Shamsul Haque, Elizabeth Sheppard - Culture and Cognition - A Collection of Critical Essays-Peter Lang (2015)

The past few decades have seen a huge increase in global interest
in psychology, with more psychologists, psychology programmes and

students than ever before. Culture and Cognition: A collection of critical
essays is made up of chapters written by experts in each topic, and
is aimed at those wishing to learn more about psychology. While cul-
ture and cognition have frequently been regarded as separate areas of
study in psychology, this book brings together essays on both of these
topics as well as several that consider the direct interplay between
culture and thinking.
Essays focus on a range of fascinating topics, such as how culture af-
fects memory for events in our own lives or our perceptions of human
attractiveness. Essays also address a diverse range of psychologi-
cal phenomena like déjà-vu, savant abilities, non-suicidal self-injury,
theory of mind, problem gambling and sleep disorders. Socio-cultural
and professional issues specifically within the Asian context are also
discussed.
Shamsul Haque is Head and Associate Professor of Psychology at

Monash University Malaysia. He earned his BSc (Honours) and MSc
in Psychology from the University of Dhaka, and PhD in Cognitive
Psychology from the University of Bristol, UK. Previously he was
Lecturer in Psychology at the University of Dhaka, and Assistant
Professor at the International Islamic University Malaysia.
Elizabeth Sheppard is Head and Associate Professor of Psychology

at the University of Nottingham Malaysia Campus. She earned her BA
(Honours) in Experimental Psychology from the University of Oxford,
and MSc and PhD in Psychology from the University of Nottingham,
UK. From 2015, she will be affiliated with Nottingham Trent University.
www.peterlang.com
Culture and Cognition
Shamsul Haque &
Elizabeth Sheppard (eds.)
Culture and
Cognition
A collection of
critical essays
PETER LANG
Bern · Berlin · Bruxelles · Frankfurt am Main · New York · Oxford · Wien
Bibliographic information published by die Deutsche Nationalbibliothek
Die Deutsche Nationalbibliothek lists this publication in the Deutsche
Nationalbibliografie; detailed bibliographic data is available on the Internet
at ‹http://dnb.d-nb.de›.
British Library Cataloguing-in-Publication Data: A catalogue record for this book

is available from The British Library, Great Britain
Library of Congress Control Number: 2015932284
Shamsul Haque is supported by a publication grant from the Jeffrey Cheah School of
Medicine and Health Sciences, Monash University Malaysia, and Elizabeth Sheppard by
the Nottingham University Malaysia campus. The editors thank both institutions for
their support.
ISBN 978-3-0343-1558-6 pb. ISBN 978-3-0351-0826-2 eBook
This publication has been peer reviewed.
© Peter Lang AG, International Academic Publishers, Bern 2015

Hochfeldstrasse 32, CH-3012 Bern, Switzerland
info@peterlang.com, www.peterlang.com
All rights reserved.

All parts of this publication are protected by copyright.
Any utilisation outside the strict limits of the copyright law, without the permission
of the publisher, is forbidden and liable to prosecution.
This applies in particular to reproductions, translations, microfilming, and storage
and processing in electronic retrieval systems.
Contents
Preface................................................................................................... 9
Part I: Overview
Shamsul Haque and Elizabeth Sheppard

Introduction..........................................................................................13
Part II: Cultural Influence on Cognitive Processes
Steve M. J. Janssen and Shamsul Haque

Cultural life scripts in autobiographical memory................................ 27
Ian D. Stephen and Tan Kok Wei

Healthy body, healthy face? Evolutionary approaches
to attractiveness perception..................................................................45
Gregory B. Bonn
Why culture matters: Social context and how we make
sense of our lives.................................................................................. 67
Karen Jennifer Golden and Jeanette Liaw Hui Jean

Understanding neurodevelopmental disorders in context:
Autism Spectrum Disorder and the Family System............................. 83
6 Contents
Part III: Cognitive Psychology and Neuroscience
Peter Mitchell
Developing a theory of mind............................................................. 109
Elizabeth Sheppard
Savant abilities and Autism Spectrum Disorders............................... 123
Radka Jersakova, Akira R. O’Connor and Chris J. A. Moulin

What’s new in déjà vu?...................................................................... 137
Matthew R. Johnson
Model systems of thought: A neuroscience perspective
on cognitive frameworks.................................................................... 151
Ruth C. Tatnell and Penelope A. Hasking

Emotion regulation, the anterior cingulate cortex
and non-suicidal self-injury............................................................... 163
Marisa H. Loft
Sleep-related problems and their contributing factors....................... 179
Part IV: Psycho-Social and Professional

Issues in the Asian Context
Miriam S. Park
Changing family perceptions across cultures:
The Malaysian context....................................................................... 197
Cai-Lian Tam and Qiu-Ting Chie

Factors influencing voting behaviour in Malaysia............................. 211
Contents 7
Jasmine M. Y. Loo
A primer in problem gambling........................................................... 223
Alvin Lai Oon Ng

Clinical psychology in Malaysia: Roles and issues........................... 241
About the editors................................................................................257
List of contributors............................................................................. 259

Preface
In recent years, interest in psychology has been growing worldwide.

Globally, there has been a steady rise in the number of Universities
offering degree courses in psychology. From our own marketing and re-
cruitment activities we have observed that prospective students and their
families have a serious interest in psychology, and many aspire to build
a career as a practising or academic psychologist – but their knowledge
of the subject is often rather limited. Moreover, some have misconcep-
tions about what the discipline actually involves. Many people may also
be unfamiliar with some of the exciting recent developments in psy-
chological science, which have given rise to a greater variety of career
options for psychology graduates than ever before.
This book of essays aims to meet the need of such individuals for
up-to-date information about some selected areas of psychology, writ-
ten in an accessible style but retaining a definite academic flavour. The
individuals who contributed are all scholars who are active in research,
and publishing in their respective fields. Many of them are relatively
young, “up-and-coming” researchers whose work will shape the future
of the discipline. This book comprises fourteen essays which have been
carefully selected from the domain of cognitive and social psychology.
The essays are split into three sections; the first section comprises four
essays that show how socio-cultural factors influence cognition, the
second contains six essays highlighting a number of basic cognitive
processes, and the last section comprises four essays presenting various
psycho-social and professional issues in the Asian context. We hope
that this book will inspire current and future students of psychology, as
well as offer an insight into psychology that is accessible and readable
by the broader community.
Part I
Overview
Shamsul Haque and Elizabeth Sheppard
Introduction
Psychology is a fast-moving discipline and has witnessed some import-

ant developments in recent years. These changes have arisen partly from
the wide variety of new and sophisticated methods for investigation
which have become available. For example, brain imaging techniques
such as functional magnetic resonance imaging have enabled us to start
determining the neural underpinnings of thought and behavior. Mean-
while, eye-tracking technologies can be used to identify with a high
degree of precision where a person is looking, allowing researchers to
make inferences about the ways in which people perceive, attend to,
and ultimately come to know their environment. However, it is not just
technology that has had a major impact on psychology as a modern
discipline. Society itself is becoming increasingly globalized and this
leads to an ever-changing set of challenges for psychologists who aim
to understand the mind and behavior in this context. Due to the faster
pace of development, people who are interested to learn about psy-
chology often face difficulty in finding materials that address current
issues in the subject, while being relatively accessible. In this collection
of essays, some popular topics in contemporary social and cognitive
psychology are discussed by academics who are specialists in the field.
The broader theme of this volume is “culture and cognition”. We
carefully selected fourteen essays that form three distinct parts of this
book. The first part comprises four essays that stand at the crossroads
of culture and cognition, showing how socio-cultural variables (e.g.,
cultural models) influence thinking – the ways in which people interpret
their experiences and guide action in diversified life contexts. The sec-
ond part contains six essays that discuss the basic cognitive processes
likely to be associated with different types of behavior in different age
groups. The third part is made up of four essays that discuss social and
professional issues in psychology in the Asian context. Although social
psychology and cognitive psychology are often studied as standalone
14 Shamsul Haque and Elizabeth Sheppard
domains (at least they are often portrayed this way in text books), they
are necessarily interrelated and influence each other in a reciprocal
manner (see for a review Nisbett & Norenzayan, 2002). Several essays
in this volume show the robustness of this link between culture and
cognition with the support of currently available data.
Many early scientists and philosophers, including Wilhelm Wundt
who is regarded as the father of experimental psychology, recognized the
importance of studying both cognitive processes and cultural diversities
in order to understand human nature. For him, human psyche is better
understood when laboratory studies on cognitive processes are supple-
mented with evidence from culture in which a person lives (Wundt,
1916). In this context, he emphasized the role of cultural history, folk
theories, ethnography, and linguistic tradition. Even before Wundt, a
number of German scholars, known as folk psychologists, dealt with
the study of the collective mind, meaning a societal way of thinking
within the individual. The concept of collective mind, later termed
as group mind, was studied by other scholars such as Gustav LeBon
(1896/1908), William McDougall (1920), and Solomon Asch (1951).
The main essence of these studies was to understand the complexities
of an individual’s behavior in the presence of other group members and
within their interpersonal relationships.
Systematic research on human behavior in cultural contexts,
however, started only after World War II. This trend grew rapidly in
1960s, 70s, and 80s with a number of ground-breaking studies that
were published (see Adler & Gielen, 2001; Hogan & Sussner, 2001;
Triandis, 1980 for an overview). Unfortunately, most of these studies
were conducted with participants either from Northwestern Europe or
North American cultures. In this context, a group of cross-cultural psy-
chologists from Asia and other non-Western countries advocated for
a paradigm shift, which initiated a large number of studies within a
new research framework called indigenization of psychology (Azuma,
1984; Bond & Smith, 1996; Diaz-Guerrero, 1975; Enriquez, 1977; Kao,
1997; Kim, 1993; Kwon, 1979; Lau & Hoosain, 1999; Legmay, 1984;
Pandey, 1996; Sinha, 1986; Yang, 1997). According to them, while ex-
amining the cultural issues of behavior and cognition, informal folk
theories of human functioning that are specific to a particular culture
should be studied with care and formalized in current psychological
Introduction 15
theories (Greenfield, 2001). A large number of studies have been con-

ducted in the recent decades in Asia and other parts of the world along
this line (see for example, Liu & Woodward, 2013; Mozumder, 2013).
The first part of this book contains four essays that address how
culture affects cognition. In the first essay, Steve Janssen and Shamsul
Haque (chapter 2) discuss cultural beliefs about the timing of import-
ant life events. They examine why people recall significantly more
memories of personal experiences from adolescence and early adult-
hood compared to the adjacent lifetime periods – a phenomenon pop-
ularly known as reminiscence bump. They review current literature
that favours life script theory over cognitive and identity theories to
explain this phenomenon. The life script – prescriptive time line for
transitional life events (i.e., age to start college, complete graduation,
get married, have children and retire) and its cross-cultural variations
are thoroughly discussed. The authors argue that older adults tend to
recall more memories from the bump period because most memo-
ries encompassing the bump are highly positive, and the timing for
such memories is dictated by the life scripts prevailing in a particular
culture. Unlike the other two theories, the life script theory explains
adequately why there is no bump for negative memories as the society
does not have any expectations about when negative events should
occur (e.g., death of a close relative, personal sickness, loosing job,
and divorce).
Why do we find certain individuals beautiful? Ian Stephen and Tan
Kok Wei (chapter 3) discuss psychological approaches to physical at-
tractiveness in the second essay. They focus on the question of whether
attractiveness is subjective and culturally determined or whether there
are certain features of appearance that are widely and globally regarded
as attractive. The chapter discusses a variety of aspects of appearance
for which there are fairly clear attractiveness preferences across cul-
tures, including face and body shape, skin colour and texture, and sexual
dimorphism. The authors go on to review research which shows that
these same aspects of appearance provide cues to one’s actual state of
physical health. It is argued that these findings support the notion that
humans have evolved mechanisms for identifying whether members
of the opposite sex are healthy in order to maximise their chances of
reproductive success.
Gregory Bonn (chapter 4) discusses how the culture in which peo-

ple grow shapes their overall perspective on life: their preferences, be-
liefs and practices, and the way they make sense of their existence. The
need for interdependence and learning from others is discussed from an
evolutionary perspective. It is reiterated that cultural training through
which people learn social norms, values, expectations, and practices
is largely implicit, often invisible to the individual. To signify the role
of society, it is stated that the acquisition of language, which requires
a brain with integrated neural networks and some perceptual abilities, is
measurably molded by social contact. The chapter discusses in some de-
tail how children learn to talk about their own life experiences through
the process of cooperative storytelling in a socially approved manner.
How the ability to tell a coherent life story during adolescence is de-
veloped and how it is associated with the development of an individual
identity is discussed at length.
In the fourth essay (chapter 5), Karen Jennifer Golden and Jeanette
Liaw Hui Jean offer a snapshot of autism spectrum disorder (ASD) – a
neurodevelopmental disorder, generally diagnosed during early child-
hood, with a growing number of cases reported worldwide. Apart from
discussing the cognitive and behavioral patterns associated with ASD,
the authors highlight the complexities of their social functioning; how
families of children with ASD are affected by this condition. Various
sub-systems of family with particular importance are addressed, such
as the parental subsystem, the marital subsystem, the sibling subsystem
and the extended family subsystem. Although the authors indicate that
causes for ASD are still unidentified and there is “no cure” for ASD,
they talk about some treatment options. Early interventions, especially
with comprehensive behavioral treatments and combined multi-modal
treatments (e.g., incorporating speech therapy, occupational therapy,
modeling, and social skills training) are suggested to be helpful to chil-
dren with ASD. Finally the authors speculate on how the cultural con-
text may impact on ASD including through perceptions/beliefs about
the condition and coping strategies.
The second part of the book is composed of six essays covering a
range of topics in contemporary cognitive psychology. Cognitive psy-
chology became popular in the 1960s and has been the mainstay of
experimental psychology since then. It arose to prominence as a reaction
Introduction 17
to the Behaviorist movement which had dominated psychology in the

first half of the 20th Century. Behaviorists such as John Watson (e.g.
Watson, 1913) or B.F. Skinner (e.g. Skinner, 1954) argued that because
mental states (such as thoughts, beliefs, desires, feelings) are not directly
observable they are not amenable to scientific investigation – hence in
order for psychology to be an objective natural science, psychologists
should stick to studying behavior which is directly observable. The early
cognitive scientists such as Noam Chomsky (e.g. Chomsky, 1959) dis-
agreed about this, claiming that many complex behaviors e.g. language
can be understood much more effectively if we make inferences about
the internal mental processes mediating those behaviors. The develop-
ment of cognitive psychology was boosted by advances in computer sci-
ence, which enabled increasingly sophisticated computer simulations
of mental processes. These models allowed cognitive psychologists to
demonstrate how a system could implement specific functions of the
mind, bringing the focus of investigation back to the processes them-
selves rather than merely behavior. More recently, cognitive psychology
has been influenced by the development of brain imaging techniques
which have been applied in the field to map mental processes onto brain
regions and gain a greater understanding of the timing of mental events.
This discipline, known as cognitive neuroscience, has kept the study of
cognition at the forefront of psychological research.
The first chapter in this part of the book (chapter 6) discusses an
area known as “Theory of Mind”. Many of us wish, from time to time,
that we possess some psychic power or can at least better work out
what other people (such as our friends, family or spouses) are think-
ing or feeling. In this essay, Peter Mitchell addresses psychologists’
investigations of our ability to make judgments about other people’s
thoughts, beliefs and feelings, referred to in the literature as “Theory
of Mind”. The essay informs us about some of the classic studies that
have explored the development of this capacity in children, with a
particular emphasis on the biases we have in making judgments about
others’ minds. The essay also includes sections addressing research
that demonstrates individual and cross-cultural differences in how we
make these judgments.
The second essay (chapter 7) maintains the theme of ASD, focus-
ing on one particularly fascinating aspect of the condition. We’ve all
seen movies about people who have a diagnosis of autism but display
almost superhuman talents in certain specific areas of performance.
In this chapter, Elizabeth Sheppard discusses autistic savants, individ-
uals who have an autism spectrum disorder but nevertheless display
outstanding, disproportionate talent in a particular area of functioning
(such as music, mathematics or memory). The chapter focuses mainly
on savant artists as a means of illustrating some of the theories psychol-
ogists have proposed to explain savant skill. In addition, it sheds light
on some questions relating to this puzzling syndrome, such as whether
savant skills can be differentiated from normal talents and why savant
abilities appear to be closely associated with having a diagnosis of an
autism spectrum disorder.
In the third essay (chapter 8), Radka Jersakova, Akira O’Connor,
and Chris Moulin discuss an interesting topic called déjà vu – a phe-
nomenon in which people have a strong subjective feeling that an event
which just occurred has been experienced in the past, no matter whether
it actually happened or not. So why do people experience déjà vu then?
The authors discuss two theories; bottom-up and top-down theories.
According to the bottom-up theory, déjà vu is elicited by something
in the environment that triggers this unique internal response. In sup-
port of this account, similarity hypothesis – the idea that the situation
eliciting the déjà vu is in some way similar to a prior experience – is
particularly discussed, with support from the most recent laboratory ex-
periments. The top-down theory, however, suggests that déjà vu is a
“random mental event” which is a result of incorrect neural activations.
Towards the end, the authors discuss the possibility of there being more
than one type of déjà vu, and other methodological issues related to déjà
vu research.
The fourth essay (chapter 9) sees Matthew Johnson discussing
one of the key challenges involved with experimental psychological
research: how to investigate a system as complex as the human mind
or nervous system while at the same time maintaining experimental
control in a laboratory context. He advocates a ‘components approach’
to understanding human thought, whereby the basic building blocks of
consciousness are studied in simplified laboratory tasks. The chapter
starts by discussing the use of animal models, whereby researchers will
frequently investigate traits or behaviors in relatively simple organisms
Introduction 19
such as the fruit fly or sea slug in order to make inferences about these
features in humans. It is then argued that by the same token, we can
design experiments which isolate individual key aspects of human
thought while controlling others. The chapter ends by discussing some
of the work that the author has conducted on the fundamental nature of
thought.
The fifth essay (chapter 10) written by Ruth Tatnell & Penelope
Hasking discusses non-suicidal self-injury (NSSI), defined as the delib-
erate destruction of body tissue that is performed without any conscious
intent of suicide. This behavior is associated with huge psychological
distress, and seen as a risk factor for more severe self-injury and later
suicidal behavior. The reasons why people would self-injure is the main
focus of this chapter. The authors indicate that the primary function of
NSSI is to regulate emotion; people injure themselves at a time when
they experience heightened arousal and negative affect and by doing
this act they decrease their mental agony. The chapter also reviews find-
ings revealing the neurobiological correlates of NSSI. Evidence from
EEG, MRI and fMRI studies suggests that the anterior cingulate cortex
in the limbic system regulates emotional behavior such as non-suicidal
self-injury.
It is really difficult to find someone who has never experienced
a sleep problem at some point in their life, yet a good night’s sleep
is the precursor of optimal functioning during day time. Marisa Loft
(chapter 11) discusses the importance of sleeping well in our daily life.
The question would arise then, how to measure the quality of sleep? This
chapter highlights various subjective and objective ways to determine if
someone is sleeping well along with the factors which contribute to bad
sleep. In this context, work-related demands, and immediate environ-
mental factors are discussed. Special attention is given to sleep-related
issues in at-risk populations such as factory workers, problem gamblers
and children with autism. Based on the insights offered, this chapter
should help readers recognise how they may be able to take action to
improve their own sleep.
The third part of the book consists of four essays that examine
psycho-social and professional issues in the Asian context with partic-
ular reference to Malaysia. In the first essay (chapter 12), Miriam Park
examines how people form their views and attitudes toward family, and
what role culture plays in this process. The author focuses on the family
perceptions prevailing in Malaysia – a country that has been experi-
encing rapid social, political, and economic changes in recent decades.
A number of theories of family change are discussed to identify what
factors influence the perception of family centeredness and democrati-
zation. Cross-cultural studies on family perceptions are reviewed and a
pattern demonstrated in these studies, where people from individualistic
cultures show more non-traditional family views as compared to collec-
tivist cultures, is discussed. The chapter also introduces individual-level
factors (e.g., values and beliefs toward the “self ” and personal self in re-
lation to close others) that influence family views and attitudes. Finally,
how rapid economic growth would help promote egalitarian decision
making in the family, better and higher education for all, and women’s
participation in workplace, thus resulting in liberalizing effects on
family perceptions and gender roles will be discussed.
Cai-Lian Tam and Qiu-Ting Chie (chapter 13) explore the psy-
chology of voting behavior with a view to demystifying people’s voting
choices in the recent General Election (2013) in Malaysia. The chapter
discusses the impact of both psychological (such as decision making
processes, personality and peer conformity) and demographic factors
(such as education level, income, gender, occupation, and age) on vot-
ing behavior. Based on their review of the literature, the chapter goes
on to speculate on factors which may specifically affect voting within
the Malaysian context, tackling issues such as the influence from
friends and family, general level of political interest, and corruption.
The chapter finishes by highlighting the need for more research on this
particular topic in future.
Jasmine Loo (chapter 14) discusses the nature and prevalence of
problem gambling in the Asian region by examining factors that are
likely to be responsible. In this context, mood states (depression and
anxiety), personality traits, and dysfunctional cognitions are identified
as potential reasons for problem gambling. Various approaches to treat
such problems are discussed in detail, with particular attention to cog-
nitive behavior therapy and positive psychological methods. A further
section is dedicated to the tools, together with their psychometric prop-
erties, commonly used to assess problem gambling. Finally, the author
discusses issues relating to the problem gambling assessment tools that
Introduction 21
are developed in the Western countries such as USA, UK and Canada,

and are used in the Asian context without proper validation and contex-
tualization.
In the final essay (chapter 15), Alvin Lai Oon Ng discusses the
current status of clinical psychology in Malaysia. Clinical psychology
as a profession is relatively new in the country as compared to psy-
chiatry and counseling. As such, it naturally faces a lot of challenges
such as registration issues, professional regulation, training, and clin-
ical supervision. Although a new generation of locally and overseas
trained clinical psychologists is visible in the market place, the response
from the wider community is rather discouraging. The chapter indi-
cates that more awareness campaigns and advertisements are needed
to help the public understand the role of clinical psychologists so that
they become more interested to seek professional assistance from them.
It is suggested that negotiation with the government is needed to pass
legislation to establish the Psychology Board of Malaysia to guide the
profession, and create more jobs for clinical psychologists in public and
private hospitals. The author also recommends that efforts should also
be taken to work with insurance companies to let them understand the
need to cover costs for mental health services by the health policies.
References
Adler, L. L., & Gielen, U. P. (2001). Cross-cultural topics in psychology

(2nd ed.). Westport, CT: Praeger Publishers.
Asch, S. E. (1951). Effects of group pressure upon the modification and
distortion of judgements. In H. Guetzkow (Ed.), Groups, leader-
ship and men (pp. 177–190). Pittsburgh, PA: Carnegie Press.
Azuma, H. (1984). Psychology in a non-Western culture: The Philip-
pines. Psychological Bulletin, 102, 272–292.
Bond, R., & Smith, P. B. (1996). Culture and conformity: A meta-
analysis of the Asch line judgment task. Psychological Bulletin,
119, 111–137.
Chomsky, N. (1959). Review of B. F. Skinner’s Verbal Behavior.

Language, 35, 26–58.
Diaz-Guerrero, R. (1975). Psychology of the Mexican: Culture and
Personality. Austin, TX: University of Texas Press.
Enriquez, V. (1977). Filipino psychology in the third world. Philippine
Journal of Psychology, 10, 3–18.
Greenfield, P. M. (2001). Three approaches to the psychology of cul-
ture: Where do they come from? Where can they go? Asian Journal
of Social Psychology, 3, 223–240.
Hogan, J. D., & Sussner, B. D. (2001). Cross-cultural psychology
in historical perspective. In L. L. Adler & U. P. Gielen (Eds.),
Cross-cultural topics in psychology (2nd ed., pp. 15–28). Westport,
CT: Praeger Publishers.
Kao, H. S. R. (1997). Asian perspectives on psychology. New York, NY:
Sage Publications.
Kim, U. (1993). Indigenous psychologies: Research and experience in
cultural context. London: Sage Publications.
Kwon, T. H. (1979). Seminar on Koreanizing Western approaches to
social sciences. Korea Journal, 19, 20–25.
Lau, C. W., & Hoosain, R. (1999). Working memory and language dif-
ference in sound duration: A comparison of mental arithmetic in
Chinese, Japanese, and English. Psychologia: An International
Journal of Psychology in the Orient, 42, 139–144.
Liu, J. H., & Woodward, M. (2013). Towards an indigenous psychol-
ogy of religious terrorism with global implications: Introduction
to AJSP’s Special Issue on Islamist terrorism in Indonesia. Asian
Journal of Social Psychology, 16, 79–82.
LeBon, G. (1896/1908). The crowd: A study of the popular mind. Lon-
don: Unwin. Available: <http://cupid.ecom.unimelb.edu.au/het/leb
on/crowds.pdf>.
Legmay, A. V. (1984). Western psychology in the Philippines: Impact
and response. International Journal of Psychology, 19, 31–44.
McDougall, W. (1920). The group mind. London: Cambridge Univer-
sity Press.
Mozumder, M. K. (2013). Cognitive determinants of racial prejudices
(Unpublished Doctoral dissertation), Monash University Malaysia.
Introduction 23
Nisbett, R. E., & Norenzayan, A. (2002). Culture and cognition. In

H. Pashler & D. L. Medin (Eds.), Stevens’ Handbook of Experi-
mental Psychology: Cognition (3rd edition). New York, NY: Wiley.
Pandey, J. (1996). Asian contributions to cross cultural psychology.
New York, NY: Sage Publications.
Sinha, D. (1986). Psychology in a Third World Country: The Indian
Experience. New Delhi: Sage Publications.
Skinner, B. F. (1954). A critique of psychoanalytic concepts and theo-
ries. Reprinted in Cumulative record (3rd ed.), Englewood Cliffs,
NJ: Prentice-Hall, 1972.
Triandis, H. C. (1980). Values, attitudes and interpersonal behavior. In
H. H. Howe & M. M. Page (Eds.), Nebraska symposium on motiva-
tion (Vol. 27). Lincoln, NE: University of Nebraska Press.
Watson, J. B. (1913). Psychology as the behaviorist views it. Psycholog-
ical Review, 20, 158–177.
Wundt, W. (1916). Elements of folk psychology: Outlines of a psycho-
logical history of the development of mankind. London: Allen &
Unwin (German original 1912).
Yang, K. S. (1997). Indigenous compatibility in psychological research
and its related problems. Indigenous Psychological Research in
Chinese Societies, 8, 75–120 (in Chinese).
Part II
Cultural Influence on
Cognitive Processes
Steve M. J. Janssen and Shamsul Haque*1
Cultural life scripts in autobiographical memory
When people are referring to the memories they have of their own life
experiences, they speak of autobiographical memory (Robinson, 1986).
Autobiographical memory is taxonomically speaking a part of episodic
memory, but autobiographical memories are more complex than epi-
sodic memories. They can involve seeing, hearing, smelling, tasting,
and touching, and they can vary greatly in spatial, temporal, emotional
and narrative content (Rubin, 2005). Autobiographical memory con-
sists of both vivid memories and autobiographical facts (Brewer, 1986;
Cermak, 1984; Conway, 1987).
When looking at the temporal distribution of autobiographical
memory, one can distinguish three components (Rubin, Rahhal, &
Poon, 1998; Rubin, Wetzler, & Nebes, 1986). First, people hardly re-
call any personal events from the period before early childhood, which
is called childhood or infantile amnesia. They only start to remember
events from the ages of 3 or 4 years. Second, there is an increased recall
of events from the last five to ten years, because these recent memories
are less likely to be forgotten than distant memories. Third, people tend
to recall more personal events from the period in which they were be-
tween 10 and 30 years old than from adjacent lifetime periods, which is
called the reminiscence bump. In Figure 1 which is taken from Janssen,
Rubin, and St. Jacques (2011), we have given 12 typical lifetime distri-
butions of autobiographical memories recalled by participants between
the ages of 16 and 75. To make the figure easier to read, the distributions
were divided over three panels.
* The authors thank Ministry of Higher Education Malaysia for supporting

the publication of this work through a Fundamental Research Grant Scheme
(FRGS/2/2010/ST/MUSM/01/2). The authors also thank Prof. Ali Tekcan for
providing his research data for the meta-analyses reported in this chapter.
28 Steve M. J. Janssen and Shamsul Haque
0.6 16-20
31-35
0.5 46-50
61-65
0.4
Proportion
0.3
0.2
0.1
0.0
0-5 6-10 11- 16- 21- 26- 31- 36- 41- 46- 51- 56- 61- 66- 71-
15 20 25 30 35 40 45 50 55 60 65 70 75
Age at Event
0.6 21-25
36-40
0.5 51-55
66-70
0.4
Proportion
0.3
0.2
0.1
0.0
0-5 6-10 11- 16- 21- 26- 31- 36- 41- 46- 51- 56- 61- 66- 71-
15 20 25 30 35 40 45 50 55 60 65 70 75
Age at Event
0.6 26-30
41-45
0.5
56-60
71-75
0.4
Proportion
0.3
0.2
0.1
0.0
0-5 6-10 11- 16- 21- 26- 31- 36- 41- 46- 51- 56- 61- 66- 71-
15 20 25 30 35 40 45 50 55 60 65 70 75
Age at Event
Figure 1: Twelve temporal distributions of autobiographical memories recalled by

participants between the ages of 16 and 75 years (taken from Janssen, Rubin &
St. Jacques, 2011).
Cultural life scripts in autobiographical memory 29
The reminiscence bump is one of the most robust findings in auto

biographical memory research. It has been found in many different
cultures and subpopulations with many different methods, but there are
two results that have not been given the attention that they deserve. First,
there is a reminiscence bump in the lifetime distribution of memories
that are cued with extremely positive emotions, but not in the lifetime
distribution of memories that are cued with extremely negative emotions
(Berntsen & Rubin, 2002; Haque & Hasking, 2010; Rubin & Berntsen,
2003). Second, there is also a difference in the location of the reminis-
cence bump between word-cued memories and highly important memo-
ries (Rubin & Schulkind, 1997). When personal events are elicited with
neutral cue words, the reminiscence bump tends to be located in the
second decade (10–20 years), but when participants are asked to tell
their life story or to name the most important events of their lives, the
reminiscence bump is usually located in the third decade (20–30 years).
There are several explanations for the occurrence of the reminis-
cence bump (cf., Rubin et al., 1998). According to the cognitive account,
there may be more novel events in adolescence and early adulthood,
such as the first driving lesson or the first kiss. These first-time experi-
ences are encoded more strongly and recalled more often, because they
will be used later in life as exemplars when people experience similar
events (Pillemer, 2001; Robinson, 1992). Both the identity-formation
account (Conway, 2005; Conway & Pleydell-Pearce, 2000) and the
self-narrative account (Fitzgerald, 1988; 1996) hypothesize that people
may form their identity during adolescence and early adulthood. Many
self-defining moments, which are vivid and emotional memories of per-
sonal events that have a large impact on the identity of a person, come
from those lifetime periods (Conway, Singer, & Tagini, 2004), and peo-
ple often retrieve these events when they talk or think about their own
lives. According to the life script account, more transitional events tend
to occur during late adolescence and early adulthood. When people are
asked to tell their life story or to name the most important events of their
lives, they use semantic information about the structure of life stories
to recall personal events, such as graduation, marriage and retirement
(Berntsen & Rubin, 2002; Rubin & Berntsen, 2003).
These four accounts are not mutually exclusive, but the life script
account is the only one that has explicitly addressed (Berntsen & Rubin,
2004; Rubin, Berntsen, & Hutson, 2009) the difference between life-
time distributions of memories cued with positive and of memories
cued with negative emotions and the difference between lifetime distri-
butions of word-cued memories and of highly significant events.
What are cultural life scripts?
Life scripts are culturally shared knowledge about the order and tim-
ing of highly important and prevalent events in an idealized life course
which are used to structure the recall of life story events from auto-
biographical memory (Berntsen & Rubin, 2004). They are distorted
from actual lives to favour positive events and events expected to occur
in early adulthood. Life scripts combine the concept of story scripts
(Schank & Abelson, 1977) with cultural norms for the timing of salient
life events (e.g., Neugarten, Moore, & Lowe, 1965).
Story scripts are structures that describe the appropriate sequence
of events or actions in a particular context or in a well-known situation
(Schank & Abelson, 1977), which are used when people share a story
about an event. An example of a story script is the restaurant script: A
person goes into a restaurant, is seated, receives the menu and orders a
meal. The waiter or waitress writes down the order and brings the food
when it has been prepared by the cook. When the person has finished
the meal, he or she asks for the cheque, pays and leaves the restaurant.
Story scripts are pre-existing knowledge that is shared by the
speaker and the listener, so certain elements do not have to be intro-
duced or can be omitted from the narrative (Schank & Abelson, 1977).
In a story about a restaurant visit, the waiter or waitress and the cook
do not need to be introduced and it does not need to be said that the
waiter or the waitress wrote down the order or that the cook prepared
the food. Not all visits to restaurants follow the restaurant script, but
there is an unspoken agreement between the speaker and the listener
that this story script describes the sequence of events that represent
most visits to restaurants. The life script account assumes that people
have similar shared knowledge about the sequence in which significant

personal events should happen within the course of a person’s life.
Cultural life scripts have the following ten properties, of which the
first six are derived from Schank and Abelson’s (1977) original story
script notion. The four remaining properties were developed specifi-
cally for the life script account (Berntsen & Rubin, 2004; Rubin et al.,
2009): (1) Life scripts are semantic knowledge about expectations of
life events in a given culture and not personal memories of those life
events. (2) Life scripts are a series of temporally ordered life events. (3)
Life scripts form a hierarchical arrangement with transitional events
forming a higher order ‘scene’, in which a series of subordinate actions
or episodes are nested. (4) Life scripts can be described in terms of time
slots and their requirements. (5) The time slots are culturally important
transitional events and their requirements are the culturally-sanctioned
timing of these events. (6) Life scripts are used to process life stories.
(7) Life scripts do not represent an average life, but they represent an
idealized life from which many common and some important events are
left out. (8) Because life scripts represent a normative life course, life
scripts are not extracted from personal actions in recurrent contexts, but
are transmitted by tradition. Young people, who have lived through a
smaller part of their life, still know the entire life script of their culture.
(9) Life scripts are distorted from actual lives to favour positive events.
(10) Life scripts are distorted from actual life stories to favour events
expected to occur in the early adulthood.
How does one examine cultural life scripts?
There are two methods which can be used to examine cultural life
scripts. One could use extreme emotions to elicit personal events (i.e.,
Berntsen & Rubin, 2002; Haque & Hasking, 2010; Rubin & Berntsen,
2003), or one could ask participants to name highly important events
that will most likely occur in the life of an average person (e.g., Berntsen
& Rubin, 2004).
In the first type of studies, participants are asked when they ex-
perienced the happiest, most important, saddest, and most traumatic
events of their lives (Berntsen & Rubin, 2002) or they are asked when
they felt most afraid, most proud, most jealous, most in love, and most
angry, when they had experienced the most important event of their
lives, and whether this important event was positive or negative (Rubin
& Berntsen, 2003). These studies, which were successfully replicated
by Haque and Hasking (2010), have found large reminiscence bumps
in the temporal distributions of events related to positive emotions in
the periods in which the participants had been between 10 and 20 or
between 20 and 30 years old and smaller or no reminiscence bumps in
the temporal distributions of events related to negative emotions.
In the second type of studies, participants are instructed to imagine
an infant with same gender and cultural background as themselves (e.g.,
Berntsen & Rubin, 2004). This child should not be a specific person that
the participant knows, but it has to be an ordinary child with an average
life ahead. The participants are asked to name the seven most important
events that will most likely occur in the infant’s life. Subsequently, partici-
pants have to rate the importance and valence of each event on seven-point
scales and indicate at what age the events are expected to occur and how
many people out of 100 are expected to experience the events at least
once in their lives. The events that are mentioned by the participants can
be categorized. Berntsen and Rubin regarded event categories that were
mentioned by at least 4% of the participants a part of the life script. This
criterion was arbitrarily chosen. Categories that were often mentioned are:
Marriage, having children, begin school and college. Falling in love, first
full-time job and parents’ death were also frequently mentioned.
Erdoğan, Baran, Avlar, Taş, and Tekcan (2008) slightly altered
Berntsen and Rubin’s (2004) design. They asked Turkish students to
name either the seven most important events that a newborn baby would
experience in the rest of his or her life or the seven most important
events that an elderly person would have experienced in his or her life.
The positive events came most frequently from the third decade of the
infant’s or the elderly person’s life, whereas the negative events were
in both groups distributed equally across the life span. Although both
groups named most often events from the third decade, participants in
the newborn group named relatively more events that were expected
to occur in the first two decades, whereas the participants in the other
group named relatively more events that were expected to occur when
the elderly person would have been between 30 and 70 years old.
What are the general findings of cultural life scripts studies?
Cultural life scripts have been examined with the second method in
several countries: Denmark (e.g., Berntsen & Rubin, 2004), Turkey
(Erdoğan et al., 2008), the United States (Rubin et al., 2009), the
Netherlands (Janssen & Rubin, 2011), and Japan (Janssen, Uemiya,
& Naka, 2014). They have also been examined in Germany (Haber-
mas, 2007, Study 2), Qatar (Ottsen & Berntsen, 2014) and Mexico
(Zaragoza-Scherman, 2013), but the results of these studies have not
been published yet or the participants were not asked to rate the events.
The findings of the studies are very robust. They have all found
that: (1) Participants mention as requested highly important and highly
prevalent events. The mean importance of the mentioned events ranged
across the studies from 5.94 to 6.25, and the mean prevalence ranged
from 76.9 to 87.7. (2) A large proportion of the mentioned events are
positive, and only a small proportion is negative or neutral. The propor-
tion of mentioned events that was rated as positive ranged across the
studies from .69 to .77. (3) Positive events are heavily tilted towards ear-
ly adulthood, whereas negative events are equally distributed over the
entire lifespan. In each study, more than half of the positive events were
expected to occur during early adulthood (range: .52–.56). Across the
studies, participants expected that about a third of the positive events
occur before the age of 16 (range: .33–.36). The remaining positive
events were expected to occur after the age of 30 (range: .08–.15). These
three proportions were more equal for the neutral and negative events
with the understanding that the period after early adulthood (range:
.33–.52) is longer than the periods before (range: .21–.34) and during
early adulthood (range: .19–.33). (4) The standard deviations of the
expected age of occurrence of positive event categories are smaller than
the standard deviations of the expected age at occurrence of negative
event categories. The results regarding the first and second finding are
given in Table 1, whereas the results regarding the third finding are giv-
en in Table 2.
Table 1: For each study, the mean importance and mean prevalence of the mentioned
events and the proportion of positive events and the proportion of neutral and negative
events.
Study Mean Mean Proportion Proportion

Importance Prevalence Positive Events Neutral and
Negative
Events
Berntsen & 6.05 87.7
Rubin (2004)
Erdoğan et al. 6.16 78.9 0.693 0.307
(2008)*
Janssen & 5.94 80.1 0.733 0.267
Rubin (2011)
Janssen et al. 6.25 76.9 0.767 0.233
(2014)
Rubin et al. 6.04 83.7
(2009)**
*Results of the participants who were given the newborn instructions.
**Ratings excluding the events in the ‘other’ category.
Table 2: For each study, the proportion of positive events and neutral or negative
events expected to occur before (0–15), during (16–30) or after (31–100) early
adulthood.
Study Positive Events Neutral and Negative Events

0–15 16–30 31–100 0–15 16–30 31–100
Erdoğan et al. .328 .564 .108 .337 .331 .331
(2008)*
Janssen & Ru- .362 .554 .084 .290 .192 .517
bin (2011)
Janssen et al. .336 .519 .145 .206 .299 .495
(2014)
*Results of the participants who were given the newborn instructions.
Are cultural life scripts episodic or semantic?
An important property of life scripts is that they are semantic knowl-

edge about expectations of life events in a given culture and not personal
memories of those life events (Berntsen & Rubin, 2004). This claim is
essential, because life scripts are supposed to structure autobiographical
memory recall rather than be a product of it (Janssen & Rubin, 2011).
Although older adults have lived through a larger part of their lives than
young or middle-aged adults, all three age groups should still share the
same cultural life script. The proportion of mentions per event category
should therefore be similar across age groups. The life script account,
however, allows for minimal age differences if they are caused by cohort
effects that reflect genuine changes in cultural views.
Three studies have examined whether the cultural life script is sim-
ilar for young and older adults, but they yielded contradictory results.
Whereas Bohn (2010) found minor differences between the life scripts
of younger and older adults, both Janssen and Rubin (2011) and Janssen
et al. (2014) found no differences across the life scripts of young,
middle-aged and older adults. Half the participants in Bohn’s study were,
however, first asked to give their life story, which may have affected their
answers on the subsequent life script questionnaire. The participants in
Janssen and Rubin and in Janssen et al. were not required to give their
life story, and the results of those two studies supported the idea that
cultural life scripts structure the recall of autobiographical memory.
Are there differences between cultures?
The number of event categories that were mentioned by at least 4% of

the participants (i.e., the number of events in the cultural life script)
can be used to examine the homogeneity of a culture (or the domi-
nance of one life script within an ethnically diverse society). Rubin
et al. (2009) found that the American life script consisted of merely 24
events, whereas the Turkish life script consisted of 27 events (Erdoğan
et al., 2008) and the Japanese life script consisted of 31 events (Jans-
sen et al., 2014). Berntsen and Rubin (2004) found that the Danish life
script consisted of 35 events, whereas the Dutch life script consisted of
37 events (Janssen & Rubin, 2011). Lower numbers indicate a higher
agreement among the participants about which events are important
and prevalent and therefore suggest a more dominant cultural life script
(e.g., the United States, Turkey and Japan), whereas higher numbers
indicate a lower agreement and therefore a less dominant cultural life
script (e.g., Denmark, the Netherlands).
Although the life script account assumes that there might be
cross-cultural differences in the content of the mentioned events, the
lifetime distribution of the mentioned events should be similar. Jans-
sen et al. (2014) examined whether there were differences between the
Japanese and the Dutch life script. They found that the Japanese life
script consisted of fewer events than the Dutch life script, but there
was considerable overlap between the two. Of the seven most frequently
mentioned events, five event categories could be found in both life
scripts: Marriage, first fulltime job, having children, begin school and
parents’ death. Whereas 25 events could be found in both life scripts,
there were 6 events that were unique to the Japanese life script and 12
events that were a part of the Dutch but not of the Japanese life script.
The six event categories that could not be found in the life script accord-
ing to Dutch participants were: high school entrance exam, children
leave home, major achievement, seijinshiki ceremony (a coming-of-age
ceremony at age 20), shichi-go-san festival (a celebration for three- and
seven-year-old girls and five-year-old boys) and adulthood. The three
most prominent event categories from the Dutch life script that could
not be found in the Japanese life script were: leave home, first sexual
experience and death of grandparents.
The content of the two life scripts was different, but the lifetime
distributions of the positive and negative events were similar. Japanese
participants, like Dutch participants, mentioned more positive than neg-
ative events, and many positive events were in both groups expected
to occur in early adulthood. The ages at which negative events were
expected to occur were in both groups equally distributed across the
age range. Although the two life scripts consisted of only a few nega-
tive events, there was in both groups more agreement about the ages at
which positive events were supposed to happen than about the ages at
which negative events were supposed to happen.
When are cultural life scripts used?
People use life scripts when they tell their life story or when they are
asked to give the most important events from their lives, but not when
their memories are cued with (neutral) words (Berntsen & Rubin,
2004). There is a substantial overlap between the life scripts and life sto-
ries of young (Bohn, 2010; Rubin et al., 2009) and middle-aged adults
(Collins, Pillemer, Ivcevic, & Gooze, 2007), and there is an even larger
overlap between the life scripts and life stories of older adults (Bohn,
2010; Glück & Bluck, 2007; Thomsen & Berntsen, 2008). This increase
across the age groups is expected, because the lives of older adults have
covered a larger part of the life script than the lives of younger adults.
Cultural life scripts are even used when participants have to report
surprising or unexpected events (Dickson, Pillemer, & Bruehl, 2011).
Cultural life scripts are not only used when people tell their life
story. They also seem to be a pre-requisite for the development of life
stories (cf., Bohn & Berntsen, 2013). Although the ability to remem-
ber personal events emerges across the preschool years (e.g., Fivush &
Nelson, 2004), children only start to develop a coherent life story in ad-
olescence (e.g., Habermas & Bluck, 2000). Bohn and Berntsen (2008)
asked children who attended third, fifth and sixth, or eight grade to re-
call a recent personal event, their life story and the cultural life script. A
group of young adults were only asked to provide the cultural life script.
Bohn and Berntsen rated the recent events and the life stories on global
coherence, whereas the life script of the young adults was used to estab-
lish the typicality of the children’s life script. Bohn and Berntsen found
that the coherence of the single event and the life story both increased
with age, but there was no correlation between the coherence of the
single event and the life story when they controlled for age. Further-
more, the life scripts became more similar to the norms provided by the
young adults as the children became older. There was, however, a strong
correlation between typicality of the life script and the coherence of the
life story. Children who named ten events in the life script study that
were often named by the young adults also told coherent life stories.
Besides using life scripts to retrieve past events, people also use life
scripts to imagine future events. In Berntsen and Jacobsen (2008), young
adults were asked to recall past events and to generate future events. Re-
cent past events, which had happened less than two years ago, and recent
future events, which were imagined to occur less than two years into the
future, contained few life script events (less than 20%), but remote past
events, which had happened two or more years ago, and especially remote
future events, which were imagined to occur two or more years into the
future, contained many life script events (more than 20%). In Berntsen
and Bohn (2010), young adults were also asked to recall past events and to
generate future events. The events were recalled or generated with the help
of cue words or they were important past or future events. The past and fu-
ture events that were cued with words consisted of fewer life script events
(20% and 25%) than the important past and future events (71% and 71%).
The last couple of years has also seen a rise of research in which
cultural life scripts are used to understand depression and PTSD (Ber-
ntsen, Rubin, & Siegler, 2011; Pecchioni, 2012; Rubin et al., 2009). In-
dividuals’ answers on the life script questionnaire (i.e., event categories,
prevalence and valence) can be compared with the answers of the group
on the questionnaire. Some people might mention events that are hardly
mentioned by the group, or they might rate the mentioned events as less
prevalent or less positive than the group. Furthermore, individuals’ life
story events can also be compared with the events from the life script.
These measures can be used to examine whether deviation from the life
script correlates with the severity of depression and PTSD symptoms.
Conclusion
The reminiscence bump is the effect that people tend to recall more per-
sonal events from the period in which they were between 10 and 30 years
old (Rubin et al., 1986; Rubin et al., 1998). Although the reminiscence
bump is one of the most robust effects in autobiographical memory re-

search, there are two findings that have not received the attention that
they deserve. First, the temporal distribution of memories that are cued
with extremely positive emotions peaks in the second or third decade of
people’s lives, but the temporal distribution of memories that are cued
with extremely negative emotions does not have a clear peak (Berntsen
& Rubin, 2002; Rubin & Berntsen, 2003). Second, the temporal dis-
tribution of word-cued memories peaks in the second decade, whereas
the temporal distribution of highly important events peaks in the third
decade (Rubin & Schulkind, 1997).
When participants are asked to tell their life story or when they are
asked to recall the most important events from their lives, they use cul-
tural life scripts, which are semantic information about the structure of
life stories (Berntsen & Rubin, 2004). Life scripts are distorted from ac-
tual lives to favour positive events and events expected to occur in early
adulthood, causing a reminiscence bump in the temporal distribution of
important positive events in the period in which the participants were
between 20 and 30 years old. Although the life script account explains
why there is a difference between the temporal distributions of word-
cued memories and highly important events, it does not explain why the
reminiscence bump in the temporal distribution of word-cued memories
is located in the second decade (Berntsen & Rubin, 2004). The account
only explains why there is a shift to the third decade when participants
are asked to tell their life story.
Besides the life script account, there are three other explanations
for the occurrence of the reminiscence bump which are often used
(cf., Rubin et al., 1998): the cognitive account, the identity-formation
account and the self-narrative account. Like the life script account, these
accounts seem to be able to predict the results of studies in which par-
ticipants have to tell their life story or give the most important personal
events from their lives, but they have difficulties explaining the results
of studies in which participants retrieve personal events with the help of
cue words (Conway & Haque, 1999; Janssen & Murre, 2008; Rubin &
Schulkind, 1997). These studies showed that the reminiscence bump of
word-cued memories does not consist of more novel, more emotional
or more important events as predicted by those accounts, but of both
more remarkable events that are rated high on novelty, emotionality
and importance and more mundane events that are rated low on these
scales. There was no difference between the memories from the remi-
niscence bump and the memories from other periods, there were just
more memories.
A fifth explanation for the reminiscence bump, called the cognitive
abilities account, seems to be able to explain the lifetime distribution of
memories elicited with cue words. This account states that more person-
al events are stored or that personal events are stored more strongly in
adolescence and early adulthood (e.g., Janssen, Murre, & Meeter, 2008;
Janssen & Murre, 2008; Rubin et al., 1998), because the memory sys-
tem works at an optimum in those time period (e.g., Li et al., 2004; Park
et al., 2002; Salthouse, 2004). The cognitive abilities account, however,
cannot explain the lifetime distribution of highly important events.
Besides for explaining the presence and absence of the reminiscence
bump in the distribution of extremely positive and negative memories
and the shift in the location of the reminiscence bump when comparing
word-cued memories and highly significant events, cultural life scripts
can also be used to understand other issues within autobiographical
memory research. Life scripts are not only used when people tell their
life story or when they give the most important personal events from
their lives. The development of life scripts in children has also been
linked to the coherence of their life stories (Bohn & Berntsen, 2008),
and people often use life scripts to generate future events (Berntsen &
Jacobsen, 2008; Berntsen & Bohn, 2010).
References
Berntsen, D., & Bohn, A. (2010). Remembering and forecasting: The

relation between autobiographical memory and episodic future
thinking. Memory & Cognition, 38, 265–278.
Berntsen, D., & Jacobsen, A. S. (2008). Involuntary (spontaneous)
mental time travel into the past and future. Consciousness and
Cognition, 17, 1093–1104.
Berntsen, D., & Rubin, D. C. (2002). Emotionally charged autobiograph-

ical memories across the life span: The recall of happy, sad, traumat-
ic, and involuntary memories. Psychology and Aging, 17, 636–652.
Berntsen, D., & Rubin, D. C. (2004). Cultural life scripts structure
recall from autobiographical memory. Memory & Cognition, 32,
427–442.
Berntsen, D., Rubin, D. C., & Siegler, I. C. (2011). Two version of life:
Emotionally negative and positive events have different roles in the
organization of life story and identity. Emotion, 11, 1190–1201.
Bohn, A. (2010). Generational differences in cultural life scripts and
life story memories of younger and older adults. Applied Cognitive
Psychology, 24, 1324–1345.
Bohn, A., & Berntsen, D. (2008). Life story development in childhood:
The development of life story abilities and the acquisition of cul-
tural life scripts from late middle childhood to adolescence. Devel-
opmental Psychology, 44, 1135–1147.
Bohn, A., & Berntsen, D. (2013). Cultural life scripts and the develop-
ment of personal memories. In P. J. Bauer & R. Fivush (Eds.), The
handbook of the development of children’s memory (pp. 626–644).
Chichester: John Wiley & Sons.
Brewer, W. F. (1986). What is autobiographical memory? In D. C. Rubin
(Ed.), Autobiographical memory (pp. 25–49). Cambridge: Cam-
bridge University Press.
Cermak, L. S. (1984). The episodic-semantic distinction in amnesia.
In L. R. Squire & N. Butters (Eds.), Neuropsychology of memory
(pp. 55–62). New York, NY: Guilford Press.
Collins, K. A., Pillemer, D. B., Ivcevic, Z., & Gooze, R. A. (2007). Cul-
tural scripts guide recall of intensely positive life events. Memory &
Cognition, 35, 651–659.
Conway, M. A. (1987). Verifying autobiographical facts. Cognition, 26,
39–58.
Conway, M. A. (2005). Memory and the self. Journal of Memory and
Language, 53, 594–628.
Conway, M. A., & Haque, S. (1999). Overshadowing the reminiscence
bump: Memories of a struggle for independence. Journal of Adult
Development, 6, 35–44.
Conway, M. A., & Pleydell-Pearce, C. W. (2000). The construction of

autobiographical memories in the self-memory system. Psycholog-
ical Review, 107, 261–288.
Conway, M. A., Singer, J. A., & Tagini, A. (2004). The self and auto
biographical memory: Correspondence and coherence. Social
Cognition, 22, 491–529.
Dickson, R. A., Pillemer, D. B., & Bruehl, E. C. (2011). The reminis-
cence bump for salient personal memories: Is a cultural life script
required? Memory & Cognition, 39, 977–991.
Erdoğan, A., Baran, B., Avlar, B., Taş, A. Ç., & Tekcan, A. İ. (2008). On
the persistence of positive events in life scripts. Applied Cognitive
Psychology, 22, 95–111.
Fitzgerald, J. M. (1988). Vivid memories and the reminiscence phe-
nomenon: The role of a self narrative. Human Development, 31,
261–273.
Fitzgerald, J. M. (1996). The distribution of self-narrative memories in
younger and older adults: Elaborating the self-narrative hypothesis.
Aging, Neuropsychology, and Cognition, 3, 229–236.
Fivush, R., & Nelson, K. (2004). Culture and language in the emergence
of autobiographical memory. Psychological Science, 15, 573–577.
Glück, J., & Bluck, S. (2007). Looking back across the life span: A life
story account of the reminiscence bump. Memory & Cognition, 35,
1928–1939.
Habermas, T. (2007). How to tell a life: The development of the cultural
concept of biography. Journal of Cognition and Development, 8,
1–31.
Habermas, T., & Bluck, S. (2000). Getting a life: The emergence of the
life story in adolescence. Psychological Bulletin, 126, 748–769.
Haque, S., & Hasking, P. A. (2010). Life scripts for emotionally charged
autobiographical memories: A cultural explanation of the reminis-
cence bump. Memory, 18, 712–729.
Janssen, S. M. J., Murre, J. M. J., & Meeter, M. (2008). Reminiscence
bump in memory for public events. European Journal of Cognitive
Janssen, S. M. J., & Murre, J. M. J. (2008). Reminiscence bump in autobi-
ographical memory: Unexplained by novelty, valence, emotionality
or importance of personal events. The Quarterly Journal of Experi-

