N = 26), performed inductive thematic analysis of these interviews, and then further examined the inductive findings by surveying specialists (N = 275). We identified 16 qualities of significant nature situations  and 10 abilities that constitute children's HNC . We elaborated three principles to answer our research questions: (1) significant nature situations are various and with differing consequences for children's HNC; (2) children's HNC is a complex embodied ability; (3) children's HNC progresses over time through diverse nature routines. Together, these findings form the Assessment framework for Children's Human Nature Situations (ACHUNAS). ACHUNAS is a comprehensive framework that outlines what to quantify or qualify when assessing “child-nature connecting” environments. It guides the assessment of where and how children connect to nature, stimulating both the design of nature-connecting human habitats as well as pedagogical approaches to HNC.The design of the green infrastructure in urban areas largely ignores how people's relation to nature, or human-nature connection (HNC), can be nurtured. One practical reason for this is the lack of a framework to guide the assessment of where people, and more importantly children, experience significant nature situations and establish nature routines. This paper develops such a framework. We employed a mixed-method approach to understand what qualities of nature situations connect children to nature (RQ1), what constitutes children's HNC (RQ2), and how significant nature situations and children's HNC relate to each other over time (RQ3). We first interviewed professionals in the field of connecting children to nature ( Academic discourse is increasingly focused on how people see themselves in relation to nature . Bai and Romanycia  suggest that environmental consciousness raising is really about […] making ecological principles into habits of mind, body and heart […] creating spaces for multiple, meaningful interactions to take place  and providing contextual embodied experiences ” .“Gibson hardly wanted to divide the world up into material, social, or cultural worlds, as he was against all division of environmental experience”  here, instead of “connecting” nature experiences for two reasons. The first reason is to be coherent with existing literature. Significant nature experiences have long been used in the literature to denote those life experiences that “connect” people to nature  in the field of connecting children to nature in two consecutive steps. The first pool of practitioners (N = 11) was chosen to represent a wide range of professional competencies and complementary conceptualizations of children's HNC. A second set of practitioners (N = 15) was selected from within a Swedish organization of nature preschools (“I Ur och Skur”) whose outdoor-focused pedagogical approach has contributed to increase interest and attachment to nature in young children through direct nature interaction since 1983  years of expertise in the field so we refer to them in the paper as “professionals.” All interviewees provided informed consent prior to the interview. The interviews lasted 50 min on average and followed interview guidelines that covered the three main areas of interest identified by the RQs: what constitutes a “connecting” nature experience for children, what the traits of a connected child are, how children's HNC changes over time. The interviews were recorded, transcribed, and coded using Atlas.ti. Inductive coding was performed for all interviews following the systematic process for thematic analysis described by Braun and Clarke , children's HNC (RQ2), and their relationship over time (RQ3) were discussed between researchers and interpreted according to the objectives and the relational approach of the paper. We differentiated between themes when they were critically dissimilar and aggregated them when their differences were only of terminological nature. For example, when resulting themes were positive or negative manifestations of the same concept we aggregated them into an overarching theme. When the resulting themes were overlapping we highlighted their diversity whereas for nested themes we retained the most general. These inductive results were used to formulate the criteria of the assessment framework, which were then examined further by additional professionals using an online survey in phase 2.all possible constituents of children's HNC was, and subsequently asked to rank all the constituents from the one children learn first to the one children learn last . The fourth page examined the practicality and potential transferability of these constituents across a multitude of actors. In this exercise, we asked respondents to choose one constituent of children's HNC, to state a nature activity they perform in their everyday work to significantly nurture that constituent, and then to assess the reported significant nature activity rating how important each quality of SNS obtained in phase 1 was on a five-point Likert scale ranging from “not important” to “essential” . Professionals were then asked to perform the same assessment exercise for another constituent of children's HNC, and were allowed to further perform it a third time.The online survey was developed following the process identified by Artino et al.  to desigWe chose the number of questions (14 were compulsory) in the survey to be practical and simultaneously adequately comprehensive to capture the complex essence of children's SNS and HNC. We favored simple English vocabulary to suit the