singled out because people have very close attachment with their teachers after the parents due to the number of days/hours and years they spend with a single teacher and every other teacher very far into their development. Teacher in this write up include both those met in the formal learning and informal learning (e.g. class room teachers and skill acquisition teachers). What the teacher hands over to the child has a long way in influencing the child’s development, the kind of teacher/student attachment in place influences the child’s overall well-being. In as much as teachers exert huge influences on the students, such may be controlled by the choices of the kind of teachers the parents and the individual make for themselves. Interestingly, not minding the kind of teacher in question, the parents and the child who ordinarily will not meet because they are parallel will then meet at one side through the help of the teachers. In other words, there could be a closure of the inter-relation at one side of the rectangle based on the quality or dearth of quality teachers.

Others

The second short line O in Figure 1 of the rectangle symbolically represents others (society, family, relatives, peers, schools, social media, religious beliefs, etc).In human development, attachment and overall well-being, line O (others) is adjacent to line T, which suggests that they are parallel in nature also and they are equally very close without line P (parent) and line I (Individual). This suggests that they are both separately and jointly powerful in shaping human life since they exist even before the birth of an individual. As a child develops, the various choices of the parents concerning the kind of society to train the child, shapes the individual’s life through development. Others such as the kind of religious affiliation children are exposed to exert its influence too. Types of schools and types of friends the child interacts with while growing up are vital in shaping the individual’s life. Social media also exert their influences on the individual during development. Therefore, any other factor capable of exerting influence on the child development, attachment and overall well-being is certainly under the umbrella of others. The choices of others in this inter-relationship depend on the parents and the individual. Just like line T which widens the relationship between parent and individual, line O does same too. As others (O) exert its pressures from the other side, it widens the gap between parent and individual, then through O; P and I which were parallel will meet. If the influences of O in P and I are positive it makes the association stronger otherwise, if it is negative it weakens the P and I attachment. Table 1 below further portrays the above assertions.

Table 1: PITO four dimensions and its many characteristics.

Observation of the above table holds that there are about seven characteristics of (P) which represents parents’ dimension of PITO which is further divided into biological with two characteristics and foster with five characteristics. Under individual dimension of PITO, three characteristics have been identified, while six characteristics have been identified under teacher dimension of PITO and finally, ten characteristics were identified under others dimension of PITO. However, in another context PITO and its nature of influence is demonstrated in Figure 4 below:

Figure 4: PITO dimensions and its nature of expected influence and or relationship with human development, attachment and wellbeing/ill-being.

Owing to the above narratives, the following key assumptions of PITO theory of overall well-being or ill-being ensue:

  1. Overall well-being is essential in human existence as it often reflects individual’s upbringing and attachment.
  2. Human developmental stages aid overall well-being or ill-being.
  3. Attachment via parent(s), teachers and others account for either overall well-being or ill-being in an individual.
  4. Overall well-being or ill-being depends on parent(s), individual, teachers and others (PITO).
  5. Rectangular shape depicts perfect PITO positive (overall well-being) or PITO negative (overall ill-being).

At this juncture, it is pertinent to note that PITO theory of overall well-being or ill-being is a relatively new concept, whereas, PITO is entirely a new ideology in explaining overall well-being theory. Thus, the new theory is of psychology as a scientific discipline which implies that others in other disciplines who choose to use PITO should apply it in their discipline. Again, empirical investigations are needed to verify the assumptions arising from PITO development bearing in mind that PITO will have implications for culture, gender, age, etc. Certainly the author will collaborate with other researchers in response to the future of PITO overall well-being or ill-being.

Conclusion

The author proposes in this write up that ideal human development, attachment and overall well-being are the ones achieved when a perfect rectangular shape is formed. The author opined that achieving a perfect rectangle shape characterizes either healthy human development, quality attachment between parent(s) and the individual and overall well-being. On the other hand, the shape may depict underdevelopment, lack of adequate parent(s) and individual attachment and overall ill-being. Overall well-being is essential in human existence as it often reflects individual’s upbringing and attachment.

References

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