mental Psychology, 61, 1347–1360.
Janssen, S. M. J., & Rubin, D. C. (2011). Age effects in cultural life
scripts. Applied Cognitive Psychology, 25, 291–298.
Janssen, S. M. J., Rubin, D. C., & St. Jacques, P. L. (2011). The tempo-
ral distribution of autobiographical memory: Changes in reliving
and vividness over the lifespan do not explain the reminiscence
bump. Memory & Cognition, 39, 1–11.
Janssen, S. M. J., Uemiya, A., & Naka, M. (2014). Age and gender
effects in the cultural life script of Japanese adults. Journal of
Cognitive Psychology, 26, 307–321.
Li, S-C., Lindenberger, U., Hommel, B., Ascherleben, G., Prinz, W., &
Baltes, P. B. (2004). Transformations in the couplings among intel-
lectual abilities and constituent cognitive processes across the life
span. Psychological Science, 15, 155–163.
Neugarten, B. L., Moore, J. W., & Lowe, J. C. (1965). Age norms, age
constraints, and adult socialization. American Journal of Sociolo-
gy, 70, 710–717.
Ottsen, C. L., & Berntsen, D. (2014). The cultural life script of Qatar
and across cultures: Effects of gender and religion. Memory, 22,
390–407.
Park, D. C., Lautenschlager, G., Hedden, T., Davidson, N. S., Smith,
A. D., & Smith, P. K. (2002). Models of visuospatial and verbal mem-
ory across the adult life span. Psychology and Aging, 17, 299–320.
Pecchioni, L. L. (2012). Interruptions to cultural life scripts: Can-
cer diagnoses, contextual age, and life narratives. Research on
Aging, 34, 758–780.
Pillemer, D. B. (2001). Momentous events and the life story. Review of
General Psychology, 5, 123–134.
Robinson, J. A. (1986). Autobiographical memory: A historical pro-
logue. In D. C. Rubin (Ed.), Autobiographical memory (pp. 19–24).
Cambridge: Cambridge University Press.
Robinson, J. A. (1992). First experience memories: Context and functions
in personal histories. In M. A. Conway, D. C. Rubin, H. Spinnler, &
W. A. Wagenaar (Eds.), Theoretical perspectives on autobiographi-
cal memory (pp. 223–236). Dordrecht: Kluwer Academic.
Rubin, D. C. (2005). A basic-systems approach to autobiographical

memory. Current Directions in Psychological Research, 14, 79–83.
Rubin, D. C., & Berntsen, D. (2003). Life scripts help to maintain auto-
biographical memories of highly positive, but not highly negative,
events. Memory & Cognition, 31, 1–14.
Rubin, D. C., Berntsen, D., & Hutson, M. (2009). The normative and the
personal life: Individual differences in life scripts and life stories
among U.S.A. and Danish undergraduates. Memory, 17, 54–68.
Rubin, D. C., Rahhal, T. A., & Poon, L. W. (1998). Things learned in
early adulthood are remembered best. Memory & Cognition, 26,
3–19.
Rubin, D. C., & Schulkind, M. D. (1997). Distribution of important and
word-cued autobiographical memories in 20-, 35-, and 70-year-old
adults. Psychology and Aging, 12, 524–535.
Rubin, D. C., Wetzler, S. E., & Nebes, R. D. (1986). Autobiographical
memory across the adult life span. In D. C. Rubin (Ed.), Autobio-
graphical memory (pp. 202–221). Cambridge: Cambridge Univer-
sity Press.
Salthouse, T. A. (2004). What and when of cognitive aging. Current
Directions in Psychological Science, 13, 140–144.
Schank, R. C., & Abelson, R. P. (1977). Scripts, plans, and knowledge.
In P. N. Johnson-Laird & P. C. Wason (Eds.), Thinking: Readings
in cognitive science (pp. 421–432). Cambridge: Cambridge Uni-
versity Press.
Thomsen, D. K., & Berntsen, D. (2008). The cultural life script and life
story chapters contribute to the reminiscence bump. Memory, 16,
420–435.
Zaragoza-Scherman, A. (2013). Cultural life script theory and the
reminiscence bump: A reanalysis of seven studies across cultures.
Nordic Psychology, 65, 13–119.
Ian D. Stephen and Tan Kok Wei
Healthy body, healthy face? Evolutionary

approaches to attractiveness perception
The human face contains a large amount of observable information

about the bearer, providing cues to age, sex, ethnic group and emotional
state. Observers also make spontaneous judgements about more appar-
ently subjective attributes, such as how attractive they consider the face
to be. Recent developments in evolutionary psychology suggest that
these perceptions of attractiveness may not be so subjective after all,
and may in fact reflect aspects of the underlying health and fertility of
the bearer. In order for a cue to health to be valid, however, it must both
relate to the actual health of the bearer and be perceived as healthy and/
or attractive by observers (Coetzee, Perrett, & Stephen, 2009; Fig. 1). In
this chapter, we will introduce the theoretical approaches to attractive-
ness research, and discuss the evidence for health cues in the face and
agreement and variation in face preferences.
Theoretical approaches to attractiveness research
Most people will have heard the proverb “beauty is in the eye of the
beholder”, which implies that attractiveness is somewhat arbitrary and
subjective. This opinion was adopted by Darwin in his Descent of Man,
where he writes “the men of each race prefer what they are accustomed
to” (Darwin, 1871), implying that preferences are learned from the so-
cial environment, and imprinted on those faces we see around us during
development. In the 20th century, feminist thinkers adopted this theme,
with Naomi Wolf suggesting in The Beauty Myth that female beauty was
arbitrary, socially constructed and culturally imposed by the patriarchy
46 Ian D. Stephen and Tan Kok Wei
as a method of maintaining control over women (Wolf, 1991). In this

framework, concepts of beauty are predicted to vary substantially and
arbitrarily across individuals and across cultures. However, studies have
repeatedly shown that, while small variations in face preferences are
seen between individuals and between cultures, there is a high degree of
agreement on what makes a face attractive and a mate desirable (Buss,
1989; Langlois et al., 2000), calling the social construct hypothesis into
doubt.
Buss (1989) conducted a large scale survey of 37 diverse cultures
from around the world, finding that women rated cues to ability and will-
ingness to invest in her and her offspring (such as ambition and good
financial prospects) as important in a husband. Men, on the other hand,
prioritised cues to youth and fertility in women (Buss & Schmitt, 1993;
Townsend & Wasserman, 1998; Li, Valentine, & Patel, 2011). There is
also considerable agreement across cultures on what makes a face look
attractive. Similar preferences have been found for symmetrical faces in
cultures as diverse as Australian, Japanese (Rhodes et al., 2001), Scottish
(Perrett et al., 1998), Hadza (an African hunter-gatherer society; Little et
al., 2007), and even in Rhesus macaque monkeys (Waitt & Little, 2006).
Preferences for faces close to the population average shape (Rhodes et
al., 2001), as well as for slightly redder, yellower and lighter skin colour
(Stephen et al., 2009a; 2012; Stephen, Coetzee, & Perrett, 2011; Scott et
al., 2010) and for more feminine female faces (Perrett et al., 1998) have
all been found cross-culturally as well. While some variation in pref-
erences does exist between cultures (DeBruine et al., 2010; Marlowe,
Apicella & Reed, 2005; Tovee et al., 2006), it is important to ask why
these traits are considered desirable in diverse cultures.
Researchers have begun to use evolutionary theory to explain at-
tractiveness as a mate selection mechanism (Lee et al., 2008), allowing
people to identify and attract healthy mates with whom to reproduce
(Thornhill & Gangestad, 1999). Mate selection is of critical importance
in sexually reproducing species, since it determines the levels of direct
and indirect benefits that will accrue to offspring. Direct benefits include
nuptial gifts, such as meat provided by men to women in exchange for
sexual access in many traditional societies (Wood & Hill, 2000) and
parental care of offspring, whereas indirect benefit refers to the genes
that are passed on to the offspring (Trivers, 1972). Since healthy mates
Healthy body, healthy face? 47
represent a lower risk of infection during courtship and mating, and are
likely to be able to provide higher quality investment and better genes
to the offspring, it is clear that choosing a healthy mate is an important
ability. Those individuals who are able to identify and choose healthi-
er mates will leave more healthy offspring; and genes for identifying
and choosing healthy mates will increase in frequency in the population
(Trivers, 1972). Similarly, those individuals who are best able to adver-
tise their health and attract high quality mates will leave more healthy
offspring, and thus their genes will increase in frequency in the popula-
tion. This process is known as sexual selection (Darwin, 1871).
In most animal species, the female invests more in the offspring
than does the male. For female mammals, the minimum investment re-
quired to produce a healthy offspring involves investing considerable
time and energy in gestation, breastfeeding and in many species pro-
longed periods of infant dependence upon the mother for protection
and food. For males, on the other hand, the minimum investment in a
healthy offspring is a small amount of time and energy invested in the
act of mating itself (Trivers, 1972). Further, female mammals are lim-
ited by biology in the number of offspring they can produce, whereas
males can potentially produce a much larger number of offspring, pri-
marily limited by access to females (Bateman, 1948). For this reason,
in most species, females tend to be choosier than males, whereas males
compete for access to females, for example by fighting (for example
in the elephant seal; LeBouef, 1974) or by exhibiting large, brightly
coloured ornaments (for example in the goldfinch; Saks, Ots & Horak,
2003). However, in species where male investment is substantial, such
as humans, evolutionary theory predicts that males will also be choosy,
at least when looking for a long term mate (Trivers, 1972).
What defines attractiveness?
In recent decades, researchers have begun to identify the facial cues

that affect attractiveness, with studies showing effects of symmetry
(Gangestad, Thornhill, & Yeo, 1994; Grammer & Thornhill, 1994;
Mealey, Bridgstock, & Townsend, 1999; Penton-Voak et al., 2001;

Perrett et al., 1999), averageness (Langlois & Roggman, 1990; Langlois,
Roggman, & Musselman, 1994; Rhodes, Sumich, & Byatt, 1999),
masculinity or femininity (also known as sexual dimorphism; Perrett
et al., 1998; Rhodes et al., 2003; Rhodes et al., 2007) and skin colour
(Stephen et al., 2012; Scott et al., 2010). Many of these studies have
suggested that these aspects of facial appearance are perceived as at-
tractive because they represent valid cues to health. However, in order
for a trait to be a valid cue to health, it must be shown to relate both
to perceived health and/or attractiveness and to an aspect of underly-
ing health (Fig 1; Coetzee et al., 2009). While relationships have been
found between many facial traits and apparent health/attractiveness,
studies connecting these traits to aspects of real, underlying health are
less abundant (Coetzee et al., 2009).
Figure 1: In order for a facial trait to be considered a valid cue to health, it must relate
to both an aspect of actual health and healthy and/or attractive appearance.
Evidence connecting perceived health to actual health
Face shape
Symmetry is perceived as attractive by humans in diverse cultures

(Gangestad et al., 1994; Grammer & Thornhill, 1994; Mealey et al.,
1999; Penton-Voak et al., 2001; Perrett et al., 1999), and is preferred in
mates by non-human animals such as macaques (Waitt & Little, 2006),
barn swallows (Møller, 1994) and zebra finches (Swaddle & Cuthill,
1994). This fulfils one half of the requirement for a valid cue to health
(fig 1), but a connection from symmetry to actual health is also required
(Coetzee et al., 2009). Under this hypothesis, it has been proposed that
symmetry is an indicator of the health of the individual during develop-
ment (see Perrett et al., 1999). Our genes provide a “blueprint” for how
to build a fully grown adult and, in ideal conditions, this fully grown
adult would be symmetrical. However, ideal conditions are hard to find
in the real world, and a variety of occurrences will interfere with optimal
development, such as infectious diseases and illnesses, malnutrition or
poor diet. It is proposed that the fluctuating asymmetry (small devia-
tions from perfect symmetry in the face and body) of a face reflects the
bearer’s developmental stability, and therefore is a good indicator of
how often and how severely the individual’s development was interrupt-
ed, and also how well that individual was able to resist the interruption –
for example how well his immune system was able to fight off the
infection (Møller, 1990).
A number of studies have attempted to relate facial symmetry to
measures of actual health, including developmental (childhood) health.
Shackelford and Larsen (1997) collected a wide range of mental and
physical health measures by questionnaires, and measured symmetry
from photographs of 101 students in Michigan, USA, in order to see if
symmetry correlated with health. They found 54 relationships between
the psychological health measures and the symmetry of the partici-
pants. However, Perrett (2010) points out that, with so many compari-
sons (918 in all), we would expect to find almost this many significant
relationships through chance alone, so this study does not provide the
evidence we need. Rhodes et al. (2001) attempted to provide a more
reliable link between developmental health and facial symmetry in
a sample of 316 adolescents. They used medical records from child-
hood and adolescence (and gave each individual health scores based on
these records), and symmetry measured from photographs. While they
found evidence of a link between symmetry and attractiveness, they
found no relationship between the developmental health and symmetry
measures. Most recently, Pound et al. (2014) used a large sample of
4000 individuals from the ALSPAC database in Avon, UK. Symmetry
was measured from 3D laser scans and health measures were made at
intervals during childhood. They found no lasting effect of childhood

illnesses on symmetry, but did find that illness made children tempo-
rarily less symmetrical. They also found that children from wealthier
backgrounds had more symmetrical faces. So it may be that symmetry
is a better indicator of the childhood and adolescent nutrition aspects of
developmental stability than it is of childhood and adolescent illness.
Averageness is another cue that has been found to appear healthy and
attractive. It is possible to make average blends of faces using computer
technology. This involves marking many points on each face photograph,
such as the corners of the eyes and mouth, and giving each point a set
of coordinates. By taking the average location of each point across your
whole set of face photographs, you can make a face of average shape.
By then averaging the colour of each pixel across the faces, you make
your average shaped face have average colour too (Tiddeman, Stirrat, &
Perrett, 2005). Langlois and Roggmann (1990) found that these average
faces are more attractive than the individual faces from which they are
made. Rhodes et al. (2001) found that this effect is found cross-culturally
by testing in Japan. It was suggested that the reason these faces looked
attractive is participants were avoiding distinctive faces, which might
suggest that they are suffering from some kind of illness or that they are
carrying unhealthy genes (Rhodes & Tremewan, 1996), whereas individ-
uals who have average faces may have more heterozygosity in the area
of DNA known as the major histocompatibility complex (MHC). This
means that they have more varied genes for immune function and can
therefore produce the necessary immune proteins to fight off a broader
range of pathogens (Thornhill & Gangestad, 1993). It has since been
found that people with very distinctive faces do suffer from more illness-
es than average-looking people (Zebrowitz & Rhodes, 2004; Rhodes
et al., 2001), and that people with more heterozygosity in the MHC are
perceived as looking (Roberts et al., 2005) and even smelling (Thornhill
et al., 2003) more attractive. Interestingly, it was recently found that peo-
ple who are very sensitive to feeling disgusted when they see something
that carries a risk of infection (e.g. vomit, faeces, and rotten food) find
unattractive faces even less attractive than other people do. This suggests
that these hypersensitive people might be trying to avoid any chance of
infection by avoiding unattractive people who might be more susceptible
to illness (Park, van Leeuwen, & Stephen, 2012).
Body shape
Body weight is also an important determinant of attractiveness. It has

been found that, in developed societies, men typically find women in
the middle of the healthy body mass index range (BMI; 19–24.5 for
Caucasian populations) look the healthiest, whereas women at the lower
end of the healthy range look the most attractive (Tovee et al., 1998,
Tovee & Cornelissen, 1999; Thornhill & Grammer, 1999; Swami &
Tovee, 2005; Stephen & Perera, 2014a, b). This weight is also visible
in the face (Coetzee et al., 2009), and facial adiposity (apparent weight
in the face) consistent with the same body weight also looks healthi-
est and most attractive (Coetzee et al., 2011). The connection between
body weight and health is also very well known, with overweight and
obese individuals at increased risk of a range of illnesses including di-
abetes, coronary illnesses, stroke and various cancers (Wilson et al.,
2002). Underweight individuals have reduced immune function, energy
levels and are more prone to infection (Ritz & Gardner, 2006). Both
overweight and underweight women are also at increased risk of infertil-
ity (Green, Weiss, & Daling, 1988). Increased facial adiposity has also
been associated with risk factors such as increased blood pressure, in-
creased susceptibility to infections (Coetzee et al., 2009) and decreased
progesterone levels (Tinlin et al., 2012). Interestingly, in parts of the
world where food security is less reliable, and heavier body weight thus
represents an ability to find sufficient food, such as sub-Saharan Africa
(Tovee et al., 2006) and rural parts of Malaysia (Swami & Tovee, 2005),
preferences shift towards higher body weight, suggesting that prefer-
ences respond to ecological and social environmental conditions in a
way that is consistent with evolutionary theory. So, it seems like body
weight and facial adiposity may represent valid cues to health.
Sexual dimorphism
Sexual dimorphism can be thought of as masculinity or femininity.

That is, how typically male or typically female a person is. Sex-typical
characteristics of the face and body develop under the influence of sex
hormones. In males, testosterone drives increased muscle mass, taller
stature, increased body hair, jaw, nose and brow ridge growth (see
Penton-Voak & Chen, 2004), while in females, oestrogen drives the de-
velopment of breasts, buttocks and lips, and inhibition of body hair,
nose, jaw and brow ridge growth. Oestrogen in women is associated
with increased fecundity, with women with higher levels of oestrogen
being more likely to conceive (Stewart et al., 1993; Lipson & Ellison,
1996; Baird et al., 1997, 1999). Perrett et al. (1998), transformed Cau-
casian and Japanese women’s faces to make them more typically female
(feminised) or more typically male (masculinised), and asked Cauca-
sian and Japanese participants to indicate the most attractive level of
feminisation or masculinisation. Participants chose faces that were fem-
inised, regardless of ethnicity. Law Smith et al. (2006) found that wom-
en’s oestrogen levels predict ratings of femininity, attractiveness and
health, making femininity a valid cue to women’s reproductive health.
Men’s masculinity, similarly, has been suggested to be a valid cue
to men’s health, reflecting increased testosterone levels. Since testoster-
one is thought to suppress the immune system, men who can maintain
high levels of testosterone during development, in order to produce a
masculine face shape, and still be able to fight off infection, must be
of high quality and have good genes (Hamilton & Zuk, 1982; Zahavi,
1975). This is known as the Immunocompetence Handicap Hypothe-
sis (Hamilton & Zuk, 1982). It was therefore predicted that masculine
men would be considered more attractive. However, Perrett et al. (1998)
found that women preferred more feminine male faces. It was suggested
that the negative personality traits, such as aggression and infidelity,
attributed to masculine men may limit the attractiveness of masculine
facial appearance (Perrett et al., 1998; Mazur & Booth, 1998). More
recent research has shown that women’s preferences for masculinity
in men’s faces changes in response to the social environment, as well
as to changes in women’s fertility and own attractiveness. It has been
suggested that women should prefer more feminine men, who would
make a better partner and father, for a long term partner, and prefer
more masculine men, who carry “good genes” during the fertile phase
of the menstrual cycle. This would allow her to obtain good genes for
her offspring from a masculine man, while securing the parental invest-
ment of a feminine man. Indeed, this has been confirmed, as women’s
preferences shift to prefer more masculine men during the fertile
phase of the menstrual cycle (Penton-Voak et al., 1999; Penton-Voak

& Perrett, 2000) and when seeking short term relationships (Little
et al., 2002). Cross-cultural factors also cause changes in women’s
preferences for men’s masculinity, with women who live in countries
with high levels of income inequality, competition and parasites pre-
ferring more masculine men, who are perhaps better able to compete in
such environments, than women who live in less unequal, competitive
and parasite-laden environments (Brooks et al., 2011; DeBruine et al.,
2010). So the picture for masculinity preferences reflects trade-offs in
the reproductive and health benefits that can be provided by mascu-
line and feminine men, whereby masculine men offer good genes and
feminine men offer parental investment. Women’s preferences changing
according to social and ecological environment and own fertility, is in
line with the predictions of evolutionary theory.
Skin colour and texture
The skin itself may also hold cues to the health of individuals. Jones et
al. (2004) cropped squares of skin from photographs of people’s fac-
es, and asked participants to rate how healthy the skin looked. People
whose skin was rated as looking healthier were also rated as more at-
tractive from photographs of their whole face, suggesting that having
healthy looking skin is an important aspect of attractiveness. It has since
been shown that both skin colour distribution (Fink, Grammer, & Matts,
2006; Fink et al., 2012; Matts et al., 2007) and overall skin colour (Scott
et al., 2010; Stephen et al., 2009a, 2009b, 2011, 2012) play an import-
ant role in the attractive and healthy appearance of faces. Skin with a
smoother, more even colour distribution appears younger, healthier and
more attractive in both women’s (Matts et al., 2007) and men’s (Fink
et al., 2012) faces. This colour distribution relates to actual health in
that exposure to damaging UV light, as well as ageing, cause pigments
to become less evenly distributed throughout the skin (Matts & Fink,
2010). The attractiveness of an even skin colour distribution therefore
reflects less skin damage and degradation.
Overall skin colour also affects the healthy and attractive appear-
ance of faces. Participants were asked to use a computer programme
to manipulate the colour of skin portions of colour calibrated face

photographs to make them appear as healthy as possible. Participants
chose to increase the redness, yellowness and lightness of the skin (Ste-
phen et al., 2009a). Skin redness is primarily determined by the amount
of blood and the oxygenation state of the haemoglobin (the red pigment
in blood that transports oxygen around the body) in the blood. Since
increased blood perfusion and oxygenation are associated with phys-
ical fitness (Armstrong & Welsman, 2001; Johnson, 1998), increased
oestrogen (a female sex hormone) in women (Charkoudian et al., 1999)
and the absence of certain respiratory and cardiac diseases (Panza
et al., 1990), the researchers suggested that this preference for red skin
may represent a valid cue to health. Indeed, further studies showed that
increased oxygenated blood colour in particular enhances the apparent
health of faces (Stephen et al., 2009b).
The yellow colour of the skin is primarily influenced by melanin (the
dark brown pigment associated with sun tanning; Stamatas et al., 2004)
and carotenoids (Alaluf et al., 2002). Melanin protects the skin from
the damaging effects of ultraviolet light, and from sunburn and cancer
(Robins, 1991), but can prevent the formation of vitamin D, potentially
leading to osteomalacia and rickets (weak, deformed bones; Murray,
1934). Carotenoids are antioxidant pigments that we get from fruit and
vegetables in our diet (Alaluf et al., 2002). Carotenoids protect the body
from the damaging effects of reactive oxygen species (ROS). These ROS
are chemicals formed in the body by metabolic processes, especially due
to immune functioning and the reproductive system, and they can damage
cell structures including proteins and DNA if they are not neutralised by
antioxidants, such as carotenoids (Dowling & Simmons, 2009). Indeed,
reduced carotenoid levels have been associated with infectious diseas-
es such as HIV and malaria (Friis et al., 2001). Stephen et al. (2011),
found that the preference for yellow skin is explained by a much stronger
preference for the particular hue of yellow caused by increased levels
of carotenoids in the skin than by the yellow-brown colour of melanin.
Further, they found that individuals who eat a healthy diet with higher
levels of fruit and vegetables have yellower skin (Stephen et al., 2011). It
therefore seems that skin colour represents a valid cue to health, reflect-
ing carotenoid levels in the diet and, possibly, freedom from infection.
Further, it has been shown that humans can detect smaller changes in
colour in human facial skin than they can in simple patches of colour,
supporting the suggestion that facial skin colour has special salience (Tan
& Stephen, 2013). It has even been suggested that primate colour vision
evolved to allow us to detect colour-based social information from faces
(Changizi, Zhang, & Shimojo, 2006).
Interestingly, these colour cue mechanisms are also found in other
animal species. While colour signals are not found in non-primate
mammals, who do not have trichromatic vision (what humans would
consider to be full colour vision; Carroll et al., 2001), they are found
in primates, many species of which do have trichromatic colour vi-
sion, and in many bird and fish species, many of which can distinguish
more colours than humans. In rhesus macaques (monkeys), male faces
become redder in the mating season, in response to increased levels
of testosterone (Rhodes et al., 1997). Female macaques show prefer-
ential looking behaviour towards redder versions of photographs of
male faces (Waitt et al., 2003). Male mandrills (a type of baboon) have
a bright red ornamented face, which becomes redder with increased
testosterone levels (Setchell & Dixson, 2001). Other males avoid vi-
olent conflict with redder faced males (Setchell & Wickings, 2005),
and female mandrills prefer to mate with males with redder faces,
regardless of dominance rank (Setchell, 2005). Females also use red
skin signals to advertise their health and fertility. Female rhesus ma-
caques experience “sexual swellings”, with the skin around the genital
area becoming redder when the female is in oestrus (fertile). Males
pay more attention to, and direct more mating effort towards, redder
females (Waitt et al., 2006). Many species of birds and fish also use
colourful ornaments to signal health, often based upon carotenoids.
For example, the size and brightness of greenfinches’ (a bird with a
bright yellow feathered ornament) carotenoid based ornament reflects
parasite load, with those individuals with bigger and brighter orna-
ments having fewer parasites (Saks et al., 2003; Horak et al., 2004),
and there is evidence that goldfinches select mates based on the size
and brightness of carotenoid ornament (MacDougall & Montgomerie,
2003). It seems, therefore, that similar mechanisms may be operating
in very different species.
Conclusion
In conclusion, the human face and body provide an array of cues that are
interpreted by observers as healthy and/or attractive. While the social
construct hypothesis predicts that these preferences are arbitrary, a range
of evidence from across psychology, anthropology and animal behaviour
suggests that the preferences are predictable by considering their rela-
tionship with the underlying health of the bearer. While a number of
cues have been identified as appearing healthy and attractive, and some
have been confirmed as valid cues to health, such as facial adiposity and
skin colour, by relating them to aspects of real health, more research is
needed to reliably connect some other cues, such as symmetry or aver-
ageness, to real health. Contrary to popular belief, evolutionary theories
of attraction do not predict preferences that are unchanging regardless
of social and ecological environment, but rather predict flexible prefer-
ences that vary according to the environment, in order to allow people to
identify appropriate and high quality mates in the prevailing conditions.
The literature reviewed here shows considerable cross-cultural agree-
ment in attractiveness preferences, but also shows changing preferences
in response to social and environmental factors.
References
Alaluf, S., Heinrich, U., Stahl, W., Tronnier, H., & Wiseman, S. (2002).
Dietary carotenoids contribute to normal human skin color and UV
photosensitivity. Journal of Nutrition, 132, 399–403.
Armstrong N., & Welsman J. R. (2001). Peak oxygen uptake in relation
to growth and maturation in 11–17-year-old humans. European
Journal of Applied Physiology, 85, 546–551.
Baird, D. D., Wilcox, A. J., Weinberg, C. R., Kamel, F., McConnaughey,
D. R., Musey, P. I., & Collins, D. C. (1997). Preimplantation hor-
monal differences between the conception and non-conception
menstrual cycles of 32 normal women. Human Reproduction
Update, 12(12), 2607–2613.
Baird, D. D., Weinberg, C. R., Zhou, H., Kamel, F., McConnaughey,

D. R., Kesner, J. S., & Wilcox, A. J. (1999). Preimplantation uri-
nary hormone profiles and the probability of conception in healthy
women. Fertility & Sterility, 71, 40–49.
Bateman, A. J. (1948). Intra-sexual selection in Drosophila. Heredity,
2, 349–368.
Brooks, R., Scott, I. M., Maklakov, A. A., Kasumovic, M. M., Clark,
A. P., & Penton-Voak, I. S. (2011). National income inequality pre-
dicts women’s preferences for masculinised faces better than health
does. Proceedings of the Royal Society of London B. 278, 810–812.
Buss, D. M. (1989). Sex differences in human mate preferences: evo-
lutionary hypotheses tested in 37 cultures. Behavioral and Brain
Sciences, 12, 1–49.
Buss, D. M., & Schmidt, D. P. (1993). Sexual strategies theory: an evo-
lutionary perspective on human mating. Psychological Review,
100, 204–232.
Carroll, J., Murphy, C. J., Neitz, M., ver Hoeve, J. N., & Neitz, J. (2001).
Photopigment basis for dichromatic colour vision in the horse.
Journal of Vision, 1, 80–87.
Changizi, M.A., Zhang, Q., & Shimojo, S. (2006). Bare skin, blood and
the evolution of primate colour vision. Biology Letters, 2, 217–221.
Charkoudian, N., Stephens, D. P., Pirkle, K. C., Kosiba, W. A., & John-
son, J. M. (1999). Influence of female reproductive hormones on
local thermal control of skin blood flow. Journal of Applied Physi-
ology, 87, 1719–1723.
Coetzee, V., Perrett, D. I., & Stephen, I. D. (2009). Facial adiposity: a
cue to health? Perception, 38, 1700–1711.
Coetzee, V., Re, D., Perrett, D. I., Tiddeman, B. P., & Xiao, D. (2011).
Judging the health and attractiveness of female faces: Is the most
attractive level of facial adiposity also considered the healthiest?
Body Image, 8, 190–193.
Darwin, C. (1871). The Descent of Man and Selection in Relation to
Sex. London: John Murray.
DeBruine, L. M., Jones, B. C., Crawford, J. R., Welling, L. L. M., &
Little, A. C. (2010). The health of a nation predicts their mate
preferences: Cross-cultural variation in women’s preferences for
masculinized male faces. Proceedings of the Royal Society of
London B, 277(1692), 2405–2410.
Dowling, D. K., & Simmons, L. W. (2009). Reactive oxygen species as

universal constraints in life-history evolution. Proceedings of the
Royal Society of London B, 276, 1737–1745.
Fink, B., Grammer, K., & Matts, P. J. (2006). Visible skin color dis-
tribution plays a role in the perception of age, attractiveness,
and health in female faces. Evolution and Human Behavior, 27,
433–442.
Fink, B., Bunse, L., Matts, P. J., & D’Emiliano, D. (2012). Visible
skin colouration predicts perception of male facial age, health
and attractiveness. International Journal of Cosmetic Science, 34,
307–310.
Friis, H., Gomo, E., Kastel, P., Ndhlovu, P., Nyazema, N., Krarup, H., &
Michaelsen, K. F. (2001). HIV and other predictors of serum
β-carotene and retinol in pregnancy: a cross-sectional study
in Zimbabwe. American Journal of Clinical Nutrition, 73, 1058–
1065.
Gangestad, S. W., Thornhill, R., & Yeo, R. A. (1994). Facial attractive-
ness, developmental stability, and fluctuating asymmetry. Ethology
and Sociobiology, 15, 73–85.
Grammer, K., & Thornhill, R. (1994). Human (Homo sapiens) facial
attractiveness and sexual selection: The role of symmetry and aver-
ageness. Journal of Comparative Psychology, 108, 233–242.
Green, B. B., Weiss, N. S., & Daling, J. R. (1988). Risk of ovulato-
ry infertility in relation to body weight. Fertility and Sterility, 50,
721–725.
Hamilton, W. D., & Zuk, M. (1982). Heritable true fitness and bright
birds: a role for parasites? Science, 218, 384–387.
Horak, P., Saks, L., Karu, U., Ots, I., Surai, P. F., & McGraw, K. J.
(2004). How coccidian parasites affect health and appearance of
greenfinches. Journal of Animal Ecology, 73, 935–947.
Johnson, J. M. (1998). Physical training and the control of skin blood
flow. Medicine and Science in Sports and Exercise, 30, 382–386.
Jones, B. C., Little, A. C., Burt, D. M., & Perret, D. I. (2004). When
facial attractiveness is only skin deep. Perception, 33, 569–576.
Langlois, J. H., Kalakanis, L., Rubenstein, A. J., Larson, A., Hallam, M., &
Smoot, M. (2000). Maxims or myths of beauty? A meta-analytic
and theoretical review. Psychological Bulletin, 126(3), 390–423.
Langlois, J. H., & Roggman, L. A. (1990). Attractive faces are only

average. Psychological Science, 1(2), 115–121.
Langlois, J. H., Roggman, L. A., & Musselman, L. (1994). What is av-
erage and what is not average about attractive faces? Psychological
Science, 5(4), 214–220.
Law Smith, M. J., Perrett, D. I., Jones, B. C., Cornwell, R. E., Moore,
F. R., Feinberg, D. R., & Hillier, S. G. (2006). Facial appearance
is a cue to oestrogen levels in women. Proceedings of the Royal
Society of London B, 273, 135–140.
LeBouef, B. L. (1974). Male-male competition and reproductive suc-
cess in elephant seals. American Zoologist, 14, 163–176.
Lee, L., Loewenstein, G., Ariely, D., Hong, J., & Young, J. (2008). If I’m
not hot, are you hot or not? Physical-attractiveness evaluations and
dating preferences as a function of one’s own attractiveness. Psycho-
logical Science, 19(7), 669–677.
Li, N.P., Valentine, K.A., & Patel, L. (2011). Mate preferences in
the U.S. and Singapore: A cross-cultural test of the mate pref-
erence priority model. Personality and Individual Differences,
50, 291–294.
Little, A. C., Jones, B. C., Burt, D. M., & Perrett, D. I. (2007). Prefer-
ences for symmetry in faces change across the menstrual cycle.
Biological Psychology, 76, 209–216.
Little, A. C., Jones, B. C., Penton-Voak, I. S., Burt, D. M., & Perrett,
D. I. (2002). Partnership status and the temporal context of relation-
ships influence human female preferences for sexual dimorphism
in male face shape. Proceedings of the Royal Society B: Biological
Sciences, 269, 1095–1100.
Lipson, S. F., & Ellison, P. T. (1996). Comparison of salivary steroid
profiles in naturally occurring conception and non-conception
cycles. Human Reproduction, 11(10), 2090–2096.
MacDougall, A. K., & Montgomerie, R. (2003). Assortative mat-
ing by carotenoid-based plumage color: A quality indicator in
American goldfinches, Carduelis tristis. Naturwissenschaften,
90, 464–467.
Marlowe, F., Apicella, C., & Reed, D. (2005). Men’s preferences for
women’s profile waist-to-hip ratio in two societies. Evolutionary
Human Behavior, 26, 458–468.
Matts, P. J., & Fink, B. (2010). Chronic sun damage and the perception
of age, health and attractiveness. Photochemical and Photobiologi-
cal Sciences, 9, 421–431.
Matts, P. J., Fink, B., Grammer, K., & Burquest, M. (2007). Colour
homogeneity and visual perception of age, health and attractive-
ness of female facial skin. Journal of the American Academy of
Dermatology, 57(6), 977–984.
Mazur, A., & Booth, A. (1998). Testosterone and dominance in men.
Behavioural and Brain Sciences, 21, 353–397.
Mealey, L., Bridgstock, R., & Townsend, G. C. (1999). Symmetry and
perceived facial attractiveness: A monozygotic co-twin comparison.
Journal of Personality and Social Psychology, 76(1), 151–158.
Møller, A. P. (1990). Parasites and sexual selection: Current status of
the Hamilton and Zuk hypothesis. Journal of Evolutionary Biology,
3, 319–328.
Møller, A. P. (1994). Sexual selection and the barn swallow. Oxford:
Oxford University Press.
Murray, F. G. (1934). Pigmentation, sunlight and nutritional disease.
American Anthropologist, 36(3), 438–448.
Panza, J. A., Quyyimi, A. A., Brush, J. R., & Epstein, S. E. (1990).
Abnormal endothelium-dependent vascular relaxation in patients
with essential hypertension. New England Journal of Medicine,
323, 22–27.
Park, J. H., van Leeuwen, F., & Stephen, I. D. (2012). Homeliness is in
the disgust sensitivity of the beholder: relatively unattractive faces
appear especially unattractive to individuals higher in pathogen
disgust. Evolution and Human Behavior, 33, 569–577.
Penton-Voak, I. S., & Chen, J. Y. (2004). High salivary testosterone is
linked to masculine male facial appearance in humans. Evolution-
ary Human Behavior, 25, 229–241.
Penton-Voak, I. S., Jones, B. C., Little, A. C., Baker, S., Tiddeman, B.,
Burt, D. M., & Perrett, D. I. (2001). Symmetry, sexual dimorphism
in facial proportions and male facial attractiveness. Proceedings
of the Royal Society of London B: Biological Sciences, 268, 1617–
1623.
Penton-Voak, I. S., & Perrett, D. I. (2000). Female preference for male
faces changes cyclically. Evolution and Human Behavior, 21, 39–48.
Penton-Voak, I. S., Perrett, D., Castles, D., Burt, M., Koyabashi, T., &
Murray, L. K. (1999). Female preferences for male faces change
cyclically. Nature, 399, 741–742.
Perrett, D. (2010). In Your Face: The New Science of Human Attraction.
New York, NY: Palgrave Macmillan.
Perrett, D. I., Burt, D. M., Penton-Voak, I. S., Lee, K. J., Rowland, D. A., &
Edwards, R. (1999). Symmetry and human facial attractiveness.
Evolution and Human Behavior, 20, 295–307.
Perrett, D. I., Lee, K. J., Penton-Voak, I. S., Rowland, D. R., Yoshikawa,
S., Burt, D. M., & Akamatsu, S. (1998). Effects of sexual dimor-
phism on facial attractiveness. Nature, 394, 884–887.
Pound, N., Lawson, D.W., Toma, A.M., Richmond, S., Zhurov, A.I.,
& Penton-Voak, I.S. (2014). Facial fluctuating asymmetry is not
associated with childhood ill-health in a large British cohort study.
Proceedings of the Royal Society of London B: Biological Sciences,
281, 20141639.
Rhodes, G., Chan, J., Zebrowitz, L. A., & Simmons, L. W. (2003). Does
sexual dimorphism in human faces signal health? Proceedings of
the Royal Society of London B: Biological Sciences, 270, S93–S95.
Rhodes, G., Sumich, A., & Byatt, G. (1999). Are Average Facial
Configurations Attractive Only Because of Their Symmetry? Psy-
chological Science, 10(1), 52–58.
Rhodes, G., & Tremewan, T. (1996). Averageness, exaggeration and
facial attractiveness. Psychological Science, 7, 105–110.
Rhodes, G., Yoshikawa, S., Palermo, R., Simmons, L. W., Peters, M.,
Lee, K., & Crawford, J. R. (2007). Perceived health contributes to
the attractiveness of facial symmetry, averageness, and sexual di-
morphism. Perception, 36, 1244–1252.
Rhodes, G., Yoshikawa, S., Clark, A., Lee, K., McKay, R., & Akamatsu,
S. (2001). Attractiveness of facial averageness and symmetry in
non-Western cultures: In search of biologically based standards of
beauty. Perception, 30, 611–625.
Rhodes, G., Zebrowitz, L. A., Clark, A., Kalick, S. M., Hightower, A., &
McKay, R. (2001). Do facial averageness and symmetry signal
health? Evolution and Human Behaviour, 22(1), 31–46.
Rhodes, L., Argersinger, M. E., Gantert L. T., Friscino, B. H., Hom, G.,
Pikounis, B., & Rhodes, W. L. (1997). Effects of administration
of testosterone, dihydrotestosterone, oestrogen and fadrozole, an

aromatase inhibitor, on sex skin colour in intact male rhesus ma-
caques. Journal of Reproduction and Fertility, 111, 51–57.
Ritz, B. W., & Gardner, E. M. (2006). Malnutrition and energy restric-
tion differentially affect viral immunity. The Journal of Nutrition,
136, 1141–1144.
Roberts, S. C., Little, A. C., Gosling, L. M., Perrett, D. I., Jones,
B. C., Carter, V., & Petrie, M. (2005). MHC-heterozygosity and
human facial attractiveness. Evolution & Human Behavior, 26,
213–226.
Robins, A. H. (1991). Biological Perspectives on Human Pigmentation.
Cambridge: Cambridge University Press.
Saks, L., Ots, I., & Horak, P. (2003). Carotenoid-based plumage
coloration of male greenfinches reflects health and immunocompe-
tence. Oecologia, 134, 301–307.
Scott, I. M. L., Pound, N., Stephen, I. D., Clark, A. P., & Penton-Voak,
I. S. (2010). Does masculinity matter? The contribution of sex-
typical appearance to male attractiveness in humans. PLoS ONE, 5,
e13585.
Setchell, J. M. (2005). Do female mandrills prefer brightly coloured
males? International Journal of Primatology, 26(4), 715–735.
Setchell, J. M., & Dixson, A. F. (2001). Changes in the Secondary
Sexual Adornments of Male Mandrills (Mandrillus sphinx) Are
Associated with Gain and Loss of Alpha Status. Hormones and
Behavior, 39(3), 177–184.
Setchell, J. M., & Wickings, J. (2005). Dominance, status signals and
coloration in male mandrills (Mandrillus sphinx). Ethology, 111,
25–50.
Shackelford, T. K., & Larsen, R. J. (1997). Facial asymmetry as an indi-
cator of psychological, emotional, and physiological distress. Jour-
nal of Personality and Social Psychology, 72, 456–466.
Stamatas, G. N., Zmudzka, B. Z., Kollias, N., & Beer, J. Z. (2004).
Non-invasive measurements of skin pigmentation in situ. Pigment
Cell Research, 17(6), 618–626.
Stephen, I. D., Coetzee, V., & Perrett, D. I. (2011). Carotenoid and mel-
anin pigment coloration affect perceived human health. Evolution
and Human Behavior, 32(3), 216–227.
Stephen, I. D., Coetzee, V., Smith, M. L., & Perret, D. I. (2009). Skin
blood perfusion and oxygenation colour affect perceived human
health. PLoS One, 4(4), e5083.
Stephen, I. D, Scott, I. M, Coetzee, V., Pound, N., Perrett, D. I., &
Penton-Voak, I. S. (2012). Cross-cultural effects of color, but not
morphological masculinity, on perceived attractiveness of men’s
faces. Evolution & Human Behavior, 33, 260–267.
Stephen, I. D., Smith, M. J. L., Stirrat, M. R., & Perrett, P. I. (2009).
Facial Skin Coloration Affects Perceived Health of Human Faces.
International Journal of Primatology. 30(6), 845–857.
Stephen, I.D., & Perera, A.T.M. (2014a). Judging the difference be-
tween attractiveness and health: Does exposure to model images
influence the judgments made by men and women? PLoS one, 9,
e86302.
Stephen, I.D., & Perera, A.T.M. (2014b). Judging the difference be-
tween women's attractiveness and health: Is there really a differ-
ence between judgments made by men and women? Body Image,
11, 183–186.
Stewart, D., Overstreet, J., Nakajima, S., & Lasley, B. (1993). En-
hanced ovarian steroid secretion before implantation in early
human pregnancy. Journal of Clinical Endocrinology & Metab-
olism, 76(6), 1470–1476.
Swaddle, J. P., & Cuthill, I. C. (1994). Preference for symmetrical
males by female zebra finches. Nature, 367, 165–166. doi:10.1038/
367165a0.
Swami, V., & Tovée, M. J. (2005). Female physical attractiveness in
Britain and Malaysia: A cross-cultural study. Body Image, 2,
115–128.
Tan, K.W., & Stephen, I.D. (2013). Colour detection thresholds in faces
and colour patches. Perception, 42, 733–741.
Thornhill, R., & Gangestad, S. W. (1993). Human facial beauty: Av-
erageness, symmetry, and parasite resistance. Human Nature, 4,
237–269.
Thornhill, R., & Gangestad, S. W. (1999). Facial attractiveness. Trends
in Cognitive Sciences, 3 (12), 452–460.
Thornhill, R., Gangestad, S. W., Miller, R., Scheyd, G., McCollough,
J. K., & Franklin, M. (2003). Major histocompatibility complex
genes, symmetry, and body scent attractiveness in men and women.

Behavioural Ecology, 14(5), 668–678.
Thornhill, R., & Grammer, K. (1999). The body and face of a woman:
one ornament that signals quality? Evolution and Human Behav-
iour, 20, 105–120.
Tiddeman, B. P., Stirrat, M. R., & Perrett, D. I. (2005). Towards realism
in facial transformation: results of a wavelet MRF method. Com-
puter Graphics Forum, 24(3), 449–456.
Tinlin, R. M., Watkins, C. D., Welling, L. L. M., DeBruine, L. M., Al-
Dujaili, E. A. S., & Jones, B. C. (2012). Perceived facial adiposity
conveys information about women’s health. British Journal of Psy-
chology, 104, 235–348. doi: 10.1111/j.2044-8295.2012.02117.x.
Trivers, R. L. (1972). Parental investment and sexual selection. In
B. Campbell (Ed.), Sexual Selection and the Descent of Man:
1871–1971 (pp. 136–179). Chicago, IL: Aldine.
Tovée, M. J., & Cornelissen, P. L. (1999). The mystery of female beauty.
Nature, 399, 215–216.
Tovée, M. J., Reinhardt, S., Emery, J. L., & Cornelissen, P. L. (1998).
Optimum body-mass index and maximum sexual attractiveness.
Lancet, 352(9127), 548–548.
Tovée, M. J., Swami, V., Furnham, A., & Mangalparsad, R. (2006).
Changing perceptions of attractiveness as observers are exposed to
a different culture. Evolution and Human Behavior, 27(6), 443–456.
Townsend, J. M., & Wasserman, T. (1998). Sexual strategies theory: an
evolutionary perspective on human mating. Evolution and Human
Behavior, 19, 171–191.
Waitt, C., Gerald, M. S., Little, A. C., & Kraiselburd, E. (2006). Selec-
tive attention toward female secondary sexual color in male rhesus
macaques. American Journal of Primatology, 68, 738–744.
Waitt, C., & Little, A. C. (2006). Preferences for symmetry in conspe-
cific facial shape among Macaca mulatta. International Journal of
Primatology, 27, 133–145.
Waitt, C., Little, A. C., Wolfensohn, S., Honess, P., Brown, A. P.,
Buchanan-Smith, H. M., & Perrett, D. I. (2003). Evidence from
rhesus macaques suggests that male coloration plays a role in
female primate mate choice. Proceedings of the Royal Society of
London B, 270, S144–S146.
Wilson, P. W., D’Agostino, R. B., Sullivan, L., Parise, H., & Kannel, W. B.
(2002). Overweight and obesity as determinants of cardiovascu-
lar risk: the Framingham experience. Archive of Internal Medicine,
162, 1867–1872.
Wolf, N. (1991). The beauty myth: How images of beauty are used
against women. New York, NY: William Morrow and Company.
Wood, B., & Hill, K. (2000). A test of the “showing-off” hypothesis with
Ache hunters. Current Anthropology, 41, 124–125.
Zahavi, A. (1975). Mate selection – a selection for a handicap. Journal
of Theoretical Biology, 53, 205–214.
Zebrowitz, L. A., & Rhodes, G. (2004). Sensitivity to ‘bad genes’ and
the anomalous face overgeneralization effect: cue validity, cue uti-
lization, and accuracy in judging intelligence and health. Journal
of Nonverbal Behavior, 28, 167–185.
Gregory B. Bonn
Why culture matters: Social context

and how we make sense of our lives*
From time to time, in the course of conducting cultural research, the

question arises, “Why does ethnicity or nationality matter? Aren’t we
just one human race?” In fact, from a principled standpoint, most psy-
chologists would agree with the statement that ethnicity, per se, really
does not matter as a psychological variable. Partially for this reason,
through the history of psychology, sociocultural variables have been
largely ignored (Henrich, Heine, & Norenzayan, 2010). Over the past
several decades more psychologists have begun to investigate variables
such as ethnicity and nationality not because of any particular interest in
the color of a person’s skin, what language their parents speak, or even
what country they live in. These variables however are clues to a per-
son’s cultural background; they hint at the social beliefs and practices
that a person has been immersed in throughout their life. Generally,
people are not consciously aware of their cultural environment (e.g.
Adler, 1975). They live in a certain environment, among people who
speak and behave in certain ways, and value certain things. It’s easy and
natural to implicitly assume that all of these familiar and comfortable
ways of going through life are “normal”. Most people don’t consider
their own culture much at all until they come into contact with other,
different ways of doing things.
In fact though, there is an enormous amount of variation through-
out the world in how groups of people think and behave. In this chapter
we will briefly explore how some of these differences come about; how
people, immersed from early childhood in a cultural environment, learn
implicitly and automatically (i.e. without any reflexive awareness) to
* This work was supported by a Fundamental Research Grant (FRGS/2/2013/SS02/