intended international audience of professionals working with children's HNC. Prior to releasing the survey, we conducted expert validation with four colleagues for content validity; eight cognitive interviews with additional professionals in the field for response process validity; and performed two phases of pilot testing  or “essential” (N = 218) for their profession were analyzed. This resulted in the removal of only 7 respondents suggesting that the survey was correctly targeted. Of all respondents 93% had at least 3 years of professional experience in the field of connecting children to nature , so, as with the interviewees in phase 1, we considered the respondents of the survey “professionals” in the field. Additionally, their heterogeneous professional competencies and institutions covered the full-spectrum of potential insights into what SNS are. Most professionals worked with several age groups at the same time. Only few respondents (13%) worked with the age group “0 to 1 years old,” 37% worked with “2 to 3 years old,” most of them (80%) worked with the age group “4 to 7 years old,” while 53% worked with “8 to 11 years old,” and 34% worked with “12 to 18 years old.”The 275 respondents of the survey were from more than 200 different organizations. These organizations included primary, secondary and high schools, forest and gardening schools, national parks, local and national organizations of environmental conservation, municipalities, and international organizations devoted to the cause of connecting children to nature. These organizations and schools were located in Sweden, Finland, Netherlands, US, England, Australia, Canada, Colombia, New Zealand, Scotland, Wales, Spain, Norway, Northern Ireland, Belgium, Mexico, Malaysia, India, Indonesia, Austria, Estonia, and Portugal. Only the data from respondents that had stated that connecting children to nature is either “very important”  and subsequently performed hierarchical clustering. The dendrogram (agglomerative coefficient = 0.30) and clustering of the qualities of SNS at this level showed six separated clusters , moderately (24%), very (63%), or fully comprehensive (7%).Across all abilities of HNC, at least 79% of survey respondents % Figure . Furtherroutinization and progression.The inductive analysis of professionals' interviews and survey exercises showed that qualities of SNS relate to children's abilities of HNC through two interrelated dynamics of change: Routinization fosters the development of children's HNC within abilities of HNC. It happens through reoccurring nature activities with similar qualities of SNS, but possibly across different socio-environmental situations. That is, the set of relations existing between different spatial natural features, social circumstances, and children's abilities generates qualities of SNS that develop certain abilities of HNC in depth. We selected few illustrative quotes from the interviews to exemplify the dynamic of routinization.It is practice that gives them that skill. […] With the skiing for example, they can go downhill a hundred times and fall a hundred times. And the 101st time, they stand the whole hill down.”“3 things that make nature play impactful: right kind of play, right kind of place, and the right kind of re-play […] is this frequency thing […] basically that it needs to happen, not necessarily everyday, but frequently.”“Progression is the development of children's HNC across abilities of HNC. That is, the set of relations existing between different spatial natural features, social circumstances, and existing children's abilities generates qualities of SNS that allow children to develop abilities of HNC that they did not have before and broaden the development of their HNC; we selected few illustrative quotes from the interviews to exemplify the dynamic of progression.Also, to build a positive feeling for nature you need to establish this sense of comfort already in young [children]- Being comfortable that you're able to, or dare to, carry your own backpack for example. That is sort of the first step. And then as you get a little bit older- To be able to walk a bit further away, maybe to another place.”“First; you have to get accustomed to nature somehow, explore and discover, before you can play. […] Then you can start becoming interested in… Well, maybe practicing your agility by jumping from rocks or climbing tree logs or something.”“[In a new place], you have to sort of start over, from this first phase .”“being IN nature.” The second cluster is defined by children's abilities of “acting in natural spaces,” “feeling attached to natural spaces,” “reading natural spaces,” “knowing about nature,” and “recalling memories with nature,” so we termed it “being WITH nature.” The last cluster is defined by children's abilities of “caring about nature”, “taking care of nature,” and “being one with nature,” so we termed this cluster “being FOR nature.”In order to fully appreciate the progression of children's abilities of HNC, we use a weighted average to rank the results from the ordering exercise in the survey. “Feeling comfortable in natural spaces” was found to be the first ability of HNC that children learn and “being one with nature” the last one Figure . We alsobeing IN nature” performed nature activities that were mostly “child-driven,” characterized by high “engagement of senses”, “awe,” “physical activity,” but with little “structure/instructions.” Conversely, professionals who aimed to teach children to be capable of “being FOR nature” performed nature activities that were