MUSM/03/1) from the Ministry of Higher Education, Malaysia.
68 Gregory B. Bonn
look at, and understand their world according to certain cultural models
(Quinn, 2003). We’ll explore some of the processes by which individ-
uals absorb the norms and habits of their social groups; how humans,
by nature, unconsciously absorb the practices and beliefs of the people
they are surrounded by (Swidler, 1986), and how doing so enables the
individual to seamlessly interact with and understand the people whom
he depends upon for survival.
Depending upon and learning from others to survive
Evidence shows that human beings have evolved to engage socially with
and learn from others (Bowlby, 1969; Siegel, 1999). From early infancy
children have been found to prefer human faces to other types of stimuli
(Frank, Vul, & Johnson, 2009), to pay attention to objects that nearby
adults are looking at (Hoehl, Reid, Mooney, & Striano, 2008), and to be
highly sensitive to the emotional states of others (Schore, 2003). Such
hard-wired early behaviors stem from basic survival instincts common
to all mammals. Like other newborn mammals, humans are not physi-
cally equipped to survive on their own; they begin life in a state of de-
pendence upon other mature members of their species for nourishment
and protection (Bowlby, 1980; Cozolino, 2002). Humans, however, dif-
fer from most other mammals in that they depend upon other members
of their species for more than just basic physiological and emotional
needs. Most mammals are more or less equipped to survive once they
reach a level of physical maturity; they can function within their limit-
ed natural and social habitats by utilizing largely instinctual behaviors.
Groups of humans, however, develop unique patterns of behaviors and
customs specifically tailored to life within one specific social and geo-
graphical habitat out of an enormous range of human-habitated envi-
ronments. Each successive generation of individuals thus has the best
chance of survival if it can learn such location and culture-specific skills
as efficiently and smoothly as possible.
Although it has been argued convincingly that some animals do
learn through social interactions, thus demonstrating culture-like
Why culture matters 69
characteristics (e.g. Laland & Galef, 2009) it is indisputable that humans

are socially programmed to a degree far beyond that of any other species.
Human beings, unlike any other species, successfully inhabit every con-
tinent of the earth, not due to innate physical capabilities, but because
shared knowledge and cooperative behaviors transmitted through the
routine operation of culture allow them to do so. Modern city life, for
example, with its complex modes of production and abstract methods
of exchange requires a much different set of “tools” (e.g. Swidler, 1986)
than those required of forest-dwelling tribesmen who hunt, forage, and
barter for their needs. Likewise, while those in farming societies must
learn the subtleties of planting, harvesting, and storing crops, Inuit
tribesmen must learn to exploit a much different set of resources to sur-
vive in the arctic; such as hunting whales, caribou, and char. The bulk of
knowledge necessary for survival in any environment is learned through
observing and interacting with other people. As a species, humans are
capable of surviving in extremely diverse habitats because their behav-
iors and mental abilities are extremely flexible. Instead of having most
behaviors hardwired into the organism, human brains are wired to key
into and copy the behavioral, speech, and narrative patterns of others
(LeDoux, 2003; Quinn, 2003; Siegel, 1999). This flexibility of thought
and behavior allows humans to benefit from the collective experience
and knowledge accumulated by many preceding generations. Through
the essentially automatized absorption of surrounding customs and
behaviors human children are able to seamlessly acquire any one (or
more) of an enormous range of cultural tool kits, and thus unthinkingly
adapt to practically any given environment.
Skills are embedded within social norms
Practical skills are not learned in isolation however. The practices nec-
essary for survival in any given environment come embedded with-
in multiple layers of traditional social practices and beliefs (Erikson,
1950; Quinn, 2003). Norms of communication and behavior, beliefs
about what is good and appropriate, traditional means of exchange and
70 Gregory B. Bonn
arbitration, all are intertwined with more practical skills and become
equally embedded within the behavioral and narrative repertoire of the
enculturated individual. Cultural conceptions of how a person ought to
behave, of the type of person that is considered to be good or admirable
(e.g. MacIntyre, 1981) become an important part of every social milieu,
often persisting in groups even after their economic means or geograph-
ical situations have changed (Arnett, 2002). Because societies must
focus their attention on different types of objects, and require divergent
kinds of awareness and skill sets, they also learn to value different qual-
ities or virtues within a person (Rosenthal & Roer-Strier, 2006). Each
group teaches its’ members what behaviors are acceptable, desirable
and appropriate, and how to be a “good” person by that culture’s stan-
dards through the consistent reinforcement of culture-specific “ways of
being” starting in early childhood (Quinn, 2003).
As mentioned earlier, an important quality of this sort of cultural
training is that it is largely implicit, it is so deeply ingrained that it is
essentially invisible to the individual. Those who have been surrounded
all their lives by and enculturated into a certain set of traditions, cus-
toms, and beliefs tend to feel that those ways of being are “normal” and
natural; that others, who engage with their surroundings in other ways,
are odd. They probably feel uneasy around those that are different. Cul-
tural ways of looking at the world and understanding the self are so well
rehearsed over the course of many years that they, literally, change the
way the brain is wired (LeDoux, 2003; Quinn, 2003). There is mounting
evidence of culture having deep and lasting effects on the way that each
of us sees (Masuda, Gonzalez, Kwan, & Nisbett, 2008) and understands
the world, and even how the brain neurally represents the self and others
(Zhu, Zhang, Fan, & Han, 2006). Because cultural outlooks are so deep-
ly etched in the person, the path of least resistance, that taken by most
people, is to implicitly assume that one’s own perspective is normal
(e.g. Castells, 2010) and correct, that those who think differently are
somehow unaware or incorrect.
Social patterns become embedded in how people think
It may not be intuitively obvious that social interactions can actually

influence the way that people see the world and understand themselves.
In truth, much visual and auditory processing is essentially “hardwired”
or biological in nature, meaning the neural structures operate the same
in all people. However, evidence is mounting that executive parts of the
brain play a large role in the “top down” parsing and interpretation of
sensory information (Petersen & Posner, 2012); that expectations and
goals, which are shaped by culture, play a role in guiding the neural
processing of sensory information in sorting through and deciding at a
neural level which information is attended to and which is disregarded
(Mesgarani & Chang, 2012). For example, the ventral visual process-
ing areas, those that are commonly associated with the interpretation
or meaning of visual input (e.g. Goh & Park, 2009), as well as some
related to attentional control (Ketay, Aron, & Hedden, 2009) show mea-
surable differences in how stimuli are processed between East Asian
and Western populations. In a very simplified sense, what seems to hap-
pen during the enculturation process is that through the repetition of
certain patterns of experience, specific patterns of neural connections
are reinforced through repetition (LeDoux, 2003). Literally, each time
specific objects or people are meaningfully juxtaposed, those relation-
ships become more and more firmly encoded in actual neural pathways.
The neural pathways that are used most often, those that correspond to
regularities within a given culture, become reinforced and strengthened
through use while other potential neural connections become weaker
from relative neglect (LeDoux). Thus, over time, a person’s behavior and
cognition becomes intrinsically biased towards the patterns, priorities,
and connections that are oft repeated within their social circles (Domin-
guez, Lewis, Turner, & Egan, 2009). These default patterns of behavior
and cognition serve as a kind of autopilot for most people, most of the
time. The sociocultural nature of how we think and do things does not
normally occur to us when we are in familiar surroundings; we just “act
naturally” and things turn out the way that we expect. It is usually only
when our implicit expectations are challenged, when things don’t turn
72 Gregory B. Bonn
out the way they “should”, that we are forced to rethink our assumptions
and possibly retrain ourselves.
A natural question to ask at this point then is “What is it about dif-
ferent cultures that cause people to think and behave differently? How
does cultural transmission take place?” The simple (and not very use-
ful) answer is that cultural transmission takes place all throughout a
culture, at all times, and at all stages of life. Individuals are immersed
in a culture like they are immersed in the air they breathe. Although
essentially invisible, it always surrounds the person; they take it in, are
nourished by it, and incorporate parts of it into their being without con-
scious awareness. The more complicated, and yet to be fully understood,
answer is that there seem to be periods of development during which
the brain is most sensitive to specific types of information (Dominguez
et al., 2009; Rochat, 2003). It seems cultural knowledge and practices
are adopted gradually, over-time, with newly acquired information
building upon and elaborating that acquired at earlier stages (e.g. Erik-
son, 1950; Habermas & Bluck, 2000).
Early socialization
As mentioned earlier, infants in every culture start life instinctually

driven to connect with others (e.g. Bowlby, 1969; Cozolino, 2002;
Main, 1999). Human infants also seem to have a basic drive to learn
and acquire the use of language, and this is one of the first ways that
we see the brain and perceptual abilities being measurably molded by
social contact. Kuhl (2010) and others (e.g. Conboy et al., 2008, Zhang
et al., 2005), for example, have demonstrated that neural responses to
native (as opposed to foreign) language speakers are measurably differ-
ent for children at six months of age and older, but not for newborns.
These findings converge with many earlier studies (e.g. Werker & Tees,
1984) indicating that newborns have the ability to distinguish between
the phonemes used in every language, but, over the first year of life,
they gradually lose the ability to distinguish sounds used in foreign lan-
guages while developing a preference for the sounds of the language
which they hear most often in their surroundings (not surprisingly, at

this early age they also develop a preference for people who speak fa-
miliar languages). In essence, then, we can see that the young brain
is like a socially adaptive learning machine that is preprogrammed to
learn to understand the people that surround it. This sort of learning
is unconscious and automatic; it occurs as a natural process for the
child. A healthy child naturally craves and seeks out social interaction
(e.g. Schore, 2003) and the shape of those interactions literally wires
the brain to function in harmony with certain sets of cultural practices
(Quinn, 2003). This sort of programming is not set in stone however;
brains continue to be malleable throughout life (Cozolino, 2002). People
can learn second languages, for example, and adapt to second cultures
as well (Minoura, 1992). It requires, however, greater effort to absorb
such knowledge after the sensitive period or period of accelerated learn-
ing for a specific type of information has passed (Bialystok & Hakuta,
1994). As such, cultural skills acquired later usually don’t hold the same
sort of privileged position as those acquired during the period when the
brain is especially sensitive to certain types of information (Minoura).
Learning to tell stories
Moving ahead to later in childhood, from toddlerhood through the

early school years children continue to develop language and vocab-
ulary skills at an accelerated rate. As their language skills become
more complex, children learn to shape their iterations according to cul-
ture-specific linguistic and social rules (Miller, Wiley, Fung, & Liang,
1997). They learn ways of talking about themselves and their experi-
ences through the process of cooperative storytelling or co-narration:
Elders engage children by cooperatively constructing stories about their
experiences, helping them to tell stories that make sense to others from
their culture (Miller, Fung, & Mintz, 1996; Quinn, 2003). By prompting
certain types of statements and encouraging specific associations, par-
ents, largely without realizing it, train their children to tell stories about
their lives that fit within their own cultural models. Implicit emotional
74 Gregory B. Bonn
cues as well as explicit corrections are applied consistently over time

in every sociocultural environment. They serve to encourage the telling
of stories about the self that are congruent with that culture’s expecta-
tions, while at the same time discouraging others. This may seem trivial
at first, but when one actually compares the transcripts of parent-child
interactions between different cultures some striking differences can
arise. For example, in their comparisons of Chinese and European
American families, Miller, Wiley, Fung, and Liang found a strong ten-
dency for Chinese parents to encourage their children to explain their
experiences in terms moral and social standards (i.e. did the child or
did he not follow the rules set out by society). American families, on
the other hand, were more likely to encourage a child to talk about what
he did as interesting and entertaining or to emphasize his successes
and how he stood out in some way. Thus, a child within a given soci-
ety is taught through a kind of scaffolding process to create meaning
and make sense of their experiences according to a specific template.
As each person goes through life repeatedly describing themselves and
their experiences according to set patterns and is concurrently exposed
to others framing their own lives in similar ways, the types of associa-
tions and pathways that make up common stories and themes become
well-worn and comfortable; they become the “normal” way of thinking
about the self for that person (e.g. McAdams, 2001; Quinn, 2003).
Shaping the child’s environment
Similarly, Tobin and his colleagues (2009) observed striking cross-

cultural differences in how children’s environments and activities are
structured during preschool. For example, American children were
provided with a wide array of different toys and activities to choose
from and were allowed to try different activities and settle, of their
own volition, on whichever activities they were most intrigued by. Chi-
nese preschoolers, on the other hand, were expected to engage in the
same activities as their classmates. Throughout the whole day Chinese
students activities were dictated by their instructors, even to the point of

scheduled group restroom breaks (explained as instilling self-control).
Japanese preschool, by contrast, was more a mix between unplanned
and scheduled group activities, with plenty of time for uncoordinated
group play and interaction. One noticeable contrast between American
and Japanese teachers, however, was that when students acted out, or
had disagreements and even physical fights, Japanese teachers tended
not to intervene when Americans (or Chinese) certainly would have.
Japanese teachers explained that students need to learn how to resolve
problems with peers and practice working out their differences within
groups. American teachers, on the other hand, focused on encouraging
children to express themselves and find their interests, but were quick to
rein them in if they caused or engaged in conflict with others. Chinese
teachers, by contrast, spoke of self-control and discipline as the traits
they hoped to instill in their students. Thus, we see children embedded
within societal frameworks that emphasize clearly contrasting concep-
tions of what is normal, desirable, and good: The patterns of speech, be-
havior, and thought molded within each of those frameworks, because
they are consistently reinforced from earliest childhood, become the
default patterns for how a child understands their world. They learn to
see their society’s unique way of understanding the world as normal, ap-
propriate, and desirable. Around the world and throughout history such
cultural contrasts have been observed: From salmon fishing Indians in
the pacific northwest of the U.S. to nomadic buffalo hunting plains In-
dians (Erikson, 1950) to savanna dwelling African tribesmen to South
Pacific islanders (Quinn, 2003) to different social classes within the
modern United States (Snibbe & Markus, 2005; Wiley, Rose, Burger, &
Miller, 1998); all these groups structure (largely unintentionally, at least
without the conscious awareness of doing so) the environments, activi-
ties and interactions of their children so that they repetitively replay the
behavioral and narrative patterns considered appropriate and desirable
within that social milieu. Through continual rehearsal, children learn
culturally unique ways of looking at the world; ways of thinking about
what is important, and how objects and people of importance relate to
each other.
76 Gregory B. Bonn
Expanding influences and the formation of a life story
The rehearsal and reinforcement of cultural scripts continues through-

out life, although the nature of influences and the complexity of scripts
changes as a person progresses through school age and into adulthood
(Damon & Hart, 1982). Generally, from early childhood to school age
and adolescence, the primary sources of socialization shift outward
from the family towards broader circles of similar-aged peers (Harris,
1998). Also, in later childhood and adolescence, influences such as
education, religion, and mass media play a part in modeling cultural
concepts of biography (Habermas & Bluck, 2000), which are idealized
narratives or models of how normal lives ought to progress within that
society. Cultural concepts of biography provide a kind of template in
relation to which people learn to evaluate their experiences and accom-
plishments (Arnett, 1995; 2002; McAdams, 2001).
The increasing complexity of these new influences, along with a
host of cognitive developments that accompany adolescence (e.g. Stein-
berg, 2005) tend to drive the individual towards a way of organizing
their experiences and ideas in meaningful ways. During adolescence,
this type of mental organization begins to take the form of an ongoing
master narrative or life story (Erikson, 1968; McAdams, 2001) which
integrates the many experiences and impressions floating around in an
individual’s memory into a meaningful whole. Facilitated by the ab-
stract, causal reasoning and meta-cognitive capacities arising in the ad-
olescent brain (Habermas & Bluck, 2000; Hammack, 2008), the life
story fulfills a commensurately developing need for self-understanding
(e.g. Damon & Hart, 1982; Erikson, 1950): It places the individual,
their experiences, and their beliefs within a meaningful context, ex-
plaining from the individual’s point of view who they are, what they are
capable of, where they came from, and what they want. A coherent life
story thus provides the individual with a clearer sense of future possi-
bilities and how they might navigate into that future, quite important
notions to grasp of for an adolescent coming to terms with life outside
the shelter of parental protection. In studying the psychology of life
stories McAdams (2001) has proposed that the thematically integrat-
ed life stories that begin to appear during adolescence are essentially
representations of what Erikson originally referred to as personal iden-

tity. The life story becomes an ongoing internal narrative by which
an individual makes sense of his experiences, and how he fits into the
world. It represents the self as the protagonist, and through the narrative
process places his various experiences and relationships into meaning-
ful context.
Shaping the life story in context
Stepping back and reflecting, based upon our earlier discussion, about
the ways in which a person would go about forming or structuring their
life story, it should be evident by this point that sociocultural context
would express itself to a great degree in how the individual narrates
and makes sense of their existence (Berntsen & Bohn, 2009). Of course
each individual must construct their own narrative out of their own
unique experiences, but the patterns and tools that are available to each
person are heavily dependent upon their surroundings. As they implic-
itly absorb many of the practices, assumptions, and patterns of their
surroundings, each person also absorbs cultural ideas about how a life
normally plays out (Habermas & Bluck, 2000) and what a good life
should look like (Tafarodi et al., 2012). Thinking, having been shaped
thus, uses these existing patterns to organize, structure, and evaluate
information going forward. The ways that objects are symbolically re-
lated to each other, how they are given meaning and value, in the sto-
ries circulated among groups of people become the standards by which
most people within those groups come to understand their world and
account for their existence. It is arguably possible to think in novel and
different ways, or to create new narrative structures and novel practices
(e.g. Cozolino, 2002), but doing so is effortful and thus not an efficient
or seemingly useful path for the majority of people.
Thus, we can begin to see some reasons why culture matters, and
why cultural psychologists are interested in people’s ethnic and cultural
backgrounds; not because of a belief in essential, genetic differences
between groups of people, but because the practices, traditions, and
78 Gregory B. Bonn
narratives shared by groups hold them together (Swidler, 1986; Quinn,

2003), and provide them with collective meaning systems through
which they commune with each other as well as interpret their worlds
(Hammack, 2008). Of course every sociocultural group contains a great
deal of variation, but shared meanings and scripts, because they are re-
peated and rehearsed so often within every group, become deeply etched
into most individual’s default patterns of thinking and thus influence
how they interpret and account for their experiences throughout life.
References
Adler, P. S. (1975). The transitional experience: an alternative view of

culture shock. Journal of Humanistic Psychology, 15, 13–23.
Arnett, J. J. (1995). Broad and narrow socialization: the family in the
context of a cultural theory. Journal of Marriage and the Family,
57, 617–628.
Arnett, J. J. (2002). The psychology of globalization. American Psy-
chologist, 57, 774–783.
Berntsen, D., & Bohn, A. (2009). Cultural life scripts and individual
life stories. In P. Boyer and J. Wertsch (Eds.), Memory in Mind and
Culture (pp. 62–82). Cambridge: Cambridge University Press.
Bialystok, E., & Hakuta, K. (1994). In other words: The science and
psychology of second-language acquisition. New York, NY: Basic
Books.
Bowlby, J. (1969). Attachment and loss, volume I: Attachment. New
York, NY: Basic Books.
Bowlby, J. (1980). Attachment and loss, volume III: Loss. New York,
NY: Basic Books.
Castells, M. (2010). The power of identity, 2nd edition. Sussex: Black-
well.
Conboy, B. T., Rivera-Gaxiola, M., Silva-Pereyra, J., & Kuhl, P. K.
(2008). Event-related potential studies of early language process-
ing at the phoneme, word, and sentence levels. In A. D. Friederici
& G. Thierry (Eds.), Early language development: Bridging brain

and behavior (Vol. 5, pp. 23–64). Amsterdam: John Benjamins.
Cozolino, L. J. (2002). The neuroscience of psychotherapy. New York,
NY: Norton.
Damon, W., & Hart, D. (1982). The development of self-understanding
from infancy through adolescence. Child Development, 53, 841–864.
Dominguz, D. J. F., Lewis, E. D., Turner, R., & Egan, G. F. (2009). The
brain in culture and culture in the brain: a review of core issues in
neuroanthropology. Progressive Brain Research, 178, 43–64.
Erikson, E. H. (1950). Childhood and society. New York, NY: Norton.
Erikson, E. H. (1968). Identity, youth and crisis. New York, NY: Norton.
Frank, M. C., Vul, E., & Johnson, S. P. (2009). Development of infant’s
attention to faces during the first year. Cognition, 110, 160–170.
Goh, J. O., & Park, D. C. (2009). Culture sculpts the perceptual brain.
Progress in Brain Research, 178, 95–111.
Habermas, T., & Bluck, S. (2000). Getting a life: The development of
the life story in adolescence. Psychological Bulletin, 126, 748–769.
Hammack, P. L. (2008). Narrative and the cultural psychology of identi-
ty. Personality and Social Psychological Review, 12, 222–247.
Harris, J. R. (1998). The nurture assumption. New York, NY: Touchstone.
Henrich, J., Heine, S. J., & Norenzayan, A. (2010). The weirdest people
in the world? Behavioral and Brain Sciences, 33, 61–135.
Hoehl, S., Reid, V. M., Mooney, J., & Striano, T. (2008). What are you
looking at? Infants’ neural processing of an adult’s object-directed
eye gaze. Developmental Science, 11, 10–16.
Ketay, S., Aron, A., & Hedden, T. (2009). Culture and attention: evi-
dence from brain and behavior. Progressive Brain Research, 178,
79–92.
Kuhl, P. K. (2010). Brain mechanisms in early language acquisition.
Neuron, 67, 713–727.
Laland, K. N., & Galef, B. G. (2009). The question of animal culture.
Cambridge, MA: Harvard University Press.
LeDoux, J. (2003). Synaptic self: How our brains become who we are.
New York, NY: Penguin.
MacIntyre, A. (1981). After virtue: A study in moral theory. Notre
Dame, IN: University of Notre Dame Press.
80 Gregory B. Bonn
Main, M. (1999). Epilogue: Attachment theory: Eighteen points with

suggestions for future studies. In J. Cassidy & P. R. Shaver (Eds.),
Handbook of attachment theory: Research and clinical applica-
tions (pp. 845–857). New York, NY: Guilford Press.
Masuda, T., Gonzalez, R., Kwan, L. Y., & Nisbett, R. E. (2008). Culture
and esthetic preference: Comparing the attention to context of East
Asians and Americans. Personality and Social Psychology Bulle-
tin, 34, 1260–1275.
McAdams, D. P. (2001). The psychology of life stories. Review of Gen-
eral Psychology, 5, 100–122.
Mesgarani, N., & Chang, E. F. (2012). Selective cortical representation
of attended speaker in multi-talker speech perception. Nature, 485,
233–237.
Miller, P. J., Fung, H., & Mintz, J. (1996). Self-construction through
narrative practices: A Chinese and American comparison of early
socialization. Ethos, 24, 237–280.
Miller, P. J., Wiley, A., Fung, H., & Liang, C. H. (1997). Personal sto-
rytelling as a medium of socialization in Chinese and American
families. Child Development, 68, 557–568.
Minoura, Y. (1992). A sensitive period for the incorporation of a cultur-
al meaning system: A study of Japanese children growing up in the
United States. Ethos, 20, 304–339.
Petersen, S. E., & Posner, M. I. (2012). The attention system of the
human brain: 20 years after. Annual Review of Neuroscience, 35,
73–89.
Quinn, N. (2003). Cultural selves. Annals of the New York Academy of
Sciences, 1001, 145–176.
Rochat, P. (2003). Five levels of self-awareness as they unfold early in
life. Consciousness and Cognition, 12, 717–731.
Rosenthal, M., & Roer-Strier, D. (2006). “What sort of an adult would
you like your child to be?” Mothers’ developmental goals in
different cultural communities in Israel. International Journal of
Behavioral Development, 30, 517–528.
Schore, A. N. (2003). Affect regulation and the repair of the self. New
York, NY: Norton.
Siegel, D. J. (1999). The Developing Mind. New York, NY: Guilford.
Snibbe, A. C., & Markus, H. R. (2005). You can’t always get what
you want: Educational attainment, agency, and choice. Journal of
Personality and Social Psychology, 88, 703–720.
Steinberg, L. (2005). Cognitive and affective development in adoles-
cence. Trends in Cognitive Sciences, 9, 69–74.
Swidler, A. (1986). Culture in action: symbols and strategies. American
Sociological Review, 51, 271–286.
Tafarodi, R. W., Bonn, G., Liang, H., Takai, J., Moriizumi, S., Belhekar,
V., & Padhye, A. (2012). What makes for a good life? A four-nation
study. Journal of Happiness Studies, 13, 783–800. doi: 10.1007/
s10902-011-9290-6.
Tobin, J., Hsueh, Y., & Karasawa, M. (2009). Preschool in three cul-
tures revisited: China, Japan, and the United States. Chicago, IL:
University of Chicago.
Werker, J. F., & Tees, R. C. (1984). Cross-language speech perception:
evidence for perceptual reorganization during the first year of
life. Infant Behavior and Development, 7, 49–63.
Wiley, A. R., Rose, A. J., Burger, L. K., & Miller, P. J. (1998). Con-
structing autonomous selves through narrative practices: a com-
parative study of working-class and middle-class families. Child
Zhang, Y., Kuhl, P. K., Imada, T., Kotani, M., & Tohkura, Y. (2005).
Effects of language experience: neural commitment to language-
specific auditory patterns. Neuroimage, 26, 703–720.
Zhu, Y., Zhang, L., Fan, J., & Han, S. (2006). Neural basis of cultural
influence on self-representation. NeuroImage, 34, 1310–1316.
Karen Jennifer Golden and Jeanette Liaw Hui Jean*2
Understanding neurodevelopmental disorders

in context: Autism Spectrum Disorder
and the Family System
Autism Spectrum Disorder (ASD) is a lifelong neurodevelopmental

disorder that affects not only the child, but the family system as well
(e.g., Hayes & Watson, 2013; Morgan, 1988). Approximately 67 mil-
lion families in the world are affected by ASD (Kopetz & Endowed,
2012). Reported increases in the number of people with ASD (Centers
for Disease Control and Prevention, 2012) have prompted greater inter-
est in examining the complexities of ASD and how diverse families of
children with ASD are affected by the condition. Thus, this review will
first present a snapshot about what are neurodevelopmental disorders
as well as provide a background on what is ASD. Then, Family System
Theory will be introduced as a way to better understand the family
functioning of families of children with ASD in a family context. The
impact of ASD on the various sub-systems (or parts) of a family will
be described in more detail, including the the parental subsystem, the
marital subsystem, the sibling subsystem and the extended family sub-
system. Furthermore, the review will discuss the impact of the cultural
context on families of children with neurodevelopmental disorders like
ASD. Finally, the limitations of this research area and clinical implica-
tions will be examined.
* This work is supported by the Ministry of Higher Education Malaysia through a

Fundamental Research Grant Scheme (FRGS/1/2013/SKK10/MUSM/02/1), and
Monash University Australia through a Faculty (Medicine, Nursing and Health
Sciences) Strategic Grant Scheme (SPG066). Both organizations are acknowl-
edged for their research funding support. The authors also thank Siew Lee Tan and
Kartini Ilias for giving constructive feedback on an earlier draft of the chapter.
84 Karen Jennifer Golden and Jeanette Liaw Hui Jean
Neurodevelopmental disorders
Studying about Neurodevelopmental Disorders (NDDs) is a valu-

able process because knowledge about them can be an important key
to understand typical child development (Filippi & Karmiloff-Smith,
2012). Human brain development involves a complex process that be-
gins during early pregnancy (three weeks after conception) and con-
tinues through infancy, childhood and late adolescence (e.g., see Stiles
& Jernigan, 2010). The recently published Diagnostic and Statistical
Manual of Mental Disorders (5th ed.; DSM-5) (American Psychiatric
Association, 2013a) just added in a new diagnostic category called Neu-
rodevelopment Disorders (NDDs). In the DSM-5, NDDs are defined as
“disorders with onset in the developmental period, often before start-
ing school, and characterized by a range of developmental deficits that
impair normal functioning” (American Psychiatric Association, 2013a,
p. 31). The category of NDDs in the DSM-5 includes Intellectual De-
velopmental Disorders, Communication Disorders, Autism Spectrum
Disorder (ASD), Attention-Deficit/Hyperactivity Disorder (ADHD),
Specific Learning Disorder, and Motor Disorders.
NDDs are “complex and dynamic in nature and are therefore un-
likely to have a simple causal mechanism” (Cornish & Wilding, 2010,
p. viii). These disorders likely result from multiple contributing factors
(such as a combination of genetic, biological, psychological, social and
environmental risk factors) rather than one single cause. NDDs include
a highly heterogeneous (diverse) group of conditions marked by diffi-
culties in communication, cognition (ways of thinking about, learning,
and processing information), behaviour, and motor functioning result-
ing from atypical brain development (Moreno-De-Luca et al., 2013).
Other common NDDs include cerebral palsy and genetic conditions
such as Down Syndrome (Vicari, Pontillo, & Armando, 2013) and Frag-
ile X syndrome (Cornish, Turk, & Hagerman, 2008). Some researchers
classify conditions like Fetal Alcohol Spectrum Disorders (Davis, Des-
rocher, & Moore, 2011) and schizophrenia as NDDs as well (Rapoport,
Giedd, & Gogtay, 2012).
Approximately 12% of children aged 3 to 17 years have a NDD
(e.g., Environmental Protection Agency, 2013). When studying NDDs,
Understanding neurodevelopmental disorders in context 85
comorbidity is the rule rather than the exception (Moreno-De-Luca et

al., 2013). Comorbidity is a term used to describe the co-occurrence of
two or more diagnosed disorders in one individual. For example, ASD
is commonly comorbid with other NDDs, such as ADHD and Fragile
X Syndrome (e.g., Zafeiriou, Ververi, & Vargiami, 2007). Furthermore,
NDDs impact family functioning with family members of children with
NDDs experiencing greater health and psychosocial problems, especially
when the NDD co-occurs with behavior problems (e.g., Lach et al., 2009).
Background on Autism Spectrum Disorder
In 1943, Leo Kanner, a psychiatrist, noticed some children who be-

haved in ways that were not common in children with other disabilities
(Kanner, 1943). He described their behaviours using the term “autism”.
The DSM-5 now characterizes ASD symptoms into two behavioral
domains, which include having persistent difficulties in social commu-
nication and social interaction across contexts, and restricted, repetitive
behaviors, interests or activities (RRBs). ASD criteria in the DSM-5
require symptoms be present during “early childhood”, even if those
symptoms are not fully manifested until later when increasing social de-
mands exceed limited capacities to cope. All of these symptoms should
together limit and impair everyday functioning (American Psychiatric
Association, 2013a).
In the recently published DSM-5, ASD will now be one single um-
brella category, replacing the four different subtypes in the DSM-IV TR.
In the DSM-IV TR (4th edition, text rev.) (American Psychiatric Asso-
ciation, 2000), Autism Spectrum Disorders such as Autistic Disorder
were placed under the category of Pervasive Developmental Disorders,
which also included Asperger’s Disorder, Pervasive Developmental
Disorder-Not Otherwise Specific, and Childhood Disintegrative Dis-
order. Since autism is defined by a common set of behaviors, it was
thought that autism is best represented as a single diagnostic category
(Autism Spectrum Disorder), reflecting the findings that there are
more overlaps than differences in the DSM-IV TR subcategories. Also,
researchers found that the separate diagnoses in the DSM-IV TR were

not applied consistently across different treatment centers and clinics
(American Psychiatric Association, 2013b).
The DSM-5 also includes a new assessment of ASD symptom se-
verity along a continuum related to the degree of impairment. Some
people with ASD display severe symptoms (e.g., remain nonverbal–do
not learn to speak) and require very substantial support, while others
have mild symptoms and need less support. Like everyone, each indi-
vidual with ASD is unique with differing characteristics, intellectual
functioning, and personalities.
Children with ASD may seem as if they are “living in their own
world”. Other common behaviors include problems with initiating so-
cial contact and responding appropriately in social contexts. They may
not respond when their name is called. They may demonstrate reduced
sharing of interest (e.g., not pointing to objects or imitating others).
Problems with non-verbal communication may also be present (e.g.,
impaired use of eye contact, postures, and gestures). Several behaviors
that show problems in social awareness and insight include deficits in
developing and maintaining relationships and friendships. For exam-
ple, individuals with ASD may appear withdrawn or aloof, preferring
to spend time alone. They may struggle with dating relationships. Addi-
tionally, they may be less aware of social cues and conventions.
RRBs are also important to study as they can interfere broadly
with functioning in individuals with ASD and impact family function-
ing (e.g., Richler, Huerta, Bishop, & Lord, 2010). RRBs can affect the
ability to attend to and learn from the world (Richler et al., 2010), and
they can be difficult for families to manage since individuals may dis-
play tantrums or “meltdowns” if their RRBs are hindered or triggered.
RRBs often include atypical speech, movements, and play. Examples
of atypical speech include repeating of words or phrases (i.e., echo-
lalia), making pronoun reversals (e.g., using “you” for “I”), and using
unusually formal language (e.g., a child speaks like an adult or a “little
professor”). Atypical movements and play may include hand-flapping,
lining up toys, or repetitively turning on/off lights. RRBs also include
unusual preoccupations with objects or topics (e.g., spinning wheels
on a toy car), excessive adherence to routines or rituals, strong resis-
tance to change (e.g., throw tantrums when using a different route to
school), rigid thinking (e.g., difficulty understanding humor and nonlit-

eral speech), restricted and fixated interests (e.g., obsessions with bus
schedules). Over or under-reactivity to sensory input is also a common
behavior that can make family life challenging (e.g., hyper-sensitivity to
sounds or food textures, high or low pain tolerance, or disliking touch).
The reported rate of ASD has been increasing worldwide (e.g.,
Blumberg et al., 2013). ASD now reportedly affects approximately 1 in 88
American children (Centers for Disease Control and Prevention, 2012),
with about four times more boys than girls diagnosed. Controversy and
debate remain in the research area about whether the increasing rate is
because of increased awareness about the condition, judgements in the
assessment process by professionals, broadening of the diagnostic cate-
gory, or a true (real) increase (e.g., Kopetz & Endowed, 2012). There also
remains a debate in the literature regarding the most accurate terminology
for the disorder and how the disorder should be conceptualized (e.g., Vi-
vanti et al., 2013). For instance, Moreno-De-Luca et al. (2013) recently
proposed that ASD could be best understood as part of an even larger
umbrella term called Developmental Brain Dysfunction (DBD), instead
of using behaviorally-defined labels such as autism or schizophrenia.
For the very large majority of cases, the causes of ASD are still yet
to be identified; however, there is growing evidence that suggests the
role of genetic and neurobiological factors (e.g., Rutter, 2000). Numer-
ous different genes rather than a single gene are thought to be involved
(Poot, 2013). The lack of clarity about ASD terminology, etiology (the
cause of the condition), symptoms, and which treatments to choose also
increase the confusion families face and risks delaying diagnosis and
treatment planning.
Further complicating the situation, ASD is often comorbid with symp-
toms of other NDDs and psychiatric conditions, such as ADHD (e.g., Cor-
nish & Wilding, 2010; Gargaro, Rinehart, Bradshaw, Tonge, & Sheppard,
2011), Intellectual Disability (e.g., Matson & Shoemaker, 2009), anxiety
disorders (e.g., van Steensel, Bögels, & Perrin, 2011), depression (e.g.,
Mayes, Gorman, Hillwig-Garcia, & Syed, 2013), and sleep disorders (e.g.,
Hoffman et al., 2008). Comorbidity rates with various health conditions,
such as epilepsy (Tuchman & Rapin, 2002) and allergic/autoimmune dis-
eases like asthma, dermatitis, and diabetes (Chen et al., 2013), are higher
in individuals with ASD than in individuals with typical development.
Research has shown that these comorbid symptoms along with primary
ASD symptoms significantly affect the quality of life of both persons with
ASD and their families (e.g., Gardiner & Iarocci, 2012).
Although there is no “cure” for ASD, long-term and impressive
outcomes can occur for many children when they receive early and in-
tensive interventions (National Autism Center, 2011). Early interven-
tions, especially with comprehensive behavioral treatments (e.g., the
Early Start Denver Model) and combined multi-modal treatments (e.g.,
incorporating speech therapy, occupational therapy, modeling, social
skills training, parent education and family approaches), have been
found helpful to children with ASD and their families (e.g., National
Autism Center, 2011). However, these treatments lead to high costs,
further amplifying the burden faced by families, especially in countries
where resources are limited (e.g., Yeo & Lu, 2012).
Individuals with ASD have a range of educational and training op-
tions, although opportunities are limited in countries and regions with
less resources and governmental support services. Treatment and sup-
port options are becoming increasingly available globally; however,
accessibility remains a challenge (Richmond, 2011). Many individuals
with ASD attend special education schools or programs. An increasing
number of students are attending mainstream public or private schools,
sometimes with the help of a support assistant (shadow aide). Develop-
ment of an individualized education plan (IEP) tailored to their unique
cognitive profile of strengths and areas for development is recommend-
ed. Much research attention has focused on weaknesses; however, in-
dividuals with ASD often display strengths and positive characteristics,
including good rote memory, drawing skills, music skills, visual skills
and honesty. Vocational supports and/or residential assisted-living are
often needed in adulthood; however, resources to support adults with
ASD and their families are often more limited. Symptoms may also
change over the course of development; there is a wide range of po-
tential outcomes. Interestingly, recent estimates suggest that 1 in 100
college students may have symptoms of ASD, although most have not
been officially diagnosed (White, Ollendick, & Bray, 2011).
Indeed, ASD impacts not only children across their lifespans, but
the family members of the children in multiple complex ways, both neg-
atively and positively (e.g., Zablotsky et al., 2013). Families of children
with ASD often report impairments in family functioning (e.g., poor

communication, marital stress, sibling conflict) (e.g., Morgan, 1988)
and difficulty in dealing with the child’s behavior problems (e.g.,
Herring et al., 2006). Undoubtedly, there is a crucial need to study fam-
ilies of children with ASD. Understanding the family can lead to better
treatment outcomes and family wellbeing.
Family stress and coping in families of children with ASD
Parents of children with ASD have often been found to have higher lev-
els of stress and depression, and lower levels of wellbeing than parents
of typically developing children and children with other developmental
disabilities (e.g., Down Syndrome) (e.g., Abbeduto et al., 2004; Hayes
& Watson, 2013). However, as children with Down Syndrome are gen-
erally characterized as affectionate, cheerful and good natured, these
findings should be understood cautiously since children with Down
Syndrome are frequently the participants in comparison groups (Hayes
& Watson, 2013). The time and cost demands for care and therapies
also change life for everyone in the family.
Some past research has used a framework called the “Double
ABCX Model” to study families of children with ASD (e.g., Manning,
Wainwright, & Bennett, 2011). Research findings using this framework
have suggested that families may face initial stressors, such as the se-
verity of autism symptoms (e.g., Meirsschaut et al., 2010). They may
also experience a pile-up of other stressors, such as illness, divorce, or
job loss, which may not relate to ASD, but intensify the effects of the
strain caused by ASD. However, the research proposed that family adap-
tive resources, such as social support, could lead to successful parental
coping in families of children with ASD (e.g., Gray, 1998; Manning
et al., 2011). Furthermore, the family’s perceptions, or the meaning they
give to the crisis situation (their appraisal), can lead to reframing, which
has been linked with lower levels of depression in parents of children
with ASD (e.g., Manning et al., 2011). Additionally, positive parental
psychological acceptance and empowerment has been associated with
less severe mental health problems (Liaw, 2012; Weiss, Cappadocia,

MacMullin, Viecili, & Lunsky, 2012). Finally, the outcome of the model
represents family adaptation. This exists on a continuum of outcomes
ranging from positive adaptation to maladaptation (poor adaptation) to
the crisis (e.g., Hastings, Koyshoff, et al., 2005).
In the research literature, having a child with ASD in the family
has more often been associated with negative experiences rather than
positive experiences (e.g., Hayes & Watson, 2013). However, qualitative
studies, which allow more opportunities to explore the broader context,
tend to discuss more positives than do quantitative studies. Quantita-
tive research generates data that can be converted into numbers and is
most often collected in the form of a questionnaire or survey on a large
population sample. Whereas, qualitative research, aiming to understand
in-depth the way participants make sense of their lives, gathers partici-
pants’ perceptions and experiences in a descriptive narrative form, often
through interviews, focus group discussions, and fieldwork observations.
Increasingly, researchers are recognizing families who have ex-
pressed positive experiences as a result of having a family member with
ASD (e.g., Hastings, Beck, & Hill, 2005). For example, Bayat (2007)
reported that about 40% of the families of children with autism de-
scribed feeling stronger as a result of living with a child with autism;
they became more patient and compassionate and less judgmental.
A growing area of inquiry concerns exploring resilience in families
of children with ASD and other NDDs (e.g., Bayat & Schuntermann,
2013). Protective factors that promote resilience include social support,
time since diagnosis, internal locus of control (sense of control over
events), positive cognitive appraisal, and religious beliefs and spiritual-
ity (Bekhet, Johnson, & Zauszniewski, 2012).
Family Systems Theory
Family Systems Theory assumes that all people in the family unit
play an important role in the way they function in relation to each
other (Bowen, 1974; Minuchin, 1985). Understanding Family System
Theory is valuable because the family can be examined as a whole.

Exploring family patterns of interaction over time is important in or-
der to understand how a child with ASD affects the family dynamic
(Turnbull, Turnbull, Erwin, & Soodak, 2006) and vice versa (how the
family dynamic affects the child’s development). Past research has
often focused attention on exploring the unidirectional relationship
(one-way relationship), showing the child with ASD affecting their
family members; however, the effect is bidirectional (two-way) as well
(Meadan et al., 2010). Understanding the family system of an individ-
ual with a NDD can improve outcomes and family members’ quality
of life.
Family systems theory can generally be understood and represented
as a mobile (like the toy placed over an infant’s cot or crib) (Satir, 1972),
with the family system being the mobile and the pieces dangling from
the mobile representing the different family members. When the mobile
is not in balance and one piece moves, other pieces move as well. Fami-
ly members do not exist in isolation. When there are any changes in the
family (e.g., such as a child’s ASD diagnosis), the family system will be
affected (Morgan, 1988). Also, when a family subsystem is affected, the
whole family system will be impacted as well (Bowen, 1974).
Parental subsystem
Research has suggested that parents of children with ASD are at risk for
poor mental health (e.g., Zablotsky et al., 2013) and face other stress-
ors such as financial troubles that indirectly intensify their stress (e.g.,
Benson, 2006). Parents have also reported poor quality interactions with
their child with ASD (e.g., Braunstein, Peniston, Perelman, & Cassano,
2013). Pointing to the importance of adressing children’s emotional and
behavior problems and other comorbid symptoms, Herring et al. (2006)
found that the child’s emotional and behavioral problems contributed
significantly more to mothers’ stress, parent mental health problems,
and perceived family dysfunction than the child’s dignosis or presence
of a development delay. The parental subsystem can impact the family
system, leading to a restructuring (changing or reorganizing) of roles
within the family to cope (Morgan, 1988).
Mothers of children with ASD often play the role of the primary
caregiver in the family (e.g., Braunstein et al., 2013; Gray, 2003; Liaw,
2012). Compared to fathers, they often report higher levels of stress and
burnout from caring for a child with ASD (Heller et al., 1997; Herring
et al., 2006), display more psychological problems such as depression
(Hastings, Koyshoff, et al., 2005; Olsson & Hwang, 2001), and have
lower levels of wellbeing (Olsson & Hwang, 2008). Recent investiga-
tions of parents of children with ASD suggest the experience of mothers
and fathers differ in important ways; however, problematically fathers
have been underrepresented in research studies (e.g., see Braunstein
et al., 2013). Recent research highlights a range of innovative inter-
ventions to assist parents, such as telehealth parent trainings (Vismara,
McCormick, Young, Nadhan, & Monlux, 2013). Telehealth refers to the
delivery of health-related information and services via telecommunica-
tion technologies, which in this study utilized video-conferencing and
DVDs (Vismara et al., 2013).
Marital subsystem
Some researchers have described that having a child with ASD negative-
ly impacts the marital subsystem (e.g., Brobst, Clopton, & Hendrick,
2009; Gau et al., 2012). Rodrigue, Morgan, and Geffken (1990) found
that mothers of a child with ASD often reported less marital satisfaction
compared to mothers of a child with Down Syndrome or a typically
developing child. Hartley et al. (2010) reported that parents of children
with an ASD had a higher rate of divorce.
However, the impact of a child with ASD on the marriage sub-
system has been inconclusive as there have been conflicting and limit-
ed findings regarding this subsystem (e.g., Karst & Van Hecke, 2012).
According to Freedman, Kalb, Zablotsky, and Stuart (2012), despite
speculation of a high divorce rate, very little research has addressed the
cause of divorce and separation among the population. Furthermore,
Freedman et al.’s (2012) study of 77, 911 parent interviews revealed
no evidence to suggest that children with ASD are at an increased risk
for living in a home not comprised of their two parents compared to
children without ASD. Having a child with ASD in the family was also
found to strengthen and enrich marriages for couples with satisfying

relationships before the child was born, by dealing with the challenges
of caring for a child with ASD together (Brobst et al., 2009). As men-
tioned by Hartley, Barker, Seltzer, Greenberg, and Floyd (2011), marital
satisfaction could significantly impact the parenting experience of
parents with children with ASD.
Sibling subsystem
Parents dealing with high levels of parenting stress may be in a less

healthy state to respond to the needs of a child with ASD; this stress may
affect the development of the child with ASD and siblings with typical
development (e.g., Karst & Van Hecke, 2012). Additionally, children
with ASD have a range of challenging behaviours, which may impact the
sibling relationship (e.g., Rivers & Stoneman, 2003). Moreover, the mar-
ital subsystem was found to be an important predictor of the quality of
the sibling relationship between the child with ASD and the sibling with
typical development (Rivers & Stoneman, 2003). When marital prob-
lems arise, siblings with typical development may then associate these
marital problems to the ASD diagnosis, blaming the child with ASD.
Findings on the impact of having a sibling with ASD have also been
inconsistent (e.g., Macks & Reeve, 2007; Mascha & Boucher, 2006).
Some findings have found that siblings of children with ASD tend to
perceive their sibling relationships positively (Rivers & Stoneman,
2003) and have reported to be proud of being able to care for their sib-
lings with ASD (Quintero & McIntyre, 2010). Siblings also reported to
have learned to be more compromising and to maintain a close sibling
relationship with the sibling with ASD (e.g., Karst & Van Hecke, 2012).
Extended family subsystem
Due to the limited studies conducted on extended family members of

children with ASD (e.g., aunts, uncles, and grandparents), it is diffi-
cult to determine how the family system is affected by extended family
members. There have been some findings examining the grandparents
of the child with ASD, (e.g., reporting they expressed denial that the
child is not experiencing normal development and placing the blame on
bad parenting) (Perry, Harris, & Minnes, 2005; Tait & Mundia, 2012),
which could affect the parental and marital subsystem. Many other stud-
ies suggest the important support roles that extended family members
offer (e.g., Bayat & Schuntermann, 2013; Bekhet et al., 2012).
Most studies that were conducted on families of children with
ASD were conducted in Western countries and there have been limited
similar studies in developing countries or within collective cultures,
where extended family members often play an important role (Brobst
et al., 2009; Gau et al., 2012). It is difficult to generalize the findings
from Western countries with the families from other countries and cul-
tures (Norbury & Sparks, 2012; Yeo & Lu, 2012). More cross-cultural
research is recommended examining ASD and other NDDs (Norbury &
Sparks, 2012).
ASD in a cultural context
The cultural context of families impacts their perspectives of ASD.

Culture impacts their beliefs about disability as well as shapes their
opinions on the cause of ASD, diagnosis, and treatment (Ennis-Cole,
Durodoye, & Harris, 2013). Researchers have highlighted the need
for an increased awareness of cultural issues regarding understanding
ASDs (Norbury & Sparks, 2012). Just recently, growing research is be-
ginning to explore a multicultural perspective to understanding ASD in
diverse families internationally. For example, some countries involved
in ASD studies include Iran (e.g., Samadi & McConkey, 2012), India
(e.g., Desai, Divan, Wertz, & Patel, 2012, Taiwan (e.g., Lin, Tsai, &
Chang, 2008), China (e.g., Wang, Michaels, & Day, 2011), Korea (e.g.,
Lee, Hong, Kim, & Ju, 2010), and Turkey (Bilgin & Kucuk, 2010).
There are studies on Arab children with ASD as well (e.g., Alqahtani,
2012). Spiritual factors in the cultural context have also been found to
shape perception and coping. Significant relationships were observed
between Islamic beliefs and coping in a sample from American Muslim
immigrants (Jegatheesan, Miller, & Fowler, 2010) and Muslim popula-

tion in Brunei (Tait & Mundia, 2012).
As Kwok and Wong (2000) described, culture may play a part in
the stress experienced by some parents of children with ASD. Dyches,
Wilder, Sudweeks, Obiakor, and Algozzine’s (2004) study on the be-
liefs about ASD among parents from different ethnic groups found
that “members of various cultures may appraise the stressor of autism
differently, and these appraisals may be considered to be negative or
positive” (p. 219). Indeed, in Yeo and Lu’s (2012) recent quantitative
study comparing mothers of children with autism in Malaysia and Chi-
na, cross-cultural differences were found. High cost of treatment and
increasing years since diagnosis were found to be more significant
risk factors contributing to stress in mothers in Malaysia compared to
mothers in China. Differences may be due to the dissimilar educational
systems between the two countries and the larger family size in Ma-
laysia (Yeo and Lu, 2012). In various cultures, spiritual or folk beliefs
may also shape perceptions of the cause of the disorder, in some cases
leading to greater feelings of stigma and/or leading parents to seek al-
ternative treatment interventions (Alqahtani, 2012; Hastings, Koyshoff,
et al., 2005; Kopetz & Endowed, 2012). For example, Chinese mothers
in Malaysia reportedly were told by their extended families that they
have a child with ASD because of the traditional Chinese belief on “past
lives” and karma (Liaw, 2012).
Limitations of the research
Research on NDDs and ASD has been increasing rapidly. However,

the majority of the existing literature focuses too narrowly on certain
populations and the broader environmental context (such as the family
system and cultural context) has not been explored in adequate depth.
Most of the previous research has focused on Western, individualis-
tic cultures rather than developing and collective cultures. Fathers and
other extended family members have been underrepresented with most
of the research conducted on mothers (e.g., Braunstein et al., 2013).
Additionally, although much is known about boys with NDDs, less in

known about girls who may show unique symptom profiles (Rinehart,
Cornish, & Tonge, 2011). Adults with ASD are rarely able to live in-
dependently, thus impacting the family across the lifespan. However,
most research focuses on children rather than looking at the impact on
families as the children age into adulthood or even late adulthood.
Another limitation concerns the methodology (research study
methods) used in previous research. The majority of studies have uti-
lized a quantitative (numerical analysis) approach. Qualitative studies
(e.g., interview studies), when used, have tended to have small sam-
ple sizes. Mixed-methods research and more longitudinal studies are
recommended in the future to obtain a deeper understanding of the
dynamic contextual impacts on development. Also, future research is
encouraged to more clearly differentiate the different genetic and be-
havioral subtypes of the individuals within the ASD samples (e.g., Lai,
Lombardo, Chakrabarti, & Baron-Cohen, 2013).
Clinical implications
Understanding Family System Theory and the experiences of family

members is crucial due to the rising prevalence of ASD and the in-
creased involvement of family members in early intervention services.
A family-centered clinical and treatment approach has been shown to
lead to better outcomes (e.g., Shields, 2001). In fact, in order to maxi-
mize the outcome of parent intervention for children with ASD, several
authors have recommended that the parent’s wellbeing be assessed, and
symptoms of stress and depression be addressed, before implementa-
tion of the intervention (e.g., Osborne, McHugh, Saunders, & Reed,
2008). Targeting parental mental health problems is imperative, as it
may benefit both the child and parent. It is beneficial as well for clini-
cians to increase their involvement with fathers of children with ASD
as they play an important role in the family system (Braunstein et al.,
2013). Outcomes are best when there is close collaboration and clear
communication between all members of the inter-disciplinary treatment
team and the family system. Newer efforts have pointed to the value of
tailoring treatment techniques to match the specific characteristics and
phenotype of the child with ASD (e.g., Sherer & Schreibman, 2005),
and further investigations in this area is recommended.
Conclusion
Autism Spectrum Disorder (ASD) is a complex, lifelong neurodevel-

opmental disorder (NDD) affecting approximately 1 in 88 individuals
(Centers for Disease Control and Prevention, 2012). Symptoms develop
in early childhood and include persistent deficits in social communi-
cation and social interaction as well as restricted, repetitive patterns of
behavior, interests, or activities. Similar to other NDDs, ASD affects the
family system in multiple complex ways (e.g., Zablotsky et al., 2013).
Further examination of the comorbidities of NDDs and greater explo-
ration of the processes that foster family resilience are recommended.
Additional international research is needed to understand how cultural
context shapes the expression of NDDs and their treatment, especially
in developing countries. Lastly, a collaborative, multi-disciplinary ap-
proach is suggested to improve outcomes and better understand NDDs.
References
Abbeduto, L., Seltzer, M. M., Shattuck, P., Krauss, M. W., Orsmond, G., &
Murphy, M. M. (2004). Psychological well-being and coping in
mothers of youths with autism, Down Syndrome, or Fragile X syn-
drome. American Journal on Mental Retardation, 109, 237–254.
Alqahtani, M. M. J. (2012). Understanding autism in Saudi Arabia: A
qualitative analysis of the community and cultural context. Journal
of Pediatric Neurology, 10(1), 15–22.
American Psychiatric Association. (2000). Diagnostic and statistical

manual of mental disorders (4th ed., text rev. ed.). Washington,
DC: Author.
American Psychiatric Association. (2013a). Diagnostic and statistical
manual of mental disorders (5th ed.). Arlington, VA: American
Psychiatric Publishing.
American Psychiatric Association. (2013b). Autism Spectrum Disorder
Fact Sheet. Arlington, VA: American Psychiatric Publishing. Re-
trieved from <http://www.dsm5.org/Documents/Autism%20Spec
trum%20Disorder%20Fact%20Sheet.pdf>.
Bayat, M. (2007). Evidence of resilience in families of children with au-
tism. Journal of Intellectual Disability Research, 51(9), 702–714.
Bayat, M., & Schuntermann, P. (2013). Enhancing resilience in families
of children with autism spectrum disorder. In D. S. Becvar (Ed.),
Handbook of Family Resilience (pp. 409–424). NY: Springer.
Bekhet, A. K., Johnson, N. L., & Zauszniewski, J. A. (2012). Ef-
fects on resilience of caregivers of persons with autism spec-
trum disorder: The role of positive cognitions. Journal of the
American Psychiatric Nurses Association, 18(6), 337–344. doi:
10.1177/1078390312467056.
Benson, P. R. (2006). The impact of child symptom severity on de-
pressed mood among parents of children with ASD: The mediating
role of stress proliferation. Journal of Autism and Developmental
Disorders, 36, 685–695.
Bilgin, H., & Kucuk, L. (2010). Raising an autistic child: Perspectives
from Turkish mothers. Journal of Child and Adolescent Psychiatric
Nursing, 23(2), 92–99. doi: 10.1111/j.1744-6171.2010.00228.x.
Blumberg, S. J., Bramlett, M. D., Kogan, M. D., Schieve, L. A., Jones, J. R.,
& Lum, M. C. (2013). Changes in prevalence of parent-reported
autism spectrum disorder in school-aged US children: 2007 to
2011–2012. National Health Statistics Reports, 65, 1–11.
Bowen, M. (1974). Alcoholism as viewed through family systems the-
ory and family psychotherapy. Annals of the New York Academy of
Sciences, 233, 115–122.
Braunstein, V. L., Peniston, N., Perelman, A., & Cassano, M. C. (2013).
The inclusion of fathers in investigations of autistic spectrum dis-
orders. Research in Autism Spectrum Disorders, 7(7), 858–865.
Brobst, J. B., Clopton, J. R., & Hendrick, S. S. (2009). Parenting chil-

dren with autism spectrum disorders. Focus on Autism and Other
Developmental Disabilities, 24(1), 38–49.
Centers for Disease Control and Prevention. (2012). Prevalence of au-
tism spectrum disorders – Autism and developmental disabilities
monitoring network, 14 sites, United States, 2008. Morbidity and
Mortality Weekly Report, 61(3), 1–19.
Chen, M., Su, T., Chen, Y., Hsu, J., Huang, K., Chang, W., Bai, Y. (2013).
Comorbidity of allergic and autoimmune diseases in patients with
autism spectrum disorder: A nationwide population-based study.
Research in Autism Spectrum Disorders, 7(2), 205–212.
Cornish, K., Turk, J., & Hagerman, R. (2008). The fragile X continuum:
New advances and perspectives. Journal of Intellectual Disability
Research, 52(6), 469–482. doi: 10.1111/j.1365-2788.2008.01056.x.
Cornish, K., & Wilding, J. (2010). Attention, genes, and developmental
disorders. New York, NY: Oxford University Press.
Davis, K., Desrocher, M., & Moore, T. E. (2011). Fetal Alcohol Spectrum
Disorder: A review of neuropsychological findings and interventions.
Journal of Developmental & Physical Disabilities, 23(2), 143–167.
Desai, M. U., Divan, G., Wertz, F. J., & Patel, V. (2012). The discovery
of autism: Indian parents’ experiences of caring for their child with
an autism spectrum disorder. Transcultural Psychiatry, 49(3–4),
613–637. doi: 10.1177/1363461512447139.
Dyches, T. T., Wilder, L. K., Sudweeks, R. R., Obiakor, F. E., & Al-
gozzine, B. (2004). Multicultural issues in autism. Journal of Au-
tism and Developmental Disorders, 34(2), 211–222.
Ennis-Cole, D., Durodoye, B. A., & Harris, H. L. (2013). The impact
of culture on autism diagnosis and treatment: Considerations for
counselors and other professionals. The Family Journal, 21, 279–
287. doi: 10.1177/1066480713476834.
Environmental Protection Agency. (2013). American children and the
environment 3rd ed. (ACE3). Washington, DC: U.S. Environmental
Protection Agency.
Filippi, R., & Karmiloff-Smith, A. (2012). What can neurodevelopmen-
tal disorders teach us about typical development? In C. Marshall
(Ed.), Current issues in developmental disorders (pp. 193–204).
New York, NY: Psychology Press.
Freedman, B. H., Kalb, L. G., Zablotsky, B., & Stuart, E. A. (2012). Re-
lationship status among parents of children with autism spectrum
disorders: A population-based study. Journal of Autism and Devel-
opmental Disorders, 42(4), 539–548. doi: 10.1007/s10803-011-
1269-y.
Gardiner, E., & Iarocci, G. (2012). Unhappy (and happy) in their own
way: A developmental psychopathology perspective on quality
of life for families living with developmental disability with and
without autism. Research in Developmental Disabilties, 33, 2177–
2192. doi: 10.1016/j.ridd.2012.06.014.
Gargaro, B. A., Rinehart, N. J., Bradshaw, J. L., Tonge, B. J., & Shep-
pard, D. M. (2011). Autism and ADHD: How far have we come in
the comorbidity debate? Neuroscience & Biobehavioral Reviews,
35(5), 1081–1088. doi: 10.1016/j.neubiorev.2010.11.002.
Gau, S. S., Chou, M., Chiang, H., Lee, J., Wong, C., Chou, C., & Wu, Y.
(2012). Parental adjustment, marital relationship, and family
function in families of children with autism. Research in Autism
Spectrum Disorders, 6(1), 263–270.
Gray, D. E. (1998). Autism and the family: Problems, prospects, and
coping with the disorder. Springfield, IL: Charles C. Thomas.
Gray, D. E. (2003). Gender and coping: The parents of children with
high functioning autism. Social Science & Medicine, 56, 631–642.
Hartley, S. L., Barker, E. T., Seltzer, M. M., Floyd, F., Greenberg, J.,
Orsmond, G., & Bolt, D. (2010). The relative risk and timing of
divorce in families of children with an autism spectrum disorder.
Journal of Family Psychology, 24(4), 449–457.
Hartley, S. L., Barker, E. T., Seltzer, M. M., Greenberg, J., & Floyd, F.
(2011). Marital satisfaction and parenting experiences of moth-
ers and fathers of adolescents and adults with autism. American
Association on Intellectual and Developmental Disabilities,
116(1), 81–95.
Hastings, R. P., Beck, A., & Hill, C. (2005). Positive contributions made
by chidlren with an intellectual disability in the family: Mothers’
and fathers’ perceptions. Journal of Intellectual Disability, 9(2),
155–165.
Hastings, R. P., Koyshoff, H., Ward, N. J., degli Espinosa, F., Brown, T.,
& Remington, B. (2005). Systems analysis of stress and positive
perceptions in mothers and fathers of pre-school children with