more characterized by “thought-provocation,” “social/cultural endorsement” and “structure/instructions” and less by “physical activity” or “entertainment.”The dynamics between the qualities of SNS and children's abilities of HNC have been further explored using the results of the assessment exercise performed in the survey. This showed that in order to teach children specific abilities of HNC, professionals used nature activities that had different configurations of qualities of SNS Figure . For exabeing IN nature,” “being WITH nature,” and “being FOR nature.” The results showed that many qualities of SNS were statistically different for different phases of abilities of HNC; that is, “entertainment” , “thought-provocation” , “intimacy” , “surprise” , “physical activity” , “social/cultural endorsement” , “structure/instructions” , “engagement of senses”  and “child-driven” . For these qualities of SNS, Tukey post-hoc tests showed that there were significant differences between teaching children to be in or with nature and being for nature   Figure . ACHUNASthree crucial questions to address the problem of assessing child-nature-connectedness of environments: “what are the qualities of significant nature situations?” (RQ1), “what constitutes children's human-nature connection?” (RQ2), and “how do qualities of significant nature situations and children's human-nature connection relate to each other over time?” (RQ3). Below, we discuss the results that answer each of these questions with a principle. The three resulting principles set the boundaries of the assessment framework and guide how it should be interpreted and operationalized in the future.This paper identified environmental epiphanies” are identified in the literature as “‘aha’ moments […] that shift the fundamental self-nature relationship”  are characterized by configurations of qualities of SNS that are statistically different from the other phases of HNC progression  a child has to develop over time the ability to be in (1st phase) and with nature (2nd phase). In other words, before feeling care or concern for the environment, and before feeling responsible and motivated to act for it, a child has to at least feel at ease and comfortable in the natural elements of the outdoors. Children's ability to just enjoy and being curious about natural spaces is therefore a gateway to more profound forms of human nature relationships, but the progression across such abilities of HNC cannot be considered linear. Since these abilities are embodied in specific socio-environmental contexts, their progression is also context-dependent. As one of the interviewees stated “[In a new place], you have to sort of start over, from this first phase.” The three phases of HNC progression can indeed be seen as an indication of multiple states of equilibrium. This also implies that the development of children's HNC is likely to be characterized by potential threshold effects between one phase of HNC progression and another. For instance, only when a child is comfortable in nature in several social-environmental contexts can s/he then begin to know how to read specific environmental features. Abilities of HNC can indeed progress in depth  and breadth , and can nurture one another . The third guiding principle to support the use of ACHUNAS is, therefore, that children's HNC does not grow linearly, but it progresses dynamically over time through the routinization of diverse qualities of SNS.The thematic analysis of professionals' interviews showed that children's HNC progresses dynamically over time through routinization and progression like most other human abilities. In the survey, professionals suggested a model of development for children's HNC that begins with “feeling comfortable in natural spaces” and “being curious about nature,” and ends with “caring about nature” and “being one with nature” Figure . The relCurrent literature proposes models of development for HNC that grow linearly in independent and pre-identified psychological traits Tam, . The amoquantify or qualify when assessing child-nature-connecting environments. Similar to the lists of qualities used to assess the “child-friendliness” property of environments  are chosen by the evaluator. For a more complete assessment, the evaluator might also consider principle 3 of ACHUNAS  and assess how frequently children visit the park and how long they have exposure to nature activities for, or perform the same assessment for all the parks of a neighborhood or a city.ACHUNAS can be used, for example, to assess the extent and type of “extinction of experiences” that many authors also believe undermines children's well-being , 74% considered the list of sixteen qualities of SNS to be “very” or “fully comprehensive” to assess ” Figure . The samWe identify three limitations of ACHUNAS to assess child-nature-connecting environments. The first limitation is the completeness and generalizability of ACHUNAS. 