autism. Journal of Autism and Developmental Disorders, 35(5),
635–644.
Hayes, S. A., & Watson, S. L. (2013). The impact of parenting stress:
A meta-analysis of studies comparing the experience of parenting
stress in parents of children with and without autism spectrum
disorder. Journal of Autism and Developmental Disorders, 43(3),
629–642.
Heller, T., Hsieh, K., & Rowitz, L. (1997). Maternal and paternal car-
egiving of persons with mental retardation across the lifespan.
Family Relations, 46(4), 407–415.
Herring, S., Gray, K., Taffe, J., Tonge, B., Sweeney, D., & Einfeld, S.
(2006). Behaviour and emotional problems in toddlers with per-
vasive developmental disorders and developmental delay: Associ-
ations with parental mental health and family functioning. Journal
of Intellectual Disability Research, 50(12), 874–882.
Hoffman, C. D., Sweeney, D. P., Lopez-Wagner, M. C., Hodge, D., Nam,
C. Y., & Botts, B. H. (2008). Children with autism: Sleep problems
and mothers’ stress. Focus on Autism and Other Developmental
Disabilities, 23(3), 155–165.
Jegatheesan, B., Miller, P. J., & Fowler, S. A. (2010). Autism from a
religious perspective: A study of parental beliefs in South Asian
Muslim immigrant families. Focus on Autism and Other Develop-
mental Disabilities, 25(2), 98–109.
Kanner, L. (1943). Autistic disturbances of affective contact. Nervous
Child, 2, 217–250.
Karst, J. S., & Van Hecke, A. V. (2012). Parent and family impact of
autism spectrum disorders: A review and proposed model for inter-
vention evaluation. Clinical Child and Family Psychology Review,
15(3), 247–277.
Kopetz, P. B., & Endowed, E. D. L. (2012). Autism worldwide: Preva-
lence, perception, acceptance, action. Journal of Social Sciences,
8(2), 196–201.
Kwok, S., & Wong, D. (2000). Mental health of parents with young
children in Hong Kong: The roles of parenting stress and parenting
self-efficacy. Child & Family Social Work, 5(1), 57–65.
Lach, L. M., Kohen, D. E., Garner, R. E., Brehaut, J. C., Miller, A. R.,
Klassen, A. F., & Rosenbaum, P. L. (2009). The health and psy-
chosocial functioning of caregivers of children with neurodevel-
opmental disorders. Disability and Rehabilitation 31(8), 607–618.
Lai, M.C., Lombardo, M.V., Chakrabarti, B., Baron-Cohen, S. (2013).
Subgrouping the Autism “Spectrum”: Reflections on DSM-5. PLoS
Biology, 11(4): e1001544. doi:10.1371/journal.pbio.1001544.
Lecavalier, L., Leone, S., & Wiltz, J. (2006). The impact of behavior
problems on caregiver stress in young people with autism spectrum
disorders. Journal of Intellectual Disability Research, 50, 172–183.
Lee, A. R., Hong, S. W., Kim, J. S., & Ju, S. J. (2010). Life transition
of mothers of children with autism. Journal of Korean Academy of
Nursing 40(6), 808–819. doi: 10.4040/jkan.2010.40.6.808.
Liaw, J. H. J. (2012). Well-being of mothers of children with autism: An
exploratory study in the Malaysian context. (Unpublished honour’s
thesis), Monash University Malaysia.
Lin, C. R., Tsai, Y. F., & Chang, H. L. (2008). Coping mechanisms of
parents of children recently diagnosed with autism in Taiwan: A
qualitative study. Journal of Clinical Nursing, 17(20), 2733–2740.
doi: 10.1111/j.1365-2702.2008.02456.x.
Macks, R. J., & Reeve, R. F. (2007). The adjustment of non-disabled
siblings of children with autism. Journal of Autism and Develop-
mental Disorders, 37(6), 1060–1067.
Manning, M. M., Wainwright, L., & Bennett, J. (2011). The double
ABCX model of adaptation in racially diverse families with a
school-age child with autism. Journal of Autism and Developmen-
tal Disorders, 41, 320–331.
Mascha, K., & Boucher, J. (2006). Preliminary investigation of a qual-
itative method of examining siblings’ experiences of living with a
child with ASD. The British Journal of Developmental Disabilities,
52(102), 19–28.
Matson, J. L., & Shoemaker, M. (2009). Intellectual disability and its
relationship to autism spectrum disorders. Research in Develop-
mental Disabilities, 30(6), 1107–1114.
Mayes, S. D., Gorman, A. A., Hillwig-Garcia, J., & Syed, E. (2013).
Suicide ideation and attempts in children with autism. Research in
Autism Spectrum Disorders, 7, 109–119.
Meadan, H., Halle, J. W., & Ebata, A. T. (2010). Families with children
who have autism spectrum disorders: Stress and support. Excep-
tional Children, 7(1), 7–36.
Meirsschaut, M., Roeyers, H., & Warreyn, P. (2010). Parenting in fam-
ilies with a child with autism spectrum disorder and a typically
developing child: Mothers’ experiences and cognitions. Research
in Autism Spectrum Disorders, 4(4), 661–669.
Minuchin, P. (1985). Families and individual development: Provoca-
tions from the field of family therapy. Child Development, 56(2),
289–302.
Moreno-De-Luca, A., Myers, S. M., Challman, T. D., Moreno-De-Luca, D.,
Evans, D. W., & Ledbetter, D. H. (2013). Developmental brain dys-
function: Revival and expansion of old concepts based on new genetic
evidence. The Lancet Neurology, 12(4), 406–414.
Morgan, S. (1988). The autistic child and family functioning: A
developmental-family systems perspective. Journal of Autism and
Developmental Disorders, 18(2), 263–280.
National Autism Center. (2011). Evidence-based practice and autism in
the schools. Randolph, MA: National Autism Center.
Norbury, C. F., & Sparks, A. (2012). Difference or disorder? Cultural
issues in understanding neurodevelopmental disorders. Develop-
mental Psychology, 49(1), 45–58.
Olsson, M. B., & Hwang, C. P. (2001). Depression in mothers and fathers
of children with intellectual disability. Journal of Intellectual
Disability Research, 45(6), 535–543.
Olsson, M. B., & Hwang, C. P. (2008). Socioeconomic and psycholog-
ical variables as risk and protective factors for parental well-being
in families of children with intellectual disabilities. Journal of
Intellectual Disability Research, 52(12), 1102–1113.
Osborne, L. A., McHugh, L., Saunders, J., & Reed, P. (2008). Parenting
stress reduces the effectiveness of early teaching interventions for
autistic spectrum disorders. Journal of Autism and Developmental
Disorders, 38, 1092–1103.
Perry, A., Harris, K., & Minnes, P. (2005). Family environments and
family harmony: An exploration across severity, age, and type of
DD. Journal on Developmental Disabilities, 11(1), 17–29.
Poot, M. (2013). Towards identification of individual etiologies by

resolving genomic and biological conundrums in patients with
autism spectrum disorders. Molecular Syndromology, 4, 213–226.
doi: 10.1159/000350041.
Quintero, N., & McIntyre, L. L. (2010). Sibling adjustment and maternal
well-being: An examination of families with and without an au-
tism spectrum disorder. Focus on Autism and Other Developmental
Disabilities, 25(1), 37–46.
Rapoport, J. L., Giedd, J. N., & Gogtay, N. (2012). Neurodevelopmen-
tal model of schizophrenia: Update 2012. Molecular Psychiatry,
17(12), 1228–1238.
Richler, J., Huerta, M., Bishop, S. L., & Lord, C. (2010). Developmen-
tal trajectories of restricted and repetitive behaviors and interests in
children with autism spectrum disorders. Developmental Psycho-
pathology, 22(1), 55–69.
Richmond, A. S. (2011). Autism spectrum disorder: A global perspec-
tive. Perspectives on Global Issues in Communication Sciences
and Related Disorders, 1(2), 39–46. doi:10.1044/gics1.2.39.
Rinehart, N. J., Cornish, K. M., & Tonge, B. J. (2011). Gender differences
in neurodevelopmental disorders: Autism and Fragile X syndrome.
In J. C. Neill & J. Kulkarni (Eds.), Biological basis of sex differences
in psychopharmacology (pp. 209–229): New York, NY: Springer.
Rivers, J. W., & Stoneman, Z. (2003). Sibling relationships when a child
has autism: Marital stress and support coping. Journal of Autism
and Developmental Disorders, 33(4), 383–394.
Rodrigue, J., Morgan, S., & Geffken, G. (1990). Families of autistic
children: Psychological functioning of mothers. Journal of Clini-
cal Child Psychology, 19(4), 371–379.
Rutter, M. (2000). Genetic studies of autism: From the 1970’s to the
millennium. Journal of Abnormal Child Psychology, 28(1), 3–14.
Samadi, S. A., & McConkey, R. (2012). The impact on Iranian moth-
ers and fathers who have children with an autism spectrum disor-
der. Journal of Intellectual Disability Research: JIDR, 1–12. doi:
10.1111/jir.12005.
Satir, V. (1972). Peoplemaking. Palo Alto, CA: Science and Behaviour
Books.
Sherer, M. R., & Schreibman, L. (2005). Individual behavioral profiles

and predictors of treatment effectiveness for children with autism.
Journal of Consulting and Clinical Psychology, 73, 525–538.
Shields, J. (2001). The NAS earlybird programme: Partnership with
parents in early intervention. Autism, 5(49), 49–56.
Stiles, J., & Jernigan, T. L. (2010). The basics of brain development.
Neuropsychological Review, 20(4), 327–348. doi: 10.1007/s11065-
010-9148-4.
Tait, K. T., & Mundia, L. (2012). The impact of a child with autism
on the Bruneian family system. International Journal of Special
Education, 27(3), 1–14.
Tuchman, R., & Rapin, I. (2002). Epilepsy in autism. The Lancet
Neurology, 1(6), 352–358.
Turnbull, A. P., Turnbull, H. R., Erwin, E., & Soodak, L. (2006). Fam-
ilies, professionals, and exceptionality: Positive outcomes through
partnerships and trust (5th ed.). Upper Saddle River, NJ: Merrill/
Prentice Hall.
van Steensel, F. J., Bögels, S. M., & Perrin, S. (2011). Anxiety disor-
ders in children and adolescents with autistic spectrum disorders:
A meta-analysis. Clinical Child and Family Psychology Review,
14(3), 302–317. doi: 10.1007/s10567-011-0097-0.
Vicari, S., Pontillo, M., & Armando, M. (2013). Neurodevelopmental
and psychiatric issues in Down’s syndrome: Assessment and in-
tervention. Psychiatric Genetics, 23(3), 95–107. doi: 10.1097/
YPG.0b013e32835fe426.
Vismara, L. A., McCormick, C., Young, G. S., Nadhan, A., Monlux, K.
(2013). Preliminary finding of a telehealth approach to parent
training in autism. Journal of Autism and Developmental Disor-
ders. doi: 10.1007/s10803-013-1841-8.
Vivanti, G., Hudry, K., Trembath, D., Barbaro, J., Richdale, A., & Dis-
sanayake, C. (2013). Towards the DSM-5 criteria for autism: Clin-
ical, cultural and research implications. Australian Psychologist,
1–4. doi: 10.1111/ap.12008.
Wang, P., Michaels, C. A., & Day, M. S. (2011). Stresses and coping
strategies of Chinese families with children with autism and other
developmental disabilities. Journal of Autism and Developmental
Disorders, 41(6), 783–795.
Weiss, J. A., Cappadocia, M. C., MacMullin, J. A., Viecili, M., &

Lunsky, Y. (2012). The impact of child problem behaviors of
children with ASD on parent mental health: The mediating role
of acceptance and empowerment. Autism, 16, 261–274. doi:
10.1177/1362361311422708.
White, S. W., Ollendick, T. H., & Bray, B. C. (2011). College students on
the autism spectrum: Prevalence and associated problems. Autism,
15(6), 683–701. doi: 10.1177/1362361310393363.
Yeo, K. J., & Lu, X. (2012). Parenting stress and psychological dis-
tress among mothers of children with autism in Johor Bahru and
Hangzhou. Journal of Educational Psychology & Counseling, 6,
129–153.
Zablotsky, B., Bradshaw, C. P., & Stuart, E. A. (2013). The associa-
tion between mental health, stress, and coping supports in moth-
ers of children with autism spectrum disorders. Journal of Autism
and Developmental Disorders, 43(6), 1380–1393. doi: 10.1007/
s10803-012-1693-7.
Zafeiriou, D. I., Ververi, A., & Vargiami, E. (2007). Childhood autism and
associated comorbidities Brain and Development, 29(5), 257–272.
Part III
Cognitive Psychology
and Neuroscience
Peter Mitchell
Developing a theory of mind
‘Theory of mind’ refers to the ability to infer what other people are
thinking, feeling and perceiving, amongst other things. Psychology as
an academic discipline has strived for more than one hundred years
to understand and predict peoples’ thoughts, feelings and perceptions;
latterly, in one branch of academic psychology, the focus has shifted to
investigate how ordinary people come to understand these things and,
moreover, how such understanding develops. But why call this ability
‘theory of mind?’ Why not call it ‘empathizing?’
Evidently, ‘theory of mind’ and ‘empathizing’ are related, for one
might experience empathy if one can imagine how it feels to be in the
same difficult situation that another person has to endure. And we might
say that if you can imagine being in that same difficult situation, then
you must, by definition, have a theory of mind. Nevertheless, ‘theory
of mind’ and ‘empathizing’ are not the same. ‘Theory of mind’ refers
to an intellectual feat, the ability to calculate what another person is
thinking, feeling or perceiving. ‘Empathizing’, in contrast, has connota-
tions associated with affective functioning. To illustrate, a toddler might
empathize when in the company of another child who is crying because
they hurt themselves or became scared of something. The observing
toddler might herself cry in a way that resonates with the child she is
observing and this behaviour probably deserves to be called ‘empathy’,
but it does not necessarily follow that the toddler has calculated what
the other child is thinking, feeling or perceiving. Then how can we tell
whether or not a child has made such a calculation that deserves to be
called ‘theory of mind?’
The obvious way to find out if a child can calculate what another
person is thinking would be to ask them, for example, where does Maxi,
a fictional character, think his chocolate is? Let us suppose that the child
participant asserts that Maxi thinks the chocolate is in the fridge! Do
we then have enough evidence to conclude that the child has calculated
110 Peter Mitchell
what Maxi is thinking and therefore that the child should be credited
with having a theory of mind? No, not necessarily. Imagine, for the sake
of argument, that the child did not have a theory of mind and was unable
to calculate what Maxi is thinking. Imagine that, notwithstanding, we
ask this child to guess what Maxi is thinking – where does Maxi think
his chocolate is located? Not having a theory of mind, the child would
have absolutely no idea what is being asked and therefore could remain
mute in the face of this unfathomable question. Alternatively, the child
might have a strategy for answering, a strategy that usually leads to a
correct answer: They might simply state what they think. In this partic-
ular case, they would name the place where they themselves think the
chocolate is located. Most of the time, probably the place where they
think the chocolate is would be the same place where Maxi thinks it is
located.
In short, the trouble with asking a child to state what another per-
son is thinking is that in answering they might not give any attention to
the other person’s thought but simply state what they themselves think.
As researchers, we could thus be fooled into thinking that a child has a
theory of mind when in fact they do not. How do we solve this problem?
The solution is not to present a test of true belief but to present a test of
false belief. To this end, Wimmer and Perner (1983) designed the classic
‘unexpected transfer test:’
Maxi put chocolate in the kitchen cupboard and then went out into the garden to
play. In his absence and without his knowledge, Maxi’s mother moved the choco-
late to the fridge so that it would not melt. After playing for a while, Maxi became
hungry and wanted a snack. He went to the kitchen to eat some of his chocolate.
Test Question: Where will maxi look for his chocolate?
Control Question 1: Where did Maxi put his chocolate before he went out to play?
Control Question 2: Where did Mum put his chocolate?/ Where is the chocolate
now?
Children aged around 3 and 4 years are likely to wrongly say that Maxi
will look in the fridge, suggesting that instead of reporting what Maxi
thinks, they report what they themselves think. Is that because they have
very poor memory or poor story comprehension and forgot or did not
Developing a theory of mind 111
understand that Maxi put the chocolate in the cupboard before he went
out to play? No: Even though children give a correct answer to Con-
trol Question 1, those aged 3 and 4 years, are liable to say that Maxi
will look in the fridge. Wimmer and Perner (1983) concluded that these
children were unable to calculate Maxi’s belief and that there was no
evidence to suggest that they possessed a theory of mind.
What of the older children, those aged 5 and 6 years? They suc-
cessfully judged that Maxi would vainly search for his chocolate in the
cupboard, the place where he left it. Is it possible that these children,
while appearing to calculate Maxi’s false belief, have merely forgotten
or not noticed that the chocolate was moved to the fridge? No: Chil-
dren aged 5 or 6 years have no difficulty saying that Mum moved the
chocolate to the fridge and that the chocolate is indeed currently in the
fridge. Hence, these children give one answer when asked about their
own belief (fridge) and a different answer when asked about Maxi’s be-
lief (cupboard). Evidently, they can calculate what Maxi is thinking (at
least to a limited degree) and therefore we could conclude that they
have a theory of mind.
Children perform in a similar way on other versions of the false
belief test (e.g. Perner, Leekam, & Wimmer, 1987). Imagine I present a
Smarties tube, ask the child to guess the content, and the child, not sur-
prisingly, says, ‘Smarties!’ I open the lid to reveal that really the tube only
contains a pencil. Then I close the lid with the pencil still inside and ask
the child to predict what their friend, little Johnny, who has never seen
this particular tube before, will say is inside. Those aged about 3 or 4
years usually predict that Johnny will say the tube contains a pencil –
presumably because this is what they themselves think and they have
difficulty separating what they think from what another person thinks.
An older child, aged 5 or 6 years, in contrast, will probably judge that
little Johnny will think the tube contains Smarties.
The kind of error young children make is not confined to judgments
of what other people are thinking. They seem to have general difficulty
in acknowledging that thoughts can be wrong. Suppose we ask the child
not what Johnny thinks is in the tube but what they themselves used to
think was in the tube before we opened the lid. Those aged around 3
and 4 years will probably say that they had thought the tube contained a
pencil, while children aged 5 and 6 years will probably say that they had
112 Peter Mitchell
thought the tube contained Smarties (Gopnik & Astington, 1988). Sim-
ilarly, if presented with a deceptive object, like a sponge painted in the
disguise of a rock, children experience difficulties (Flavell, Flavell, &
Green, 1983). On first encountering the object, children are fooled into
thinking it is a rock, which is perfectly understandable. On handling
the object, they quickly realise that it is a sponge. At this point, 5- and
6-year-olds are comfortable saying that the object looks like a rock but
is really a sponge. In contrast, 3- and 4-year-olds commonly say that the
object is really a sponge and that it looks like a sponge! In short, they
have difficulty acknowledging that minds (their own or other minds)
can misrepresent the world.
Is it true that children aged three and four years

lack a theory of mind?
Putting it another way, how else can we explain young children’s diffi-
culty? One obvious possibility is that young children really do have a
theory of mind but this competence is masked by their lack of under-
standing of the experimenter’s question. To investigate this possibility,
some researchers have tried to clarify the test question by making it
more explicit in the hope of finding that young children’s underlying
competence in theory of mind can be unmasked (Lewis & Osborne,
1990; Siegal & Beattie, 1991). The research had limited success in
helping some to get the correct answer but still the vast majority of 3
and 4 year olds tend to report their own current belief in tests designed
to probe theory of mind ability (Wellman, Cross, & Watson, 2001).
Another way of revealing early competence involves on a nover-
bal procedure, where the evidence of what children understand is not
from their verbal response but from their eye movements. Onishi and
Baillargeon (2005) discovered that 15-month-old infants looked for a
prolonged duration (as if surprised) when another person searched for
an object in its correct location, as if he did not have a false belief. In
this procedure, the person in question had not witnessed the object be-
ing moved from location A to B and the observing infant knew that this
was the case. Under a control condition, the person in question reached
to the empty location and infants did not show prolonged looking, sug-
gesting this was an event they expected to happen. If Onishi and Baillar-
geon’s interpretation is correct, it seems to imply that even babies aged
15 months understand about false belief, at least on some level. This is
a striking possibility, one that is supported by converging evidence from
subsequent studies (e.g. Southgate, Senju, & Csibra, 2007).
Researchers who argue that children’s errors on a false belief test
are caused by misunderstanding of the test question are effectively de-
nying that children have a deep-seated difficulty. Taking into account
the research suggesting competence in infancy, is it possible that chil-
dren do have a deep-seated difficulty, but this difficulty is not that they
lack a theory of mind? Even if children understand that their own and
others’ beliefs (or their own current belief and their own past belief)
can be different, perhaps they are biased to report their own current
belief (Mitchell, 1996). Hence, we have two rival theories: One says
that young children fail to acknowledge false belief because they lack
a theory of mind (lack of competence theory) and the other says that
they fail to acknowledge false belief because they are biased to report
their own current belief (bias theory). Do these two theories make the
same prediction? No. The ‘bias theory’ makes specific predictions
about children having a better or worse chance of giving a correct judg-
ment of false belief depending on the severity of the bias; it makes no
prediction about there being a specific age at which children suddenly
acquire competence in theory of mind. In contrast, the ‘lack of compe-
tence theory’ makes no predictions about factors that can increase or
decrease the probability of children making a correct judgment but it
does predict that children suddenly acquire competence at a particular
age (around 4 years of age), after which they are said to have a level of
competence that is similar to an adult’s theory of mind (Perner, 1991).
What does the evidence say?
Using a standard test of false belief, like the ones described above,
children usually begin to give a correct judgment some time after their
fourth birthday and usually before their fifth birthday. This finding has
been sufficient for many researchers to conclude that there is a point
in development before which children lack a theory of mind and after
which children have acquired the requisite competence (Wellman et al.,
114 Peter Mitchell
2001). Such researchers demonstrably adhere to the ‘lack of compe-

tence theory’ (e.g. Perner, 1991). If we manipulate the salience of the
child’s current belief, then this impacts on the point in development
when children give a correct judgment. Specifically, it is possible to
elevate the salience of the false belief by associating it with a physical
token. Mitchell and Lacohee (1991) introduced such a manipulation by
first asking children what they thought was inside a Smarties tube (they
all said ‘Smarties’) and then asking them to select a photo of Smarties
and post the said photo into a postbox where it remained out of view.
Subsequently, the true content of the tube was revealed to be none other
than a pencil, which was returned to the tube and the lid closed. Finally,
children were asked to report what they had thought was in the tube
at the time they posted their picture. The results quite clearly showed
that three-year-old children enjoyed much greater success in reporting
‘Smarties’ than in a standard procedure that did not involve posting
pictures. Hence, three year old children seemed to be competent in ac-
knowledging false belief, even though the standard procedure belies
such competence.
Or is there an alternative explanation? Is it possible children an-
swered correctly in the posting procedure without having a theory of
mind? Perhaps they misinterpreted the test question to mean, ‘What
is on the picture you posted?’ If so, their reply of ‘Smarties’ does not
signify that they have a theory of mind but only tells us that they have
a good memory for the picture in the postbox. If this explanation had
been correct, then tell-tale errors would be apparent in a control condi-
tion, in which children posted a picture not of Smarties, but of their fa-
vourite cartoon character (e.g. Mickey). In this control condition, when
asked, ‘When you posted the picture what did you think was in this
tube?’ children would or should reply, ‘Mickey,’ but none did so and this
alternative explanation can be rejected.
Another possibility is that posting the picture allowed clarification
in the child’s mind as to the point in time the experimenter was referring
to. When asked what he or she used to think was in the tube, the child
might wonder about the point in time being referred to, considering
the he or she thought different things at different times. That posting
procedure disambiguates the temporal reference: What did you think
specifically at the time you posted the picture (and before you opened
the lid and saw the pencil)? If this explanation were correct, then chil-
dren would be just as likely to answer correctly with ‘Smarties’ in the
cartoon posting condition as in the condition in which they posted a pic-
ture of Smarties. In fact, performance in the cartoon posting condition
was comparable to a standard condition that did not involve posting any
pictures while the Smarties posting condition was associated with better
performance in recalling a prior false belief than in either the standard
or the cartoon posting condition. Hence, this alternative account, based
on temporal clarification, can also be rejected as an explanation for chil-
dren’s good performance in the Smarties posting condition.
We are thus left with the default explanation that children per-
formed well in the Smarties posting procedure because it entailed a
manipulation of salience: When the salience of the child’s prior belief
was elevated by being associated with a physical token (a posted picture
of Smarties), children had a better chance of giving a correct judgment
on the content of their prior belief. In summary, this explanation implies
that children are not incompetent but are biased to report their own
current belief when asked about another person’s belief or when asked
about their own prior belief. This explanation does not say that the bias
vanishes at the age of 4 years; rather, it says that children become more
effective in overcoming the bias as they get older. This leads to a strik-
ing prediction: There should be vestiges of bias to one’s own current
belief well beyond the age of 4 years, maybe continuing into adulthood.
Imagine that you receive conflicting information – you see that a
jug contains juice but an hour later your friend, Rebecca, tells you that
it contains milk: Do you believe what you saw with your own eyes or
do you believe another person’s testimony? Do you believe the most
recent information (the testimony) or do you believe previous informa-
tion that could well be obsolete? Most adult participants in Birmingham
UK who watched a video of such a scenario judged that the recipient
of conflicting information (Kevin) would believe what he saw in prefer-
ence to what he was told, and this finding is perhaps not very surprising
or newsworthy. Under a slightly different condition, though, the find-
ings were dramatically different: Observing participants (but not Kevin
the protagonist) were told by the narrator’s voice that in Kevin’s ab-
sence and without his knowledge, Rebecca entered the kitchen, poured
away the juice and replaced it with milk, meaning that when Rebecca
116 Peter Mitchell
subsequently told Kevin that the jug contained milk, she was report-
ing a true state (though Kevin had no way of verifying her testimony).
Under this condition, a majority of (different) participants judged that
Kevin would believe the testimony in preference to what he saw with
his own eyes. In other words, participants’ estimation of what Kevin
believed was biased by their own knowledge of the true state of affairs.
Apparently, this bias presented an obstacle to participants’ ability to dis-
tinguish between what they and another person believed. Accordingly,
vestiges of bias that we see in young children can also be identified in
adult participants, calling into question the assertion that competence in
theory of mind is achieved at around 4 years of age. Rather, the findings
are more consistent with the possibility that young children and adults
are united in having some difficulty in guessing another person’s belief
because they are biased to report their own belief. Granted, this bias
might well be stronger in young children than in adults, but it seems
that during development we change by a matter of degree; there is no
compelling evidence to suggest that we undergo a radical shift in the
way we think.
How does culture impact on theory of mind?
Children raised in different nations that have their own unique customs
and traditions nevertheless usually begin to acknowledge false belief
at around 4 years of age when tested with a standard procedure. This
is true in the UK (Perner, Leekam, & Wimmer, 1987), central Europe
(Wimmer & Perner, 1983), Canada (Gopnik & Astington, 1988), the
USA (Bartsch & Wellman, 1989), Australia (Siegal & Beattie, 1991),
Japan (Naito & Koyama, 2006) and even the rainforest of the Camer-
oon (Avis & Harris, 1991). It is tempting to think, therefore, that it is
quite natural for children to begin life trapped in their own perspective,
whereupon the process of development enables the child gradually to
overcome this bias to their own perspective. There is still scope, never-
theless, for culture to influence the way people make judgments about
other people’s beliefs. Consider once again the dilemma Kevin faces
when seeing one thing but hearing (one hour later) something else. In
the absence of additional information, saying that Rebecca had replaced
the juice with milk, most adult participants in Birmingham UK judged
that Kevin would believe that the jug contains what he saw – juice.
One might say that the UK, including Birmingham, has grown
into a rather individualistic society, where people are inclined to follow
their own judgment and are perhaps sceptical of information originating
from a third party. On the Mediterranean Island of Cyprus – particularly
in the mountain villages that are somewhat immune from the developed
world – things are different. The culture has more of an interdependent
or collectivist character, where people are trusting and heavily influ-
enced by information from other people. In that culture, interestingly,
participants did not judge differently between the two experimental con-
ditions (additional information saying that Rebecca had replaced the
juice with milk versus no additional information), primarily because
participants were inclined to judge that Kevin would believe testimony
from another person (in preference to what he had seen at an earlier
point in time), irrespective of whether or not they had additional in-
formation indicating that the testimony was true (Mitchell, Souglidou,
Mills, & Ziegler, 2007). In short, people’s judgments of what another
person is thinking are liable to be influenced by cultural factors.
Are there individual differences in the ability

to guess what another person is thinking?
The condition of autism, a pervasive developmental disorder, seems to

be associated with poor abilities in estimating what other people are
thinking. Indeed, it seems that children with autism are developmen-
tally delayed in passing a standard test of false belief (Happe, 1995).
This finding led Baron-Cohen and colleagues (Baron-Cohen, Leslie, &
Frith, 1985) to posit the ‘theory of mind hypothesis of autism’ stating
that individuals with autism primarily suffer from a cognitive deficit
that prevents them making inferences of another person’s beliefs. Many
of the features of autism were supposedly explained by this specific
118 Peter Mitchell
cognitive deficit. However, the theory of mind hypothesis falls down

because the data do not support conditions of uniqueness and univer-
sality (Rajendran & Mitchell, 2007). Some children who do not have
autism nevertheless have developmental delay in passing tests of false
belief (e.g. Woolfe, Want, & Siegal, 2002; Minter, Hobson, & Bishop,
1998), indicating that delayed theory of mind is not unique to autism.
And some children with autism can successfully and reliably pass a test
of false belief, showing that impaired theory of mind is not universal
among those with autism.
Any theory that has to be qualified by saying, ‘these are the core
and defining features of autism, except some people who do not have
autism also show the features and not all people with autism show the
features’, is patently inadequate. Having said that, on average, people
with autism seem less effective in guessing what others are thinking
than people who do not have autism. Hence, it is fair to say that being
poor at guessing others’ thoughts is associated with autism but is not
a defining feature of autism. In summary, then, and in answer to the
question posed by the subheading, there are individual differences in
the ability to guess what another person is thinking and the condition of
autism is a relevant factor but the theory of mind hypothesis of autism
is open to criticism.
Conclusion
One of the main controversies surrounding research into the develop-

ment of a theory of mind concerns the question of whether or not chil-
dren below about 4 years lack the competence to estimate what another
person is thinking. If they did lack competence, then we would need
to explain what kind of developmental change took place that allows
a child above 4 years to successfully make an educated guess of what
another person is thinking. Traditionally, researchers believed that chil-
dren experience a radical conceptual shift that allows them to process
information in a new way, thereby allowing then to guess another per-
son’s thought. An alternative view maintains that young children do not
lack competence in this area of functioning but rather their reasoning is

prone to bias. This view makes no assumptions about any radical con-
ceptual shift and instead assumes there is continuity between childhood
and adulthood in the form of reasoning (except child reasoning is more
susceptible to bias).
How do children and adults calculate what another person is think-
ing? One possibility, known as the ‘simulation theory,’ is that partici-
pants use their imagination to project themselves through their mind’s
eye into the situation of another person and then imagine how they
would think or feel in that same situation. Another possibility, known as
the ‘theory theory,’ is that participants use rules and principles to work
out what another person knows or thinks without needing to imagine
themselves in that situation. It is entirely plausible to suppose that par-
ticipants actually use both methods and, in particular, perhaps a rule-
based approach develops from a simulation approach as a kind of ‘short
cut’ (Mitchell, Currie, & Ziegler, 2009). It is actually quite difficult to
determine the process people use for guessing another’s thoughts and
debate on the matter is on-going in the psychological and philosophical
literature.
References
Avis, J., & Harris, P. (1991). Belief-desire reasoning among Baka chil-
dren: Evidence for a universal conception of mind. Child Develop-
ment, 62, 460–467.
Baron-Cohen, S., Leslie, A.M., & Frith, U. (1985). Does the Autistic
Child have a ‘theory of mind’? Cognition, 21, 37–46.
Bartsch, K., & Wellman, H. (1989). Young children’s attribution of
action to beliefs and desires. Child Development, 60, 946–964.
Flavell, J.H., Flavell, E.R., & Green, F.L. (1983). Development of the
appearance-reality distinction. Cognitive Psychology, 15, 95–120.
Gopnik, A., & Astington, J.W. (1988). Children’s understanding of rep-
resentational change, and its relation to the understanding of false
120 Peter Mitchell
belief and the appearance-reality distinction. Child Development,

59, 26–37.
Happé, F. G. E. (1995). The role of age and verbal-ability in the theory
of mind task- performance of subjects with autism. Child Develop-
ment, 66, 843–855.
Lewis, C., & Osborne, A. (1990). Three-year-olds’ problems with false
belief: Conceptual deficit or linguistic artefact? Child Develop-
ment, 61, 1514–1519.
Minter, M., Hobson, R. P., & Bishop, M. (1998). Congenital visual im-
pairment and ʻtheory of mind᾿. British Journal Of Developmental
Mitchell, P. (1996). Acquiring a Conception of Mind: A Review of Psy-
chological Research and Theory. Hove: Psychology press.
Mitchell, P., & Lacohee, H. (1991). Children᾿s early understanding of
false belief. Cognition, 39, 107–127.
Mitchell, P., Currie, G., & Ziegler, F. (2009). Two routes to perspec-
tive: Simulation and rule-use as approaches to mentalizing. British
Journal of Developmental Psychology, 27, 513–543.
Mitchell, P., Souglidou, M., Mills, L., & Ziegler, F. (2007). Seeing is be-
lieving: How participants in different subcultures make judgments
of people’s credulity. European Journal of Social Psychology, 37,
573–585.
Naito, M., & Koyama, K. (2006). The development of false-belief
understanding in Japanese children: Delay and difference? Interna-
tional Journal of Behavioral Development, 30, 290–304.
Onishi, K. H., & Baillargeon, R. (2005). Do 15-month-old infants
understand false beliefs? Science, 308, 255–258.
Perner, J. (1991). Understanding the Representational Mind. London:
MIT Press.
Perner, J., Leekam, S., & Wimmer, H. (1987). Three-year-olds’ diffi-
culty with false belief: The case for a conceptual deficit. British
Journal of Developmental Psychology, 5, 125–137.
Rajendran, G., & Mitchell, P. (2007). Cognitive Theories of Autism.
Developmental Review, 27, 224–260.
Siegal, M., & Beattie, K. (1991). Where to look first for children’s
knowledge of false beliefs. Cognition, 38, 1–12.
Southgate, V., Senju, A., & Csibra, G. (2007). Action anticipation

through attribution of false belief by 2-year-olds. Psychological
Science, 18, 587–592.
Wellman, H. M., Cross, D., & Watson, J. (2001). Meta-analysis of
theory-of-mind development: The truth about false belief. Child
Wimmer, H., & Perner, J. (1983). Beliefs about beliefs: Representa-
tion and constraining function of wrong beliefs in young children᾿s
understanding of deception. Cognition, 13, 103–128.
Woolfe, T., Want, S. C., & Siegal, M. (2002). Signposts to development:
Theory of mind in deaf children. Child Development, 73, 768–778.
Elizabeth Sheppard
Savant abilities and Autism Spectrum Disorders
One aspect of my work people find particularly intriguing is the ex-

istence of savants – people whom, despite having an intellectual im-
pairment, nevertheless demonstrate outstanding skill or talent in one
specific area of performance. Savantism (or the ‘savant syndrome’;
Treffert, 1989) was made famous by the popular movie ‘Rain Man’ in
which Dustin Hoffman starred as Raymond, an adult with autism who
had considerable difficulty negotiating even simple tasks of everyday
life but demonstrated a number of astonishing talents including stagger-
ing recall memory and phenomenal mathematical ability. Some people
are aware that Raymond’s character was based on real-life savant, Kim
Peek – however, many are uncertain about the extent to which the movie
makers have exaggerated or embellished true savant skill for the pur-
poses of entertainment.
So do such people really exist? In this chapter I hope to answer this
and to discuss some associated questions. For example, if these abilities
do exist, then why or how do they form? Another question I wish to
consider is whether savant skills should be considered the same as nor-
mal talents or whether there are certain features that make these skills
distinct? Moreover, is there an association between savant abilities and
Autism Spectrum Disorders (ASD), as was the case for Raymond? To
discuss these issues, I will focus on savant artistry for purposes of illus-
tration. However, it should be noted that many of the theories are more
general and apply to other forms of savant skill too.
124 Elizabeth Sheppard
Do savant skills really exist?
There are in fact quite a number of well documented cases of real-life

savants with the kind of skills exhibited by Raymond. These days,
some savants experience a degree of celebrity and even make a good
living from performing publically. Nevertheless, individuals with sa-
vant skills are very rare and it has proved difficult to obtain a reliable
estimate of their prevalence. Hill (1977) conducted a survey of 107
institutions for individuals with cognitive disability and care-workers
reported 54 cases of savant ability, corresponding to a prevalence of
0.6% or 1 in about 2000. However, one shortcoming of this study was
that the exact definition or criteria for assessing savant skill were not
clearly stated, leaving open the possibility of differing interpretations
by the institutions involved. What seems clear is that savant skills are
more common amongst individuals who have a diagnosis of an Autism
Spectrum Disorder (ASD) than amongst the wider population with
cognitive disability. Rimland (1978) conducted a study that surveyed
parents of children with an ASD diagnosis and found that around 1
in 10 had a special ability of this nature. Contrasted with the preva-
lence found for individuals with cognitive disability in general in Hill’s
study, we can see that savant abilities are relatively common in ASD.
This implies that these various talents may share a common root and
has led to attempts by researchers to establish what it is about ASD that
leads to this higher occurrence of savant skills than in any other group.
Another interesting aspect of savant abilities that researchers have
sought to explain is that they tend to occur in a rather narrow range
of abilities. There are an almost infinite number of human skills in
which someone could potentially be talented. However, savant skills are
commonly observed in one of a few specific areas: music, art (usually
drawing), mathematics (usually arithmetic), memory, and calendar
calculation (an unusual ability to make complicated computations
based on the calendar. For instance, when given a specific date e.g. 13th
April 1822 a calendar calculator can almost instantly state the day of the
week on which that date fell). Any theory of savant abilities ought to be
able to account for why savant skills tend to cluster in these particular
domains and not in others.
Savant abilities and Autism Spectrum Disorders 125
Savant art
The work of savant artists has given great pleasure to a large number
people the world over. One famous savant artist is Simon Wiltshire who
was discovered by Hermelin and O’Connor when he was just fifteen
years old (Hermelin, 2001). Simon’s drawings have a very characteristic
style: he draws pictures of buildings and cityscapes in extraordinary de-
tail from memory, often after having only seen the subject matter once.
Another famous case was a girl called Nadia who was first reported at
just nine years old by Lorna Selfe (Selfe, 1977). Nadia drew pictures
of horses in a realistic and dynamic style that few adults could man-
age, let alone a child. Like many savants, both Simon and Nadia have
a diagnosis of an ASD, which entails difficulties in socialization and
communication, and having restricted or repetitive interests (DSM-IV,
American Psychiatric Association, 1994).
What is special about savant artists?
Early studies on savant artistry were mainly aimed at trying to identify

what is distinctive or special about savant artists in comparison with
untalented individuals or even those who have artistic talent who are
not savants. Some studies have scrutinized the drawings produced by
such individuals under controlled conditions to determine if there is
anything different about the manner in which savants draw particular
subject matter. Hermelin and O’Connor (1990) conducted one such
study for which they recruited a group of savant artists and a group of
neuro-typical individuals who were also artistically gifted. They pre-
sented participants with a scene composed of small three-dimensional
models of a tree, a horse, a cow and a person. Participants were asked
to draw the scene, copy a photograph of the same scene, draw the scene
from memory, and finally draw the scene how it would look to someone
sitting at 90 degrees to themselves (hence having a different view of
the objects). Once all the drawings were completed, expert judges were
asked to rate the drawings on five scales relating to artistic competence:

liveliness & sensitivity; vitality of line and texture; distinct personal
style; composition; and compelling image. The experts were members
of a University art department and were kept unaware about whether the
drawings were produced by the savant artists or the gifted neuro-typical
individuals. This was done so that their ratings would not be influenced
by their knowledge of the group of which the participant was a member.
No differences were found in the ratings given to savants versus gifted
neuro-typical individuals, suggesting that the kinds of drawings pro-
duced by savants and gifted artists are broadly similar in many stylistic
features.
Another study conducted by Hermelin and Pring (1998) com-
pared the use of perspective in a group of savant artists with a group of
non-savant gifted artists. Participants were given paper and instructed to
draw a road starting at the bottom of the paper and ending at the top, and
then to add three cars at varying distances along the road. In particular
the researchers were interested to see whether participants would use
two pictorial devices to communicate depth: linear perspective (depict-
ing the road as two slanted lines angled inwards towards a vanishing
point) and size (depicting the cars in the distance i.e. further up the road
as smaller). Both of these pictorial conventions have been around for
centuries in western art, since the Italian renaissance. It was found that
almost all participants in both groups used these devices – again, not
revealing anything that distinguishes savant artists from regular artists
in the drawings produced.
Other studies have asked whether there are certain abilities
apart from artistic skill itself that set savant artists aside from other
non-talented individuals. O’Connor and Hermelin (1990) investigated
the role of recognition memory. They reasoned that one feature evi-
dent in the artwork of many savant artists is an impressive ability to
represent accurately large numbers of specific details of objects and
scenes implying they may have superior visual memory. They carried
out a series of experiments with three groups of participants: a group
of savant artists with ASD, a group of gifted artists who did not have
a diagnosis of ASD (who had a higher IQ), and a group of non-gifted
individuals who had the same IQ as the savant group. The first exper-
iment involved presenting participants with a target shape and asking
them to select which out of an array of possible shapes was identical to

the target. The second experiment was the same as this, but this time the
target was removed before the array was presented so participants were
required to remember it to make their selection. Results showed that the
participants with ASD were poorer at both these tasks than the gifted
artists who did not have an ASD diagnosis, and their performance was
at a similar level as the non-gifted comparison participants who were
matched for IQ. This was in spite of the fact that when asked to draw or
copy the same shapes, the savants were as accurate as the gifted artists
and much better than the non-gifted comparison participants. O’Connor
and Hermelin went on to do a further experiment with the same par-
ticipants, this time involving motor shape matching. Participants were
blindfolded and required to trace around shapes made from wire with
their fingers. Then their blindfold was removed and they were either re-
quired to pick out the shape from an array (visual recognition) or draw
it. For recognition, savants performed no better than the IQ matched
comparison participants. However, for drawing savants performed as
well as the gifted higher IQ comparison participants. These results sug-
gest any superiority in performance of artistic savants is very closely
linked to the domain of their special skill, while it seems that shape
matching and memory relate to general intelligence (IQ).
However, Hermelin, Pring and Heavey (1994) discovered there may
be some skills aside from drawing itself that differentiate savant artists
with ASD from non-gifted individuals who have an ASD diagnosis.
They presented a battery of tasks and found that savant artists were su-
perior at a task that involved moving a wire loop along a curved stretch
of wire from one end to the other without touching the wire. Similarly,
savant artists were more successful at a task that involved poking a metal
rod inside holes of increasingly small diameter without touching the
edge of the holes. Savant artists were better at copying simple shapes
while viewing their hand in a mirror (so their hand appeared to move
in the opposite direction to that expected). Finally, savant artists were
better at assembling a picture from a set of pieces (similar to a jigsaw).
These findings suggest that savants may be particularly good at certain
tasks involving fine motor control, as well as tasks involving adjust-
ing movements based on perceptual feedback (mirror drawing). These
abilities may all be factors that explain why some individuals with an
ASD diagnosis become savants and others do not develop outstanding

talents. But what is the link between ASD and savant skill?
Savant artistry and ASD
Perhaps one reason why people marvel at the works of savant artists is
the fact that adults are generally poor at drawing realistically, despite
our best efforts. In order to understand why some individuals develop
savant artistic ability, we may first need to consider why it is that most
people never become able to draw well. Drawing is a complex task
involving various sub-components, including perception of the object
to be drawn, decision making, planning, and motor control. However,
research seems to suggest that most drawing inaccuracies result from
perceptual errors (Cohen & Bennett, 1997). More specifically, both
typically developing children and adults tend to produce drawings that
reflect what they know about objects rather than what can be seen from
a specific viewpoint (e.g. Freeman & Janikoun, 1972; Phillips, Hobbs,
& Pratt, 1978; Mitchell, Ropar, Ackroyd, & Rajendran, 2005). We live
in a three-dimensional world and because of this what we see from our
current perspective frequently conflicts with our knowledge about the
object in question. For example, I know that the top of my dining table
is really rectangular but I rarely see the table from directly above, so the
image projected to my eye will be a parallelogram or trapezium shape,
which changes with the exact angle from which I view it. In order to
produce an accurate drawing it is necessary to ignore my prior concep-
tion that my table top is a rectangle shape and focus my attention on
purely its perceptual features (how it looks from my current viewpoint).
Bearing in mind this observation that drawing errors tend to result
from an over-reliance on knowledge about the object to be drawn, some
theories of ASD may be able to account for the high occurrence of sa-
vant artists within the ASD population. Perhaps the most famous of
these is the suggestion first made by Frith (1989; see also Happé & Frith,
2006) that ASD is characterized by a perceptual style known as ‘weak
central coherence’. The idea is that individuals of typical development
have a strong drive towards processing the world as meaningful wholes

(known as central coherence). So for example, we would tend to re-
member the overall gist of a story, rather than the specific words that
comprise it. In contrast, it has been suggested that people with ASD
have less of this drive than typical individuals resulting in a tendency
to focus on perceptual details rather than global or holistic information.
In support of this, it has reliably been found that people with ASD are
superior at tasks where attending to details and ignoring global mean-
ing is an advantage. For example, individuals with ASD are faster and
more accurate than neuro-typical individuals of similar age and IQ at
the embedded figures task (Shah & Frith, 1983). This task involves try-
ing to find a simple shape (such as a triangle) hidden somewhere within
a more complex figure (such as a picture of a rocking horse). It seems
that neuro-typical individuals find it difficult to overcome their global
perception of the object as a whole and consider its isolated parts; but
less so people with ASD. Given the evidence reviewed above that sug-
gests drawing errors result from a tendency to focus on the meaning
of objects rather than their perceptual properties, it seems reasonable
to think that having weak central coherence could be advantageous for
realistic drawing. Could it be that savants represent the extreme end of a
central coherence continuum, having very weak coherence?
Evidence consistent with this was provided in a study conducted
by Pring, Hermelin and Heavey (1995). The study enlisted four groups
of participants: savant artists with ASD, non-talented individuals with
ASD, students studying for a University art degree (i.e. artistically ca-
pable but without ASD) and non-talented neuro-typical individuals.
Participants completed a test known as the Block Design task, in which
participants are presented with a series of increasing complex geomet-
ric designs printed on paper in red and white ink, and are required to
reconstruct the same design from a set of red and white blocks, some-
what similar to a jigsaw. This task is quite challenging, as it requires an
ability to ignore the overall pattern presented and mentally segment it
into its component parts. It has frequently be found people with ASD
are faster than neuro-typical individuals at completing it (as predicted
by weak central coherence e.g. Shah & Frith, 1993). In Pring et al.’s
study, it was found that both groups of participants with ASD had high-
er scores than those without ASD but that the savant artists were the
fastest of all. This suggests that savants may have even weaker central
coherence than the general population of ASD and could explain why
only some individuals become savants.
A somewhat similar theory of ASD was proposed by Mottron and
Burack (2001) known as the Enhanced Perceptual Functioning model
(EPF). This theory proposes that people with ASD simply have supe-
rior perceptual skills compared with individuals without the condition.
According to this theory, all savant skills, including artistry, are ground-
ed in perception and rely upon building up an eventually complex form
from simple elements or units through operation of rules. For example,
a picture is built up from individual lines, or a piece of music is built
from individual tones. EPF essentially proposes that people with autism
are superior at perceiving the simple elements and as a consequence
become better at combining them. Thus, this theory goes some way to
explaining why savant skills occur in the particular domains they do:
they tend to be skills that involve combining simple perceptual units
into more complex ones. EPF also claims that expertise is developed
through repetitive behaviours within the domain of interest (whether
music, art or calendars). So through extensive practice, mastery is
eventually achieved. As mentioned earlier, repetitive behaviours are
regarded as a defining feature of ASD and hence may help pave the way
for savant abilities to develop over time.
The notion that practice is required for savant skills to develop im-
plies that ‘splinter skills’ – superior but not prodigious abilities in the
same areas of functioning (art, music, memory and so on) – may occur
more widely amongst ASD populations. This indeed appears to be the
case: children and adolescents with ASD who are not artistically talent-
ed are nevertheless less affected by three-dimensionality than typically
developing children when copying line drawings of objects (Sheppard,
Ropar, & Mitchell, 2007; 2009). Typically-developing children gener-
ally have a lot of difficulty copying line drawings that represent objects
in three dimensions. For example, typically-developing children under
the age of about 12 years struggle to copy the drawing of the truck on
the left which contains depth cues, but find it relatively easy to copy the
drawing on the right – even though both drawings are constituted from
exactly the same lines. Children with ASD, on the other hand, find these
two drawings to be of a similar level of difficulty. While this aspect of
performance in itself is not sufficient for visually realistic drawings, it

may be an important constituent skill that enables savant abilities to
occur.
Figure 1: Lorry represented in three-dimensions (left) and two-dimensions (right) used

in Sheppard et al. (2007).
Another view on how savant skills develop was put forward by Snyder
and Thomas (1999), who argued that savants have access to lower lev-
els of neural information that are not readily available to neuro-typical
individuals. In neuro-typical individuals visual processing is driven
by high-level mental representations (i.e. our knowledge), so we can
recognise and use objects effectively, but artists need to work from
lower-level perceptual information about shading, orientations of lines
etc. This idea is an interesting one in that it suggests that the kind of
processing that supports savant skill takes place in each and every one
of us – however, most of us do not have access to the outputs. This
framework for understanding savant abilities ties in with the previously
mentioned theories of ASD which suggest that processing of concepts
or meaning is reduced in ASD, which becomes associated with superior
perceptual processing. Snyder and Thomas’ theory is also supported by
there being documented cases where savant skills have arisen in a pre-
viously normal individual following brain damage. Miller et al. (1998)
reported a group of patients with fronto-temporal dementia (dementia
affecting areas mainly towards the front of the brain) who started to
show savant artistic abilities during the course of their condition. These
abilities accompanied an overall cognitive decline as is typical in indi-
viduals suffering from dementia. That superior skill can arise following
damage to the brain seems counter-intuitive, but these striking cases
imply that we may all have the capacity for savant ability, which can be
unlocked under the right conditions.
Perhaps even more remarkably, some researchers claim to have in-

duced savant-like skills in healthy individuals following application of
transcranial magnetic stimulation (TMS). TMS is a technique that can,
through the application of stimulation to a particular part of the outside
of the skull, temporarily interfere with the functioning of the areas of
the brain beneath. In other words, using this technique it is possible
to temporarily “lesion” part of the brain for a short duration. Snyder
et al. (2003) carried out a study in which participants were asked to draw
pictures of various objects before, during and after TMS stimulation.
Although there was no overall change in the quality of the drawings (as
rated by assessors) during the application of TMS, there was evidence
that TMS resulted in changes in the style of the drawings produced that
were not seen in individuals who did not receive TMS. Taken together
the findings reviewed above suggest that savant abilities may arise from
certain aspects of information processing that are conducted routinely
by the brain but to which we do not have access.
Conclusion
Savant abilities are a rare phenomenon. Although it is difficult to get a

precise estimate of their prevalence, it is clear that they are relatively
common amongst individuals with an ASD. A number of theories of
ASD may help explain the association between ASD and savant skills.
What they have in common is that they propose that there is a tendency
in those with ASD to focus on perceptual details and ignore conceptu-
al meaning. While in some contexts this style of processing might be
largely problematic (for example, focusing on individual words rather
than the meaning of sentences when in conversation) it so happens that
there are some fields of skill where this style is actually advantageous –
explaining why savant skills mainly cluster in a few specific domains.
The wider population of those with ASD have been found to have
splinter skills in areas such as art and music, that is, superior spe-
cific abilities within these domains that may set the scene for savant
skills to occur. Nevertheless, something additional must be needed for
exceptional ability to develop. One possibility is that savants just have

a more extreme version of the ASD perceptual style e.g. weak central
coherence. Another possibility is that savants have some additional
abilities not present in those who have ASD but do not develop these
skills (e.g. better memory for skill-related information, better motor
control, better remapping between visual and motor domains for savant
artists). A further possibility is that savants are simply more interested
and repeat behaviours in their chosen domain until reaching the point
of expertise. Of course, it could well be a combination of all of these
factors acting together that converges on outstanding performance.
Finally, it should be noted that while the theories above provide
a useful framework to account for the majority of savant skills, there
are still a number of inconsistencies in the literature that have not yet
been explained. For example, while many of the theories emphasise the
importance of repetitive behaviours in forming savant skills, there are
cases where savant abilities onset instantaneously without the gradu-
al improvement normally seen in skill development (e.g. Nadia; Selfe,
1977). Moreover, although savant skills generally occur in the domains
mentioned previously, there is one reported case of a savant with ASD
whose special ability was in poetry – which is hard to explain if savant
abilities are rooted in lower-level perceptual expertise (Dowker, Her-
melin, & Pring, 1996). Cases such as these mean that savant abilities
remain a puzzle yet to be fully solved.
References

manual of mental disorders (4th edn.). Washington, DC: American
Psychiatric Association.
Cohen, D. J., & Bennett, S. (1997). Why can’t most people draw what
they see? Journal of Experimental Psychology: Human Perception
and Performance, 23, 609–621.
Dowker, A., Hermelin, B., & Pring, L. (1996). A savant poet. Psycho-
logical Medicine, 26, 913–924.
Freeman, N., & Janikoun, R. (1972). Intellectual realism in children’s

drawings of a familiar object with distinctive features. Child Devel-
opment, 43, 1116–1121.
Frith, U. (1989). Autism: Explaining the enigma. Oxford: Blackwell
Scientific Publications.
Happé, F., & Frith, U. (2006). The weak central coherence account:
Detail-focused cognitive style in autism spectrum disorders. Jour-
nal of Autism and Developmental Disorders, 36, 5–25.
Hermelin, B. (2001). Bright splinters of the mind: A personal story of
research with autistic savants. London: Jessica Kingsley Publishers.
Hermelin, B., & O’Connor, N. (1990). Art and accuracy: The drawing
ability of idiot-savants. Journal of Child Psychology and Psychia-
try, 31, 217–228.
Hermelin, B., & Pring, L. (1998). The pictorial context dependency
of savant artists: a research note. Perceptual and Motor Skills, 87,
995–1001.
Hermelin, B., Pring, L., & Heavey, L. (1994). Visual and motor func-
tions in graphically gifted artists. Psychological Medicine, 24,
673–680.
Hill, A. L. (1977). Idiot savants: Rate of incidence. Perceptual and Mo-
tor Skills, 44, 161–162.
Miller, B. L., Cummings, J., Mishkin, F., Boone, K., Prince, F., Ponton, M.
& Cotman, C. (1998) Emergence of artistic talent in fronto-temporal
dementia. Neurology, 51, 978–982.
Mitchell, P., Ropar, D., Ackroyd, K., & Rajendran, G. (2005). How per-
ception impacts on drawings. Journal of Experimental Psychology:
Human Perception and Performance, 31, 996–1003.
Mottron, L., & Burack, J. (2001). Enhanced perceptual functioning in
the development of autism. In J. A. Burack, T. Charman, N. Yirmiya,
& P. R. Zelazo (Eds.). The development of autism: Perspectives
from theory and research. (pp. 149–169). Malwah, N.J.: Erlbaum.
O’Connor, N., & Hermelin, B. (1990). The recognition failure and
graphic success of idiot-savant artists. Journal of Child Psychology
and Psychiatry, 31, 203–215.
Phillips, W. A., Hobbs, S. B., & Pratt, F. R. (1978). Intellectual realism
in children’s drawings of cubes. Cognition, 6, 15–33.
Pring, L., Hermelin, B., & Heavey, L. (1995). Savants, segments, art
and autism. Journal of Child Psychology and Psychiatry, 36,
1065–1076.
Rimland, B. (1978). Savant capabilities of autistic children and their
cognitive implications. In G. Serban (Ed.). Cognitive defects in
the development of mental illness. (pp. 43–65). New York, NY:
Brunner-Mazel.
Selfe, L. (1977). Nadia. A case of extraordinary drawing ability in an
autistic child. London: Academic Press.
Shah, A., & Frith, U. (1983). An islet of ability in autistic children:
A research note. Journal of Child Psychology and Psychiatry, 24,
613–620.
Shah, A., & Frith, U. (1993). Why do autistic individuals show superior
performance on the block design task? Journal of Child Psycholo-
gy and Psychiatry, 34, 1351–1364.
Sheppard, E., Ropar, D., & Mitchell, P. (2007). The impact of meaning
and dimensionality on copying accuracy in autism. Journal of
Autism and Developmental Disorders, 37. 1913–1924.
Sheppard, E., Ropar, D., & Mitchell, P. (2009). Autism and dimension-
ality: Differences between copying and drawing tasks. Journal of
Autism and Developmental Disorders, 39, 1039–46.
Snyder, A. W., Mulcahy, E., Taylor, J. L., Mitchell, D. J., Sachdev, P.
& Gandevia, S. C. (2003). Savant-like skills exposed in normal
people by suppressing the left frontotemporal lobe. Journal of Inte-
grative Neuroscience, 2, 149–158.
Snyder, A. W., & Thomas, M. (1997). Autistic artists give clues to
cognition. Perception, 26, 93–96.
Treffert, D. (1989). Extraordinary People. New York, NY: Harper and
Row.
Radka Jersakova, Akira R. O’Connor and Chris J. A. Moulin
What’s new in déjà vu?
…it was even possible that none of what he thought had taken place, really had
taken place, that he was dealing with an aberration of memory rather than of per-
ception, that he never really had thought he had seen what he now thought he once
did think he had seen, that his impression now that he once had thought so was
merely the illusion of an illusion, and that he was only now imagining that he had
ever once imagined seeing a naked man sitting in a tree at the cemetery.
Catch-22, Joseph Heller (1961, p. 309)
This essay outlines current research on the experience of déjà vu. After
introducing déjà vu and presenting data on its incidence and character,
two categories of explanations are discussed and evaluated. The first
group of explanations posits that déjà vu arises from a similarity be-
tween the current and some previous situation. The second group posits
that the experience results from aberrant neural processes and thus is
not related to our current environment in any way. Next we look at what
are perceived as two key areas of future research. A crucial question is
whether there is only one type of déjà vu or whether there are several,
with different causes and different characteristics. The answer to this
question informs whether or not we can reconcile competing theories
of déjà vu. Finally, we discuss the methodological difficulties faced
by those studying déjà vu and the steps that we must take to improve
current methodologies.
Introducing déjà vu
Déjà vu is an experience of familiarity combined with the awareness

that this experience is inappropriate. According to a review by Brown
138 Radka Jersakova, Akira R. O’Connor and Chris J. A. Moulin
(2004), questionnaire data shows that déjà vu occurs in the daily lives of
67% of the population. Its occurrence is typically once every couple of
months and it occurs most frequently in young people. Many research-
ers have linked the experience to being stressed or tired. It can happen
in new situations but is also often observed in mundane situations such
as when relaxing, commuting or when in familiar, everyday environ-
ments (e.g. at school or at work). Déjà vu then, is an infrequent and
perplexing experience, more common in younger adults, and one which
should be particularly pertinent for psychology students.
Those who have had it recently will remember that it is not merely
that we experience the feeling of having encountered a single specif-
ic object before; rather, we feel as if we have been in this particular
place, looking at this particular object, in this particular way before. It
is a truly all-encompassing subjective experience as it combines affect,
thought, perceptions and cognitions (Wild, 2005). For the psychology
student, and even the memory expert, it can be a confusing, paradoxical
sensation, as is encapsulated in Joseph Heller’s quote that prefaced this
chapter.
Déjà vu is fascinating for researchers to study because of what it
tells us about the functioning of memory (e.g. O’Connor, Moulin, &
Cohen, 2008). In déjà vu one observes a dissociation or clash between
the current mnemonic experience and one’s assessment of it; it is the
experience of familiarity combined with awareness that this feeling is
wrong. As such, while déjà vu is often described as an instance where
memory has somehow failed or tricked us, it can equally be described
as an instance where the cognitive processes that allow us to monitor
our memory are extremely successful. Déjà vu provides evidence that
two systems are at play in memory – something which relays contents of
prior episodes to mind, and something which reflects on what is brought
to mind (see Nelson & Narens, 1990). In déjà vu, the latter system al-
lows us to correctly reject an experience of familiarity as inappropriate.
As such, déjà vu has been described as ‘metacognitive’ and as evidence
that there are memory ‘feelings’ which operate in human cognition (see
Moulin & Souchay, 2013).
What’s new in déjà vu 139
Theoretical explanations of déjà vu
Theories of déjà vu can be divided into two categories, bottom-up and

top-down theories. Bottom-up theories assume that the experience is
data-driven; elicited by something in the environment that triggers this
subjective, internal response. On the other hand, top-down theories
assume that déjà vu is triggered by aberrant neural processes that sit
above our perceptions of the environment, exerting their influence on
whatever we happen to perceive at the time.
Bottom-up theories of déjà vu
While there are many theoretical explanations of déjà vu (Brown, 2004),

currently a key line of research focuses on the similarity hypothesis –
the idea that the situation eliciting the déjà vu is in some way similar to a
prior experience. This similarity gives rise to an experience of familiari-
ty even when we do not remember that prior experience, meaning we do
not understand where the sense of familiarity is coming from. Building
on this idea, Cleary, Ryals and Nomi (2009) used the recognition-with-
out-cued-recall (RWCR) paradigm to study déjà vu. In this paradigm,
participants first study pictures of internal and external scenes, such as
pictures of a room or a street, and later are presented with new scenes
some of which are similar to the pictures they studied. The similarity
between scenes is created by positioning different features of a scene in
a common configuration, so that the features across different pictures
are perceptually comparable in how they relate to each other. An exam-
ple in daily life might be driving down a country road for the first time
and seeing a church by a fountain on the left. You may not have seen that
church and that fountain before, but you may have been somewhere be-
fore with a similar configuration of a building with a spire and fountain.
In Cleary et al.’s experiment, for each presented new scene, participants
were asked to name a studied scene it resembled, rate its familiarity
and indicate whether they are in a déjà vu state. The researchers then
analyzed the rate of déjà vu responses for scenes participants were un-
able to name a corresponding scene for. The results showed that partic-
ipants reported déjà vu significantly more often for scenes configurally
similar to studied scenes (17%) as compared to completely new scenes
(13%). Further, participants reported an increase in their experience of
familiarity for the scenes when they reported experiencing déjà vu as
compared to when they did not. We will return to the small difference
between reports of déjà vu across conditions later. For now, it should be
noted that the strength of this approach is that it allows the researchers
to capture and isolate instances where subjective awareness of familiar-
ity occurs in the absence of recall – something which undoubtedly does
occur when déjà vu is experienced.
The previously described approach has been extended by Cleary
et al. (2012) to virtual reality 3D environments. Once again, the config-
ural similarity of objects was compared, this time across a number of
virtual ‘rooms’. In this virtual reality experiment, Cleary et al. (2012)
included studied (old) scenes along with the configurally similar and
new scenes. In addition to asking participants to rate familiarity of the
presented scene and report whether they are in a déjà vu state, the re-
searchers also asked them to indicate whether the scene is old or new
(presented for the first time). This allowed them to capture instances
when participants indicated that they perceived something as new and
yet reported experiencing déjà vu and familiarity for – a much closer
approximation of déjà vu in real life. They found that the probability of
déjà vu being reported was highest for old scenes incorrectly identified
as new (51%), followed by configurally similar scenes correctly identi-
fied as new (33%) and new scenes identified as new (18%). Crucially,
familiarity ratings followed the same pattern. This correspondence be-
tween déjà vu reports and familiarity ratings is consistent with bottom-up
theories of déjà vu. The conclusion from those involved in this line of
empirical work is that déjà vu results from situations similar to previous
experiences. This creates a feeling of familiarity which can nevertheless
sit alongside an explicit assessment of novelty, creating a clash between
the subjective experience and the objective evaluation of the situation.
On the face of it, these studies are the closest scientists have come in
over 100 years of research to producing déjà vu in the lab and therefore
understanding its formation. However, as O᾿Connor and Moulin (2010)
pointed out, the researchers have to explain how this RWCR is differ-
ent from a simple experience of familiarity without recollection, some-
thing which happens often in daily life and which doesn’t cause déjà vu.
Memory researchers typically recall Mandler’s (1980) description of
the butcher on the bus to illustrate a strong sensation of familiarity (“I
know that person on the bus from somewhere”) in the absence of recol-
lection (“but I don’t know who it is”). This experience can be a result of
mismatched context (recollection failed because the butcher we᾿re used
to seeing in the supermarket was seen on the bus). It is troubling that
the RWCR paradigm doesn᾿t offer a way to distinguish between experi-
ences of familiarity without recollection and déjà vu, rather it seems to
assume they are the same which still leaves us with the question of what
specifically triggers déjà vu.
Top-down theories of déjà vu
The alternative view of déjà vu formation emphasises top-down neu-

ral processes. The starting point for this research was the observation
that déjà vu is often a symptom experienced as part of the pre-seizure
aura in temporal lobe epilepsy (TLE). O᾿Connor and Moulin (2008)
reported a case of a TLE patient who experiences déjà vu that does not
subside even as he changes his perceptual focus by diverting his gaze
numerous times over the course of his experience. If déjà vu was trig-
gered by what he was looking at as bottom-up theories suggest, it would
seem changing the input, such as by looking at something else, should
end the experience. It is from this line of research that the top-down
approach to déjà vu has emerged.
The perspective of top-down theories on déjà vu is that it is a “ran-
dom mental event” (Illman, Butler, Souchay, & Moulin, 2012, p. 8).
That is to say, déjà vu is a result of aberrant neural activation which
is not driven by one᾿s immediate environment. Memory processes are
thought to rely mainly on temporal lobe structures with distinct regions
mapping onto unique processes. More specifically, Aggleton and Brown
(1999) suggested remembering is reliant on the hippocampus whereas
the experience of familiarity is based on processing in the surrounding

structures (see Fig. 1). Spatt (2002) proposed déjà vu might be linked
to incorrect activations in the regions responsible for familiarity. Cor-
respondingly, Illman et al. (2012) described their theory as the ‘decou-
pled familiarity hypothesis’: déjà vu is thought to be an instance of
the incorrect activation of the experience of familiarity decoupled from
the otherwise correct processing of one᾿s environment which indicates
everything is in fact new and so ought not be familiar.
Figure 1: Coronal Section of the Temporal Lobe showing key structures.
Research focused on identifying the specific structures related to déjà vu

has often used epileptic patients. As part of routine care and treatment,
and part of the work-up for brain surgery, epileptic patients sometimes
have electrical current applied directly to their brains. The resulting
activations, experiences and behaviours are critical for mapping brain
structures which should be spared in surgery targeting epileptic foci
(e.g. those involved in language processing). The effects that result from
these stimulations are of great value for understanding the brain.
Using such brain techniques, Bartolomei et al. (2004) concluded

that déjà vu was most reliably elicited by stimulation of subhippocam-
pal familiarity areas rather than other areas important for memory.
More specifically, and consistent with Spatt’s hypothesis, they found
stimulation of a tiny region called the entorhinal cortex to be a more
reliable elicitor of déjà vu than the amygdala or the hippocampus. How-
ever, not only do different methods of stimulations in different areas
lead to different results but stimulations of the same areas on different
days lead to different results, and this story is a long way from com-
plete. For instance, Kovacs et al. (2009) found that déjà vu could be
elicited by stimulation of another region (the globus pallidus). On the
other hand, they also observed that the instances where this stimulation
did produce déjà vu there was hyperperfusion or increased blood flow
in the temporal lobe suggesting a discharge into and involvement of
this area. Further, Bowles et al. (2007) reported a case of a TLE patient
who following surgery to the temporal lobe, particularly targetting the
perirhinal cortex while sparing the hippocampus, ceased experiencing
seizures and the accompanying déjà vu with the other product of the
intervention being impaired familiarity and preserved recollection. This
then lends support to the view that déjà vu is related to familiarity pro-
cessing and associated brain regions.
Brazdil et al. (2012) have taken the important step of expanding
this work beyond the TLE literature by looking at structural differences
in the healthy population between people that experience déjà vu and
those that do not. They observed differences in grey matter volume
between these groups, and again, it is the temporal lobe which is impli-
cated. Those experiencing déjà vu were found to have less grey matter
in this area, and the volume was inversely related to the number of
reported déjà vu experiences.
That said, Bartolomei et al. (2012) suggested that rather than look-
ing at specific structures, one should, given the current move towards
understanding brain activity in terms of complex, interconnected net-
works (e.g. Fox et al., 2005), consider how the regions work together.
Their research suggests “déjà vu is related to increased correlation
among MTL [medial temporal lobe] structures rather than being a
‘local’ phenomenon” (p. 494). Illman et al. (2012) agree that given the
complexity and uniqueness of déjà vu, it seems unlikely it can be traced
to a single structure. As mentioned, this is in line with current research

which suggests cognitive processes have to be understood in the context
of a pattern of activations rather than in the context of isolated regions
of activity (McIntosh, 2000).
In sum, the next step on the path to understanding the neural pro-
cesses underlying déjà vu will be to look closer at brain networks. For
now, however, the evidence suggests that at the very least, déjà vu in
TLE can be linked to neural processes in the temporal lobe and there
is some indication emerging that this might also be true for the healthy
brain and seizure unrelated experiences of déjà vu.
Different types of déjà vu?
One of the questions facing déjà vu research at the moment is whether

there is only one type of déjà vu experienced both as a symptom of
certain disorders such as TLE and part of normal, every-day life. One
could view the two experiences as distinct, meaning that findings from
TLE studies are not relevant to bottom-up theories of every-day oc-
currences of déjà vu. In support of this argument, Adachi et al. (2010)
showed that TLE patients can distinguish between déjà vu experienced
as part of the pre-seizure aura and déjà vu experienced as part of their
daily life. However, it is worth noting that the difference might also be
due to the fact that déjà vu related to seizure activity is not an isolated
event. It is likely to be accompanied by other experiences not present in
‘healthy’ déjà vu, such as headaches, nausea or emotional responses, all
part of epileptic activity, making it distinct.
In support of this interpretation, Warren-Gash and Zeman (2014)
used a questionnaire to assess déjà vu in TLE and controls (with and
without neurological complaint). They found that the TLE experience
was similar to the healthy experience, and it could only be differenti-
ated by the ‘company it keeps’, i.e. the other phenomena part of TLE
seizure activity. Furthermore, Brazdil et al. (2012) found structural
differences in the healthy population between people who experience
déjà vu and those that do not – implicating the same structures which
have been shown to play a role in déjà vu experienced as part of TLE.

This suggests a unified source of déjà vu experiences across patient and
non-patient groups and provides an important first link between déjà vu
in TLE and déjà vu experienced as part of daily life. Indeed the authors
suggest there is at least an overlap in the physiology of these two déjà
vu experiences. In sum, several research teams point to a continuity
between healthy and epileptic forms of déjà vu. While it is too soon to
say there isn’t a bottom-up form of déjà vu or a combination of factors
in the production of this strange experience, work such as Brazdil et al.’s
is moving us toward a unified conceptualization of déjà vu.
Methodological issues in déjà vu research
The greatest obstacle to déjà vu research and what has prevented

researchers from delving into this topic more comprehensively is the
necessary reliance on subjective self-reports. Unlike traditional memory
impairments where researchers can objectively assess memory perfor-
mance, the experience of déjà vu is entirely subjective. This means the
only way to assess whether the experience has been replicated in the lab
is to ask participants directly; “Have you experienced déjà vu?”. This is
the method Cleary et al. (2009) used to assess déjà vu occurrence fol-
lowing presentation of experimental materials which they hypothesized
would trigger déjà vu and following presentation of control materials
which should not. As O’Connor and Moulin (2010) noted, while the
probability of reporting déjà vu was 17% for the experimental items, it
was as high as 13% on the control trials – where we would not expect
déjà vu. While this difference was statistically significant, the difference
is also surprisingly small. Firstly, the researchers struggle to explain
why participants would report experiencing déjà vu on the control trials
at all, as it is not consistent with their explanation of déjà vu as famil-
iarity evoked by similarity. Secondly, given that déjà vu is reported to
only occur once in a couple of months in daily life (Brown, 2004), the
13% and 17% seem really high for a laboratory estimate. There are two
possible explanations here. First, it might be that the laboratory and real
life déjà vu are similar but differ in intensity or completeness – that is,
there may be a mild or incomplete laboratory form of déjà vu which is
easily produced. This is something which needs further research. Sec-
ond, O’Connor and Moulin (2010) suggested it might rather be the case
that the way the experiment was set up created demand characteristics.
Orne (1962) introduced the idea of demand characteristics, con-
ceptualized as cues in the experiment that convey the experimental
hypothesis to the participant without the experimenter intending them
to. He pointed out participants’ motivation to behave as they perceive
the experimenter wants them to, so as to aid the experiment by produc-
ing the expected result. Research has shown participants tailor their re-
sponses to what they perceive to be the expectations of the experimenter
in an attempt to be relevant (Norenzayan & Schwarz, 1999). What this
means in the context of déjà vu research is that when participants are
asked repeatedly about experiencing déjà vu, they might simply assume
they ought to be experiencing it and they might even want to respond
affirmatively so as to give what they suspect is the expected result. This
is clearly troubling for déjà vu research and emphasises the necessity
for better measurement tools. O’Connor and Moulin (2010) stressed
that déjà vu should be clearly defined and space should be given to
participants to give descriptive accounts of their experience along with
the chance for them to spontaneously report experiencing déjà vu. Only
after such measures should researchers start asking specific yes/no type
questions about the participants’ experiences during the experiment,
what is often referred to as ‘funnel’ debriefing. As is the case with the
know/remember distinction (Gardiner & Java, 1993), many studies ex-
plain the difference carefully before asking participants to make judg-
ments on which one they experienced (e.g. Rajaram, 1993). A similar
kind of dialogue between participants and experimenters should be
established in the study of déjà vu. Part of this might be asking par-
ticipants to bring to mind specific instances of their previous déjà vu
experiences to make them fully appreciate the nature of the experience
before they are asked whether they have experienced it during an ex-
periment. As such, the next important step for further déjà vu research
is to establish better methodologies that allow the study of the experi-
ence whilst simultaneously eliminating (or at least minimizing) demand
characteristics.
Conclusion
We have seen that déjà vu can be researched in the laboratory using

memory experiments and questionnaires in healthy groups of people
as well as people with neurological disorders. The different approaches
and populations studied give rise to different theories and results, and
we gave an overview of two competing ideas – bottom up and top down
theories of déjà vu formation. In fact, the extent to which these theories
might compete is not clear. Despite the massive progress we have made
in the last ten years, it seems that we are still in the early days of under-
standing déjà vu.
To follow from here, there are two main points to consider. First,
we should not confuse déjà vu with other similar mental experiences
such as familiarity without recollection. Rather the focus should be on
understanding how déjà vu differs from, or indeed incorporates, these
related, more prevalent phenomena as a way of gaining better under-
standing of it. Second, we must recognize that déjà vu research is sus-
ceptible to demand characteristics and that this needs to be carefully
controlled for to increase confidence in and usefulness of our data.
Reaching a common consensus on means of experimentally generating
déjà vu and exerting better control over our experimental paradigms
opens up the opportunity to start bridging the gaps in our understanding
of this nebulous, fascinating experience.
References
Adachi, N., Akanuma, N., Ito, M., Adachi, T., Takekawa, Y., Adachi, Y.,
& Kato, M. (2010). Two forms of déjà vu experiences in patients
with epilepsy. Epilepsy and Behavior, 18, 218–220.
Aggleton, J. P., & Brown, M. W. (1999). Episodic memory, amnesia
and the hippocampal-anterior thalamic axis. Behavioral and Brain
Sciences, 22, 425–489.
Bartolomei, F., Barbeau, E., Gavaret, M., Guye, M., McGonigal, A.,
Regis, J., & Chauvel, P. (2004). Cortical stimulation study of the
role of rhinal cortex in déjà vu and reminiscence of memories.
Neurology, 63, 858–864.
Bartolomei, F., Barbeau, E. J., Nguyen, T., McGonigal, A., Regis, J.,
Chauvel, P., & Wendling, F. (2012). Rhinal-hippocampal interac-
tions during déjà vu. Clinical Neurophysiology, 123, 489–495.
Bowles, B., Crupi, C., Mirsattari, S. M., Pigott, S. E., Parrent, A. G.,
Pruessner, J. C., Yonelinas, A. P., & Kohler, S. (2007). Impaired
familiarity with preserved recollection after anterior temporal-lobe
resection that spares the hippocampus. Proceedings of the National
Academy of Sciences of the United States of America, 104, 16382–
16387.
Brazdil, M., Marecek, R., Urbanek, T., Kasparek, T., Mikl, M., Rek-
tor, I., & Zeman, A. (2012). Unveiling the mystery of déjà vu: The
structural anatomy of déjà vu. Cortex, 48, 1240–1243.
Brown, A. S. (2004). The déjà vu experience. Hove: Psychology Press.
Cleary, A. M., Brown, A. S., Sawyer, B. D., Nomi, J. S., Ajoku, A. C.,
& Ryals, A. J. (2012). Familiarity from the configuration of objects
in 3-dimensional space and its relation to déjà vu: A virtual reality
investigation. Consciousness and Cognition, 21, 969–975.
Cleary, A. M., Ryals, A. J., & Nomi, J. S. (2009). Can déjà vu result from
similarity to a prior experience? Support for the similarity hypoth-
esis of déjà vu. Psychonomic Bulletin and Review, 16, 1082–1088.
Fox, M. D., Snyder, A. Z., Vincent, J. L., Corbetta, M., Van Essen, D. C.,
& Raichle, M. E. (2005). The human brain is intrinsically organ-
ized into dynamic, anticorrelated functional networks. Proceed-
ings of the National Academy of Sciences of the United States of
America, 102, 9673–9678.
Gardiner, J. M., & Java, R. I. (1993). Recognising and remembering.
In A. F. Collins, S. E. Gathercole, M.A. Conway and P.E. Morris
(Eds.), Theories of memory (pp. 163–188), Hove: Erlbaum.
Heller, J. (1961). Catch-22. London: Vintage Classics.
Illman, N. A., Butler, C. R., Souchay, C., & Moulin, C. J. A. (2012).
Déjà experiences in temporal lobe epilepsy. Epilepsy Research and
Treatment, 15 pages. doi:10.1155/2012/539567.
Kovacs, N., Auer, T., Balas, I., Karadi, K., Zambo, K., Schwarcz, A.,
& Janszky, J. (2009). Neuroimaging and cognitive changes during
déjà vu. Epilepsy and Behavior, 14, 190–196.
Mandler, G. (1980). Recognizing: The judgment of previous occur-
rence. Psychological Review, 87, 252–271.
McIntosh, A. R. (2000). Towards a network theory of cognition, Neural
Networks, 13, 861–870.
Moulin, C. J. A., & Souchay, C. (2013). Epistemic feelings and memory.
In T. Perfect & S. Lindsay (Eds.), Handbook of Applied Memory.
520–539.
Nelson, T.O., & Narens, L. (1990). Metamemory: A theoretical frame-
work and new findings, The Psychology of Learning and Motiva-
tion, 26, 125–173.
Norenzayan, A., & Schwarz, N. (1999). Telling what they want to know:
participants tailor causal attributions to researchers’ interests.
European Journal of Social Psychology, 29, 1011–1020.
O’Connor, A. R., & Moulin, C. J. A. (2008). The persistence of er-
roneous familiarity in an epileptic male. Challenging perceptual
theories of déjà vu activation. Brain and Cognition, 68, 144–147.
O’Connor, A. R., & Moulin, C. J. A. (2010). Recognition without iden-
tification, erroneous familiarity and déjà vu. Current Psychiatry
Reports, 12, 165–173.
O’Connor, A. R., Moulin, C. J. A., & Cohen, G. (2008). Memory and
Consciousness. In G. Cohen & M. A. Conway (Eds.), Memory in
the real world (3rd edn, pp. 327–356), Hove: Psychology Press.
Orne, M. T. (1962). On the social psychology of the psychological ex-
periment: With particular reference to demand characteristics and
their implications. American Psychologist, 17, 776–783.
Rajaram, S. (1993). Remembering and knowing: Two means of access
to the personal past. Memory and Cognition, 21, 89–102.
Spatt, J. (2002). Déjà vu: Possible parahippocampal mechanisms. Jour-
nal of Neuropsychiatry and Clinical Neuroscience, 14, 6–10.
Warren-Gash, C., & Zeman, A. (2014). Short report: is there anything
distinctive about epileptic déjà vu?. Journal of Neurology, Neuro-
surgery and Psychiatry, 85, 143–147.
Wild, E. (2005). Déjà vu in neurology. Journal of Neurology, 252, 1–7.
Matthew R. Johnson
Model systems of thought: A neuroscience

perspective on cognitive frameworks
One of the core issues in psychology and neuroscience research is that

the nervous systems and behavior of human beings are complex, yet
laboratory experiments must be kept relatively simple in order to be
well-controlled and thus provide definitive answers to research ques-
tions. In this chapter, I first discuss how “model organisms” are used to
reduce the complexity of scientific investigations in low-level (cellular)
neuroscience research; that is, even if researchers are ultimately inter-
ested in the human mind and brain, it is often easier to begin by asking
reduced forms of their questions about animals with simpler nervous
systems, and attempt to build towards an understanding of increasingly
complex systems. A similar approach can be taken in psychological
studies of human beings. It is impossible to simultaneously examine all
the multitude of factors that drive human behavior, so instead we must
study individual facets of human behavior in the laboratory, and hope to
build towards a more unified understanding. Here, I argue for a “com-
ponent process” approach to studying human thought, wherein we use
extremely simple laboratory tasks in an effort to identify fundamental
“building blocks” of cognition that may form the basis of more complex
thoughts and behaviors.
Model systems
As a scientist, one of my pet peeves is when media pundits or public fig-

ures take scientific investigations to task without properly understand-
ing the context of the research. For example, in my home country (the
152 Matthew R. Johnson
United States), one might hear political candidates denouncing “exces-

sive” government spending by saying things like, “Last year we spent
millions of taxpayer dollars on research into microscopic roundworms!
Why are we wasting money on such unnecessary experiments?”
Of course, it’s true that some scientific studies are better and more
important than others, but sometimes the types of experiments cited in
the media as “ridiculous” or “unnecessary” are actually quite important.
For instance, the microscopic roundworm Caenorhabditis elegans is
one of the primary organisms used to study genetics and cellular biol-
ogy. C. elegans, as it is called in the community, is extremely hardy, is
an excellent candidate for genetic manipulations, and grows from egg
to adulthood in only a few days. It has just 959 cells in its body, but
302 of those are neurons. Thus, it is infinitely easier (and more ethi-
cal!) to manipulate and study neural processes at the cellular level using
C. elegans than using human beings.
Fortunately, many of the genes, proteins, structures, and other as-
pects of C. elegans’ cellular neurobiology are either identical or at least
homologous (similar) to corresponding aspects of the human nervous
system. So it’s not entirely accurate if a pundit denounces spending all
that money “just to study roundworms.” By studying roundworms, we
are actually gaining knowledge about fundamental biological processes
that apply to humans and many other species – not just roundworms.
And we are gaining that knowledge while spending far less time and
money than if we studied those processes in human beings directly.
We call species like C. elegans “model organisms” or “model sys-
tems” of human biology because, just like other types of models (for
example, a model of a building or an airplane), they are a smaller or
more simplified, but still generally accurate, representation of a larg-
er or more complex thing. Just as an architect might build a model
of a skyscraper to work out design problems before constructing the
real one, biologists work out many fundamental principles in model
organisms before attempting to apply those principles to solve more
complex problems (for example, developing new medications) in
human biology.
C. elegans are far from the only model organisms used to study
neuroscience and behavior. Our basic understanding of how a signal
travels through a nerve cell comes from experiments on squid neurons.
Model systems of thought 153
Studies of the sea slug Aplysia californica have contributed greatly to

our knowledge of how memory operates on the cellular level. And the
research that forms the foundation of our understanding of the mamma-
lian visual system came from experiments on ordinary house cats. (All
three of those bodies of research resulted in Nobel Prizes, by the way.)
Sometimes model organisms are chosen because they exhibit
specific biological features that make them convenient to study. For
example, certain squid neurons have a very large axon (the part of a
neuron that conducts a signal towards other neurons) called, appropri-
ately enough, the squid giant axon. The squid giant axon can be several
hundred times thicker than the typical axon found in humans or other
animals, making it significantly easier to pierce with a recording elec-
trode in a laboratory experiment.
But aside from specific features like these, a good rule of thumb is
that scientists try to use the simplest animal possible that exhibits the
biological trait or behavior they want to study. A good scientist hates
unnecessary complexity – he or she tries to study an experimental ques-
tion in the purest form possible, while trying to avoid nuisance factors
that might complicate interpretations of the data or make it more diffi-
cult to perform a well-controlled experiment. Anecdotally, Eric Kandel
(who won the Nobel Prize for studies of memory in Aplysia) began his
academic career intending to become a psychoanalyst of human beings,
then joined a laboratory studying neural communication in systems of
thousands of mammalian neurons, and eventually decided that his inter-
est in the biological machinery of learning and memory would be best
served by studying the even simpler nervous system of the modest sea
slug (Kandel, 2001).
Of course, the complexity of the experimental question determines,
to some degree, what will be the optimal laboratory setup and model
organism for addressing that question. For simple traits or behaviors, a
roundworm or a fruit fly may suffice. Other areas of research – say, into
drug addiction or aging-related dementia – are associated with the more
complex brains of mammals, but still, a mouse or rat can often work
nicely. For still other questions – say, how the brains of more intelligent
mammals can recognize specific faces or objects – we might need to
record signals from the brains of small monkeys.
Now, I myself am a cognitive neuroscientist – meaning I use safe,

non-invasive neural recording techniques like functional magnetic res-
onance imaging (fMRI) and electroencephalography (EEG) to study the
brains and behavior of human beings. For all the sometimes frustrating
complexities of our nervous systems and behavior patterns, these same
complexities also make humans much more interesting subjects of
study (at least, to me) than animals with simpler brains. There are logis-
tical advantages to studying humans as well, foremost being the use of
language. Although other animals can communicate with each other in
various ways, no other species uses a full-featured language that allows
it to express complex ideas with anywhere near the efficiency of human
language. Thus, much like the squid giant axon is convenient for studies
of neural transmission, the unique human facility for language actually
makes us an excellent “model system” for studying certain neural or
mental processes.
For example, say that I want to investigate how the visual system
distinguishes between different individuals’ faces, versus two different
pictures of the same individual. To examine this question, I could make
some kind of neural recording while subjects perform a face-identifica-
tion task: On each trial, I show a subject two face pictures, and the sub-
ject presses a button to indicate whether he/she thinks the two pictures
are of the same or different individuals. Later on, I’ll analyze the neural
recording data to look for differences between trials where the subject
(correctly) judges that the faces are different and trials where they are
judged to be the same. (It might be interesting to analyze error trials too,
but let’s forget about those for now.)
Now, you could certainly teach a monkey, and perhaps other spe-
cies, to perform this task. But it could take weeks or months to train
an animal to do it correctly, whereas a human subject could be given
adequate instructions in under a minute. Assuming the neural recording
techniques we can ethically use on human beings are sufficient for our
purposes, it may be easiest to use human rather than animal subjects in
this example.
Operationalization: Putting theoretical constructs

into an experimental setting
I have just told you that my own research focuses on human beings, and
that humans can be the most convenient research subjects for answering
certain questions. So you might justifiably wonder why I spent one-third
of this essay discussing advantages of working with model organisms.
The main reason is that many of the points made about animal mod-
els can also apply to the way we study mental processes in humans.
As stated above, we don’t necessarily study C. elegans because we are
particularly interested in roundworms; instead, we study them because
we are interested in fundamental questions about how things like genes
and proteins work, and C. elegans provides a simplified environment in
which to study those biological concepts.
The corresponding point regarding psychology and cognitive neu-
roscience research is that the lofty big-picture questions that fascinate
us may not always be apparent from a straightforward description of the
experiments we perform. Whether a contemporary psychologist wants
to study how we fall in love, what makes some people more intelli-
gent than others, how we perceive the cues that let us perform social
interactions, how language works, or any of a thousand other intrigu-
ing and complex questions, he/she may address that question with what
seems like a relatively boring and simple experiment: Participants sit in
a small, plain room with a single personal computer, viewing pictures
or videos on the screen, performing some simple cognitive task, and re-
sponding by pressing buttons. Just like C. elegans gives us a simplified
biological model of human genetics, tasks in psychology experiments
give us simplified cognitive models of human thought. And just like
the connection between sea slugs and human memory, the connection
between a button-pressing task and falling in love may not always be
apparent to the untrained eye.
This means that psychologists can discuss our research on two levels:
The overarching questions that drive our work, or the nuts and bolts of the
experiments we conduct and the data we collect. (And there can be various
levels of theory connecting these two extremes.) In other words, simple
cognitive tasks and laboratory experiments let us operationalize – define
and measure in a straightforward way – more complex or general theoret-

ical concepts. As professional scientists speaking amongst ourselves, we
are accustomed to making the connections between these levels and in-
ferring the big-picture context of an experiment automatically, but I think
we sometimes forget about making such connections more explicit when
addressing general audiences. So, with the remainder of this chapter, I’d
like to introduce some of the big questions my research group studies, as
well as some of the experiments we have designed to operationalize and
answer those questions.
The building blocks of thought
Simply put, my research focuses on one primary question: How do

people think? Now, this might be the most general question in all of
psychology, and in a sense, all psychologists study this question. How-
ever, many researchers focus on particular domains: How does emo-
tion work? How does vision work? How does long-term memory work?
How does a particular everyday task (such as reading or driving) work?
However, my research (much of which has been done in collabo-
ration with my former PhD supervisor, Marcia K. Johnson, as well as
others) concentrates primarily on thinking in the general sense – what
processes combine to create the ongoing stream of conscious thought
that we experience most of our waking hours, every day of our lives.
I want to know what constitutes a thought, how we shift focus from
one mental representation to another, how we synthesize information
to create novel ideas, and what compels our attention to move on after
thinking about something for a while, rather than dwelling on the same
thought forever.
At first, it may not even be evident that these questions need to be
asked. Thinking is something that “just works,” right? Does it really
need to be explained further? But like anything that “just works” – think
of your car, or your smartphone – a lot of engineering may go into dis-
guising the true complexity of the underlying machinery, in order to
present a system whose operation appears straightforward and seamless
on the outside. In other words, precisely because thinking feels so ef-

fortless, it may disguise the fact that, without your conscious knowl-
edge, your brain is actually performing many complex operations every
second just to keep your train of thought chugging along smoothly.
Of course, studying everyday thought in its usual form is not easy –
people’s normal train of thought is too rapid, too chaotic, and too diffi-
cult to track in a laboratory setting. Instead, we need to study thought
in a “model system” that retains the core operations we are interested
in, while eliminating unnecessary complications. To help accomplish
this, we take what we call a “component process” approach – we try to
break up complex mental processes into smaller components that we
can study in isolation.
For example, imagine you’re making plans for dinner tonight.
You could probably break this thought process up into several simpler
sub-processes – for example, retrieving information from long-term
memory (where you will be tonight, how much money you have, some
foods you like to eat), sorting through lists of options retrieved from
memory (what food items you have at home, what restaurants will be
nearby), and evaluating the pros and cons of each choice with regard to
your goals/desires (what will taste best, what is quickest, what will cost
the least, what is healthiest). Each of these sub-tasks could be broken
down into even more basic processes as well.
When you plan dinner each day, your brain easily and automatical-
ly manages dozens of such tasks and sub-tasks, but in the laboratory, we
generally want to isolate one or two simple processes at a time to figure
out how they work. One process we have studied extensively so far is
called refreshing, using what we call a “refresh task” (for review: M. K.
Johnson et al., 2005).
At any given time, you probably have several different representa-
tions active in short-term memory that are related to whatever you’re
thinking about. Refreshing is the process of shifting your internal men-
tal attention among those items. So if you’re thinking about potential
dinner options you have at home (chicken, pasta, salad…), after you
have retrieved the list from long-term memory, you will likely refresh –
or shift your mental spotlight onto – each option as you evaluate it.
In the laboratory, we try to control this process by explicitly telling
people which items to think about, rather than letting their thoughts
flow freely. In a typical refresh task (Figure 1), we might first present
two items on the computer screen (usually either a pair of pictures or a
pair of words) for a brief period of time (about 1500ms). The study par-
ticipant will view these items and encode them into short-term memory.
Then, after a short delay (about 500ms), we show the participant an
arrow pointing to the location where one of those items was just pre-
sented. The arrow is the participant’s cue to briefly (for about another
1500ms) turn his/her mental attention to the item that was presented
in the cued location, and not to think about the other item. (For studies
using picture stimuli, we typically tell participants to briefly visualize
the item in their mind; for studies using word stimuli, we typically ask
them to say it aloud. Generally, though, we obtain fairly similar results
no matter what type of stimuli we use.) It’s a very simple (and slight-
ly boring) task, but it allows us to study this particular component of
everyday thought in isolation, without the complications that tend to
accompany more elaborate tasks.
Figure 1: Structure of a typical refresh task used in functional MRI experiments.
When we scan people’s brains using fMRI while they perform a re-
fresh task, we typically observe activity in several brain regions, most
notably an area in the front-left portion of the brain known as the dor-
solateral prefrontal cortex (DLPFC). More specifically, there is great-
er activity in DLPFC when people do a refresh task than when they
perform other tasks like passively viewing pictures. This suggests that
DLPFC is a key area involved in shifting mental attention from one

item to another. Furthermore, as studies frequently also observe
DLPFC activity in much more complicated mental tasks involving ex-
tensive planning or manipulation of many items in short-term memory
(tasks collectively called executive functions), we could theorize that
some of that activity occurs because refreshing is a sub-component of
those complex tasks.
In one series of studies (M. R. Johnson, Mitchell, Raye, D’Esposito,
& M. K. Johnson, 2007; M. R. Johnson & M. K. Johnson, 2009), we
scanned participants’ brains with fMRI while they performed a refresh
task in which the initial stimuli were a picture of a face and a visual
scene, as in Figure 1. Note that on all trials, participants saw the exact
same visual display: First a screen with one face and one scene picture,
then an arrow. However, depending on which sides of the screen the
face and scene were shown on, and which way the arrow pointed, the
arrow cue would indicate to participants either to think about (refresh)
the face or the scene. It’s important that the actual visual items shown
onscreen (face, scene, arrow) were identical regardless of which item
participants refreshed, because the critical differences in brain activity
were in visual brain areas. When participants turned their mental at-
tention to the face (and ignored the scene), we observed more activity
in brain areas associated with visual processing of faces. When they
instead turned their attention to the scene (and ignored the face), we
observed more activity in areas associated with visual processing of
scenes. However, we observed DLPFC activity whenever participants
refreshed an item, regardless of whether it was a face or a scene.
This suggests a more refined picture of how refreshing operates in
the brain: Perhaps DLPFC is the area that generates the initial neural
signal to shift our mental attention to a certain item, regardless of what
the item is. This signal then modulates (affects) activity in visual areas
corresponding to the refreshed item. In other words, when the instruc-
tion “visualize the scene you just saw” is given, the DLPFC instructs
scene-processing brain areas to replay the neural activity they experi-
enced when the scene was first viewed. This model may be somewhat
oversimplified, but it is generally consistent with the results we observe
in our experiments, as well as others’ interpretations of how these pro-
cesses and brain regions operate.
Here’s another experiment we ran recently (M. R. Johnson et al.,

2013). This one is purely behavioral – i.e., we measured no brain ac-
tivity, and relied only on reaction times (RTs). In this study (Figure 2),
we presented participants with two everyday words, followed by an
arrow cue instructing them to refresh (say aloud) one of the words. So
far, this is very similar to previous refresh tasks. However, in this study,
we added something: Immediately after participants refreshed a word,
we printed either that word (the refreshed item) or the other word that
was initially presented, but not refreshed (the unrefreshed item) again
on the screen. When that final word was presented, participants were
instructed to read it aloud as quickly as possible, and we measured their
RTs to say it.
Figure 2: Structure of a refresh task used in a recent cognitive psychology experiment.
Before running the study, we expected participants to be faster at saying

the refreshed item than the unrefreshed item, because we thought their
mental representations of the refreshed item would be more active and
thus more accessible. In fact, we found the exact opposite – they were
significantly faster to say the unrefreshed item. (We have also replicated
this result using pictures in a modified version of the task.) Although
this was initially surprising, we now suspect that we have discovered the
mental-attention version of a well-known visual attention effect called
inhibition of return (IOR). Briefly, IOR is the finding that when partic-
ipants are viewing (and shifting attention to) different items on a visual
display, they are slower to return attention to a recently-visited location

than to shift it to an unvisited location (Posner & Cohen, 1984; Posner,
Rafal, Choate, & Vaughan, 1985). Some researchers interpret this as
an aspect of our visual system’s design that facilitates foraging (Klein,
2000). In other words, when viewing a scene, it usually makes sense to
move your eyes around to different parts and explore the whole thing,
rather than examining the same location over and over.
We will need more experiments to validate the following conjec-
ture, but it is exciting to consider whether our mental attention system –
whatever moves the “spotlight” of consciousness from one thought to an-
other – is designed for foraging as well. Put another way, perhaps these
studies will help reveal a mental mechanism responsible for our having
a “stream” of consciousness rather than a “lake” – explaining why our
thoughts tend to flow smoothly toward new possibilities rather than get
stuck forever in a single place. And perhaps something about this mech-
anism is disrupted in conditions like autism, where patients may focus
obsessively on one object or activity, or attention deficit hyperactivity
disorder, where patients may shift attention away from the current train
of thought too easily, and thus have difficulty staying on task.
These possibilities, and many more, remain to be explored. Perhaps
future experiments will reject these hypotheses and suggest new ones.
Perhaps these conjectures about the nature of thought are too broad to
be justified by a few experiments on refreshing words or pictures. Per-
haps these laboratory tasks represent an oversimplified or inaccurate
model of natural thought processes. At least, however, the “model sys-
tem” approach allows us to begin with well-controlled experiments and
clear-cut results, and use these as the fundamental building blocks of
more complex – and complete – theories of human thought.
References
Johnson, M. K., Raye, C. L., Mitchell, K. J., Greene, E. J., Cunning-

ham, W. A., & Sanislow, C. A. (2005). Using fMRI to investigate a
component process of reflection: prefrontal correlates of refreshing
a just-activated representation. Cognitive, Affective & Behavioral

Neuroscience, 5(3), 339–61.
Johnson, M. R., Higgins, J. A., Norman, K. A., Sederberg, P. B., Smith,
T. A., & Johnson, M. K. (2013). Foraging for thought: an inhibition
of return-like effect resulting from directing attention within work-
ing memory. Psychological Science, 24, 1104–1112.
Johnson, M. R., & Johnson, M. K. (2009). Top-down enhancement and
suppression of activity in category-selective extrastriate cortex
from an act of reflective attention. Journal of Cognitive Neurosci-
ence, 21(12), 2320–7. doi:10.1162/jocn.2008.21183.
Johnson, M. R., Mitchell, K. J., Raye, C. L., D’Esposito, M., & John-
son, M. K. (2007). A brief thought can modulate activity in ex-
trastriate visual areas: Top-down effects of refreshing just-seen
visual stimuli. NeuroImage, 37(1), 290–9. doi:10.1016/j.neuroim-
age.2007.05.017.
Kandel, E. R. (2001). Eric R. Kandel – Nobel Prize Autobiography.
Retrieved September 4, 2012, from <http://www.nobelprize.org/no
bel_prizes/medicine/laureates/2000/kandel-autobio.html>.
Klein, R. M. (2000). Inhibition of return. Trends in Cognitive Sciences,
4(4), 138–147. doi:10.1016/S1364-6613(00)01452-2.
Posner, M., & Cohen, Y. (1984). Components of visual orienting. In
H. Bouma & D. Bouwhuis (Eds.), Attention and performance
Vol. X (pp. 531–556). Hillsdale, NJ: Erlbaum.
Posner, M. I., Rafal, R. D., Choate, L. S., & Vaughan, J. (1985). Inhibi-
tion of return: Neural basis and function. Cognitive Neuropsychol-
ogy, 2(3), 211–228. doi:10.1080/02643298508252866.
Ruth C. Tatnell and Penelope A. Hasking
Emotion regulation, the anterior cingulate cortex

and non-suicidal self-injury
Non-suicidal self-injury (NSSI), the deliberate destruction or alteration

of body tissue, performed without conscious suicidal intent and for
purposes not socially sanctioned (ISSS, 2007), is a topic of enquiry
that has received increasing research attention over the last decade. Al-
though delineated from suicidal behaviour, NSSI is a significant risk
factor for more severe self-injury and later suicidal behaviour, and is
associated with considerable psychological distress, even among those
performing relatively mild NSSI (Hasking, Momeni, Swannell, & Chia,
2008). As a result, considerable work has been done in an attempt to ex-
plain why people self-injure in order to better inform prevention, early
intervention and treatment efforts. Theoretical and empirical research
consistently concludes that the primary function of NSSI is to regulate
emotion (Klonsky, 2007; 2009). In this essay we offer a preliminary
introduction to the neurobiological evidence suggesting an emotion
regulatory role for NSSI.
The nature and extent of NSSI
Historically, definitional confusion has hindered attempts to accurately

estimate the extent of NSSI. Terms such as ‘deliberate self-harm’ may
include NSSI but might also include behaviours related to suicide, such
as suicide attempts. Similarly, some researchers include indirect acts
of self-harm, whereby tissue damage is not the intended outcome of
the behaviour (e.g. substance use, risky behaviours). By limiting our
definition to exclude suicidal acts and acts of indirect harm we can
164 Ruth C. Tatnell and Penelope A. Hasking
gain a more accurate understanding of how widespread the behaviour

is and a more detailed appreciation of the function it serves. Although
the behaviours constituting NSSI vary, common methods include cut-
ting, burning, severe scratching, hitting a part of the body on a hard
surface and punching or hitting objects (Hasking et al., 2008; Martin,
Swannell, Harrison, Hazell, & Taylor, 2010). Onset of NSSI is typically
during the adolescent years (12–14 years), yet the prevalence of NSSI
peaks among youth aged 18–24 years (Martin et al., 2010). A recent
epidemiological study observed 9.4% of adolescents (10–17 years) had
engaged in NSSI at some point in their lives, with 5.4% doing so in the
previous 12 months. Conversely, almost 20% of 18–24 year olds report-
ed a lifetime history and 7.0% reported NSSI in the previous 12 months
(Martin et al., 2010). Many believe NSSI to be more common among
girls and young women. However recent estimates suggest there is no
gender difference in the rates of NSSI among participants recruited
from the general community, but rather a gender difference in the meth-
ods employed; girls are more likely to cut and scratch themselves, while
boys are more likely to punch or hit hard objects (Martin et al., 2010;
Whitlock, Eckenrode, & Silverman, 2006; Whitlock, Muehlenkamp,
& Eckenrode, 2008). This distinction underscores the importance of
clearly defining NSSI, and having an unambiguous conceptualisation
of which behaviours are considered under this definition.
As noted, above, the primary function of NSSI is to regulate emo-
tion (Klonsky, 2007; 2009). People who self-injure report difficulty
in identifying emotions, a trait known as alexithymia (Anderson &
Crowther, 2012; Howe-Martin, Murrell, & Guarnaccia, 2012). Yet, the
ability to identify emotion is a necessary pre-cursor to being able to reg-
ulate them. Not surprisingly then, people who self-injure tend to respond
to negative and stressful events with a greater degree of arousal than
people who do not self-injure (Linehan, 1993). Further, experimental
and self-report studies have indicated an elevation in arousal and neg-
ative affect prior to an episode of NSSI, which decreases following the
behaviour (Klonsky, 2007; Nock & Prinstein, 2004; Nock, Printstein,
& Sterba, 2010). Finally, the observation that people who self-injure
tend to report deficiencies in adaptive coping skills (Evans, Hawton, &
Rodham, 2005; Stanford & Jones, 2009) supports the notion that some
people self-injure to better cope with intense emotional experiences.
Emotion regulation, the anterior cingulate cortex and NSSI 165
While self-report studies are useful in gaining an initial under-

standing of factors that may be related to NSSI, they are restricted
by several methodological limitations. Reliance on individuals to be
honest in their responses, the potential for memory bias and the need
for individuals to possess sufficient awareness of their emotional states
in order to report on them all constrain the interpretations that can
be made from such studies. Physiological and imaging studies, on the
other hand, provide an opportunity not only to conduct arguably more
objective scientific studies, but also to better understand the neural
underpinnings of NSSI. Given the apparent emotion regulatory func-
tion of NSSI, it seems prudent that exploration of the neurological
mechanisms which may facilitate NSSI focus on areas of the brain that
are implicated in emotion regulation.
The neural underpinnings of emotion regulation
The neural structures associated with the feeling of emotion are togeth-
er termed ‘the limbic system’ and are found deep in the brain, around
the corpus callosum, the bundle of nerves which connects the two hemi-
spheres (Allman, Hakeem, Erwin, Nimchinsky, & Hof, 2001; Bear,
Conners, & Paradiso, 2001).
The limbic system consists of the thalamus, hypothalamus, cin-
gulate gyrus (or cortex), amygdala, hippocampus and the basal gan-
glia (Bear et al., 2001). The part that is of greatest interest in the area
of emotion regulation is the cingulate cortex, or more specifically the
frontal part of the cingulate cortex, the anterior cingulate cortex (ACC).
Due to the position of the ACC it has connections both with the re-
maining limbic system structures, and also the prefrontal and frontal
cortex areas involved in decision-making, which have been shown to be
associated with a number of psychological problems, including antiso-
cial, violent, and suicidal behaviour (Stevens, Hurley, Taber, & Hayman,
2011; Wagner et al., 2012; Yang & Raine, 2009).
While the dorsal or front section of the ACC is involved in cog-
nition, the ventral or middle section, is more strongly associated with
emotion. Supporting this, the ventral ACC is usually active when visu-
alising sad or angry situations in participants, however in people who
are depressed, not only is this activity reduced, but so is the overall size
of the ventral ACC (Dougherty et al., 1999; Drevets et al., 1997; Pardo,
Pardo, & Raichle, 1993). Wagner et al. (2012) also observed that the
size of the ACC and other prefrontal cortex structures were significantly
reduced in depressed patients with a high suicide risk. In addition, there
is evidence that while ACC grey matter is reduced in individuals with
Borderline Personality Disorder (BPD), of which NSSI is a diagnostic
feature, activity is not always related to volume (Hazlett et al., 2005).
Specifically, in contrast to the similarities in the ACC size and activity
in depressed and BPD patients presented above, Minzenberg, Fan, New,
Tang and Siever (2007) found that among those with BPD, activity in
the ACC increased when presented with angry faces, and decreased
when presented with sad faces, suggesting a more complex relationship
between emotion and activity than first anticipated.
The ACC is particularly active when people are focussing on emo-
tional cognition tasks, those which require identifying emotions. Anx-
iety can, however decrease this activity, whereas alleviating anxiety is
associated with an increase in activity (Mizuki et al., 1989; Suetsugi
et al., 2000). Dennis and Solomon (2010) observed that during both
a fearful and a sad mood induction, there was an inverse relationship
between anxiety and frontal EEG activity.
Whilst compelling, all of this evidence was obtained using EEG
technology, which although providing information about exactly when
changes in neural activity occur, can give only broad indications about
where in the brain activity is occurring. In order to assess exactly
which neural structures are involved in emotion regulation, magnetic
resonance imaging (MRI) and functional magnetic resonance imaging
(fMRI) studies are required. Imaging studies allow researchers to see
exactly which parts of the brain have the most activity in terms of me-
tabolism, blood flow, and neuronal firing. Combining fMRI and EEG
would allow researchers to assess exactly when activity occurs, as well
as identifying individual structures.
Phillips, Drevets, Rauch and Lane (2003) provided a review of
fMRI studies related to emotional perception and regulation, the find-
ings of which support the EEG evidence above. They showed that the
ACC is activated and experiences an increase in cerebral blood flow