63% of professionals found the abilities of HNC “very comprehensive” and 67% of them thought the same for qualities of SNS, but only 7% of them found these lists to be “fully comprehensive.” This shows that ACHUNAS might not yet integrate all the qualities that can categorize an environment as more or less child-nature-connecting and, therefore, the lists of qualities of SNS and abilities of HNC require formal validation. Further research is required to test the lists for convergence or divergence. For generalizability, cross-cultural assessments are needed to understand if certain qualities of SNS and abilities of HNC are more suitable than others to assess specific socio-cultural contexts. Despite having tested ACHUNAS on a very international and heterogeneous group of respondents, the framework lacks the contributions of non-English speaking professionals and the potentially valuable input from indigenous communities.what to assess, but it does not provide guidance on how to assess child-nature-connectedness. Comparability across assessments that operationalize ACHUNAS with different methodologies might, therefore, be limited. Defining standard operationalizations of ACHUNAS through trandisciplinary collaborations would greatly increase the comparability of results across different socio-environmental contexts.Second, because of the nature of ACHUNAS, the framework does not suggest which method is the most suitable to assess each item in the lists. ACHUNAS highlights Third, ACHUNAS is a framework built upon professionals' understanding of children's HNC. The results are therefore a representation of a multitude of adults' perspectives and lack the direct input of children's insights. In order to further improve the validity of ACHUNAS as a framework, interviews of children and self-reporting methodologies performed with children can be implemented to better integrate children's perspectives into the ACHUNAS framework. In pursuing this endeavor, we also see the potential contribution of children with differing socio-demographic backgrounds.We identified three future research directions that have great potential to promote the design of nature-connecting human habitats or to inform educational curricula that promote children's HNC. The most obvious is operationalizing ACHUNAS to assess where and how children connect to nature. Implementing standard operationalizations of ACHUNAS would allow understanding which relations of children's abilities of HNC and socio-environmental features afford qualities of SNS. This would be a further step forward in unveiling the ecological properties that can categorize an environment as more or less child-nature-connecting. Furthermore, such knowledge would be a stepping stone toward the design of nature-connecting human habitats.A second area of research of fundamental importance is the analysis of interdependencies between qualities of SNS and abilities of HNC. The fundamental unit of analysis in ACHUNAS is at the confluence of children's abilities of HNC, qualities of SNS, and the socio-environmental context. The results shown above already indicated that certain configurations of qualities of SNS significantly relate to certain abilities of HNC (see Table Lastly, it is plausible that children's HNC may vary not just in relation to SNS and nature routines, but also with respect to the child's cognitive, emotional, moral, and physical stages of development. Although this has not been the goal of this paper, we recognize that studying the progression of HNC in relation to children's stages of development is a promising area of research that could directly promote comprehensive and holistic curricula to nurture children's HNC. For the sake of facilitating such academic endeavor, we believe that Piaget's stages of development Piaget, , VygotskThe results of this study have obvious implications for the practice of sustainable urban design and environmental education. It is common for urban green infrastructure to be promoted and developed for biophysical management, e.g., stormwater management, flood control, urban cooling, reduction in carbon emissions etc., but its role in the development of children's HNC has been so far largely ignored. For example, access rights, spatial accessibility, ecological and biological diversity are just some of the variables of the green infrastructure that can promote children's nature routines and their HNC; all of which are already intentionally designed in the human habitat. Whether intentional or incidental, recurring experiences of nature situated in the everyday habitat of children are opportunities to develop their abilities of HNC (Giusti et al., As environmental educators have already acknowledged, promoting children's HNC also means facilitating frequent nature activities and the results of this study confirm this position (Chawla and Cushing, ACHUNAS is a starting point for cross-fertilization between different disciplines interested in child-nature-connectedness. The academic literature on HNC has been systematically divided into epistemological silos (Ives et al., In this study, through the use of inductive thematic analysis and a practitioner survey we identified and tested three components of an Assessment framework for Children's Human Nature Situations that we called ACHUNAS Figure . First, Questions like “where children connect with nature?” and “what kind of nature experiences are missing from cities?” are central to the design of nature-connecting human habitats as much as to the generation of sustainable futures. ACHUNAS is sufficiently comprehensive, transferable, and practical to provide a starting point to answer these questions and to guide the assessment of where and how children connect to nature. It can be operationalized to assess the extent and typology of “extinction of experience” and inspire the design of nature-based human habitats that also connect children and people to nature. Similarly, it can be used to evaluate curricula that aim to connect children to nature, providing useful information to such educational programs. Overall, ACHUNAS is a transdisciplinary framework that allows cross-fertilization and integration of