during mood induction states. They concluded that the ACC, in particu-
lar the ventral ACC “appears to have an important role in the processing
of emotional information during arousal and the production of affective
states” (Phillips et al., 2003 p. 508).
Emotion recognition and alexithymia
As noted previously, an awareness of emotion is a necessary condition

for accurate self-report on emotional states and related behaviours, a
clear limitation of the self-report NSSI literature. Recent research in
NSSI has shown a possible link between alexithymia and NSSI; people
who engage in NSSI tend to score highly on measures purporting to as-
sess alexithymia (Anderson & Crowther, 2012; Howe-Martin, Murrell,
& Guarnaccia, 2012), which may be a prime reason these individuals
use NSSI to regulate emotion. This being the case, it is appropriate to
examine neural mechanisms in people high in alexithymia, and peo-
ple who engage in NSSI, in order to determine the emotion regulatory
mechanisms among people with alexithymia.
In addition to having difficulty identifying their own emotions,
people high in alexithymia struggle with recognising emotions in
other people (Moriguchi et al., 2007). When assessing empathy util-
ising a non-facial emotive image (pictures of hands and feet in pain),
Moriguchi et al. (2007) reported less activation of the ACC in alexithy-
mic individuals than in non alexithymic people. Japanese and Korean
studies have found opposing results when examining ACC activity in
alexithymic people. For example, Kano et al. (2003) found that when
exposed to angry faces the ACC was less active than in response to
neutral faces. They interpreted this as indicating a lack of cognition of
emotion. Conversely, Lee et al. (2011) found increased activation of the
ACC in response to angry faces. The findings of Dougherty et al. (1999)
however indicate that anger in particular is associated with increased
blood flow and related activity in the ACC in a group of healthy men,
which supports the findings of Lee et al. (2011).
Arguably, one might expect to see an increase in ACC activity

during cognitive reappraisal (an active problem solving, emotion reg-
ulation technique), and a decrease in ACC activity during expressive
suppression (a ‘pushing inward’ of one’s feelings and emotions; Allman
et al., 2001; Gross & John, 2003). People who regularly engage in NSSI,
and those rated as high in alexithymia, often show poorer problem solv-
ing and coping abilities than the general population, relying on suppres-
sion rather than reappraisal (Baetens, Claes, Muehlenkamp, Grietens,
& Onghena, 2011; Chapman, Gratz, & Brown, 2006; Laye-Gindhu &
Schonert-Reichl, 2005; Najmi, Wegner, & Nock, 2007; Ross & Heath,
2003; Walker, Daryl, & Schaefer, 2011). This stands to reason; if we
consider that alexithymic people have difficulty understanding their
emotions, cognitive reappraisal would be something of a challenge, and
would lead one to expect to see a decrease in ACC activity in those who
engage in NSSI or rate highly in alexithymia.
In a whole brain EEG specifically examining event-related poten-
tials (electrical currents within the brain) in alexithymic people, Walker
et al. (2011) found significant differences between people high and low
in alexithymia on suppression and reappraisal tasks. Participants were
shown negative and neutral images from the International Affective Pic-
ture System (IAPS), and asked to either reappraise (i.e. consider the
people as actors who were in no way harmed) or to suppress (i.e. hide
any sign of emotion from an observer). Their findings indicated that
highly alexithymic individuals had decreased EEG activity in general,
but more so during a reappraisal task than low alexithymic people, who
showed greater activity, particularly in the reappraisal task. This differ-
ence would indicate that the ACC was functioning at a lower rate during
the reappraisal task in alexithymic people.
However, given alexithymic people don’t respond in the same way
empathically, the effects may have been an artefact of a general lower-
ing of empathy for people in distressing situations, than active emotion
regulation. Additionally, due to the whole brain analysis, it is difficult
to ascertain which parts of the brain were most active in response to the
tasks given. Frewin, Pain, Dozois and Lanuis (2006), however, found
similar results when utilising fMRI in alexithymic people either with
or without concurrent posttraumatic stress disorder (PTSD) diagnoses.
Their findings indicated that high alexythimic people with or without
PTSD, both had reduced ACC activity in both a baseline condition, and
an imaginative trauma condition.
Supporting this, Axelrod et al. (1998) observed that people with
a greater ability to intuit their own feelings and the feelings of others
had greater activation in the ACC, indicating both greater social aware-
ness, and greater understanding of their own feelings and emotional
reactions. Whilst examining individuals from the opposite end of the
alexithymia spectrum, this evidence supports the idea that greater emo-
tional awareness leads to greater activation in the ACC, whereas less
emotional awareness is reflected in lower activity in the ACC.
Activation of the ACC and NSSI
Very little research has been completed to date in the area of neurobio-
logical models of self-injury. Most presented research has been focussed
on BPD or suicidal behaviour. Whilst NSSI shares common features
with BPD and suicidal behaviour, it is distinct from both. Nock, Joiner,
Gordon, Lloyd-Richardson and Prinstein (2006) for example showed
that only half of their sample of severe NSSI patients had concurrent
BPD symptoms, and 70% had attempted suicide at least once, with ap-
proximately half disclosing repeated attempts.
In neurobiological terms, suicidal behaviour, completion and at-
tempts have been more often associated with activity in the prefron-
tal cortex – an area associated with executive functioning and decision
making – rather than the ACC which is more commonly associated with
emotion regulation (Desmyter, van Heeringen, & Audenaert, 2011;
Oquendo & Mann, 2001; van Heeringen, Bijyyeber, & Godfrin, 2011).
These studies suggest that rather than serving an emotion regulation
function, suicidal behaviour is the result of planning and ultimately a
decision to end one’s life. Further study is needed in this area, but the
evidence suggests that two separate neural areas may be responsible for
suicidal behaviour and NSSI.
In the only study to date to use fMRI to examine NSSI, Plener,
Bubalo, Fladung, Ludolph and Lule (2012) studied the verbal and fMRI
responses of nine adolescent girls with a recent history of NSSI (and

nine matched controls with no history of NSSI or psychiatric disor-
ders), to emotionally charged images. Most images were taken from the
IAPS; however some images particularly salient to NSSI were added
by the researchers. These included pictures of razor blades, skin cut-
ting, bandaged wrists and blood (Plener et al., 2012). While also noting
increased activity in other limbic structures (amygdala and hippocam-
pus), the key finding of interest was that among those engaging in NSSI,
there was increased activity in the ACC whilst viewing the images.
Since the NSSI group and controls did not differ in their self-reported
ratings of the images or self-reported arousal, this result was interpreted
by the researchers as the ACC working to compensate for poor emo-
tion regulation (Plener et al., 2012). While an encouraging early finding
implicating the limbic system and particularly the ACC in NSSI, the
researchers recruited a mixed clinical sample (all participants with a
history of NSSI had co-morbid disorders including major depressive
disorder, BPD or post traumatic stress disorder). In addition, six of the
nine had previously attempted suicide. As such it is not clear whether
the increased activation of the ACC in response to emotional stimuli is
an artefact of NSSI or implicated in psychopathology more generally.
Given the research discussed previously, the finding of higher ac-
tivity among people who engage in NSSI is somewhat anomalous. With
anxiety, depression, alexithymia and expressive suppression all being
previously associated with NSSI, we would expect to see decreases in
ACC activity in people who self-injure. Given that the findings of Plen-
er et al. (2012) suggest the opposite, alternative reasons for this must
be considered.
Given that episodes of NSSI are often prompted by social situa-
tions (e.g. problems with friends, family, partners etc) increased ACC
activation to emotional stimuli as observed by Plener et al. (2012) could
reflect hyperarousal in response to others and over interpretation of
their actions. Nock and Mendes (2008) provide support for this hypoth-
esis. Their findings demonstrated that compared to controls, a group of
adolescents who engaged in NSSI became distressed and physiolog-
ically more aroused, faster, in response to social frustration. Distress
and arousal were measured both through self-report and physiological
measures of skin conductance, giving more credence to the idea that
people who engage in NSSI become emotionally hyperaroused and

overwhelmed more easily than those who don’t.
Similarly, one could consider that alexithymia is in fact not related
to NSSI. Alexithymia suggests an inability to understand and express
ones emotions due to difficulty recognising them. Possibly in NSSI, the
association with self-reported alexithymia is not due to an inability to
recognise emotions, but rather these individuals are overwhelmed by
them. In a situation where one is completely overwhelmed by an emo-
tion, it can be difficult to describe the way they are feeling. Another pos-
sible suggestion for the discrepancy in results regarding ACC activation
is that NSSI acts as a solution to a perceived problem, thus reducing
anxiety/arousal (as often reported in the literature, see Klonsky, 2007;
2009; Nock & Mendes, 2008) and therefore increasing ACC activity.
One final suggestion for these differences is that it may be a result of
the age groups studied. Plener et al. (2012) examined adolescent girls
while the majority of other research included here included a broader
age range. Although speculative, differences in the findings may be ex-
plained by natural development of the brain and its functions. Specifi-
cally, maturation of the brain and improved connectivity may relate to a
change in ACC activation in response to emotional stimuli.
Clearly, these suggestions are tentative and further work is required
to explore the role of the ACC in emotion regulation and NSSI, as well
as the way in which alexithymia may be implicated. Specifically, re-
search is needed to not only determine how ACC activation is related
to NSSI, but whether structural or functional differences are related to
specific aspects of NSSI (e.g. increase vulnerability to NSSI, severity
of NSSI and/or relate to pain perception during NSSI), and whether
neuro-developmental changes relate to changes in ACC activation.
Future directions
While the neural pathways upon which NSSI behaviour is based are
of course much more complex than the introduction presented here,
there is sufficient evidence to propose a possible neurobiological model
of NSSI, in which over activity in the limbic system, particularly in

the ACC, is related to the expression of NSSI. However there are also
contradictions in the literature, leading to a number of interesting and
exciting possibilities for future research. One of the key findings in this
essay is that the majority of studies discussed do not indicate whether
ACC activation occurs in the dorsal or ventral ACC. Consequently it is
difficult to determine what the increased activation in relation to emo-
tional stimuli observed by Plener et al. (2012) actually represents. If
activation occurred in the dorsal ACC, this could indicate a conscious
effort to cope or self regulate, whereas activation of the ventral ACC
may be an indication of hyper-arousal or induction of negative mood.
Making a clear distinction between these would enable the development
of specialised and specific treatment interventions. For example, in-
creased dorsal activation might suggest an intervention aimed at teach-
ing individuals skills for coping and reappraisal, whereas increased
ventral activation might lead to an intervention based on the principles
of mindfulness.
A further line of enquiry, not elaborated on here, concerns the role
of the ACC in pain. Positron emission tomography studies have consis-
tently shown activation of the ACC during both heat and cold induced
painful stimuli, and anterior cingulotomy is a widely accepted treatment
for previously untreatable pain (Axelrod et al., 1998). Although some
who self-injure do not feel pain (Martin et al., 2010), for those who do,
the experience may be tied to the process of emotion regulation medi-
ated by the ACC.
Conclusion
In this essay we have chosen to focus on the role of the ACC and
emotion regulation in NSSI. However, the ACC is not the only neural
structure that has been implicated in NSSI. Executive functioning
(e.g. planning, decision making, memory) is primarily facilitated
through the prefrontal cortex. Although preliminary, evidence is start-
ing to emerge that people who self-injure have deficits in executive
functions (Janis & Nock, 2009) and studies with people exhibiting
suicidal behaviour report decreased perfusion in the pre-frontal cortex
(Desmyter et al., 2011). Further, the neurotransmitter serotonin has
been implicated in suicidal behaviour. Although differentiated from
NSSI, there is reason to believe that serotonin may also be related to
NSSI. Low levels of serotonin are related to depression, aggression
and impulsivity, all of which are related to NSSI (Jacobson & Gould,
2007; Stanford & Jones, 2009). Further, low levels of serotonin were
observed in girls who self-injured, although this also interacted with
environmental factors (Crowell et al., 2008). Finally, some researchers
have argued that the release of endorphins that accompanies NSSI
may reinforce the behaviour, not only through the alleviation of phys-
ical pain, but through an endorphin-related ‘high’. Others have noted
low base rates of endogenous opioids in the cerebrospinal fluid of
people who self-injure, suggesting that NSSI is used as a means of
maintaining homeostasis (Stanley et al., 2010).
Given the adverse consequences for people who self-injure, and
the effect on those that care for them, there is an urgent need to better
understand this behaviour. Whilst NSSI is an area that is gaining more
attention and research, the vast majority of this still relies on self-report
data. The future understanding of NSSI as a behaviour in its own right,
separate from BPD and suicide, lies in understanding how people who
engage in NSSI differ from those who do not through extensive neuro-
cognitive tasks, and imaging studies. Only then can we truly open the
road to recovery.
References
Allman, J. M., Hakeem, A., Erwin, J. M., Nimchinsky, E., & Hof, P.
(2001). The anterior cingulate cortex. Annals of the New York Acad-
emy of Sciences, 935(1), 107–117.
Anderson, N. L., & Crowther, J. H. (2012). Using the experiential avoid-
ance model of non-suicidal self-injury: understanding who stops
and who continues. Archives of Suicide Research, 16(2), 124–134.
Axelrod, B., Holmes, A., Lane, R. D., Reiman, E. M., Schwartz, G. E.,
& Yun, L-S. (1998). Neural correlates of levels of emotional aware-
ness: Evidence of an interaction between emotion and attention in
the anterior cingulate cortex. Journal of Cognitive Neuroscience,
10, 525–539.
Baetens, I., Claes, L., Muehlenkamp, J., Grietens, H., & Onghena, P.
(2011). Non-suicidal and suicidal self-injurious behaviour among
Flemish adolescents: A web-survey. Archives of Suicide Research,
15(1), 56–67.
Bear, M. F., Connors, B. W., & Paradiso, M. A. (2001). Neuroscience:
exploring the brain. (2nd ed.). Philadelphia, PA: Lipponcott, Wil-
liams & Wilkins.
Chapman, A. L., Gratz, K. L., & Brown, M. Z. (2006). Solving the
puzzle of deliberate self-harm: The experiential avoidance model.
Behaviour Research and Therapy, 44, 371–394.
Crowell, S. E., Beauchaine, T. P., McCauley, E., Smith, C. J., Vasilev, C. A.,
& Stevens, A. L. (2008). Parent-child interactions, peripheral sero-
tonin, and self-inflicted injury in adolescents. Journal of Consult-
ing and Clinical Psychology, 76(1), 15–21.
Dennis, T. A., & Solomon, B. (2010). Frontal EEG and emotion regula-
tion: Electrocortical activity in response to emotional film clips is
associated with reduced mood induction and attention interference
effects. Biological Psychology, 85(3), 456–464.
Desmyter, S., van Heeringen, C., & Audenaert, K. (2011). Structural
and functional neuroimaging studies of the suicidal brain. Progress
in Neuro-Psychopharmacology and Biological Psychiatry, 35(4),
796–808.
Dougherty, D. D., Shin, L. M., Alpert, N. M., Pitman, R. K., Orr, S. P.,
Lasko, M., Macklin, M. L., Fischman, A. J., & Rauch, S. L. (1999).
Anger in healthy men: A PET study using script-driven imagery.
Biological Psychiatry, 46(4), 466–472.
Drevets, W. C., Price, J. L., Simpson, J. R., Todd, R. D., Reich, T., Van-
nier, M., & Raichle, M. E. (1997). Subgenual prefrontal cortex
abnormalities in mood disorders. Nature, 386(6627), 824–827.
Evans, E., Hawton, K., & Rodham, K. (2005). Suicidal phenomena and
abuse in adolescents: A review of epidemiological studies. Child
Abuse & Neglect, 29(1), 45–58.
Frewin, P. A., Pain, C., Dozois, D. J., & Lanius, R. A. (2006). Alex-
ithymia in PTSD. Annals of the New York Academy of Sciences,
1071(1), 397–400.
Gross, J. J., & John, O. P. (2003). Individual differences in two emo-
tion regulation processes: Implications for affect, relationships,
and well-being. Journal of Personality and Social Psychology, 85,
348–362.
Hasking, P., Momeni, R., Swannell, S., & Chia, S. (2008). The nature
and extent of non-suicidal self-injury in non-clinical samples of
young adults. Archives of Suicide Research, 12, 208–218.
Hazlett, E. A., New, A. S., Newmark, R., Haznedar, M. M., Lo, J. N.,
Speiser, L. J., Chen, A. D., Mitropoulou, V., Minzenberg, M.,
Seiver, L. J., & Buchsbaum, M. S. (2005). Reduced anterior and
posterior cingulate gray matter in borderline personality disorder.
Biological Psychiatry, 58(8), 614–623.
Howe-Martin, L. S., Murrell, A. R., & Guarnaccia, C. A. (2012). Re-
petitive nonsuicidal self-injury as experiential avoidance among a
community sample of adolescents. Journal of Clinical Psychology,
68(7), 809–829.
International Society for the Study of Self-Injury (2007). <http://www.
isssweb.org/aboutnssi.php 2007. Accessed September, 28, 2012>.
Jacobson, C. M., & Gould, M. (2007). The epidemiology and phenome-
nology of non-suicidal self-injurious behavior among adolescents:
A Critical Review of the Literature. Archives of Suicide Research,
11(2), 129–147.
Janis, I. B., & Nock, M. K. (2009). Are self-injurers impulsive?: Re-
sults from two behavioral laboratory studies. Psychiatry research,
169(3), 261.
Kano, M., Fukudo, S., Gyoba, J., Kamachi, M.,Tagawa, M., Mochizuki, H.,
Itoh, M., Hong, M., & Yanai, K. (2003). Specific brain processing
of facial expressions in people with alexithymia: An H215O-PET
study. Brain, 126(6), 1474–1484.
Klonsky, E.D. (2007). The functions of deliberate self-injury: A review
of the evidence. Clinical Psychology Review, 27, 226–239.
Klonsky, E. D. (2009). The functions of self-injury in young adults who
cut themselves: Clarifying the evidence for affect-regulation. Psy-
chiatry Research, 166, 260–268.
Laye-Gindhu, A., & Schonert-Reichl. K. A. (2005). Nonsuicidal self-

harm among community adolescents: Understanding the “whats”
and “whys” of self-harm. Journal of Youth and Adolescence, 34(5),
447–457.
Lee, B., Lee, H., Park, S., Lim, J., Tae, W. S., Lee, M. S., Joe, S. H.,
Jung, I. K., & Ham, B. (2011). Neural substrates of affective face
recognition in alexithymia: A functional magnetic resonance imag-
ing study. Neuropsychobiology, 63(2), 119–124.
Linehan, M. M. (1993). Cognitive-Behavioral Treatment of Borderline
Personality Disorder. New York, NY: Guildford Press.
Martin, G., Swannell, S., Harrison, J., Hazell, P., & Taylor, A. (2010). The
Australian National Epidemiological Study of Self-Injury (ANESSI).
Centre for Suicide Prevention Studies: Brisbane, Australia.
Minzenberg, M. J., Fan, J., New, A. S., Tang, C. Y., & Siever, L. J. (2007).
Fronto-limbic dysfunction in response to facial emotion in border-
line personality disorder: An event-related fMRI study. Psychiatry
Research: Neuroimaging, 155(3), 231–243.
Mizuki, Y., Suetsugi, M., Imai, T., Kai, S., Kajimura, N., & Yamada,
M. (1989). A physiological marker for assessing anxiety level in
humans: Frontal midline theta activity. Psychiatry and Clinical
Neurosciences, 43(4), 619–626.
Moriguchi, Y., Decety, J., Ohnishi, T., Maeda, M., Mori, T., Nemoto, K.,
Matsuda, H., & Komaki, G. (2007). Empathy and Judging Oth-
er’s Pain: An fMRI Study of Alexithymia. Cerebral Cortex, 17(9),
2223–2234.
Najmi, S., Wegner, D. M., & Nock, M. K. (2007). Thought suppression
and self-injurious thoughts and behaviours. Behaviour Research
and Therapy, 45, 1957–1965.
Nock, M. K., Joiner Jr, T. E., Gordon, K. H., Lloyd-Richardson, E.,
& Prinstein, M. J. (2006). Non-suicidal self-injury among adoles-
cents: Diagnostic correlates and relation to suicide attempts. Psy-
chiatry Research, 144(1), 65–72.
Nock, M. K., & Mendes, W. B. (2008). Physiological arousal, distress
tolerance, and social problem–solving deficits among adolescent
self-injurers. Journal of Consulting and Clinical Psychology, 76(1),
28–38.
Nock, M. K., & Prinstein, M. J. (2004). A functional approach to the

assessment of self-mutilative behavior. Journal of Consulting and
Clinical Psychology, 72(5), 885–890.
Nock, M. K., Prinstein, M., J., & Sterba, S. K. (2009). Revealing the
form and function of self-injurious thoughts and behaviours: A
real-time ecological assessment study among adolescents and
young adults. Journal of Abnormal Psychology, 118(4), 816–827.
Oquendo, M. A., & Mann, J. J. (2001). Neuroimaging findings in major
depression, suicidal behavior and aggression. Clinical Neurosci-
ence Research, 1(5), 377–380.
Pardo, J. V., Pardo, P. J., & Raichle, M. E. (1993). Neural correlates
of self-induced dysphoria. The American Journal of Psychiatry,
150(5), 713–713.
Phillips, M. L., Drevets, W. C., Rauch, S. L., & Lane, R. (2003). Neu-
robiology of emotion perception I: the neural basis of normal emo-
tion perception. Biological Psychiatry, 54(5), 504–514.
Plener, P. L., Bubalo, N., Fladung, A. K., Ludolph, A. G., & Lulé, D.
(2012). Prone to excitement: Adolescent females with non-suicidal
self-injury (NSSI) show altered cortical pattern to emotional and
NSS-related material. Psychiatry Research: Neuroimaging, 203
(2–3), 146–152.
Ross, S., & Heath, N. L. (2003). Two models of adolescent self-mutila-
tion. Suicide and Life Threatening Behavior, 33, 277–287.
Stanford, S., & Jones, M. P. (2009). Psychological subtyping finds patho-
logical, impulsive, and ‘normal’ groups among adolescents who self-
harm. Journal of Child Psychology and Psychiatry, 50, 807–815.
Stanley, B., Sher, L., Wilson, S., Ekman, R., Huang, Y.-y., & Mann, J. J.
(2010). Non-suicidal self-injurious behavior, endogenous opioids
and monoamine neurotransmitters. Journal of Affective Disorders,
124(1–2), 134–140.
Stevens, F. L., Hurley, R. A., Taber, K. H., & Hayman, L. A. (2011). Ante-
rior cingulate cortex: Unique role in cognition and emotion. The Jour-
nal of neuropsychiatry and clinical neurosciences, 23(2), 121–125.
Suetsugi, M., Mizuki, Y., Ushijima, I., Kobayashi, T., Tsuchiya, K.,
Aoki, T., & Watanabe, Y. (2000). Appearance of frontal midline
theta activity in patients with generalized anxiety disorder. Neu-
ropsychobiology, 41(2), 108–12.
van Heeringen, C., Bijttebier, S., & Godfrin, K. (2011). Suicidal brains:
A review of functional and structural brain studies in association
with suicidal behaviour. Neuroscience & Biobehavioral Reviews,
35(3), 688–698.
Wagner, G., Schultz, C. C., Koch, K., Schachtzabel, C., Sauer, H., &
Schlösser, R. G. (2012). Prefrontal cortical thickness in depressed
patients with high-risk for suicidal behavior. Journal of Psychiatric
Research, 46(11), 1449–1455.
Walker, S., Daryl, B. O., & Schaefer, A. (2011). Brain potentials to
emotional pictures are modulated by alexithymia during emotion
regulation. Cognitive, Affective and Behavioral Neuroscience,
11(4), 463–475.
Whitlock, J., Eckenrode, J., & Silverman, D. (2006). Self-injurious
behaviours in a college population. Pediatrics, 117, 1939–1948.
Whitlock, J., Muehlenkamp, J., & Eckenrode, J. (2008). Variation in
nonsuicidal self-injury: Identification and features of latent class-
es in a college population of emerging adults. Journal of Clinical
Child and Adolescent Psychology, 37(4), 725–735.
Yang, Y., & Raine, A. (2009). Prefrontal structural and functional brain
imaging findings in antisocial, violent, and psychopathic individu-
als: A meta-analysis. Psychiatry Research: Neuroimaging, 174(2),
81–88.
Marisa H. Loft
Sleep-related problems and their

contributing factors
The importance of sleeping well often goes under-recognised in mod-

ern society and Malaysia is no exception. This essay aims to provide
information on how to define this problem, how to measure whether
or not someone is sleeping well and what the factors are that may con-
tribute to a person sleeping badly. In addition, the need to investigate
sleep-related issues in at-risk populations such as workplace employ-
ees, problem gamblers and children with autism is emphasised. It is
hoped that with this understanding the general population will recog-
nise how they may be able to assist in improving their own sleep. For
policy makers, the chapter provides some suggested avenues of need for
funding and target. Finally, for the research community it is anticipated
that some of the gaps in the state of the current research are highlighted
and able to be addressed.
The process of sleeping seems simple and should come naturally.
Nevertheless, for many people and increasingly so in modern times,
nights are fraught with difficulty and frustration. For these people, go-
ing to sleep seems like an impossible task and/or waking during the
night a certainty. These difficulties often go unreported and the prob-
lems unrecognised in society. The prevalence of reported sleep-related
problems in Malaysia is relatively high at 33.8% suggesting that there is
a need to understand and address the issue in this country (Zailinawati,
Ariff, Nurjahan, & Teng, 2008). It is likely that unreported sleep issues
in this country are even higher.
180 Marisa H. Loft
The importance of sleeping well
A critical function for human survival, sleep is essential for physical

and mental wellbeing. For example, insomnia or sleep deprivation has
been identified as a precursor for depression (Ohayon & Roth, 2003),
cardiovascular disease (Grandner, 2014; Tenkanen, Sjoblom, Kalimo,
Alikoski, & Harma, 1997), poor quality of life (Drake, Roehrs, & Roth,
2003), colorectal cancer (Schernhammer et al., 2003) and all-cause
mortality (Newman et al., 2000). In addition, sleep deprivation can neg-
atively affect lifestyle behaviours such as diet (Imaki, Hatanaka, Ogawa,
Yoshida, & Tanada, 2002). The relationship between sleep and health
behaviour is suggested to be reciprocal as lower levels of exercise and
poor diet can also affect sleep patterns (for a review see Atkinson &
Davenne, 2007). More immediate non health-related effects of sleep
deprivation have also been documented with regards to cognitive and
social functioning. For example, effects of sleep deprivation on pro-
ductivity at work the next day is thought to include deficits in both the
individual and the functioning of the team they work with as affects
decision-making at a multitude of levels (for a review see Harrison &
Horne, 2000).
Insomnia versus sleep deprivation
Much research has been done on the clinical condition known as in-
somnia (Morin et al., 2006). This condition is characterised by a cluster
of symptoms that include subjective sleep complaints, problems with
daytime functioning and severe distress in other vital areas like mental
health. These sleep complaints may include problems falling asleep at
bedtime (sleep onset insomnia), awakening during the night and hav-
ing difficulty in going back to sleep (sleep maintenance insomnia) and
awakening too early in the morning (terminal insomnia). For those
individuals diagnosed with insomnia the problem is often considered
chronic with 74% in one sample reporting symptoms for at least one
Sleep-related problems and their contributing factors 181
year (Morin et al., 2009). Formal diagnosis of the most common sub-
type, sleep onset insomnia, usually uses the criteria of a time to sleep
of ≥ 31 minutes for ≥ 3 nights per week for ≥ 6 months (Lichstein,
Durrence, Taylor, Bush, & Riedel, 2003).
There is a growing recognition of the need to study people who
experience sleeping difficulties in the general population but who do
not quite meet this criteria or who do not present to clinical settings
(Hagger, 2010; Loft & Cameron, 2013). This non-clinical population
may still be suffering ill effects on health and general functioning but
are not identified by the studies on clinical insomnia. There is evidence
to suggest that there are genuine biological differences between the clin-
ical arousal sub-types of insomnia and the non-clinical populations who
experience sleep difficulties through poor sleep habits (Altena, Van Der
Werf, Strijers, & Van Someren, 2008). These differences may mean that
treatments need to be modified depending on which group the individ-
ual is in. Yet, in comparison to the substantial amount of research that
has been done on insomnia (Morin, et al., 2006), there is a relative lack
of understanding of sleep deprivation in the general population (Loft &
Cameron, 2013). Therefore, adequate treatments for this population are
poorly developed and there exists a large unmet need.
Measuring the extent of the problem: Sleep assessment

and its indicators
Traditionally, much sleep-related research has been conducted using

polysomnography with the tools administered in tightly controlled sleep
laboratory settings (Uchida et al., 2011). Recently, modern technology
has also provided researchers with more portable tools such as wrist
actigraphy (Martin & Hakim, 2011) and smartphones (Krejcar, Jirka,
& Janckulik, 2011) with the capacity to measure physiological sleep
patterns. Although these physiological measurements are objective and
still useful, it is the perception of sleep quality more than the objective
measures like sleep duration that are most likely to affect daily function-
ing (Pilcher, Ginter, & Sadowsky, 1997). Further evidence also suggests
182 Marisa H. Loft
that some differences between objective and subjective measures do ex-

ist (Tworoger, Davis, Vitiello, Lentz, & McTiernan, 2005) with each
method predicting different aspects of the sleep experience. Therefore
the value of self-report measures should not go under-recognised.
The Pittsburgh Sleep Quality Index (PSQI; Buysse, Reynolds,
Monk, Berman, & Kupfer, 1989) is one of the most established and
validated self-report measures of sleeping difficulty and has shown pre-
dictive success in clinical and healthy populations. The measure covers
seven dimensions (sleep quality, sleep latency, sleep duration, sleep ef-
ficiency, sleep disturbances, use of medication, and daytime dysfunc-
tion). Each dimension is dummy coded then added together to provide a
total summary score. Scores greater or equal to 5 indicate moderate to
severe sleeping difficulty.
Despite the strength of such an instrument, sleep patterns are
known to be highly variable over time, especially for individuals who
are sleep deprived (Vallieres, Hansivers, Bastien, Beaulieu-Bonneau,
& Morin, 2005). In addition to the fact that sleep behaviour is com-
plex, this variability can induce bias when sleep patterns are assessed
by one-off self-reported measures (Gehrman, Matt, Turingan, Dinh,
& Ancoli-Israel, 2002). To resolve these issues, daily measurement is
also recommended with daily sleep diaries showing good comparison
to the pre-post administration of measures (Libman, Fichten, Bailes,
& Amsel, 2000). It is often suggested that people suffering from sleep
problems keep a sleep diary in order to identify the source and nature
of their poor sleep-related habits (Institute of Medicine of the National
Academies, 2006). To construct the daily diary measurements certain
questions are commonly taken from the PSQI and adapted to reflect
the daily assessment (Pilcher & Ott, 1998). Variables often used in
daily assessment include one-item measures of sleep quality, time of
lights out, hours of sleep, length of sleep onset, number of awakenings
during the night and time of waking. Flexibility in the response format
may also assist in improving the reliability and validity of the measure
(Gehrman et al., 2002).
Recently, an innovative tool was developed to assess the relatively
private intentions for behaviours leading up to the point of going to
sleep (Loft, 2011). Understanding these intentions is thought to be a
first step in learning how a person regulates their behaviour, how that
behaviour affects sleep and how decisions are made about temptations in
the environment. Labelled the Sleep-Relevant Cognitions Test (SRCT),
the measure uses a narrative approach which allows assessment both
qualitatively (in the behaviours that were reported) and quantitative-
ly (in the time slot the behaviour was recorded in) of intended sleep
behaviours prior to bed. In this measure participants are asked to read
a scenario about an employee’s typical day at work. From the time of
7.30pm onwards they are then asked to record which behaviours they
would be likely to do in a series of half-hour time slots and given the
set scenario. This measure was developed over four studies and used for
descriptive purposes as well as in intervention research to determine
whether the intentions varied depending on the experimental group.
Results from all studies suggested that the tool had good predictive va-
lidity and was a reliable measure to use for recording intentions for
sleep-related behaviour. Despite context being recognised as an import-
ant influence on behaviour (Grander, 2014) this is one of the first instru-
ments designed to capture the contextual influence on decision-making
processes.
The influence of work demands on sleep
Research investigating the effects of work-related stress on sleep goes

back a long time (e.g. Krueger, 1989). Recently, there has been more in-
terest in the more specific occupational demands that cause the stress and
how these demands are perceived directly. One study provided an added
need to investigate work-related demands to improve sleep as found that
these stressors were associated with poor sleep quality whereas experi-
ences at home showed no such association (Burgard & Ailshire, 2009). It
is argued that work-related demands may have greater consequences as
a person has less control over their work than their personal lives so may
be less able to regulate their behaviour in response to them (Akerstedt,
2006). Instruments such as the Copenhagen Psychosocial Questionnaire
(Kristensen, Hannerz, Hogh, & Borg, 2005) and the Occupational Stress
Inventory (Osipow, 1998) are established questionnaires designed to
184 Marisa H. Loft
measure these work-related demands. Occupational demands that are

thought to contribute to sleep difficulty in particular include conflicts
with a supervisor, interpersonal relationship difficulties, workload and
financial strain (Bastien, Vallieres, & Morin, 2004). One way these
demands may influence sleep is by causing the person to deal with
them late into the night. These actions could be considered a cogni-
tive approach to dealing with the demands which may increase arousal
levels and interfere with sleep. Second, a person may try to distract
themselves from the distressing effects of these demands through cer-
tain activities. This type of response would be seen as more of an emo-
tional approach involving distraction (e.g. by watching television) and
which does not necessarily deal with the high arousal level generated
by these emotions. These cognitive and emotional reactions to the work
demands can also vary depending on the type of environments that the
individual later faces before going to sleep.
Succumbing to temptation: The influence of the

immediate environment on sleep
When investigating why a person decides to continue in pursuit of a

longer-term goal or succumb to the more immediate distracters in the
environment, the self-regulatory frameworks provide a good basis to
start from. Central to these frameworks are the principles that cogni-
tions and emotions guide behaviour and individuals are active decision
makers with regards to their goals (Leventhal, Leventhal, & Cameron,
2001). What these models do not take into account as readily are the
external environmental factors that may interfere with this active deci-
sion making. The Health Action Process Approach (Schwarzer, 2008)
provides one explanation for how these environmental factors may dis-
rupt the intention once formed from being executed as an action. This
theory stipulates that is a combination of the motivational level for the
end stage goal and clarity in behavioural intentions that are responsible
for the action being executed.
Nevertheless, little is known with regards to the immediate actions

leading up to sleep, which are likely to interfere with sleep and which
actions are likely to promote the process. Much of the intervention
work done in this area has provided general advice on which behaviours
should and should not be executed in order to sleep well without con-
sidering whether this advice had actually been tested. Some evidence
suggests that not all the commonly held beliefs of what it takes to sleep
well may actually be correct (Jefferson et al., 2005). Further, one study
suggested that although a person may be knowledgeable about what
they should do in order to sleep well it does not mean that they will go
on to follow their own advice (Brown, Buboltz, & Soper, 2002). More
investigation into how one makes decisions about these behaviours and
how the behaviours in turn may affect sleep can guide theory and future
treatments in a number of ways (Hagger, 2010; Loft, 2012).
Treatment orientated approaches such as the formation of imple-
mentation intentions which link the intended behaviour with the sit-
uation it is likely to occur in has furthered understanding of how to
address the intention-action gap in other behaviours (Webb & Sheeran,
2006). Another recent development is the emphasis on taking the tem-
poral dimensions of these decisions into account (Hall & Fong, 2007).
Nevertheless, there is much more to be learnt about the self-regulation
of sleep-related behaviour and why one chooses to do activities which
prevent one from sleeping well, even if those activities are not desirable.
Learning more about this area will also enable understanding of the
self-regulation of behaviour in general (Hagger, 2010; Loft, 2012).
Understanding relationships between arousal and sleep
Arousal levels can be classified as coming from a cognitive source,

an emotional source or a direct physiological source yet all can affect
the sleep initiation and maintenance process (Akerstedt, Kecklund,
& Axelsson, 2007). Nevertheless, the source is important and many
interventions that focus on reducing arousal attempt to use distraction
without understanding how the arousal originated (Harvey & Payne,
186 Marisa H. Loft
2002). Of the three types many people tend to blame their sleep dis-
turbance on cognitive arousal (Johansson et al., 2007) while neglecting
the fact that emotions are likely to be closely intertwined (Brosschot,
Pieper, & Thayer, 2005). Incorporating arousal into the primarily be-
haviourally focussed self-regulatory frameworks may help to better
understand the sleep initiation process. Taking examples from clinical
psychology, the use of mindfulness-based techniques may also be a
fruitful line of treatment to pursue to reduce pre-sleep arousal (Ong,
Shapiro, & Manber, 2008). These techniques allow one to accept the
distressing thoughts that may increase arousal and then let them go
again while trying to focus on the present rather than worry about the
past or future.
Understanding sleep-related issues in specific populations
Although much is known about the act of sleeping itself and the con-
sequences from not doing so, more investigation is needed for how a
person may develop sleep problems (Morin et al., 2006). Studying pop-
ulations considered ‘at risk’ for sleep problems may give greater insight
into how these issues develop in normal populations. Symptoms can
be exaggerated and more prevalent and thus more easily identified and
treated. Certain behavioural problems may also be exaggerated giving
clues as to where one should start with behavioural based sleep inter-
ventions.
Workplace employees
Some work has been conducted with shift-workers (Rajaratnam et al.,

2011; Suzuki, Ohida, Kaneita, Yokoyama, & Uchiyama, 2005) and the
links between occupational stressors and sleep problems are becom-
ing more established (Benham, 2010). Nevertheless, more is needed
on the work-related demands that constitute the stressors arising from
the workplace and which of these demands are likely to have the most
impact on sleep. Some preliminary research suggests that prioritis-

ing sleep higher may help to shield a person from later experiencing
sleep-related problems from these demands (Loft & Cameron, 2014).
This research also tried to better understand the dynamic influences of
daily demands that are experienced by employees, how they may cause
a person to interact with their environment differently and their later
influences on sleep. Further investigation in this area will contribute to
more efficient workplaces, better home environments and a healthier
general population.
Children with autism
Another common topic of interest in sleep-related research concerns

paediatric sleep problems. One of the key concerns of any new parent
is how to get their child to settle to sleep (Dahl & El-Sheikh, 2007).
It is not an easy process however and many parents struggle with this
issue until the child is often well into their teens. For a parent with a
child with a developmental disability such as autism the sleep-related
issues are exemplified (Krakowiak, Goodlin-Jones, Hertz-Picciotto,
Croen, & Hansen, 2012). In particular, difficulties arise with the settling
routine and in night awakening, often as a result of parasomnias like
night terrors (Hasniah et al., 2012). In line with this type of problem
experienced, a recent review of the evidence suggests that behavioural
treatment is the preferred approach for treating sleep problems in chil-
dren with autism spectrum disorders (Vriend, Corkum, Moon, & Smith,
2011). Understanding sleep-related behaviours in populations with spe-
cific behavioural and attention deficit issues may help to really test sleep
interventions developed so that they hold strong in any population.
Problem gamblers
Sleep difficulties show greater prevalence among individuals that

engage in high stimulation activities such as Internet gaming, social
networking and gambling (Thomee, Harenstam, & Hagberg, 2011).
Problem gamblers represent such a population and a recent study
188 Marisa H. Loft
provides evidence that these individuals are indeed more likely to suf-
fer from a loss of sleep (Parhami et al., 2012). The Iowa Gambling
Task has long been used to assess the effects of sleep deprivation and
suggests that when sleep-deprived one is likely to take greater risks
(Harrison & Horne, 2000). Experimental work using sleep laborato-
ries also suggest that a sleep-deprived person becomes more impul-
sive with their environment (Anderson & Platten, 2011). Less is un-
derstood as to whether taking greater risks may go on to affect sleep. A
recent study (Loft & Loo, 2014) revealed that self-regulatory capacity
was an important mediator of the relationship between problem gam-
bling and later sleep difficulty.
Conclusion
Sleep and its related processes affect us all and, can have far reaching
yet poorly understood effects on society. Already, developments made
in measuring sleep, understanding it and how to improve its quality
have contributed to multiple areas of theory and practice within psy-
chology. Still, there is a growing need to continue the focus in this area
with many questions remaining unanswered and many aspects of mod-
ern life presenting a significant threat to sleeping well. Through the
topics presented in this chapter it is hoped that the importance of getting
enough sleep is recognised. In addition, it is anticipated that these ideas
will trigger new avenues for research, and more effective treatments that
improve the sleeping process across multiple populations.
References
Akerstedt, T. (2006). Psychosocial stress and impaired sleep. Scandina-

vian Journal of Work, Environment & Health, 32, 493–501.
Akerstedt, T., Kecklund, G., & Axelsson, J. (2007). Impaired sleep

after bedtime stress and worries. Biological Psychology, 76(3),
170–173.
Altena, E., Van Der Werf, Y. D., Strijers, R. L. M., & Van Someren, E. J.
W. (2008). Sleep loss affects vigilance: Effects of chronic insomnia
and sleep therapy. Journal of Sleep Research, 17, 335–343.
Anderson, C., & Platten, C. R. (2011). Sleep deprivation lowers inhi-
bition and enhances impulsivity to negative stimuli. Behavioural
Brain Research, 217(2), 463–466.
Atkinson, G., & Davenne, D. (2007). Relationships between sleep, physi-
cal activity and human health. Physiology and Behavior, 90, 229–235.
Bastien, C. H., Vallieres, A., & Morin, C. M. (2004). Precipitating
factors of insomnia. Behavioral Sleep Medicine, 2(1), 50–62.
Benham, G. (2010). Sleep: An important factor in stress health models.
Stress and Health, 26(3), 186–193.
Brosschot, J. F., Pieper, S., & Thayer, J. F. (2005). Expanding stress
theory: prolonged activation and perseverative cognition. Psycho-
neuroendocrinology, 30(10), 1043–1049.
Brown, F. C., Buboltz, W. C., & Soper, B. (2002). Relationship of sleep
hygiene awareness, sleep hygiene practices, and sleep quality in
university students. Behavioral Medicine, 28, 33–38.
Burgard, S. A., & Ailshire, J. A. (2009). Putting work to bed: stress-
ful experiences on the job and sleep quality. Journal of Health &
Social Behavior, 50(4), 476–492.
Buysse, D. J., Reynolds, C. F., Monk, T. H., Berman, S. R., & Kupfer,
D. J. (1989). The Pittsburgh Sleep Quality Index: A new instru-
ment for psychiatric practice and research. Psychiatry Research,
28, 193–213.
Dahl, R. E., & El-Sheikh, M. (2007). Considering Sleep in a Family
Context: Introduction to the Special Issue. Journal of Family
Psychology, 21(1), 1–3.
Drake, C. L., Roehrs, T., & Roth, T. (2003). Insomnia causes, conse-
quences and therapeutics: an overview. Depression and Anxiety,
18, 163–176.
Gehrman, P., Matt, G. E., Turingan, M., Dinh, Q., & Ancoli-Israel, S.
(2002). Towards an understanding of self-reports of sleep. Journal
of Sleep Research, 11(3), 229–236.
190 Marisa H. Loft
Grander, M.A. (2014). Addressing sleep disturbances: An opportunity

to prevent cardiometabolic disease? International Review of Psy-
chiatry, 26(2), 155–176.
Hagger, M. S. (2010). Sleep, self-regulation, self-control and health.
Stress & Health, 26, 181–185.
Hall, P. A., & Fong, G. T. (2007). Temporal self-regulation theory: A
model for individual health behavior. Health Psychology Review,
1(1), 6–52.
Harrison, Y., & Horne, J. A. (2000). The impact of sleep deprivation on
decision making: A review. Journal of Experimental Psychology:
Applied, 6(3), 236–249.
Harvey, A. G., & Payne, S. (2002). The management of unwanted
pre-sleep thoughts in insomnia: distraction with imagery versus
general distraction. Behaviour Research and Therapy, 40, 267–277.
Hasniah, A. L., Jamalludin, A. R., Norrashidah, A. W., Norzila, M. Z.,
Asiah, K., Anida, A. R., et al. (2012). Cross-cultural adaptation
and reliability of pediatric sleep questionnaire in assessment of
sleep-disordered breathing in the Malay speaking population.
World Journal of Pediatrics, 8(1), 38–42.
Imaki, M., Hatanaka, Y., Ogawa, Y., Yoshida, Y., & Tanada, S. (2002). An
epidemiological study on the relationship between hours of sleep
and life style factors in Japanese factory workers. Journal of Physio-
logical Anthropology and Applied Human Science, 21(2), 115–120.
Institute of Medicine of the National Academies. (2006). Sleep Dis-
orders and Sleep Deprivation. Washington, DC: The National
Academies Press.
Jefferson, C. D., Drake, C. L., Scofield, H. M., Myers, E., McClure, T.,
Roehrs, T., & Roth, T. (2005). Sleep hygiene practices in a popula-
tion-based sample of insomniacs. Sleep, 28(5), 611–615.
Johansson, A., Windahl, M., Svanborg, E., Fredrichsen, M., Swahn, E.,
Uhlin, P. Y., & Edéll-Gustafsson, U. (2007). Perceptions of how
sleep is influenced by rest, activity and health in patients with cor-
onary heart disease: A phenomenographical study. Scandinavian
Journal of Caring Sciences, 21(4), 467–475.
Krakowiak, P., Goodlin-Jones, B., Hertz-Picciotto, I., Croen, L. A.,
& Hansen, R. L. (2012). Sleep problems in children with autism
spectrum disorders, developmental delays, and typical development:

a population-based study. Journal of Sleep Research, 21(2), 231.
Krejcar, O., Jirka, J., & Janckulik, D. (2011). Use of mobile phones as
intelligent sensors for sound input analysis and sleep state detec-
tion. Sensors, 11(6), 6037–6055.
Kristensen, T. S., Hannerz, H., Hogh, A., & Borg, V. (2005). The Copen-
hagen Psychosocial Questionnaire–A tool for the assessment and
improvement of the psychosocial work environment. Scandinavian
Journal of Work, Environment & Health, 31, 438–449.
Krueger, G. P. (1989). Sustained work, fatigue, sleep loss and perfor-
mance: A review of the issues. Work & Stress, 3(2), 129–141.
Leventhal, H., Leventhal, E. A., & Cameron, L. D. (2001). Representa-
tions, procedures, and affect in illness self-regulation: A perceptual-
cognitive approach. In A. Baum, T. Revenson & J. Singer (Eds.),
Handbook of Health Psychology (pp. 19–48). New York, NY:
Lawrence Erlbaum Associates.
Libman, E., Fichten, C., Bailes, S., & Amsel, R. (2000). Sleep ques-
tionnaire versus sleep diary: which measure is better? International
Journal of Rehabilitation and Health, 5(3), 205–209.
Lichstein, K. L., Durrence, H. H., Taylor, D. J., Bush, A. J., & Riedel, B. W.
(2003). Quantitative criteria for insomnia. Behaviour Research and
Therapy, 41, 427–445.
Loft, M. H. (2012). Response to debate on the self-report habit index.
Annals of Behavioral Medicine, 44, 141.
Loft, M. H. (2011). Sleep self-regulation: understanding and im-
proving the sleep initiation process in daytime employees (Un-
published Doctoral Dissertation). University of Auckland, New
Zealand.
Loft, M.H., & Cameron, L.D. (2013). Using mental imagery to deliver
self-regulation techniques to improve sleep behaviors. Annals of
Behavioral Medicine, 46(3), 260–272. DOI: 10.1007/s12160-
013-9503-9.
Loft, M.H., & Cameron, L.D. (2014). The importance of sleep: Rela-
tionships between sleep quality and work demands, the prioritiza-
tion of sleep and pre-sleep arousal in day-time employees. Work
and Stress, 28(3), 289–304. DOI: 10.1080/02678373.2014.935523.
192 Marisa H. Loft
Loft, M. H., & Loo, J. M. Y. (2014). Understanding the mechanisms un-

derlying gambling behaviour and sleep. Journal of Gambling Stud-
ies. Eprint ahead of publication. DOI: 10.1007/s10899-014-9514.
Martin, J. L., & Hakim, A. D. (2011). Wrist actigraphy. Chest, 139(6),
1514–1527.
Morin, C. M., Bootzin, R. R., Buysse, D. J., Edinger, J. D., Espie, C. A.,
& Lichstein, K. L. (2006). Psychological and behavioral treatment
of insomnia: Update of the recent evidence (1998–2004). Sleep,
29(11), 1398–1414.
Morin, C. M., Belanger, L., LeBlanc, M., Ivers, H., Savard, J., Espie,
C. A., Gre’goire, J-P. (2009). The Natural History of Insomnia: A
Population-Based 3-Year Longitudinal Study. Archives of Internal
Medicine, 169(5), 447–453.
Newman, A. B., Spiekerman, C. F., Enright, P., Lefkowitz, D., Manolio, T.,
& Reynolds, C. F. (2000). Daytime sleepiness predicts mortali-
ty and cardiovascular disease in older adults. The Cardiovascular
Health Study Research Group. Journal of the American Geriatrics
Society, 48, 115–123.
Ohayon, M. M., & Roth, T. (2003). Place of chronic insomnia in the
course of depressive and anxiety disorders. Journal of Psychiatric
Research, 37, 9–15.
Ong, J. C., Shapiro, S. L., & Manber, R. (2008). Combining mindful-
ness meditation with cognitive-behavior therapy for insomnia: A
treatment-development study. Behavior Therapy, 39(2), 171–182.
Osipow, S. H. (1998). Occupational stress inventory-revised edition
(OSI-R): Professional manual. Lutz, FL: Psychological Assess-
ment Resources.
Parhami, I., Siani, A., Rosenthal, R. J., Lin, S., Collard, M., & Fong, T. W.
(2012). Sleep and gambling severity in a community sample of
gamblers. Journal of Addictive Diseases, 31(1), 67–79.
Pilcher, J. J., Ginter, D. R., & Sadowsky, B. (1997). Sleep quality versus
sleep quantity: relationships between sleep and measures of health,
well-being and sleepiness in college students. Journal of Psychoso-
matic Research, 42(6), 583–596.
Pilcher, J. J., & Ott, E. S. (1998). The relationships between sleep and
measures of health and well-being in college students: a repeated
measures approach. Behavioral Medicine, 23(4), 170–178.
Rajaratnam, S. M., Barger, L. K., Lockley, S. W., Shea, S. A., Wang, W.,
Landrigan, C. P., Czeisler, C.A. (2011). Sleep disorders, health, and
safety in police officers. Journal of the American Medical Associa-
tion, 306(23), 2567–78.
Rook, J. W., & Zijlstra, F. R. H. (2006). The contribution of various
types of activities to recovery. European Journal of Work and
Organizational Psychology, 15(2), 218–240.
Schernhammer, E. S., Laden, F., Speizer, F. E., Willett, W. C., Hunter,
D. J., & Kawachi, I. (2003). Night-shift work and risk of colorectal
cancer in the nurses’ health study. Journal of the National Cancer
Institute, 95, 825–828.
Schwarzer, R. (2008). Modeling health behavior change: How to pre-
dict and modify the adoption and maintenance of health behaviors.
Applied Psychology: An International Review, 57(1), 1–29.
Suzuki, K., Ohida, T., Kaneita, Y., Yokoyama, E., & Uchiyama, M. (2005).
Daytime sleepiness, sleep habits and occupational accidents among
hospital nurses. Journal of Advanced Nursing, 52(4), 445–453.
Tenkanen, L., Sjoblom, T., Kalimo, R., Alikoski, T., & Harma, M.
(1997). Shift work, occupation and coronary heart disease over 6
years of follow-up in the Helsinki Heart Study. Scandinavian Jour-
nal of Work, Environment & Health, 23, 257–265.
Thomee, S., Harenstam, A., & Hagberg, M. (2011). Mobile phone use and
stress, sleep disturbances, and symptoms of depression among young
adults–a prospective cohort study. BMC Public Health, 11, 66.
Tworoger, S. S., Davis, S., Vitiello, M. V., Lentz, M. J., & McTiernan, A.
(2005). Factors associated with objective (actigraphic) and subjec-
tive sleep quality in young adult women. Journal of Psychosomatic
Research, 59(1), 11–19.
Uchida, S., Endo, T., Suenaga, K., Iwami, H., Inoue, S., Fujioka, E.,
et al. (2011). Sleep evaluation by a newly developed PVDF sensor
non-contact sheet: A comparison with standard polysomnography
and wrist actigraphy. Sleep and Biological Rhythms, 9(3), 178–187.
Vallieres, A., Hansivers, Bastien, C. H., Beaulieu-Bonneau, S., & Morin,
C. M. (2005). Variability and predictability in sleep patterns of
chronic insomniacs. Journal of Sleep Research, 14, 447–453.
Vriend, J. L. B., Corkum, P. V. P., Moon, E. C. B. A., & Smith, I. M. P.
(2011). Behavioral Interventions for Sleep Problems in Children
194 Marisa H. Loft
With Autism Spectrum Disorders: Current Findings and Future

Directions. Journal of Pediatric Psychology, 36(9), 1017–1029.
Webb, T. L., & Sheeran, P. (2006). Does changing behavioral intentions
engender behavior change? A meta-analysis of the experimental
evidence. Psychological Bulletin, 132(2), 249–268.
Zailinawati, A., Ariff, K., Nurjahan, M., & Teng, C. (2008). Epidemi-
ology of insomnia in Malaysian adults: a community-based sur-
vey in 4 urban areas. Asia-Pacific Journal of Public Health, 20(3),
224–233.
Part IV
Psycho-Social and Professional
Issues in the Asian Context
Miriam S. Park
Changing family perceptions across cultures:

The Malaysian context
The link between culture, self and the family is an interesting one to
consider. Experiences within the family and views people hold toward
the family often differ across cultures. The unique cultural and histor-
ical backgrounds and the pattern of socioeconomic change play a big
role in shaping and influencing these family experiences and views. In-
dividuals from different cultures often think about their families, their
relationships with the family, the roles, responsibilties and commitment
within the family differently. Families in Asia are seen as unique not
only because of the more collectivistic and hierarchical relationships,
tighter and more conservative family norms and roles within the family
and the closer relations between family members, but also beacuse of
the rapid socioeconomic change that has influenced the lives and beliefs
of people in the region in recent decades (e.g., Kagitcibasi, 2007). So-
cial change often influences what is required of the people, including
their roles and responsibilities in both work and family. For example,
industrial and economic developments in Malaysia in the 1990s and
2000s have seen more women entering the labour force, and increasing
demands placed upon them in handling work and responsibilties in both
work and home (Ahmad, 2007). Other macro- or higher level variables
also impact on family perceptions, and the interrelationships between
the societal, cultural and individual-level factors and views and atti-
tudes toward the family should be noted. This chapter outlines the ways
in which individuals think about the family, how sociocultural factors
influence these views and attitudes, and the interrelationships between
the culture, society and the family can be considered, especially in the
Asian context.
198 Miriam S. Park
Family views and attitudes: Family centredness

and democratisation
Individuals’ experiences and interactional styles in the family and their

views and expectations about the family differ from one culture to
another. Different levels of factors including culture, socioeconomic
conditions, and social change have influence on perceptions of family
centredness and democratisation, for they shape expectations and
organisation of the family (e.g. Bengston & Roberts, 1991; Kagitcibasi,
2007; Park, 2010). Views and beliefs about the family can include
perceptions on the importance of the family, level of commitment to
the family, degree of dependence on the family for emotional sup-
port and decision-making, and relationship equality within the family.
Family values and attitudes relating to individuals’ sense of relatedness
to the family (e.g., Kagitcibasi, 2007) and the dimensions of Individ-
ualism-Collectivism in the family context can also be considered in
relation to the cultural influences surrounding those sharing the same
geographical space and history.
Although academic works often discuss the importance of con-
sidering family views and attitudes, little cross-cultural work has been
done, particularly in changing cultures such as Malaysia. Studies have
noted, for example, the impact of modernisation and economic de-
velopment on the family in the late nineteenth and the earlier part of
the twentieth centuries (e.g., Smith, 1995; Thornton & Fricke, 1987),
cultural differences in the role and meaning of the family (e.g., Sie-
mienska, 2002), changes in the meaning and value of the children (e.g.,
Aycicegi-Dinn & Kagitcibasi, 2010), and intergenerational differences
in attitudes and ideals toward family relationships (e.g., Delsing, Oud,
De Bruyn, & Van Aken, 2003). However, an elaborative work that inves-
tigates the families of the early twenty first century in changing cultures
by canvassing exact impacts of socio-cultural factors on family views
and attitudes is rare to find. This chapter thus sets out to outline influ-
ences on family views and attitudes in the contemporary world and dis-
cuss further the perceptions of family centredness and democratisation
in cultures that are undergoing social, political, and economic changes.
Family dynamics and relationships in the particular cultural context of
Changing family perceptions across cultures: The Malaysian context 199
Malaysia as well as possible socioeconomic influences on these aspects

of Malaysian families will also be discussed.
Key theoretical issues
In seeking to explain the processes by which family views and attitudes

are shaped, special focus should be given to the social context and so-
cialisation experiences that are unique to individuals of different gender
and generation, as well as cultural background. One of the important
tasks that this chapter sets out to accomplish is to discuss Kagitcibasi’s
(2007) new model of family change. Rather than conceptualising the
family views in the West and the East to be different and completely
opposed to one another, this theory suggests that both of the import-
ant human needs- the need for autonomy and relatedness- should be
sought out in the family regardless of the cultural background. This
theory opens the door for new ways of thinking about culture and the
family, and how cultures can adopt values that are beneficial to their
citizens and their family relationships. The directions of family change
in the contemporary era should be investigated further in order to see
whether the family in different cultural contexts is losing its meaning
and importance due to individualisation and a greater emphasis on the
autonomy of the self (e.g., Beck, 1997), or whether there is a conver-
gence toward the model of emotional interdependence with continued
family importance across cultures (e.g., Kagitcibasi, 2007).
It is also important to look at the Postmodernisation theory (Ing-
leart, 1997) and the possibility that this theory can account for some
of the changes that are happening in the ways in which the family is
perceived. Postmodernist theory highlights the importance of the in-
fluences that social change and childhood experiences have on peo-
ple’s value priorities. The theory suggests that as a society becomes
wealthier and more stable, people come to place stronger emphases on
self-expression and quality of life rather than short-term achievements
or economic security. Extending this theory to family views and atti-
tudes, the influences between different levels of factors such as societal
200 Miriam S. Park
factors and value priorities, political beliefs, self-construals and family

views and attitudes can all be linked together. This work proposes a
new comprehensive model that combine these (social constructionist,
new model of family change, Postmodernisation theory) and other (e.g.,
Allan, 2001; Schwartz, 2004; 2006) theories together, demonstrating
factors at multiple levels and their interrelations. Research on family
perceptions by the current author examined value priorities in six cul-
tures. Value priorities such as self-transcendence versus self-efficacy,
openness to change versus conservation values, and postmodernist
versus modernist values were compared across cultures. Furthermore,
political conservatism, political interest, democratic beliefs, and
self-construals were looked at (Park, 2010). By comparing responses
across cultures and generations, this work made an attempt to test and
integrate different theories of family change (Beck, 1997; Delsing et al.,
2003; Kagitcibasi, 2007) and to establish a clear understanding of what
factors impact on the perceptions of family centredness and democra-
tisation, adding to the knowledge on the views and attitudes toward the
family in the modern world. The findings demonstrated that the unique
sociocultural and economic trajectories of each culture had impact on
family perceptions, and that the general beliefs and value orientations
that individuals hold are closely linked to their family beliefs. More re-
search in the field is much needed, and more emphasis should be placed
on looking at cultural and indigenous perspectives on the family in the
less studied regions such as South East Asia. Each of these discussed
factors influencing family perceptions will be explained further in the
following sections of the chapter.
Cultural impact
As mentioned in the introduction, social, cultural, and historical con-

texts are important in understanding the family, for they often influ-
ence family norms and views (Smith, 1995; Thornton & Fricke, 1987).
Significant differences in the family and adopted family values across
cultures can be attributed to macro-level factors such as the historical
background, traditions, level of economic development, and political

and democratic stability (Garzon, 2000). Gallup research on family
values in 1997 demonstrated that individuals in the East Asian coun-
tries such as Japan and South Korea held more traditional views than
their counterparts in the Western European and North American coun-
tries such as Britain, Canada, and the United States. It also found that
the individuals in the more industrialised nations in the West exhibited
less traditional views on aspects such as importance of children in the
sense of personal fulfilment than those in the less industrialised parts
of the world (Gallup, 1997). Inglehart and Baker (2000) claim that
cultural heritage, along with economic development of the society,
has profound influence on the life experiences, and thus on the values
and beliefs of the individuals. These findings, thus, highlight the im-
portance of considering macro-level factors in understanding family
views and attitudes.
The dimension of Individualism-Collectivism (Hofstede, 1980) is
often discussed in interpreting cross-cultural differences found in the
meaning, perception, and interactional patterns in social relationships
and is pertinent to the individual’s relation to his or her family. Where-
as the focus lies on the individual himself/herself and his/her personal
independence, uniqueness, and internal attributes in individualistic cul-
tures, the emphasis on social interactions, and sense of belonging and
relatedness is characteristic of collectivistic cultures (Basabe & Ros,
2005). In this sense, how the self, and particularly, the self in relation
to the family, is conceptualised takes on a profound influence from cul-
ture. Culture also influences family centredness, adherence to in-group
norms, and value priorities. Lay and his associates (1998) found that
those from the Eastern and the Western cultures scored differently on
the Family Scale, observing cultural differences in how closely the in-
dividuals thought themselves to be connected to their families. Their
findings showed that individuals from the East had higher level of fam-
ily allocentrism, and adhered more to in-group norms than their coun-
terparts in the Western group. Basabe and Ros (2005) argued that the
cultural differences can manifest themselves in the emphases placed on
different value types. They found that Hofstede’s dimension was sig-
nificantly correlated with cross-cultural value dimensions such as those
proposed by Schwartz (1994) and Inglehart (1997). Therefore, it should
202 Miriam S. Park
be noted that researchers need to consider these close links of influence

between the levels of factors, cultural and social influences, individual
values and beliefs, and family centredness and democratisation in order
to better understand family processes in different cultures.
Individual-level factors and their influence

on family views and attitudes
Along with cultural influences, individual-level factors of values and

beliefs can also have an impact on family views and attitudes. For ex-
ample, Yabiku, Axinn, and Thornton (1999) claim that values and be-
liefs toward the ‘self’ and the society, and the conception of the self
in relation to close others have close relationship with how the family
is perceived. The value and meaning of the family would reflect the
characteristics and goals of the society (Kagitcibasi, 1996; 2007). The
concept of the self is sensitive to the cultural context in which the indi-
viduals grow up, and the level of autonomy and relatedness perceived
and emphasised in the self influence individuals to socialise and interact
with close others in their society in particular ways (Kagitcibasi, 1996).
Beck and Beck-Gernsheim (2002) and Giddens (1992) have pointed to
the changes in self-concepts and close relationships in the current times.
They noted specifically two characteristics that are most prominent: a
breakaway from the traditional and social norms and more emphasis on
the individual for making important decisions concerning his/her own
life. Values, which reflect what individuals feel as core to their lives,
including desired goals for themselves and the society (Hitlin, 2003),
can have influence on aspects of family relationships including democ-
ratisation of the family (Inglehart, 1997). Thus, the impact of these and
other individual-level factors on family views and attitudes, especially
family centredness and democratisation, should be examined further.
Gender & generation/age effects
In considering family perceptions, the differences between genders as well

as generations, and the reasons as to why these differences exist should
be noted. Conceptions about the family can be changing in the modern
world, but the rate and the type of changes occurring differ across gender
and age groups. Often, changes in family attitudes are more pronounced in
the younger generation and in the female population (e.g., Inglehart, 1997;
Siemienska, 2002; Trent & South, 1992). Thornton and Young-DeMarco
(2001) note the general trend of rising acceptance of egalitarian deci-
sion-making and less gender-specific roles in the last decades. It is believed
that improvements in economic conditions enhance individuals’ chances
of obtaining better and higher education, which in turn have liberalising
effects on the perceptions of family and gender roles (Trent & South, 1992).
Increase in women’s level of education and participation in the workforce,
and ensuing liberalisation from the traditional roles at home are facilitating
these changes (Allan, 2001). Schwartz (2006) argues that cultural and so-
cial norms determine, to some extent, what a family needs to do in order to
function smoothly by setting an expectation specifically for how the family
should be organised, how children should be raised and educated, and how
the members should interact. Differences in attitudes and values between
generations are found similarly across different nations, and these differ-
ences seem to be related to the changes in the level of education, changes
in the social structure, and economic and political situations of the society
(Siemienska, 2002). Therefore, family studies that trace the paths and char-
acteristics of these impacts and the interrelations between these macro-level
factors, values and beliefs, and family views and attitudes can be useful.
Social change
Allan (2001) argues that views and attitudes toward the family should be
studied within the context of recent economic and social transformations.
It is suggested that new ways of conceiving the family are emerging in
204 Miriam S. Park
different parts of the world in the twenty-first century, and that these are
due at least in part to the social changes that took place in the latter half
of the earlier century (e.g., Beck, 1997; Kagitcibasi, 2007; Thornton &
Young-DeMarco, 2001). Social change, or significant changes in the
economic, political, or cultural aspects of the society often impacts on
the individuals and the families, re-shaping views and attitudes toward
the self and the family (e.g., Giddens, 1992; Inglehart, 1997; Kagitcibasi,
1996; 2007). Social change also has an impact on family organisation
and structure, which often also leads to changes in views and attitudes
toward the family (Kagitcibasi, 2007). More specifically, research and
ideas revolving around Postmodernisation theory (Inglehart, 1997)
and models of family and family change (Kagitcibasi, 2007) have dis-
cussed the impact of cultural change on individuals’ values, beliefs,
and family relationships. The traditional meanings of the family might
be disappearing due to the changing societal climate, socioeconomic
conditions, increasing level of education, emphasis on the autonomy or
autonomous-relatedness of the self and democratic beliefs (e.g., Ingle-
hart, 1990; 1997). Therefore, social change can have influence on how
individuals conceptualise the self (sense of relatedness-autonomy) and
close relationships (hierarchy-equality), which in turn can have impact
on their family views and attitudes.
The impacts of recent social change on the individuals, interper-
sonal relationships, and the society are common topics of discussion
in the ‘individualisation’ literature (e.g. Allan, 2001; Beck, 2002; Gid-
dens, 1992). Some researchers suggest that there is a common trend of
increasing autonomy, especially amongst younger generations world-
wide. Beck (1997) discussed that with social change and loosening of
the traditional commitments in areas of life including personal relation-
ships and increasing level of education, younger generations are faced
with greater freedom and independence to choose their own course of
life and independence. The modern trends of increasing emphasis on
individuation, tolerance to diverse ideas, freedom, and reduced commit-
ment to the collective have influence on one’s relations to his/her own
family (Thornton & Young-DeMarco, 2001). Increasing importance of
individualisation can suggest that individuals nowadays are faced with
more freedom in choices and decisions regarding the family, and that
family relationships are becoming more egalitarian since each of its
members, including the children, may be expected to voice his or her

own opinions on family matters (e.g. Beck, 1997). The process of indi-
vidualisation does not embody only the growing sense of independence
and individual choice but also re-shaping of identities and self-beliefs,
as well as re-defining of gender roles in the family. Indeed, relationships
within the family have become more egalitarian over the last few de-
cades due to democratising societies (Delsing et al., 2003).
However, there is an alternative theory and explanation to those
that suggest unidirectional individualisation as a model of family
change. This theory of recent family change claims for convergence
of the cultural impacts, and suggests that the change is not uni-direc-
tional, in that it is not only toward the Western ideals of autonomy and
independence. For example, Kagitcibasi (2007) presents a new family
model that embraces both the emphases on dependence and indepen-
dence, which she suggests can be adopted by all cultures and is most
desirable. Her theory of family change proposes a new model of family,
where both autonomy and relatedness of the individual are emphasised,
which she termed ‘Autonomous-Related Self (-in-Family) (Kagitcibasi,
1996; 2007). She argues that the recent social change has resulted in
individuals’ reduced physical and material dependence on the family
but similar or higher level of emotional dependence and relatedness to
the family than were previously found. According to her theory, both
the influences from the Western and the Eastern cultures are merging
together to better serve the two human needs, both to belong and to be
autonomous in the modern world.
Families in Malaysia
Research data on various aspects of family relations and dynamics in

Malaysia are available, though not in abundance. Some have noted
changes on women’s roles and responsibilities in workplace and home
(see Ahmad, 2007), concluding that the recent economic development
in the country has seen women entering labour force and how this leads
to women having to handle more responsibilities at home as well as at
206 Miriam S. Park
work. Some have pointed out the importance and common occurrence
of intergenerational transfer between the parents and the children in
Malaysia (see Lillard & Willis, 1997) where it used to be the case that
pension and other old-age security schemes were rare to be found. Some
have highlighted the unique cultural and ethnic diversity in Malaysia,
and how this, along with other factors such as religion, social class and
education, can have direct influences on family communication patterns
as well as values of its people (e.g., Moschis, Hosie, & Vel, 2009). Trends
such as increasing level of university education attained by recent birth
cohort in comparison to the older generations and closing of the gaps in
educational attainments amongst different ethnic groups in the country
have been seen, and suggested effects of these on the values, beliefs and
lifestyles of the Malaysians including beliefs and expectations about
the family are commonly discussed in the literature as well (e.g., Brien
& Lillard, 1994). Some distinctive cultural influences on family values
are also found. For example, Stivens (2006) points out that the reviving
Islamic influences and the importance of ‘Asian Values’ in the organisa-
tion and structure of the family within Malaysia in the last decades have
intensified gender difference and inequality for Malays in the country.
With these research evidences, it becomes clear that the socioeconomic
developments, political agenda and the unique cultural forces within
Malaysia have plural and lasting impacts on various aspects of the fam-
ily. Considering its multi-ethnic background and the recent socioeco-
nomic changes, Malaysia provides an interesting cultural ground for
family research. More studies tracing these patterns of close social
relationships in the region should be conducted in the future.
Conclusion
Although various findings suggest that family views and attitudes can be
highly related to socioeconomic factors and childhood experiences that
shape beliefs and values individuals hold (e.g., Dalton & Shin, 2003;
Inglehart, 1997; Inglehart & Abramson, 1999; Inglehart & Baker, 2000;
Inglehart, 2008), a detailed account that explains and combines various
pathways linking the societal influences, individual-level variables, and

family views and attitudes that will contribute to understanding how
current families and beliefs about family centredness and democratisa-
tion are changing has been rare to find. Highlighting the importance of
such research, this chapter discussed the relationship between culture,
gender, age/generation, economic factors that shape life experience of
the individuals, and family centredness and democratisation in detail. It
also pointed out the possible effects of individuals’ beliefs about the self
and autonomy, values, and political beliefs on family centredness and
democratisation, looking at the linkage between the way individuals
perceive and make sense of the family as well as the world around them.
More cross-cultural and intergenerational research on the family is
needed, especially in the parts of the world that are not well studied, in-
cluding South East Asia. Individuals’ perceptions of family centredness,
including family importance, the level of commitment to the family,
dependence to the family, and democratisation within the family should
be examined further in relation to these macro-level and individual-
level variables. More studies on Asian families as well as cross-cultural
investigations should be conducted in order to provide us with better
understanding of family processes and relations which lead to particular
family perceptions in these cultures, and will be a basis for decoloniz-
ing knowledge within the psychological science.
References
Ahmad, A. (2007). Work-family conflict, life-cycle stage, social sup-

port, and coping strategies among women employees. Journal of
Human Resources & Adult Learning, 3(1), 70–79.
Allan, G. (2001). Personal relationships in late modernity. Personal
Relationships, 8, 325–339.
Aycicegi-Dinn, A., & Kagitcibasi, C. (2010). The value of children for
parents in the minds of emerging adults. Cross-Cultural Research,
44(2), 174–205.
208 Miriam S. Park
Basabe, N., & Ros, M. (2005) Cultural dimensions and social Behav-
iour correlates: Individualism-Collectivism and Power Distance.
International Review of Social Psychology, 18(1), 189–225.
Beck, U. (1997). Democratization of the family. Childhood, 4, 151–168.
Beck, U., & Beck-Gernsheim, E. (2002). Individualization. London:
Sage Publications.
Bengston, V. L., & Roberts, R. E. L. (1991). Intergenerational solidarity
in aging families: An example of formal theory construction. Jour-
nal of Marriage & the Family, 53, 856–870.
Brien, M. J., & Lillard, L. A. (1994). Education, marriage and first con-
ception in Malaysia, Journal of Human Resources, 29(4), 1167–
1204.
Dalton, R. J., & Shin, D. (2003). Democratic aspirations & democratic
ideals: Citizen orientations toward democracy in East Asia. Pro-
ceedings of the Hawaii International Conference on the Social
Sciences, Honolulu, Hawaii, June, 2002, 1–25.
Delsing, M. J. M. H., Oud, J. H. L., De Bruyn, E. E. J., & Van Aken,
M. A. G. (2003). Current & recollected perceptions of family rela-
tionships: The social relations model approach applied to members
of three generations. Journal of Family Psychology, 17(4), 445–459.
Gallup. (1997). 1997 Global Study of Family Values: GPNS Special
Report. Retrieved from <http://www.gallup.com/poll/9871/1997-
Global-Study-Family-Values.aspx#2>.
Garzon, A. (2000). Cultural change & familism. Psicothema, 12, 45–54.
Giddens, A. (1992). The Transformation of Intimacy: Sexuality, Love, &
Eroticism in Modern Societies. Cambridge: Polity Press.
Hitlin, S. (2003). Values as the core of personal identity: Drawing links
between two theories of self. Social Psychology Quarterly, 66(2),
118–137.
Hofstede, G. (1980). Culture’s Consequences: International Differences
in Work-Related Values. Beverly Hills, CA: Sage.
Inglehart, R. (1990). Culture Shift: In Advanced Industrial Society.
Princeton, NJ: Princeton University Press.
Inglehart, R. (1997). Modernization & Postmodernization: Cultural,
Economic, & Political Change in 43 Societies. Princeton, NJ:
Princeton University Press.
Inglehart, R. (2008). Changing Values among Western publics from

1970 to 2006. West European Politics, 31, 130–146.
Inglehart, R., & Abramson, P. R. (1999). Measuring Postmaterialism.
American Political Science Review, 93(3), 665–677.
Inglehart, R., & Baker, W. E. (2000). Modernization, cultural change,
& the persistence of traditional values. American Sociological
Review, 65, 19–51.
Kagitcibasi, C. (1996). Family & Human Development across Cultures:
A View from the Other Side. Mahwah, NJ: Lawrence Erlbaum
Associates, Inc., Publishers.
Kagitcibasi, C. (2007). Family, Self, & Human Development across
Cultures: Theory & Applications. Mahwah, NJ: Lawrence Erlbaum
Associates, Inc., Publishers.
Lay, C., Fairlie, P., Jackson, S., Ricci, T., Eisenberg, J., Sato, T., Teeaar, A.,
& Melamud, A. (1998). Domain-specific Allocentrism-Idiocen-
trism: A measure of family connectedness. Journal of Cross-
Cultural Psychology, 29(3), 434–460.
Lillard, L. A., & Willis, R. J. (1997). Motives for intergenerational
transfers: Evidence from Malaysia. Demography, 34(1), 115–134.
Moschis, G. P., Hosie, P., & Vel, P. (2009). Effects of family structure
and socialisation on materialism: A life course study in Malaysia.
Journal of Business & Behavioural Sciences, 21(1), 166–181.
Park, M. S. (2010). Family centredness and democratisation across
cultures and generations: Investigation of the impacts of macro-
and individual-level factors. (Unpublished Doctoral Dissertation).
Brunel University, England.
Schwartz, S. H. (1994). Are there universal aspects in the content and
structure of values? Journal of Social Issues, 50, 19–45.
Schwartz, S. H. (2004). Mapping and interpreting cultural differences
around the world. In H. Vinken, J. Soeters & P. Ester (Eds.), Com-
paring Cultures (pp. 43–73), Leiden: Brill Academic Publishers.
Schwartz, S. H. (2006). A theory of cultural value orientations: Explica-
tion and application. Comparative Sociology, 5, 136–182.
Siemienska, R. (2002). Intergenerational differences in political values
and attitudes in stable and new democracies. International Journal
of Comparative Sociology, 43(3), 368–390.
210 Miriam S. Park
Smith, S. (1995). Family theory & multicultural family studies. In B.B.

Ingoldsby & S. Smith (Eds.), Families in Multicultural Perspective.
New York, NY: The Guilford Press.
Stivens, M. (2006). ‘Family values’ & Islamic revival: Gender, rights
and state moral projects in Malaysia. Women’s Studies Internation-
al Forum, 29, 354–367.
Trent, K., & South, S. J. (1992). Sociodemographic status, parental
background, childhood family structure, and attitudes toward
family formation. Journal of Marriage and the Family, 54,
427–439.
Thornton, A., & Fricke, T. E. (1987). Social change and the family:
Comparative perspectives from the West, China, & South Asia.
Sociological Forum, 2(4), 746–779.
Thornton, A., & Young-DeMarco, L. (2001). Four decades of trends
in attitudes toward family issues in the United States: The 1960s
through the 1990s. Journal of Marriage and the Family, 63, 1009–
1037.
Yabiku, S. T., Axinn, W. G., & Thornton, A. (1999). Family integration
and children’s self-esteem. American Journal of Sociology, 104(5),
1494–152.
Cai-Lian Tam and Qiu-Ting Chie
Factors influencing voting behaviour

in Malaysia
The political structure in Malaysia is indeed complex as it combines

constitutional monarchy and parliamentary democracy. Within the
parliamentary democratic system, political parties require public sup-
port to assume power and rule the country. In order to enjoy continued
public confidence, ruling parties often adopt pro-people policies and
ensure good governance at every level of the administration (Bardes
& Oldendick, 2007). As a country that contains three major ethnic
communities, Malaysia is well known for practicing consociational
government system since its independence in 1957. Four main fea-
tures of consociational systems as identified by Lijphart are: (a) grand
coalition government (parties from different segments of society), (b)
segmental autonomy (in the cultural sector), (c) proportionality (in the
voting system and public sector employment) and (d) minority veto (as
cited in Wolff, 2006). Similar political systems are practiced in several
other countries such as Lebanon, Cyprus, Switzerland, Austria, the
Netherlands, Belgium and Fiji. The term for the Malaysian parliament
is five years and the country organised its 13th general election on 5th
May 2013 with an impressive 84.84% voter turnout (The Star, 2013).
Subsequent analysis on the voting pattern revealed that socio-economic
factors played a significant role in changing political dynamics in the
country (Raslan, 2013). Aspects such as political trends, political
choice and voting behavior are generally examined using electoral re-
sults (Ahmad, 1999; Khalid & Awang, 2008), but voters’ psychological
dispositions are rarely examined in the Malaysian context.
Psychological factors such as personality traits (Schoen &
Schumann, 2007), social or peer-conformity (Coleman, 2004), and cog-
nition (Heath, Andersen, & Sinnott, 2002) can greatly influence aware-
ness of the political situation, political choice and voting behaviour.
212 Cai-Lian Tam and Qiu-Ting Chie
Factors such as neighbourhood characteristics, education level, marital

status, gender and age (Harder & Krosnick, 2008) to name a few, may
motivate or present barriers to electoral participation. Government ini-
tiatives such as registration drives (Harder & Krosnick, 2008), time-off
laws (Sterling, 1983), and political education (Nagler, 1991) to ease
voting difficulties and increase political awareness among the young
can also influence perceptions about the ruling party and affect electoral
outcomes. Although the influence of such psychosocial factors is well
known, its literature in relation to voting behaviour in Malaysia is not
extensive. This chapter reviews current theories of voting behavior and
examines findings linking psychosocial factors with voting preferences.
Psychological factors influencing voting behaviour
Psychological factors that have a notable influence on political attitudes

are cognition, personality and peer/social conformity (Bardes & Old-
endick, 2007). Cognitive factors such as knowledge of political par-
ties and current issues may affect people’s voting preferences (Heath
et al., 2002). However, there are disputes as to whether having political
knowledge will prevent voters from making mistakes in their choices.
Popkin suggested that uninformed voters could act as knowledgeable by
using heuristics, an information shortcut to make voting decisions (as
cited in Heath et al., 2002). Voters could follow the position taken by
a leader or political group that they believe would prioritise their best
interests (Heath et al., 2002). In addition, studies of voters’ cognition
also consider factors that will benefit citizens from the act of voting.
This process has been described in several voting behaviour models.
The earliest model in voting literature was developed in 1957 by Downs
(as cited in Harder & Krosnick, 2008) in the form of an equation: R =
(B) (P) − C +D.
According to Ferejohn and Fiorina (1974), R is the total reward
an individual will gain from voting while B is the benefit an individ-
ual thinks will arise from having the candidate win. P represents an
individual’s perception of the probability that a vote will change the
Factors influencing voting behaviour in Malaysia 213
election outcome while C symbolises the cost of voting in terms of

time, money, and resources. Lastly, D represents the satisfaction gained
from voting. If R has a positive value, the citizen gains a reward from
voting that outweighs the costs and will therefore participate in the elec-
tion. The more the positive value of R, the more likely an individual is
to vote (Ferejohn & Fiorina, 1974).
A slightly different conceptual framework has recently been pro-
posed by Harder and Krosnick (2008):
motivation to vote x ability to vote

Likelihood of voting =
difficulty of voting
According to this framework, an individual’s voting behaviour is pre-
sumed to be a function of motivation to vote, the ability to vote and the
difficulty of voting. Higher motivation to vote will lead to higher turn-
out rate and vice versa. The motivation to vote could stem from a strong
preference for a particular candidate. Other motivating factors include
the belief that a responsible citizen should vote, and pressure received
from one’s friends or family to vote. The second variable, which is the
ability to vote, refers to an individual’s aptitude to make sense of politi-
cal information to form a candidate preference. Moreover, the individu-
al must be able to understand and meet the requirements to vote legally
and implement the required voting behaviour. Lastly, the difficulty of
voting refers to external conditions such as the convenience or stringen-
cy of registration procedures, the availability of information about the
candidates, the publicity of polling locations and the physical closeness
of polling centers. Therefore, the political information received through
media and the evaluation of conditions surrounding voting are essential.
The effect of personality traits on political attitudes and voting de-
cisions in Germany was examined by Schoen and Schumann (2007).
Survey data were obtained from a random group of German citizens
and the findings verified that various personality traits measured on the
Five Factor Model (FFM), contributed to political attitude formation
and decision making. The FFM (Costa & McCrae, 1992) defines per-
sonality based on five major dimensions (Table 1):
Table 1: Dimensions of five factor personality model.
FFM personality dimensions Trait definition

1. Extraversion Sociable and energetic; as opposed to introversion
whereby an individual is reserved or solitary
2. Agreeableness Compassionate and cooperative; as opposed to
being suspicious and hostile to others
3. Conscientiousness Efficient and organised, demonstrating
self-discipline and dutifulness; as opposed to
being spontaneous and easy-going
4. Neuroticism Nervous and sensitive; as opposed to emotional sta-
bility where the individual is secure and confident
5. Openness to Experience Curious and inventive, with the ability to appreci-
ate the arts, adventure and new ideas; as opposed
to being cautious and conservative
Schoen and Schumann (2007) found that openness to experience makes

citizens more liable to support social and liberal parties. Citizens who
are low in conscientiousness or high in agreeableness are more likely
to vote for economic or social liberalism. However, citizens displaying
high levels of neuroticism are more likely to support parties that offer
protection against material or cultural threats. Among the younger gen-
eration, voting behaviour is influenced by peer pressure, basically by
means of social conformity (Coleman, 2004). Coleman (2004) empha-
sised that social conformity influences the decision to vote or refrain
from voting. An example of voting conformity is the ‘bandwagon effect’
where a voter chooses a candidate who has the greatest chance of win-
ning the elections or switches for such a candidate if the chances of the
preferred one winning are minimal (Nadeau, Niemi, & Amato, 1994).
Psychosocial factors influencing voting behaviour
Campbell, Converse, Miller and Stokes (1960) proposed a framework on

how social settings influence party identification, evaluation and voters’
choice. Factors such as ethnicity, religion, education, occupation, and
socio-economic class are found to influence party identification. Party

identification will then influence evaluation about candidates, campaign
issues and relationships between the individual and family and friends
(Campbell et al., 1960). Subsequently, a voting decision will be formed
after evaluating these factors. Other social factors that may influence
voting behaviour are marital status, level of civic duty, and participa-
tion in civic activities (Harder & Krosnick, 2008). Kingston and Fin-
kel (1987) found that married or partnered couples have higher voter
turnouts compared to singles. More politically-inclined individuals will
motivate their less politically-inclined spouses through persuasion. Be-
sides that, voluntary involvement in social organisations increases civic
duty and involvement in cooperative activities will inspire citizens to
exercise their voting rights (Tate, 1991).
Neighbourhood characteristics such as education level, income,
gender, occupation, age, mobility and residency also have an impact on
voting behaviour (Harder & Krosnick, 2008). Nagler (1991) proposed
that education is associated with higher voter turnout because education
enhances the ability to understand local political processes. Education
offers civic sense and dutifulness among the young and provides a plat-
form to instil political interest (Nagler, 1991). Hillygus (2005) exam-
ined data from the Baccalaureate and Beyond Longitudinal Study and
found that individuals with high verbal SAT scores were more likely
to vote. Moreover, students majoring in social sciences were more
engaged in political activities, and students who developed language
and civic skills at school were more likely to be experienced with the
democratic process (Hillygus, 2005).
During economic recessions, citizens experiencing the adverse ef-
fect of the recession are less likely to vote, because they have less time
for voting preparations (Radcliff, 1992). In contrast, citizens earning
higher incomes have the tendency to vote because they have more time
to spare for voting and politics (Rosenstone & Hansen, 1993). More-
over, they stand to gain social and psychological rewards from voting
(Rosenstone & Hansen, 1993). Starting in the mid-1980s, women start-
ed to become more involved in voting at equal or higher rates than men
due to a rise in self-efficacy and political interest (Schlozman, Burns,
Verba, & Donahue, 1995). The efforts of the suffragettes led to import-
ant roles in the workplace for women and an equal standing with men.
As a result, women started participating in more decision making and

voting.
Bennett and Orzechowski (1983) examined the influence of oc-
cupation on voting behaviour and suggested that government work-
ers have higher turnout rates because they have a clearer stake in the
election outcome; their job positions will be greatly influenced by
the ruling political party. Highton (2000) suggested that residential
mobility interferes with the ability to vote. Individuals who have relo-
cated to a new residence are less able to devote time for the registration
process at a new voting location. In addition, citizens in rural areas
have higher voter turnout as compared to urban areas (Wolfinger &
Rosenstone, 1980). This is because most residents in rural areas tend to
be involved in agriculture and have higher stakes in election outcomes
involving farming subsidies and policies. Citizens from early to middle
adulthood are more likely to vote while citizens aged above 75 years
are less likely to vote (Strate, Parrish, Elder, & Ford, 1989). In early
adulthood, citizens gather information and voting skills. As they enter
middle adulthood, they gradually become knowledgeable voters after
watching the political parties and process in action for a few years.
After the age of 75, health and physical mobility declines, resulting in
lower voter turnouts.
Voting in the Malaysian context
Khalid and Awang (2008) examined voting patterns in various ethnic

groups in Malaysia based on data from the 2004 general elections. It
was found that political involvement among Malaysians began at a
young age as a majority of voters were 40 years or younger. In regards
to the motivation to vote, the majority stated that they would vote for
the sake of the political party, followed by the electoral candidate. As
not much work has been done to examine how psychosocial factors in-
fluence voting behaviour in Malaysia, this section will focus on findings
from other countries and try to gain some perspectives about the issue
in the multi-ethnic context of Malaysia.
There are four factors that might affect vote casting in the elections
among medium income groups. Firstly, the thought that a change in
government could bring significant development to the country. These
kinds of thoughts are more common among individuals with high po-
litical interest. Fuad et al. (2011) examined ethnic attitudes towards
politics and found that the Malays were more interested in politics as
compared to the Chinese and Indians. Secondly, the influence of friends
or family on voting preference could be crucial. Being raised in a col-
lectivist society, Malaysians are essentially interdependent and more
likely to be influenced by goals and expectations of other group mem-
bers such as family and friends (Mills & Clark, 1982). Thirdly, the level
of political trust among young voters might influence vote casting. For
example, parties that are only interested in votes but neglect the constit-
uents’ voices will not bode well with voters (Harder & Krosnick, 2008).
Fourthly, factors such as corruption and lobbying may influence
voting preferences. There is an underlying assumption that if voters
knew a political candidate was dishonest or unethical, that candidate
would be ousted (Grossman & Helpman, 1999). A link between politi-
cians and lobbyists may also negatively influence electoral behaviour.
Lobbyists are the people (could be individuals or groups) who try to in-
fluence decisions made by Government officials or politicians on behalf
of a group or individual who hires them. Malaysian voters are becoming
more vocal about what they want from the ruling party and any infor-
mation of such ties with lobbyists would greatly influence candidate
votes. Despite the fact that corrupt and lobbyist-associated politicians
are perceived negatively, there are cases where voters still voted for
them. Peters and Welch (1980) suggested four explanations for this.
Firstly, voters might be misinformed or totally uninformed about the
corrupt candidate. Young voters might be unaware of the news sur-
rounding the candidate if the corruption case happened a long time ago.
Even with reliable information about proven corruption, some voters
may misperceive or refuse to believe it. Secondly, voters might know-
ingly vote for a corrupt politician by trading votes for material gain or
economic rewards. Thirdly, although corruption is commonly seen as
a disease, some voters may perceive it as a necessary evil. The prev-
alence of corruption in both public and private sectors in Malaysia is
acknowledged, and the Malaysian Government has taken steps to curb
corruption through the National Integrity Plan (Transparency Interna-

tional, n.d). Fourthly, voters may weigh corruption charges against the
importance of other factors such as party identification.
In some cases, it is also observed that if the life circumstances of
the voters are inherently different from the party candidate, they may
not vote for him (Cutler, 2002). A negative relationship between vote
choice and voters’ sociodemographic dissimilarity with the party candi-
date was reported. More disadvantaged individuals would not vote for
candidates who do not advocate policies and subsidies for the needy, or
for candidates who are from privileged backgrounds.
Sometimes the complexity of the electoral system is seen to be an
obstacle to vote in a multi-ethnic society like Malaysia, the reason be-
ing that members of different ethnic groups might have different levels
of knowledge about the system (Wolff, 2006). When a complex elec-
toral system exists, the introduction of new reforms after a prolonged
absence of elections would require proper public information dissem-
ination and education campaigns. This is to ensure voters properly un-
derstand the election mechanics and the consequences of their votes. It
is probably the awareness of this situation that brought about a recent
proposal by the Election Commission Malaysia to introduce the elec-
tion system in the secondary school curriculum. Election Commission
records revealed that there were about 3.7 million unregistered eligible
voters in the country (Azizan, 2012). A lack of political interest among
the young, not knowing registration procedures, and a laid-back attitude
towards voting were some of the reasons given by young eligible voters.
However, the governing party also needs to remember that familiarity
with the electoral system is a double-edged sword for voters. Familiarity
enables voters to make informed decisions about their votes. However,
it can also lead to distrust of electorate results, especially if they
have experienced discrimination and disadvantages in their electoral
exercise.
The careless attitude towards voting might also stem from other
reasons. It is unfair to categorise voters who do not vote as irresponsible
because some voters may be experiencing difficulties and are too bur-
dened with daily responsibilities to vote (Azizan, 2012). Many do not
see how one vote matters since past experience may have instilled the
perception that voting will not bring any change that they want to see.
In addition to young voters’ attitudes, the Election Commission also

needs to seriously tackle barriers to registration which may influence
voter turnout before the actual voting itself (Harder & Krosnick, 2008).
Examples of such barriers include accessibility of physical registration
locations, opening hours for registration, permission for deputy regis-
trars to complete the registration process, registration drives and time-
off laws.
Although registration drives are commonly organised by the Elec-
tion Commission with the intention of reducing the registration diffi-
culties, interestingly, Cain and McCue (1985) found that people who
registered through registration drives vote at lower rates than people
who registered voluntarily. Nonetheless, registration drives do appear to
increase overall turnout rates. On the other hand, Sterling (1983) found
that “time-off” laws which allow employees time off to vote do not ap-
pear to increase registration. This suggests that work requirements are
not a serious obstacle to voting. The Electorate Commission should also
consider the circumstances for citizens with disabilities. According to
Schur, Shields, Kruse and Schriner (2002), citizens with disabilities
have lower-than-average turnout, probably because their disabilities af-
fect voting ability. Efforts to reduce time costs, such as allowing people
to vote before the actual electoral day in-person and allowing absentee
voting on paper, all lead to increases in turnout rates (Berinsky, Burns,
& Traugott, 2001). Therefore, the Election Commission and the ruling
government still have much groundwork to do to capture the citizens’
heart and encourage them to exercise their voting rights.
Conclusion
There is still much work to be done in understanding Malaysian voting

behaviour from psychosocial perspectives. There is a shortage of liter-
ature particularly in the areas of emotion, personality traits, social and
peer conformity as well as political allegiance among young voters. It is
also essential to examine the influence of social and environmental fac-
tors on political choice and voting behaviour in Malaysia. This would
help the political parties and people better understand the important
predictors that could lead to higher electoral participation and less
political dissatisfaction.
References
Ahmad, Z. H. (1999, December). The 1999 general elections: A prelim-

inary overview. Paper presented at the Trends in Malaysia Seminar
at the Institute of South Asian Studies, Singapore.
Azizan, H. (2012, 25 March). Teacher, will this come out in the exam?
The Star, p. 24.
Bardes, B. A., & Oldendick, R.W. (2007). Public Opinion: Measuring
the American Mind (3rd edition). Belmont, CA: Wadsworth/Thom-
son Learning.
Bennett, J. T., & Orzechowski, W. P. (1983). The voting-behavior of bu-
reaucrats: some empirical evidence. Public Choice, 41(2), 271–283.
Berinsky, A. J., Burns, N., & Traugott, M. W. (2001). Who votes by
mail? Public Opinion Quarterly, 65 (2), 178–197.
Cain, B. E., & McCue, K. (1985). The efficacy of registration drives.
The Journal of Politics, 47 (4), 1221–1230.
Campbell, A., Converse, P. E., Miller, W. E., & Stokes, D. E. (1960).
The American Voter. New York, NY: John Wiley & Sons.
Coleman, S. (2004). The effect of social conformity on collective voting
behavior. Political Analysis, 12 (1), 76–96.
Costa, P. T., & McCrae, R. R. (1992). NEO-PI-R, Professional manual.
Odessa, FL: Psychological Assessment Resources.
Cutler, F. (2002). The simplest shortcut of all: Sociodemographic char-
acteristics and electoral choice. The Journal of Politics, 64 (2),
466–490.
Downs, A. (1957). An economic theory of democracy. New York, NY:
Harper & Row.
Ferejohn, J. A., & Fiorina, M. P. (1974). The paradox of not voting:
A decision theoretic analysis. American Political Science Review,
68(2), 525–536.
Fuad, M. J., Junaidi, A.B., Buang, A., Selavadurai, S., Er, A. C., &
Lyndon, N. (2011). Ethnic attitudes, political preferences and the
politics of stability. World Applied Sciences Journal, 13, 34–38.
Grossman, G., & Helpman, E. (1999). Competing for endorsements.
American Economic Review, 89, 501–524.
Harder, J., & Krosnick, J. A. (2008). Why do people vote? A psycho-
logical analysis of the causes of voter turnout. Journal of Social
Issues, 64 (3), 525–549.
Heath, A., Andersen, R., & Sinnott, R. (2002). Do less informed voters
make mistakes? Political knowledge and electoral choice. Amer-
ican Political Science Review, 97, 1–19. Retrieved from <http://
www.crest.ox.ac.uk/papers/p97.pdf>.
Highton, B. (2000). Residential mobility, community mobility, and
electoral participation. Political Behavior, 22(2), 109–120.
Hillygus, D. S. (2005). The missing link: Exploring the relationship
between higher education and political engagement. 27(1), 25–47.
Khalid, K. M., & Awang, H. (2008). Voting patterns: Evidence from
the 2004 Malaysian General Elections. Journal of Politics & Law,
1(4), 33–44.
Kingston, P. W., & Finkel, S. E. (1987). Is there a marriage gap in poli-
tics? Journal of Marriage and the Family, 49(1), 57–64.
Mills, J., & Clark, M. S. (1982). Exchange and communal relationships.
In L. Wheeler (Ed.). Review of personality and social psychology
(pp. 121–144). Beverly Hills, CA: SAGE Publications.
Nadeau, R., Niemi, R. G., & Amato, T. (1994). Expectations and pref-
erences in British general elections. American Political Science
Review, 88 (2), 371–383.
Nagler, J. (1991). The effect of registration laws and education on U.S.
voter turnout. American Political Science Review, 85(4), 1393–1405.
Peters, J. G., & Welch, S. (1980). The effects of charges of corruption
on voting behavior in congressional elections. The American Polit-
ical Science Review, 74(3), 697–708. Retrieved from <http://www.
jstor.org/stable/1958151>.
Radcliff, B. (1992). The welfare state, turnout, and the economy: A
comparative analysis. American Political Science Review, 86(2),
444–454.
Raslan, K. (2013, 7 May). The changing political dynamics. The Star. Re-
trieved from <http://thestar.com.my/columnists/story.asp?col=cerita
lah&file=/2013/5/7/columnists/ceritalah/13075625&sec=Ceritalah>.
Rosenstone, S. J., & Hansen, J. M. (1993). Mobilization, participation,
and democracy in America. New York, NY: Macmillan.
Schlozman, K. L., Burns, N., Verba, S., & Donahue, J. (1995). Gender
and citizen participation: Is there a different voice? American Jour-
nal of Political Science, 39(2), 267–293.
Schoen, H., & Schumann, S. (2007). Personality traits, partisan
attitudes and voting behavior: Evidence from Germany. Political
Schur, L., Shields, T., Kruse, D., & Schriner, K. (2002). Enabling de-
mocracy: Disability and voter turnout. Political Research Quarter-
ly, 55 (1), 167–190.
Sterling, C. W. (1983). Time-off laws & voter turnout. Polity, 16 (1),
143–149.
Strate, J. M., Parrish, C. J., Elder, C. D., & Ford, C. (1989). Life span
civic development and voting participation. American Political
Science Review, 83(2), 443–464.
Tate, K. (1991). Black political participation in the 1984 and 1988
presidential elections. American Political Science Review, 85(4),
1159–1176.
The Star (2013, 6 May). GE13: EC – Record 85% turnout: BN gets 46.5%
of popular vote. Retrieved from <http://elections.thestar.com.my/
story.aspx?f ile=/2013/5/6/nation/20130506213336#.UYoAy
Up0nA0>.
Transparency International (n.d.). Towards a corruption free Malaysia.
Retrieved from <http://www.transparency.org.my/documents/TOW
ARDS%20A%20CORRUPTION%20FREE%20MALAYSIA.
pdf>.
Wolff, S. (2006). Electoral systems design and power-sharing regimes.
In I. O’Flynn & D. Russell (Eds.), Powersharing: New Challeng-
es for Divided Societies. Ann Arbor, MI: University of Michigan
Press.
Wolfinger, R. E., & Rosenstone, S. J. (1980). Who votes? New Haven,
CT: Yale University Press.
Jasmine M. Y. Loo
A primer in problem gambling
This essay aims to present a collection of key areas in problem gam-

bling. It will provide an overview of prevalence research, variables
implicated in problem gambling, and assessments utilised in the mea-
surement of problem gambling behaviour. Gambling is viewed as an
event of risking a sum of money on a specific outcome that is specified
by change, regardless of past loss. This behaviour has gained consider-
able interest among policy makers, clinicians, researchers, public health
specialists, and the common public. This essay will define the spectrum
of gambling behaviour and how its classifications have evolved over
time. Previous research has shown that every gambler is unique; hence,
treatment should be tailored to the specific needs of the individual.
However, to devise effective intervention strategies for controlling prob-
lem gambling behaviour amongst general population, more attention
should be given on theory development and evidence-based research at
the first place.
A snippet of a typical gambler
Let’s start with the case of Alexander (not the real name). For Alexander,
gambling was an occasional affair for social enjoyment during the first
32 years of his life. At age 32, he had everything going for him as he
owned a successful accounting business, had a great reputation among
his peers, and a good family. In his 33rd year, he made a trip to Las Ve-
gas and was elated when he won some money while playing blackjack.
During the next two years, he visited casinos regularly and was win-
ning a great deal of money. Suddenly, his luck changed and he began to
lose steadily and more heavily. As his gambling activities expanded to
224 Jasmine M. Y. Loo
horse racing, card games, and illegal sports gambling; the frequency of
gambling also increased. Over the next six years, he consumed all his
assets and eventually began to illegally channel his clients’ funds to fuel
his addiction to gambling. He was later indicted, arrested, and sent to
prison for using his clients’ money. His gambling addiction cost him his
accounting license, reputation, family, assets, freedom, and he nearly
took his own life.
Unfortunately, experiences like Alexander’s, which impact on
all aspects of life, are quite common among both Western and Asian
ethnic groups, particularly among the Chinese. As gambling reve-
nues increase over the years in countries such as the United States,
Australia, Macao and Singapore, it is reasonable to argue that the
percentage of individuals involved in gambling activities will also in-
crease. In Australia, approximately 16,000 adult Queenslanders are
classified as problem gamblers (PGs) and 57,000 persons are classified
in the moderate risk of gambling group (Queensland Treasury, 2006).
Furthermore, a nationwide research reported that a total of 80,000
to 160,000 Australians are adversely affected by problem gambling
(PG) and other associated effects of their addiction, while 230,000
to 350,000 are moderately affected by PG (Productivity Commission,
2010). It has been argued that despite the alarming rate of PG, many
problem gamblers (PGs) do recover after seeking treatment and they
would in turn assist other PGs struggling with gambling addiction.
Research in the area of gambling evolves periodically, resulting in a
much needed advancement in preventative methods, treatment, and
intervention strategies.
Historically, the word “gambling” elicits many different interpreta-
tions and meanings that are contingent on cultural and social contexts.
Generally, gambling can be termed as an act of risking a sum of money
on the outcome of a game or event, which is determined by chance.
Gambling occurs in many forms, most commonly pari-mutuels (horse
and dog tracks, off-track-betting parlours, Jai Alai), lotteries, casinos
(slot machines, table games), bookmaking (sports books and horse
books), card rooms, bingo and the stock market. In particular, slot or
pokies machines have emerged as a dominant form of gambling activity
in modern times, particularly among Western countries (Raylu & Oei,
2002). Gambling evokes a gamut of human emotions and behaviours
A primer in problem gambling 225
that are apparent readily when gamblers win or lose. In turn, they drive
a vicious cycle of excessive gambling in our society. Such a cycle has
been an integral part of human history and is widespread in many parts
of the world today (Shaffer, Hall, & Vander Bilt, 1997). At present, gam-
bling is legal in many countries and readily accessible to individuals
that meet the minimum requirement for age limit, which differs accord-
ing to state or country.
Nature of problem gambling
The perception of increased PG prevalence induced by the media has

driven concern and research interest among policy makers, clinicians,
researchers, and the public. Empirical data detailing the extent of PG
are useful for many purposes such as developing public health services
and medical services. This section discusses the prevalence and nature
of pathological gambling and PG among the general literature.
A selection of classifications have been used to describe problemat-
ic gambling such as compulsive, disordered, pathological, at-risk, exces-
sive, problem, and addicted (Blaszczynski & Nower, 2002; Shaffer et al.,
1997). The notion of gambling as an addiction had been a contentious
issue, but there are however some consensus in the literature that will be
discussed here. The Diagnostic and Statistical Manual of Mental Disor-
ders (DSM-5; American Psychiatric Association, 2000, 2013) describes
gambling disorder as a destructive and reoccurring gambling behaviour
that interferes with personal, familial, and occupational pursuits. In
gambling research, three widely used terms: “problem gambling (PG)”,
“compulsive gambling”, and “pathological gambling” have been used
synonymously to illustrate the above condition (Raylu & Oei, 2002).
The term “pathological” is commonly used by clinicians, while the term
“compulsive” is generally used by laypersons such as Gamblers Anon-
ymous members. Gamblers Anonymous is a group support organized
internationally to support recovering problem gamblers in their jour-
ney of gambling cessation. At present, the term “problem” is favoured
as it avoids the medical and derogatory connotations of “pathological”
(Walker & Dickerson, 1996). Nevertheless, in some studies, the term

“problem gambler” is used to categorise individuals whose gambling is
at an earlier stage and lower in frequency that does not meet diagnostic
criteria. In other studies, it is used frequently to refer to both pathological
gamblers and individuals who do not meet the diagnostic criteria.
Currently, it is safe to assume that the term “problem gambling” in-
cludes a variety of difficulties with gambling, not purely the most severe
as regularly depicted by the term “Gambling Disorder”. In this research,
problem gambling (PG) will be used to define a situation when an
individual’s gambling activity elicits harm to the gambler and/or signif-
icant others regardless of whether they meet the criteria for pathological
gambling (Lesieur & Blume, 1987). Problem gambling is also typified
by a lack of control over money and time spent on gambling behaviour
that precipitate negative consequences for the gambler and community.
The term “pathological gambling” is used to categorise individuals who
meet the diagnostic criteria in the DSM-IV-TR and combined as prob-
lem gambling (PG) at the extreme end of the continuum.
When gambling is regarded as a recreational activity, it does not
pose a threat. However, gambling can be addictive and can result in
PG and Gambling Disorder, which can lead to financial, emotional and
relational stress. A diagnosis of PG has been linked with several medi-
cal disorders such as liver disease and cirrhosis, and increased medical
utilisation and healthcare costs (Morasco et al., 2006). The spouses of
PGs are often faced with severe emotional, psychological, and financial
stresses. Their children grow up in family environments that are char-
acterised typically by parental neglect that leave the children vulnerable
to addictions themselves.
Prevalence of problem gambling
Various studies have found that approximately 70–90% of adults (Vol-

berg, Nysse-Carris, & Gerstein, 2006) and 81% of adolescents (Gupta
& Derevensky, 1997) have gambled at least once in their lifetime. In
a British prevalence survey, 32 million of adults, which made up 68%
of the population had gambled in the past 12 months (Wardle et al.,