knowledge across different academic disciplines and makes it useful to practitioners interested in promoting child-nature-connecting environments and children's HNC. In conclusion, ACHUNAS provides a starting point to classify a social-ecological system as more or less child-nature-connecting.This study was carried out in accordance with the recommendations “ESPA Ethics Principles and Procedure” produced by the Directorate of the Ecosystem Services for Poverty Alleviation, with written informed consent from all subjects. All subjects gave written informed consent in accordance with the Declaration of Helsinki. The protocol was approved by the ethical committee at the Stockholm Resilience Centre.MG: Work conception, research design, data collection, data analysis, data interpretation, paper arrangement and revision, writing, and submission; US: Data collection, data analysis, data interpretation, paper arrangement and revision, and writing; CR: Data interpretation, research design, paper arrangement and revision, and writing; TB: Data interpretation, paper arrangement and revision, and writing.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.


Currently, feasible medical treatments are hitherto not satisfying to relieve pSS symptoms, which concerns numbers of clinical doctors. Acupuncture seems to be an alternative to treat pSS and conduces to good symptomatic results. However further research is necessary. This trial is to investigate the efficacy of acupuncture on improving the key symptoms of pSS, which are dryness, pain and fatigue (DPF).The study is designed as a randomized controlled trial of two arms with a single centre. We compare acupuncture with sham acupuncture on symptomatic improvements of pSS. A total of 120 pSS patients, aged at least 18, with DPF, will be randomly assigned to acupuncture or sham acupuncture groups, where they will have needle intervention for 8 weeks with 16 weeks of follow-up. Subjects will be assessed each time before interventions during the 8-week intervention, in week 8 after all interventions and in week 12, 16, 20 and 24 for follow-up with different measurements. The primary outcome are the proportions of subjects that have 30% or greater reduction in at least 2 out of 3 items of DPF in Numeric Analog Scale (NAS) scores , calculated between the baseline and the average scores of week 2 to 8. The secondary outcome are related to individual items of NAS scores, EULAR Sjögren’s Syndrome Patient Reported Index (ESSPRI), EULAR Sjögren’s Syndrome Disease Activity Index (ESSDAI), Schirmer test score and unstimulated salivary flow, serum Immunoglobulin G, A and M levels, Medical Outcome Study Short Form 36 Short-Form Health Survey (SF-36), Salivary glands ultrasounds, Hospital Anxiety and Depression (HAD) scale score. The secondary outcome scores are to be collected at baseline, in week 8, 16, and 24. Besides, individual items of NAS will also be collected in week 12 and 20. Moreover, subjects’ satisfaction and the proportion of the subjects who identified their allocation will also be measured and analyzed.This study will be the first randomized and controlled pilot trial of acupuncture on alleviating the symptoms of pSS with relatively long-term follow-up. The result of the study might offer a new option to treat pSS and might be a clinical proof that acupuncture has beneficial effects on pSS.NCT02691377 ClinicalTrials.gov:  Primary Sjögren’s syndrome (pSS) is a systematic autoimmune disease characterized by high lymphocytic infiltration in the exocrine glands such as salivary and lacrimal gland. The incidence in different populations varies from 0.5 to 2% . There iCurrent available medical treatments for pSS may lead to either serious adverse side effects, or failure to relieve symptoms. Thus, Bio-agents , immunosuppression  or corticosteroids should be cautiously applied clinically because of their safety and cost-effectiveness, although life-threatening complications after taking them are rarely seen. Even the most frequently prescribed medicine for pSS , 5, hydrAcupuncture, as a non-pharmacologic therapy from Traditional Chinese Medicine, has been applied in a variety of disorders, including clinical symptoms of dryness . ResearcIt seems that pSS patients have a good clinical response to acupuncture therapy in daily clinical practice, with acupoints and manipulations inherited from Professor Lu Zhizheng , one of The study is a single-centre, double blinding and 24-week randomized and controlled trial with two arms, in one of which, needles will be inserted into previously set acupoints while sham acupuncture for the other group. 120 patients with symptomatic pSS are randomly assigned to acupuncture or sham acupuncture groups in 1:1 ratio. Needles are administered 3 times a week for the first 4 weeks, twice a week for the second 4 weeks, with 16-week of follow-up. All the allocation, intervention, randomization and analysis, etc., will be conducted in Guang’anmen (GAM) Hospital. The primary outcome is the two proportions of subjects in the two groups that have 30% or greater reductions in NAS scores in at least 2 out of the 3 DPF items [penetrating acupuncture: 60 subjectssham acupuncture: 60 subjectsSubjects eligible for participation will be randomly assigned to one of the following study groups, using the randomization software SAS  9.2.The statisticians will randomize assignments using a sequence of number randomly generated by the SAS  9.2, done by a third organization, a Statistical Department of State Standardized Traditional Chinese Medicine Pharmacology