2007). Gambling participation rates in Victoria have remained stable
from 2003 to 2008, averaging at 75% lifetime prevalence (McMillen,
Marshall, Ahmed, & Wenzel, 2004). However, the participation rates
of electronic gaming machines dropped from 30% in the years 2003 to
2007 to 21.46% in 2008 (Thomas & Jackson, 2008). A meta-analysis
by Shaffer, Hall, and Vander Bilt (1997) found that lifetime prevalence
rates among adults in the general population of the United States were
estimated at 1.60% for pathological gamblers (more stringent criteria)
and 5.45% for PGs and pathological gamblers combined (less stringent
criteria). Similarly, lifetime prevalence rates internationally (primarily
America, Canada and Australia) have been found to range from 0.1%
to 5.1% (Petry & Armentano, 1999), while current prevalence rates
ranged from 1% to 2% (Walker & Dickerson, 1996). In Singapore, a re-
cent survey reported that gambling prevalence rates were 1% to 2% for
symptomatic pathological gamblers and 47% of residents reported hav-
ing gambled in the past year (National Council on Problem Gambling,
2011). Reports on the Malaysian prevalence survey showed that approx-
imately 13% are probable pathological gamblers and 36.7% of these
pathological gamblers are within 21 to 30 years (Loo & Ang, 2013).
Comorbidity with pathological gambling is also common as up
to 50% of gamblers have substance use disorders (Lesieur, Blume, &
Zoppa, 1986). There are high rates of obsessive compulsive disorder,
anxiety disorders, and depressive disorders diagnosed among patholog-
ical gamblers and some studies have reported that suicide risks are high
among this population. Approximately 48–70% of PGs contemplate
suicide and 12–25% actually attempt suicide (Ledgerwood, Steinberg,
Wu, & Potenza, 2005).
Development and maintenance of problem gambling
Some people may experience excitement when gambling, whereas some

may find that risking their possessions on a game of chance not worth
their time and money. A complex interplay of factors work together to
determine the onset of gambling problems and it is not just a particular

trigger that consistently affects every problem gambler (Loo, Raylu, &
Oei, 2008). The postulated fact that PG is the outcome of interplay be-
tween various variables may also contribute to the uniqueness of each
case study. The reason why some individuals are more inclined to ac-
tively participate in gambling and why some are not, is still unclear
(Petry, 2005b). However, numerous factors have been identified in the
literature that are believed to place an individual at a higher risk of de-
veloping PG and maintaining their gambling behaviours (Blaszczynski
& Nower, 2002).
In the gambling literature, evidences suggest that mood states
(e.g., depression and anxiety) play an important role in the develop-
ment and maintenance of PG (Raylu & Oei, 2002). Affective disorders
often comorbid with PG; however, results are inconsistent. PGs also
differ from non-gamblers or other gamblers in personality traits (Za-
leskiewicz, 2001). Support exist for impulsivity and sensation-seeking
where these traits are argued to operate in PG development (Zuck-
erman, 1999). The roles of familial factors (i.e., genetics and social
learning) have also obtained empirical support for its influence in the
development and maintenance of PG (Ciarrocchi & Reinert, 1993).
There is also a lot of support for the role of dysfunctional cognitions
in PG (Petry, 2005c). When gambling, PGs are more affected by cog-
nitive biases and heuristics as compared to non-gamblers (Toneatto,
Vettese, & Nguyen, 2007). These factors have been found to have more
consistent results, while other factors such as biochemistry (e.g., neu-
rotransmitters, dysregulation, and arousal) and sociology (i.e., PG as a
symptom of an inability to cope with the larger society) have yielded
some but limited support.
Positive Psychology and treatment of problem gambling
Nevertheless, positive psychological attributes (e.g., gratitude and

hope in life) have been found to be influential on certain psychopa-
thology and addictive behaviours (Loo, Tsai, Raylu, & Oei, 2014). The
emerging field of Positive Clinical Psychology argues that there is an

added advantage in the recovery process to have an evenly weighted
focus on both negative and positive functioning when treating psycho-
logical distress (Seligman & Peterson, 2003). The focus on positive
functioning is not commonly spelt out in clinical success but it involves
utilising “deep strategies” (more commonly known as “non-specifics”
by clinicians), which are good methods in therapy such as paying atten-
tion, developing rapport, and encouraging clients to open up with trust.
For instance, instilling hope during cognitive-behaviour therapies is an
important deep strategy that is beneficial for recovery.
The influence of positive psychological attributes in developmental
psychopathology (Weems, 2009), population research (Huppert, 2004),
and oppositional defiant disorder (Milne, Edwards, & Murchie, 2001)
have been noted and has gained interests of researchers. For instance,
low positive affect (or positive emotion dysfunction) is related to nega-
tive symptoms of schizophrenia, anxiety disorders, depression, and oth-
er mood disorders (Watson & Naragon-Gainey, 2009). The subsequent
paragraphs will examine the evidences for selected positive variables.
Curiosity as a character strength or positive attribute has not been
investigated empirically in the field of gambling but it has been argued
that many gamblers approached the game out of sheer curiosity (Li,
2007). Curiosity from a Positive Psychology (PP) viewpoint relates
to independence in seeking novel experiences and degree of determi-
nation. Neurological findings on curiosity and exploratory behaviour
with gambling tasks and fMRI scan argued that exploratory behaviour
is advantageous from an evolutionary perspective for gathering resourc-
es and food (Daw, O’Doherty, Dayan, Seymour, & Dolan, 2006). This
study also reported that there are specific brain systems responsible for
exploratory behaviour. McCown (2004) suggested that interventions
for PG should acknowledge gambler’s curiosity and transform it into a
positive and creative outlet.
Despite having no research done specifically on gambling, the af-
fective state of gratitude is reportedly beneficial for the recovery from
addictive behaviours (Choong, Loo, & Ng, 2014). An individual’s re-
covery from an “alcoholic identity” has been argued to benefit from
an outlook of gratitude among other factors such as acceptance and
surrender, as overall quality of life gradually improves (Schaler, 1996).
The importance of gratitude was also highlighted in 12-step alcoholic

treatment program (Wallace, 1996). Beyond the addiction literature,
positive traits such as gratitude can uniquely predict disorders such as
depression despite the presence of negative traits and buffer against the
development of the disorder. Investigations of the predictive ability of
gratitude in gambling behaviour will expand our current knowledge of
the development and treatment of PG.
In a study on Thai gamblers, the concept of “distorted” hope was
measured with questions such as “How much do you hope to win any
prize,” and “Have you ever won any prize?” (Ariyabuddhiphongs &
Chanchalermporn, 2007)M. The authors reported that media reports in-
fluence gamblers’ superstitious beliefs, which influences their level of
hope and in turn influenced their gambling propensity. On the flipside
and in another study, PGs were more likely than non-PGs to gamble for
reasons that it gives hope for a better future and a possibility to obtain
more money (Clarke et al., 2006). Here, hope is defined as self-reported
capability in devising pathways for life goals and agency in thought
processes when implementing pathways.
Another positive trait that is investigated here is personal growth
initiative, which has been argued to be an important process of recov-
ery from mental health disorders (Robitschek, 1998). This process will
benefit the client in other aspects of their lives. For example, individuals
who are dissatisfied with their fulfilment at work may actively explore
options to increase fulfilment. In another aspect of personal growth,
Ciarrocchi and Reinert (1993) measured family environment dynam-
ics among gamblers and found that spouses of gamblers reported high-
er dissatisfaction for the personal growth of gamblers as compared to
spouses of non-gamblers. Furthermore, group therapy reported that
gamblers enrolled in long-term therapy reported greater satisfaction
with personal growth dimensions as compared to gamblers enrolled in
short-term therapy.
PG is a form of addiction that is characterised by cognitive
preoccupation with gambling and cognitive distortions such as “chas-
ing losses.” On the flipside, mindfulness or mindful attention is char-
acterised by conscious attention and awareness of the antecedents of
the present behaviour. Mindfulness has been linked with less severe
gambling problems and PGs were reported to be less mindful of the
present (Lakey, Campbell, Brown, & Goodie, 2007). Research on the

cognitive-behavioural treatment of gambling have reported that mindful
meditation is effective in reducing anxiety and depression, and helps
PGs cope with gambling-related cognitive distortions (Toneatto et al.,
2007). Culturally appropriate treatment of PG that encapsulates effec-
tive evidence-based practice tailored to suit individuals from diverse
backgrounds should be further developed (Raylu, Loo, & Oei, 2013)
and extended to possibilities of self-help treatment programs (Raylu,
Oei, & Loo, 2008).
Assessment of problem gambling and PG correlates
Numerous scales have been developed to assess prevalence rates,

diagnoses, and severity of PG. There are varieties of instruments
available—all with advantages and disadvantages, as no single
instrument is best suited for each purpose (Petry, 2005a). Building
up from these conceptual frameworks, several evidence-based instru-
ments such as the South Oaks Gambling Screen (Lesieur & Blume,
1987), DSM criteria (American Psychiatric Association, 2000),
Canadian Problem Gambling Index (Ferris & Wynne, 2001), and
Victorian Gambling Screen (Wenzel, McMillen, Marshall, & Ahmed,
2004) have been developed to measure problem and pathological
gambling. Typical items on these scales are questions such as “Have
you bet more than you could really afford to lose?” and “Have you
borrowed money or sold anything to get money to gamble?” These
scales report good psychometric properties when used among West-
ern populations of various age ranges and are valuable tools for clini-
cians to determine an individual’s PG severity.
A comparative evaluation on PG measurements suggested that the
Canadian Problem Gambling Index (CPGI) demonstrated the most
valid and reliable psychometric properties to measure PG prevalence
among Western population (McMillen & Wenzel, 2006). This was also
confirmed by another Australian national review on PG measurements
and related issues (Neal, Delfabbro, & O’Neill, 2004). The CPGI has
been used effectively in community health settings, student samples,

and also among diverse populations. The CPGI is also a preferred scale
in Canada, as well as in Australian community prevalence research
in Queensland (Queensland Treasury, 2006), Tasmania (Roy Morgan
Research, 2006), and Victoria (McMillen et al., 2004).
The predecessors of CPGI such as SOGS and DSM-IV have been
used widely in gambling research and validated among various population
groups from countries such as Hong Kong and Singapore (Arthur et al.,
2008; Tang, Wu, Tang, & Yan, 2010). However, there has been substantial
evidence that criticises the use of SOGS in community prevalence studies
as SOGS was originally developed for clinical use and it tended to over-
estimate PG prevalence (McMillen & Wenzel, 2006; Young & Stevens,
2008). Questions arose concerning the suitability of SOGS in different
ethnic groups, particularly with regards to items on money problems.
The CPGI, on the contrary, was originally developed to assess the
prevalence of PG among general population research and defined PG
as a less severe albeit destructive gambling pattern that may or may not
include pathological gambling behaviour (Ferris & Wynne, 2001). The
Canadian Problem Gambling Index (CPGI; Ferris & Wynne, 2001) is a
new, more meaningful measure of PG for use in general population sur-
veys and has been found to have higher reliability as compared to other
gambling measures. Only nine items in the CPGI are scored, which is
collectively named the Problem Gambling Severity Index (PGSI). The
PGSI adds on to current gambling measures because of its relative em-
phasis on social and environmental factors related to PG. This allows eas-
ier identification of at-risk gamblers and improves sensitivity to typically
under-represented populations (e.g., female PG). The Cronbach’s alpha
was good (high reliability), at 0.84, compared with 0.76 for the DSM-
IV and 0.81 for the South Oaks Gambling Scale – SOGS. The PGSI has
good criterion-related validity because it matches up fairly well with the
DSM-IV and the SOGS, correlating at 0.83 with both measures (Loo,
Oei, & Raylu, 2011b). Despite the fact that SOGS have been criticised
for reasons such as selective over-representation of low socioeconomic
groups, SOGS will be measured and analysed in parts of this dissertation
to allow for reliability analysis, measure comparisons, and evaluation
of past research. All other forms of gambling assessment is covered in
extensive detail in a recent evaluation of scales (see Petry, 2005c).
Conclusion
Problem gamblers (PGs) have been found to be a heterogeneous group

(Loo, Oei, & Raylu, 2011a; Oei & Raylu, 2007). Although some evi-
dences do suggest that PGs possess certain characteristics in relation to
employment status, socioeconomic status, and gender, the results are
still inconclusive (Raylu & Oei, 2002). There are some findings and
anecdotal evidences that portray high rates of gambling and PG among
certain ethnic groups, particularly among the Chinese. As gambling re-
search has been predominantly done on Western samples (Oei, Lin, &
Raylu, 2008; Raylu & Oei, 2002), there is a need for exploration of
similar concepts in other ethnic groups.
Various models such as the biomedical (Aasved, 2003), psycho-
social (Ricketts & Macaskill, 2003), personality (Strong, Breen, &
Lejuez, 2004), developmental (Strong et al., 2004), and cognitive-
behavioural (Sharpe & Tarrier, 1993) frameworks have been proposed
to understand the development of PG. One of the most comprehensive
framework for PG to date is the recent review by Sharpe (2002) that
proposed a biopsychosocial model of gambling that integrates various
areas of research in light of the complex nature of PG. The variables
(sections) included in this model are: (1) Biological vulnerability and
psychological vulnerability, (2) Gambling involvement and interpreta-
tion of win/loss pattern, (3) Gambling related arousal and cognitions,
(4) Gambling urge, and (5) Coping strategies and level of self-control.
Empirical analysis of the cognitive-behavioural component of Sharpe’s
(2002) framework through Structural Equation Modelling in AMOS 7.0
found that the model assessed fit the data (Loo, Raylu, & Oei, 2012).
One of the main purposes of Sharpe’s biopsychosocial model is to pro-
vide a hypothesised model that integrates diverse areas of gambling re-
search. This will provide an important platform for future development
in interventions, treatments and gambling antecedents.
References
Aasved, M. (2003). The biology of gambling. The gambling theory and

research series. Springfield, IL: Charles C. Thomas Publisher.
manual of mental disorders: DSM-IV-TR (4th, text revision. ed.).
Washington, DC: American Psychiatric Association.
manual of mental disorders: DSM-5 (5th ed.). Washington, DC:
American Psychiatric Association.
Ariyabuddhiphongs, V., & Chanchalermporn, N. (2007). A test of social
cognitive theory reciprocal and sequential effects: Hope, supersti-
tious belief and environmental factors among lottery gamblers in
Thailand. Journal of Gambling Studies, 23(2), 201–214.
Arthur, D., Tong, W. L., Chen, C. P., Hing, A. Y., Sagara-Rosemeyer, M.,
Kua, E. H., & Ignacio, J. (2008). The validity and reliability of four
measures of gambling behaviour in a sample of Singapore univer-
sity students. Journal of Gambling Studies, 24(4), 451–462. doi:
10.1007/s10899-008-9103-y.
Blaszczynski, A., & Nower, L. (2002). A pathways model of problem
and pathological gambling. Addiction, 97, 487–499.
Choong, L. L., Loo, J. M. Y., & Ng, W. S. (2014). The experience of re-
covering gamblers in Malaysia: A phenomenological study. Asian
Journal of Gambling Issues and Public Health (Special issue: Im-
pacts of problem gambling on families and significant others), 4(1).
doi: 10.1186/2195-3007-4-1.
Ciarrocchi, J. W., & Reinert, D. F. (1993). Family environment and
length of recovery for married male members of Gamblers Anon-
ymous and female members of GamAnon. Journal of Gambling
Studies, 9(4), 341–352.
Clarke, D., Tse, S., Abbott, M., Townsend, S., Kingi, P., & Manaia, W.
(2006). Religion, spirituality, and associations with problem gam-
bling. New Zealand Journal of Psychology, 35(2), 77–83.
Daw, N. D., O’Doherty, J. P., Dayan, P., Seymour, B., & Dolan, R. J.
(2006). Cortical substrates for exploratory decisions in humans.
Nature, 441(7095), 876–879.
Ferris, J., & Wynne, H. (2001). The Canadian Problem Gambling Index:
Final report. Ottawa (ON): Canadian Centre on Substance Abuse.
Gupta, R., & Derevensky, J. (1997). Familial and social influences on
juvenile gambling behavior. Journal of Gambling Studies, 13(3),
179–192.
Huppert, F. A. (2004). A population approach to Positive Psychology:
The potential for population interventions to promote well-being and
prevent disorder. In P. A. Linley & S. Joseph (Eds.), Positive psychol-
ogy in practice (pp. 693–709). Hoboken, NJ: John Wiley & Sons Inc.
Lakey, C. E., Campbell, W. K., Brown, K. W., & Goodie, A. S. (2007).
Dispositional mindfulness as a predictor of the severity of gam-
bling outcomes. Personality and Individual Differences, 43(7),
1698–1710.
Ledgerwood, D. M., Steinberg, M. A., Wu, R., & Potenza, M. N. (2005).
Self-reported gambling-related suicidality among gambling help-
line callers. Psychology of Addictive Behaviors, 19(2), 175–183.
Lesieur, H. R., & Blume, S. B. (1987). The South Oaks Gambling Screen
(SOGS): A new instrument for the identification of pathological
gamblers. American Journal of Psychiatry, 144(9), 1184–1188.
Lesieur, H. R., Blume, S. B., & Zoppa, R. M. (1986). Alcoholism,
drug abuse, and gambling. Alcoholism: Clinical and Experimental
Research, 10(1), 33–38.
Li, J. (2007). Women’s ways of gambling and gender-specific research.
Sociological Inquiry, 77(4), 626–636.
Loo, J. M. Y., & Ang, K. T. (2013). Prevalence of problem gambling
in Selangor urban areas. Kuala Lumpur: Monash University &
Malaysian Mental Health Association.
Loo, J. M. Y., Oei, T. P. S., & Raylu, N. (2011a). Problem gambling,
gambling correlates, and help-seeking attitudes in a Chinese sam-
ple: An empirical evaluation. Psychology, 2(4), 342–354.
Loo, J. M. Y., Oei, T. P. S., & Raylu, N. (2011b). Psychometric evalua-
tion of the Problem Gambling Severity Index-Chinese version (PG-
SI-C). Journal of Gambling Studies, 27(3), 453–466. doi: <http://
dx.doi.org/10.1007/s10899-010-9221-1>.
Loo, J. M. Y., Raylu, N., & Oei, T. P. S. (2008). Gambling among the Chi-
nese: A comprehensive review. Clinical Psychology Review, 28(7),
1152–1166. doi: <http://dx.doi.org/10.1016/j.cpr.2008.04.001>.
Loo, J. M. Y., Raylu, N., & Oei, T. P. S. (2012). Testing the validity of an
integrated cognitive behavioural model of gambling behaviour with
a Chinese sample. In A. E. Cavanna (Ed.), Psychology of gambling:
New research (pp. 119–137). New York, NY: Nova Publishers.
Loo, J. M. Y., Tsai, J. S., Raylu, N., & Oei, T. P. S. (2014). Gratitude,
Hope, Mindfulness, and Personal-Growth Initiative: Buffers or
Risk Factors for Problem Gambling? PLoS One, 9(2), e83889.
McCown, W. G. (2004). Treating compulsive and problem gambling.
In R. H. Coombs (Ed.), Handbook of addictive disorders: A practi-
cal guide to diagnosis and treatment (pp. 161–194). Hoboken, NJ:
John Wiley & Sons Inc.
McMillen, J., Marshall, D., Ahmed, E., & Wenzel, M. (2004). 2003
Victorian longitudinal community attitudes survey. Canberra,
Australia: The Centre for Gambling Research, Australian National
University.
McMillen, J., & Wenzel, M. (2006). Measuring problem gambling:
Assessment of three prevalence screens. International Gambling
Studies, 6(2), 147–174. doi: 10.1080/14459790600927845.
Milne, J. M., Edwards, J. K., & Murchie, J. C. (2001). Family treatment
of oppositional defiant disorder: Changing views and strength-
based approaches. The Family Journal, 9(1), 17–28.
Morasco, B. J., Pietrzak, R. H., Blanco, C., Grant, B. F., Hasin, D.,
& Petry, N. M. (2006). Health problems and medical utilization
associated with gambling disorders: Results from the National Ep-
idemiologic Survey on Alcohol and Related Conditions. Psychoso-
matic Medicine, 68(6), 976–984.
National Council on Problem Gambling. (2011). Gambling participa-
tion survey. Singapore.
Neal, P., Delfabbro, P. H., & O’Neill, M. (2004). Problem gambling and
harm: Towards a national definition. Melbourne: National Gam-
bling Research Program Working Party.
Oei, T. P. S., Lin, J., & Raylu, N. (2008). The relationship between gam-
bling cognitions, psychological states, and gambling: A cross-cultural
study of Chinese and Caucasians in Australia. Journal of Cross-Cul-
tural Psychology, 39(2), 147–161. doi: 10.1177/0022022107312587.
Oei, T. P. S., & Raylu, N. (2007). Gambling and problem gambling
among the Chinese. Brisbane: The University of Queensland.
Petry, N. M. (2005a). Assessment. In N. M. Petry (Ed.), Pathologi-

cal gambling: Etiology, comorbidity, and treatment. (pp. 35–54).
Washington, DC: American Psychological Association.
Petry, N. M. (2005b). Introduction. In N. M. Petry (Ed.), Pathological
gambling: Etiology, comorbidity, and treatment. (pp. 3–8). Wash-
ington, DC: American Psychological Association.
Petry, N. M. (2005c). Pathological gambling: Etiology, comorbidity,
and treatment. Washington, DC: American Psychological Associ-
ation.
Petry, N. M., & Armentano, C. (1999). Prevalence, assessment, and
treatment of pathological gambling: A review. Psychiatric Services,
50(8), 1021–1027.
Productivity Commission. (2010). Gambling: Productivity Commis-
sion Inquiry Report No. 50. Canberra.
Queensland Treasury. (2006). Queensland household gambling survey
2003–04. Brisbane: Queensland Government.
Raylu, N., Loo, J. M. Y., & Oei, T. P. S. (2013). Treatment of gam-
bling problems in Asia: Comprehensive review and implications
for Asian problem gamblers. Journal of Cognitive Psychotherapy,
27(3), 297–322.
Raylu, N., & Oei, T. P. S. (2002). Pathological gambling: A comprehen-
sive review. Clinical Psychology Review, 22(7), 1009–1061.
Raylu, N., Oei, T. P. S., & Loo, J. M. Y. (2008). The current status and
future direction of self-help treatments for problem gamblers. Clin-
ical Psychology Review, 28(8), 1372–1385. doi: <http://dx.doi.
org/10.1016/j.cpr.2008.07.005>.
Ricketts, T., & Macaskill, A. (2003). Gambling as emotion manage-
ment: Developing a grounded theory of problem gambling. Addic-
tion Research & Theory, 11(6), 383–400.
Robitschek, C. (1998). Personal growth initiative: The construct and its
measure. Measurement and Evaluation in Counseling and Devel-
opment, 30(4), 183–198.
Roy Morgan Research. (2006). The fourth study into the extent and im-
pact of gambling in Tasmania with particular reference to problem
gambling: Follow-up to the studies conducted in 1994, 1996, and
2000. Hobart, Tasmania: Gambling Support Bureau, Department
of Health and Services.
Schaler, J. A. (1996). Spiritual thinking in addiction-treatment provid-

ers: The Spiritual Belief Scale (SBS). Alcoholism Treatment Quar-
terly, 14(3), 7–33. doi: 10.1300/j020v14n03_03.
Seligman, M. E. P., & Peterson, C. (2003). Positive clinical psychology.
In L. G. Aspinwall & U. M. Staudinger (Eds.), A psychology of
human strengths: Fundamental questions and future directions for
a positive psychology (pp. 305–317). Washington, DC: American
Psychological Association.
Shaffer, H. J., Hall, M. N., & Vander Bilt, J. (1997). Estimating the
prevalence of disordered gambling behavior in the United States
and Canada: A meta-analysis. Cambridge, MA: Harvard Medical
School Division of Addictions.
Sharpe, L. (2002). A reformulated cognitive-behavioral model of prob-
lem gambling: A biopsychosocial perspective. Clinical Psychology
Review, 22(1), 1–25.
Sharpe, L., & Tarrier, N. (1993). Towards a cognitive-behavioural theory
of problem gambling. British Journal of Psychiatry, 162, 407–412.
Strong, D. R., Breen, R. B., & Lejuez, C. W. (2004). Using item re-
sponse theory to examine gambling attitudes and beliefs. Personal-
ity and Individual Differences, 36(7), 1515–1529.
Tang, C. S., Wu, A. M. S., Tang, J. Y. C., & Yan, E. C. W. (2010). Relia-
bility, validity, and cut scores of the South Oaks Gambling Screen
(SOGS) for Chinese. Journal of Gambling Studies, 26(1), 145–158.
doi: 10.1007/s10899-009-9147-7.
Thomas, S. A., & Jackson, A. C. (2008). Risk and protective factors,
depression and comorbidities in problem gambling: A report to Be-
yondblue. Melbourne: Problem Gambling Research and Treatment
Centre.
Toneatto, T., Vettese, L., & Nguyen, L. (2007). The role of mindfulness
in the cognitive-behavioural treatment of problem gambling. Jour-
nal of Gambling Issues, 19, 91–100.
Volberg, R. A., Nysse-Carris, K. L., & Gerstein, D. R. (2006). 2006
California problem gambling prevalence survey. Los Angeles, CA:
California Department of Alcohol and Drug Programs Office of
Problem and Pathological Gambling.
Walker, M. B., & Dickerson, M. G. (1996). The prevalence of problem

and pathological gambling: A critical analysis. Journal of Gam-
bling Studies, 12(2), 233–249.
Wallace, J. (1996). Theory of 12-Step-oriented treatment. In F. Rot-
gers, D. S. Keller & J. Morgenstern (Eds.), Treating substance
abuse: Theory and technique. The Guilford substance abuse series.
(Vol. viii, pp. 13–36). New York, NY: Guilford Press.
Wardle, H., Sproston, K., Orford, J., Erens, R., Griffiths, M., & Constan-
tine, R., et al. (2007). British gambling prevalence survey 2007.
London: National Centre for Social Research.
Watson, D., & Naragon-Gainey, K. (2009). On the specificity of posi-
tive emotional dysfunction in psychopathology: Evidence from the
mood and anxiety disorders and schizophrenia/schizotypy. Clinical
Psychology Review, [np]. doi: 10.1016/j.cpr.2009.11.002.
Weems, C. F. (2009). Developmental psychopathology, positive psy-
chology, and knowledge development in child and youth care: Ed-
itorial hopes and aspirations for the forum. Child & Youth Care
Forum, 38(1), 1–4.
Wenzel, M., McMillen, J., Marshall, D., & Ahmed, E. (2004). Vali-
dation of the Victorian Gambling Screen. Melbourne: Centre for
Gambling Research (CGR), ANU.
Young, M., & Stevens, M. (2008). SOGS and CGPI: Parallel compar-
ison on a diverse population. Journal of Gambling Studies, 24(3),
337–356. doi: 10.1007/s10899-007-9087-z.
Zaleskiewicz, T. (2001). Beyond risk seeking and risk aversion: Person-
ality and the dual nature of economic risk taking. European Jour-
nal of Personality, 15(1), S105-S122.
Zuckerman, M. (1999). Vulnerability to psychopathology: A biosocial
model. Washington, DC: American Psychological Association.
Alvin Lai Oon Ng
Clinical psychology in Malaysia:

Roles and issues
Clinical psychology is a relatively new mental health profession in

Malaysia, compared to more established ones such as psychiatry and
counselling. The professional recognition of its roles and functions
is only beginning to surface with more clinical psychologists being
locally trained and returning from overseas training to work in hospi-
tals, private practices and institutes of tertiary education. Clinical psy-
chologists have been increasingly involved in mental health services,
campaigns, professional training, public policy-making and academia.
The need for clinical psychologists in the mental health care sectors,
as well as multifunctional settings such as education, welfare, sports,
forensics and industrial organisations have made the profession more
sought after than before. Given increasing recognition of its roles, clin-
ical psychology is faced with many professional practice issues such as
registration, professional regulation, training, and clinical supervision.
While other South East Asian countries such as Singapore, Thai-
land, Indonesia and the Philippines have relatively established clinical
psychology services and recognition, the profession in Malaysia is still
in its early stage, only surfaced in the 1980s (Ng, Teoh, & Haque, 2003).
Postgraduate training in clinical psychology began in the mid 1990s,
and slowly expanded over the next 20 years. Given this, there are many
teething issues concerning professional training and practices, as well
as public posts. This paper briefly introduces clinical psychology in Ma-
laysia and other relevant issues pertaining to the profession. Since the
profession is relatively new in the country, this paper provides some
overview of what clinical psychologists could do besides other tradi-
tional mental health service providers. It is hoped that this paper would
help readers understand the roles of clinical psychologists not just in
the health sector, but also in other domains such as education, welfare,
community, sports, and forensics.
242 Alvin Lai Oon Ng
Clinical psychology: Definition
Clinical psychology is an applied branch of psychology that combines

science, theory and clinical knowledge to understand, prevent and re-
lieve mental distress and dysfunction with an ultimate goal to promote
well-being and personal development. The area primarily applies psy-
chological principles to assessment, diagnosis, treatment and prevention
of mental disorders. The principles underlying cognitive, emotional, be-
havioural, social and learning processes are used to understand mental
disorders and their treatment.
Mental health assessment
Various assessment tools are developed and used by clinical psycholo-

gists in various social and work contexts. The assessments generally tap
into the thought processes, emotional functions, learning capabilities,
and behavioural patterns of an individual. These assessments help to
develop a holistic understanding that helps to design appropriate in-
terventions to bring positive changes to individuals and groups so that
they are able to function effectively and happily in their life. Sometimes,
relevant families and communities are also targeted for intervention.
As already indicated, assessment is one of the major tasks that clin-
ical psychologists undertake in their professional practices. They are
therefore heavily trained in this area, which is the first stage of man-
aging mental health problems. Diagnosis and problem formulation are
key to an effective treatment. They are particularly trainined in cognitive
functioning assessments, personality and aptitude tests, and behaviour
and emotional assessments. Apart from utilizing their assessment skills
in clinical settings, they also help run different types of psychological
assessments such as measuring developmental disabilities, intellectual
capabilities among school children, and various tests for industrial em-
ployees. A range of forensic investigations are also under their purview.
Clinical psychology in Malaysia: Roles and issues 243
Numerous psychological assessment tools are available in the

market, many of which require properly trained psychologists for
their administration and interpretation. In order to buy and use those
test kits, one should produce proof of training and appropriate license
of practice. Interpretation of test results is crucial in the assessment
process, and only trained clinical psychologists are able to do so. For
example, without proper training in psychology and psychopathology,
a specialised test such as MMPI (Minnesota Multiphasic Personality
Inventory) could not be used and interpreted. Table 1 lists a number
of tests that are normally used in different health care and academic
domains.
Table 1: Areas that utilise psychological assessments.
Areas / Fields Types of psychological assessments

1. Psychiatric Diagnosis of mental illnesses, cognitive functioning
assessments, personality tests, behavioural assess-
ments and monitoring, emotional functioning
2. Medical Departments Emotional function, quality of life assessments,
pre- & post-surgery functioning, adherence, carer
burden assessment, procedure readiness assessment,
behaviour analyses, rehabilitation monitoring
3. Developmental Cognitive functioning assessments, adaptive
Disabilities behaviour assessments, symptom assessments, be-
havioural measurements and analyses, career burden,
rehabilitation monitoring
4. Academia Cognitive functioning assessments, learning disorder
assessments, aptitude tests, behaviour analyses
5. Industrial / Cognitive functioning assessments, aptitude tests,
Organisational performance tests, personality tests, behaviour
analyses, quality of life
6. Forensic / Cognitive functioning assessments, personality tests,
Correctional custody evaluation, behaviour analyses and modifica-
tion, court readiness
Diagnosis and problem formulation
Diagnoses are carried out based largely on the Diagnostic and Statisti-
cal Manual of Mental Disorders – Fifth Edition (DSM-5; APA, 2013).
Some diagnoses are made by referencing the International Classification
of Diseases – Tenth Edition (ICD-10). Apart from diagnosis, clinical
psychologists also formulate an individual’s problems by showing
how historical and triggering factors lead to the problem and how the
problem is maintained by current factors. These factors that contribute
to and maintain psychological problems are seen as an integration of
biological, psychological and social factors. As such, the understanding
of problem formulations then leads to devising intervention strategies
to bring about change that leads to the individual’s well-being. These
strategies would employ changes within the biological, psychological
and social settings to influence positive change in the individual.
Treatment and rehabilitation
While psychological treatment is largely understood as talk-therapy or

psychotherapy, it is usually more than that. Given that a disorder or
problem covers biological, psychological and social factors, treatment
is usually carried out in multiple components that tap into biological/
physiological intervention, cognitive aspects, behavioural change, skills
acquisition, and socialisation aspects.
Prevention
It has been recognised that prevention of any pathology, including

psychopathology is more economically viable in the long run, with
regards to human performance which has significant effects on social
and economic productivity. As such, clinical psychologists, together

with other mental health professionals contribute to prevention activ-
ities such as mental health campaigns, training on specific aspects of
good mental health practice such as stress management, relaxation, an-
ger management, positive parenting programs, and positive psychology
coaching.
Research and supervision
Other than the traditional roles of providing assessments, diagnoses

and treatment, clinical psychologists are also involved in research and
development as part of professional practice. They generally take the
‘scientist-practitioner’ approach where assessments and treatments are
based on evidence-based practice. Given that clinical psychology is a
competence-based clinical profession, supervision by a senior or peer is
important to keep a practitioner’s competency in check.
Training and qualification
Apart from the USA, clinical psychologists are typically trained with
at a bachelor’s degree in psychology plus at least two-years of profes-
sional training at the postgraduate level (i.e. Master’s degree) in clini-
cal psychology. For individuals without a basic degree in psychology,
a bridging degree such as the Postgraduate Diploma in Psychology is
needed before being accepted into a Master level training in clinical
psychology. In the USA, a practicing clinical psychologist must have
at least a Doctor of Psychology (PsyD) or Doctor of Philosophy (PhD)
in clinical psychology, plus a professional license to practice given by
the State’s psychology governing body. In Malaysia, there is no cur-
rent professional practice regulation for clinical psychologists but it
is generally accepted that clinical psychologists need to have at least
a professional Master degree in clinical psychology from a nationally

accredited tertiary institution.
Differences with psychiatry, counselling,

and counselling psychology
A frequently asked question about clinical psychology is its differences

with psychiatry and counselling. The basic difference between clinical
psychology and psychiatry is that clinical psychology is a specialisation
within psychology, not medicine. Psychiatry, however, is a specialisa-
tion within medicine with its practitioner being initially qualified as a
medical doctor before doing a specialisation in psychiatry, which is an
extra Master degree level training in psychological medicine or psy-
chiatry. Psychiatrists are allowed to prescribe medication, while clini-
cal psychologists are not. This, however, is not the case in some states
in the USA as some clinical psychologists, with proper qualifications,
are allowed to prescribe medication for the treatment of psychological
disorders.
Clinical psychology is also frequently confused with counselling.
While both clinical psychologists and counsellors are technically men-
tal health workers, clinical psychologists typically see cases that are
more severe, whereas counsellors deal with daily emotional distress that
are less severe. Clinical psychologists also focus more on psychological
assessments and testing, while counsellors focus more on emotional
counselling and problem-solving within the nonpsychiatric setting.
Counsellors are not trained to administer psychological tests, especially
the cognitive and personality tests as they lack basic knowledge of psy-
chological theories. While both professionals are trained in aspects of
psychotherapy, clinical psychologists tend to be more inclined to cogni-
tive-behavioural formulations and manual-based intervention, whereas
counsellors have more tendencies to focus on emotional management
form such as the Rogerian humanistic psychotherapy approaches.
Counselling psychology is a relatively new term in Malaysia with
many people using it interchangeably with counselling. This is a very
common mistake as the public and even the health care community
commonly view counselling and psychology as the same field. A later
section will explain this common misunderstanding further. Counsel-
ling psychology is basically a ‘cousin’ of clinical psychology; practi-
tioners in both of which are qualified with a basic degree in psychology
and go on to complete a Master level degree in their respective fields.
So both are grounded in psychological theories and apply them in as-
sessment and professional practices. Although their basic skills overlap,
counselling psychologists and clinical psychologists differ in terms of
the type of patients they treat; clinical psychologists focus more on se-
vere psychopathological cases within the psychiatric setting, whereas
counselling psychologists focus on issues within the community, seeing
cases that are less severe with regards to mental illness.
Table 2: Comparisons between clinical psychologists and commonly confused mental
health professions.
Clinical Psychologists Psychiatrists

Basic degree in psychology. At least Basic degree in medicine. Master degree
Master degree in clinical psychology in psychological medicine or psychiatry.
Non-medical professional Medical specialist
Cannot prescribe medication Prescribes medication
Trained in psychological assessments Not trained in psychological assessments
Trained in psychological intervention: Not necessarily trained in psychological
psychotherapy, behavioural therapy intervention or psychotherapy
Clinical Psychologists Counsellors
Basic degree in psychology. At least At least basic degree in counselling
Master degree in clinical psychology
Trained in traditional psychological Not trained in traditional psychological
assessments such as cognitive tests, assessments but trained in career assess-
adaptive behaviour tests, personality ment and intervention
tests, aptitude test.
Trained in behaviour assessment and Not trained in behaviour assessment and
intervention intervention
Attends to psychological problems of Attends to emotional problems of daily
more severe nature adjustment difficulties, non-diagnostic
individuals in overwhelming emotional,
cognitive and behavioral situations
Trained in psychotherapy with tenden- Trained in psychotherapy with ten-

cies for heavier use of cognitive and dencies for heavier use of humanistic
behavioural therapy components psychotherapy, supported by various
therapeutic techniques such as solution
focused-therapy
Clinical Psychologists Counselling Psychologists
Basic degree in psychology. Master Basic degree in psychology. Master
degree in clinical psychology degree in counselling psychology
Trained in traditional psychological Trained in traditional psychological
assessments, behavioural and cognitive assessments, behavioural and cognitive
interventions. interventions.
Attends to psychopathology issues, Attends to daily emotional issues, less of
works within psychiatric settings psychiatric cases
Trained in psychotherapy with ten- Trained in psychotherapy with tenden-
dencies for heavier use of cognitive cies for use of cognitive and behavioural
and behavioural therapy components therapy components and solution-
focusing on reducing psychopathologi- focused brief therapy, with focus on
cal symptoms improving personal function.
In the past three years there has been the appearance of Licensed
Marriage and Family Therapists setting up practice in the country. It
is important to acknowledge them as legitimate mental health profes-
sionals who complement any treatment program, and are not adjuncts.
Their area of work overlaps with those of psychologists and counsellors
in that they provide diagnostic assessments and therapy to people who
have mental health issues. The main difference between a marriage
and family therapist, and the typical psychologist and counsellor is that
the former approach tends to be systemic in its conceptualization and
treatment of mental disorders as opposed to the more individualistic
style of the latter.
Clinical psychology in Malaysia
Malaysia witnessed the first cohort of clinical psychologists in mid

1980s who returned home after completing postgraduate training
from universities in the UK, USA, and Australia. Most of them went
into private practices, while some attached themselves to public hos-
pitals. Recognition of clinical psychologists was very low at that time
as compared to Singapore (Institute of Mental Health/Woodbridge Hos-
pital, 2008) and Thailand (Tapanya, 2001). In the 1990s, the Ministry
of Health, Malaysia recognised the need for clinical psychologists and
commissioned several trainers to provide relevant training in psycholog-
ical assessment and intervention to staff with basic psychology training
at the diploma level. This effort was a one-off and did not proceed further
into a regular training for clinical psychology at the postgraduate level.
Towards the end of 1990s, institutions of tertiary education such as
Universiti Kebangsaan Malaysia (UKM) and the International Islamic
University Malaysia (IIUM) launched Master level training in clinical
psychology. Although the programs initially attracted small number of
students, later they showed steady growth, about eight students were
graduating every year. The title of the UKM programme was Master of
Arts in Clinical Psychology that was offered at Hospital UKM. Later in
2003, the programme title was changed to Master of Clinical Psychol-
ogy and handed over to the Faculty of Health Sciences. Since then, the
program has been conducted at the Kuala Lumpur campus of UKM.
The IIUM program with the title Master of Human Sciences in Clinical
and Counselling Psychology was run rather successfully until 2009. As
some issues were raised lately, the program was put on hold, and cur-
rently undergoing a thorough review process. This program is scheduled
to be re-offered as a clinical psychology only degree by 2014. The third
clinical psychology program was launched in 2009 by HELP University
at its Damansara campus. As required for professional accreditation, all
those programs contained coursework, research and clinical practicum
components.
The number of professionally trained clinical psychologists in-
creased progressively over the years. While the local programs pro-
duced some graduates, others returned home from overseas training.
The current count of clinical psychologists in Malaysia stands around
120, with nearly 60% working in the academia, 10% in public services
(including armed forces), and the rest in private practices. Most of those
clinical psychologists are located in and around Kuala Lumpur, with
a handful in other locations such as Penang, Perak, Sabah, Sarawak,
Malacca, Johor Bahru, and Kelantan. In 2010, the Malaysian Society

of Clinical Psychology was established with the purpose to regulate
the profession and maintain a register of clinical psychologists so as to
protect the public from malpractices. This was in response to the lack
of regulation and recognition of psychologists in the country given that
the Malaysian Psychological Association (PSIMA), a more established
organization, did not develop necessary guidelines for psychological
practices.
Issues of clinical psychology in Malaysia
Human resource needs and access to services
As the number of clinical psychologists in the country is remarkably

low, a clinician to population ratio is estimated at 1:280,000. An ideal
ratio suggested by the WHO is 1:35,000, which means that Malaysia
should have at least 800 clinical psychologists to serve the total popu-
lation (Nooraini, 2010). The situation appears even worse when we see
that the majority of clinical psychologists are lecturing at the universi-
ties with occasional involvement in clinical practices. This shows how
lacking Malaysia is in numbers of clinical psychologists and citizen’s
access to clinical psychology services.
The Ministry of Health Malaysia has apparently numerous posts
for clinical psychologists of which only thirteen are currently occupied.
On a more serious note, only two out of the four psychiatric hospitals
in the country have very recently obtained one clinical psychologist
each, which are hardly enough to service patients that number into the
hundreds. Another problem is the lack of well experienced clinical psy-
chologists. As the profession is quite new in the country, the majority of
practitioners are very young and relatively inexperienced. The problem
therefore could be addressed by opening up new programs of clinical
psychology at various universities and hire experienced clinical psy-
chologists from overseas and retain them. These clinical psychologists
could be hired both for academic jobs as well as hospital practices. To
retain locally trained clinical psychologists, competitive remuneration

packages should also be offered so that they do not leave the country for
better pay and recognition.
Recognition as a clinical profession
Clinical psychology was officially recognised as a profession only in

2007 by the Public Services Department (PSD) with the introduction of
the Psychology Officer Job Scheme Level S41 (PSD, 2007). Currently,
the clinical psychologist post is one of three specialisations within the
Psychology Officer scheme with the other two being counselling psy-
chologist and general psychologist. The S41 entry level position refers
to a Bachelor degree level entry, but clinical psychologists have at least
a Master level training. This relegates clinical psychologists to a lower
entry level pay received by the basic psychology degree holders who
become the general psychologist or the counsellor, without any clinical
allowance. This lack of recognition as well as the slow recruitment pro-
cess has been a deterrent for many new graduates in applying for public
service posts for clinical psychologists. The Malaysian Society for Clin-
ical Psychology has suggested that clinical psychologists come under a
U43 scheme that provides clinical allowance at Master degree entry level,
under the health professional’s category. This is still being tabled in the
government at time of publication.
Another issue with recognition is the confusion between the roles
of the counsellor, the general psychologist and the clinical psychologist
in the mental health setting. Given that the new PSD scheme is called
the Psychology Officer scheme, counsellors are now called “Psycholo-
gy Officer (Counselling)” which to some, means counselling psychol-
ogists, who can then carry out psychological assessments when they
do not have the training. Given that there are far more counsellors and
general psychologists than clinical psychologists, the usage of “psy-
chologists” has been vague with regards to job descriptions, skills, roles
and responsibilities, thus leaving much room for malpractice, misinfor-
mation and prejudice between specialisation.
Professional practice
The main issue with professional practice of clinical psychologists in

Malaysia is registration and regulation. Currently there is no law that
governs the practice of clinical psychologists, thus allowing the public
to be exposed to bogus psychologists and malpractice. The Malaysian
Society of Clinical Psychology (MSCP) is currently registering mem-
bers with professional qualifications only but is not a regulatory body
due to the absence of any legal act that determines the limits of clinical
practice.
Another main issue of clinical practice is the lack of indigenous re-
sources for assessment and treatment (Haque, 2005; 2008). Psycholog-
ical assessments used in Malaysia are mostly in English with the Malay
translations usually not scientifically validated. Clinical psychologists
in Malaysia mostly learn treatment methods developed and practiced in
the Western countries, so the methods sometimes clash with the local
values and attitudes, leading to possibly less motivation to adhere to
treatment, and reducing efficacy in treatment outcomes.
Training
Due to the shortage of clinical psychologists in the country, with many

being very young and inexperienced, universities find it immensely
difficult to run the programs. Clinical placement has been a big issue as
there are not many supervisors available who could take students. The
lack of clinical practicum sites limits the universities to accept more
trainees. Currently, each program only enrolls a maximum of 10 train-
ees per intake year.
Research
Being a young field, there is great potential for clinical psycholo-

gy research in Malaysia, particularly with indigenous psychology,
cross-cultural issues, and the development of psychological assess-
ment tools. Again, the lack of senior academics in clinical psychology
obstructs the development of the field in terms of research. The volume

of clinical psychology research is therefore very limited, and whatever
it is done, those are merely the replication and adaptation of the Western
ideas without necessarily addressing more fundamental mental health
issues appropriate for the country.
Roles of clinical psychology in Malaysia
Clinical psychologists typically work in mental health settings as part

of the team managing psychological disorders and related issues such
as trauma response, and addictions. These settings can be purely psy-
chiatric, or a mental health clinic, or within the armed forces. Clinical
psychologists were used in the Angkasawan Program in 2006 during the
selection of Malaysia’s first astronaut (ANGKASA, 2008).
Medical departments can also benefit from clinical psychologists
by taking professional services such as psychological assessments and
screening, pre- and post-surgery rehabilitation, lifestyle change, hospice
and palliative care, medical adherence, and sexual dysfunctions. Clinical
psychologists are also capable of formulating various behaviour modi-
fication strategies such as weight loss and pain management. In the area
of disability, clinical psychologists may contribute to developmental dis-
ability assessments, diagnose for welfare card or otherwise, treatment/
early intervention, rehabilitation, training, and behaviour modification.
A major area that clinical psychologists could contribute to is edu-
cation and school psychology. They may conduct aptitude tests, school
placement assessments, adaptive behaviour assessments, and offer be-
haviour management consultation in the Malaysian schools. As various
learning disorders and bullying are fairly common in the schools, the
clinical psychologists may help manage those problems. A rather slow-
ly emerging role for clinical psychology in Malaysia is in the legal arena
as expert witnesses as well as in the assessment of forensic cases and
custody cases. Perhaps a future role might include the rehabilitation of
legal offenders such as those with sexual disorders as well as those with
tendencies for violence and aggression.
Some private clinical psychologists have also branched into pro-

viding mental health consultations to corporate organisations and other
industries, focusing on human performance, well-being and productivi-
ty. To some extent these applications can flow into sports performances
and athlete well-being. Lastly, clinical psychologists contribute to aca-
demia in the area of research, clinical training and consultancy. Clinical
psychologists are often sought to provide public and professional talks
pertaining to mental well-being such as stress and anger management,
behavioural modification, mental health promotion and related issues.
Conclusion
Being a new health profession, clinical psychology has a long way to go

with regards to its professional development and research in Malaysia.
The lack of professional recognition of clinical psychologists suggests
the need for further awareness amongst the medical community (e.g.
Khan, 2007) and policy-makers on the roles of clinical psychologists. To
facilitate better education and professional development, fundamental
research, especially in the area of tests development, diagnostic meth-
ods, and clinical interventions is needed. To train clinical psychologists
at a high level, current academic curricula should be updated and more
sites for supervised training should be arranged, especially in the Gov-
ernment and privately run hospitals. Only properly trained clinicians
are able to improve mental health services in the country. The issues
of registration, professional regulation, and licensing must be resolved.
With more training programs, advanced research and mental health
care legislation, clinical psychology could be established as a respected
profession in the country.
References
American Psychiatric Association (2013). Diagnostic and statistical

manual for mental disorders (Fifth Edition). Washington DC:
American Psychiatric Association.
ANGKASA. (2008). Survival test. Retrieved on February 10, 2011, from
<http://www.angkasa.gov.my/index.php?option=com_content&
task=view&id=214&Itemid=271>.
Haque, A. (2005). Mental health concepts and program development in
Malaysia. Journal of Mental Health, 14, 183–195.
Haque, A. (2008). Culture-bound syndromes and healing practices in
Malaysia. Mental Health, Religion & Culture, 11, 685–696.
Institute of Mental Health/Woodbridge Hospital. (2008). Heartening
minds. Singapore: Institute of Mental Health/Woodbridge Hospital.
Ng, L. O., Teoh, H.-J., & Haque, A. (2003). Clinical psychology in Ma-
laysia: a brief overview. ASEAN Journal of Psychiatry, 6, 11–16.
Nooraini, D. (2010). Clinical psychologist’s services, role and chal-
lenges. Presented at 7th Kuala Lumpur Mental Health Conference:
Diversity in Psychiatry – Piecing the Puzzle Together, 26–28 July
2010, Putra World Trade Centre, Kuala Lumpur, Malaysia.
PSD (2007). Public Service Circular No. 29: Changes to Counsellor
and Assistant Counsellor Services Scheme to the Psychologists
and Assistant Psychologists Scheme. Kuala Lumpur: Public Ser-
vices Department Malaysia. [In Malay].
Rahmatullah Khan, A. W. K. (2008). Why do we need more clinical
psychologists? Malaysian Journal of Medical Sciences, 15, 1–2.
Tapanya, S. (2001). Psychology in medical settings in Thailand. Jour-
nal of Psychology in Medical Settings, 8, 69–72.
About the editors
Shamsul Haque is Head and Associate Professor of Psychology at

Monash University Malaysia. He earned his BSc (Honours) and MSc
in Psychology from the University of Dhaka, and PhD in Cognitive
Psychology from the University of Bristol, UK. Previously he was
Lecturer in Psychology at the University of Dhaka, and Assistant
Professor at the International Islamic University Malaysia.
Elizabeth Sheppard is Head and Associate Professor of Psychol-

ogy at the University of Nottingham Malaysia Campus. She earned
her BA (Honours) in Experimental Psychology from the University
of Oxford, and MSc and PhD in Psychology from the University of
Nottingham, UK. From 2015, she will be affiliated with Nottingham
Trent University.
List of contributors
Akira R. O’Connor, School of Psychology and Neuroscience, Univer-

sity of St Andrews, United Kingdom.
Alvin Lai Oon Ng, Department of Psychology, Sunway University,

Malaysia.
Cai-Lian Tam, Jeffrey Cheah School of Medicine and Health Sciences,

Monash University, Malaysia.
Chris J.A. Moulin, University of Bourgogne, France.
Elizabeth Sheppard, School of Psychology, University of Nottingham

Malaysia Campus, Malaysia.
Gregory B. Bonn, Foreign Research Fellow of the Japan Society for the
Promotion of Science, Department of Psychology and Human Develop-
ment Sciences, Nagoya University, Japan.
Ian D. Stephen, Department of Psychology, Macquarie University,

Australia.
Jasmine M. Y. Loo, Jeffrey Cheah School of Medicine and Health

Sciences, Monash University, Malaysia.
Jeanette Liaw Hui Jean, Jeffrey Cheah School of Medicine and Health
Karen Jennifer Golden, Jeffrey Cheah School of Medicine and Health

Marisa H. Loft, Jeffrey Cheah School of Medicine and Health Sciences,

260 List of contributors
Matthew R. Johnson, Department of Psychology, Yale University, USA.
Miriam S. Park, Jeffrey Cheah School of Medicine and Health Scienc-

es, Monash University, Malaysia.
Penelope A. Hasking, School of Psychology and Speech Pathology,

Curtin University, Australia.
Peter Mitchell, School of Psychology, University of Nottingham, United

Kingdom.
Qiu-Ting Chie, Jeffrey Cheah School of Medicine and Health Sciences,

Radka Jersakova, Institute of Psychological Sciences, University of

Leeds, United Kingdom.
Ruth C. Tatnell, School of Psychological Sciences, Monash University,

Australia.
Shamsul Haque, Jeffrey Cheah School of Medicine and Health Scienc-

es, Monash University, Malaysia.
Steve M. J. Janssen, School of Psychology, Flinders University,

Australia.
Tan Kok Wei, School of Psychology, University of Nottingham Malay-

sia Campus, Malaysia.

Shamsul Haque, Elizabeth Sheppard - Culture and Cognition - A Collection of Critical Essays-Peter Lang (2015)

Uploaded by

Copyright:

Available Formats

You might also like

Shamsul Haque, Elizabeth Sheppard - Culture and Cognition - A Collection of Critical Essays-Peter Lang (2015)

Uploaded by

Document Information

Original Title

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

Shamsul Haque, Elizabeth Sheppard - Culture and Cognition - A Collection of Critical Essays-Peter Lang (2015)

Uploaded by

Copyright:

Available Formats

The past few decades have seen a huge increase in global interest

in psychology, with more psychologists, psychology programmes and

Shamsul Haque is Head and Associate Professor of Psychology at

Elizabeth Sheppard is Head and Associate Professor of Psychology

British Library Cataloguing-in-Publication Data: A catalogue record for this book

Library of Congress Control Number: 2015932284

ISBN 978-3-0343-1558-6 pb. ISBN 978-3-0351-0826-2 eBook

This publication has been peer reviewed.

© Peter Lang AG, International Academic Publishers, Bern 2015

All rights reserved.

Shamsul Haque and Elizabeth Sheppard

Part II: Cultural Influence on Cognitive Processes

Steve M. J. Janssen and Shamsul Haque

Ian D. Stephen and Tan Kok Wei

Karen Jennifer Golden and Jeanette Liaw Hui Jean

Part III: Cognitive Psychology and Neuroscience

Radka Jersakova, Akira R. O’Connor and Chris J. A. Moulin

Ruth C. Tatnell and Penelope A. Hasking

Part IV: Psycho-Social and Professional

Cai-Lian Tam and Qiu-Ting Chie

Alvin Lai Oon Ng

About the editors................................................................................257

List of contributors............................................................................. 259

In recent years, interest in psychology has been growing worldwide.

Psychology is a fast-moving discipline and has witnessed some import-

theories (Greenfield, 2001). A large number of studies have been con-

Gregory Bonn (chapter 4) discusses how the culture in which peo-

to the Behaviorist movement which had dominated psychology in the

are developed in the Western countries such as USA, UK and Canada,

Adler, L. L., & Gielen, U. P. (2001). Cross-cultural topics in psychology

Chomsky, N. (1959). Review of B. F. Skinner’s Verbal Behavior.

Nisbett, R. E., & Norenzayan, A. (2002). Culture and cognition. In

Cultural life scripts in autobiographical memory

* The authors thank Ministry of Higher Education Malaysia for supporting

Figure 1: Twelve temporal distributions of autobiographical memories recalled by

The reminiscence bump is one of the most robust findings in auto­

What are cultural life scripts?

have similar shared knowledge about the sequence in which significant

How does one examine cultural life scripts?

What are the general findings of cultural life scripts studies?

Study Mean Mean Proportion Proportion

Study Positive Events Neutral and Negative Events

Are cultural life scripts episodic or semantic?

An important property of life scripts is that they are semantic knowl-

Are there differences between cultures?

The number of event categories that were mentioned by at least 4% of

When are cultural life scripts used?

bump is one of the most robust effects in autobiographical memory re-

Berntsen, D., & Bohn, A. (2010). Remembering and forecasting: The

Berntsen, D., & Rubin, D. C. (2002). Emotionally charged autobiograph-

Conway, M. A., & Pleydell-Pearce, C. W. (2000). The construction of

or importance of personal events. The Quarterly Journal of Experi-

Rubin, D. C. (2005). A basic-systems approach to autobiographical

Healthy body, healthy face? Evolutionary

The human face contains a large amount of observable information

Theoretical approaches to attractiveness research

as a method of maintaining control over women (Wolf, 1991). In this

What defines attractiveness?

The reminiscence bump is one of the most robust findings in auto