Clinic (SDSSTCMPC) granted by State Food and Drug Administration (SFDA). The sequence will be recorded and can be displayed when necessary. These assignments will be sent to a study member, who will put them into sealed, opaque envelopes with dates and signature labels over the seals. And this study member will not take part in any of patient interviews, acupuncture intervention, data collection, or statistical analysis.Before eligible subjects are randomized into different groups, informed consent contract will be obtained from each participant and they will be interviewed to ensure their baseline data recorded. Then they will allocate and come to see the acupuncturist who will open the consecutive randomization envelope, and then apply acupuncture or sham one according to the assignment without informing the subjects of their assignments. As the only one knowing the group assignments of subjects, the acupuncturist will not participate in any of the interviewing, data collection, or statistical analysis. Every time before the intervention, except the first time, which is baseline, the subjects will come to the interviewing room where the case report form (CRF) with NAS scores will be filled with their feedback on NAS scores about last 24 h instead of a time point. After the intervention, the schedule for their acupuncture and interviewing for next time (including date and time) will be informed.Age 18+To meet the American-European Consensus Group Criteria for primary Sjögren syndrome Symptoms have been appearing for less than 5 years; signed a written informed consent formWithout taking pSS medicines, or have not been taking pSS medicines for at least 4 weeks before the recruitment, or have been taking the same kinds and doses of pSS medicines  for more than 4 weeks before the recruitment, or have been taking the same kinds and doses of other pSS medicines  for more than 6 months before the recruitment.Secondary Sjogren syndromeHave been having serious systemic disorders recently  or severe renal or liver failureHave had acupuncture treatments in last 20 daysWith acupuncture contraindications Subjects who participate in any other clinical trials in last 30 days before recruitmentCurrently or planning to be pregnant, or at risk of being pregnant without contraceptionSubjects with a physical or psychological problem, which may confound the trial results, interfere with other subject’s participation, or may make it risky to follow the investigators’ requirementsSubjects known for or persistent in drug or alcohol abusesPatients will be recruited through a number of advertising strategies, with the information of physicians and the details and requirements of the trial. Posters in GAM Hospital, and advertisements on the online official medical medias, such as websites, Weibo (similar to twitter in China), and Wechat (similar to Facebook in China) of Rheumatology Department of GAM Hospital, will also be applied for recruitment. Also, another main recruiting way is that patients comes from outpatient service.Since sham control is a useful method for determining the effectiveness of a therapy, we will choose a sham needle  that hasThe sham needle is 0.30mm wide and 25mm long. It consists of an adhesive pad with a blunt tip Fig. . The adhAll of the subjects will be told that we are going to evaluate the effects of “a new kind of acupuncture” researching on “deep penetrating needles and shallow penetrating needles” on pSS, without mentioning sham, pseudo or the penetration status. The experienced acupuncturist will be trained on the sham needles and will apply both the sham and real needles throughout the whole trial. Each time before the intervention, subjects will be asked to meet the interviewer in another room to provide their answers on CRF with the feelings of the last 24 h before the intervention, excluding the first intervention, whose data will be the baseline. Acupoints and manipulations are the same in 2 groups   scores oSubjects will be asked to provide every NAS score based on the overall situation of the past 24 h  rather tThe mentioned outcome measurements will be assessed at the marked time points respectively Fig. .Fig. 3TrEULAR Sjögren’s Syndrome Patient Reported Index (ESSPRI)  is a verEULAR Sjögren’s Syndrome Disease Activity Index (ESSDAI) , 18 is aSchirmer test score and unstimulated salivary flow : these tSerum Immunoglobulin G, A, M levels : ImmunogMedical Outcome Study Short Form 36 Short-Form Health Survey (SF-36) , 22 is aSalivary glands ultrasounds : image oHospital Anxiety and Depression (HAD) scale score : A self-Secondary outcomes include each items of NAS scores from week 0 to 8. These items will be measured individually at baseline, 3 times a week in week 1 to 8, once a week in week 12, 16, 20, 24. The secondary outcomes also include:For the secondary outcomes listed above, the measurements are conducted at baseline, in week 8, 16 and 24. Besides, the satisfaction of patients in two groups and the proportion of the subjects who identified their allocation will be measured in week 8.Additionally, we will assess the patients’ satisfaction in week 24 by two questions. 1) “Would you like to come for more treatments or recommend it to your friends/relatives if they have similar symptoms?” The answer will be either “yes” or “no”. 2) "What is your feeling for the series of treatment?” The answers will include “excellent”, “good”, “satisfactory”, “It’s okay” and “poor”. The difference in satisfaction between two groups will be analyzed.To evaluate the success rate of blinding, we will ask subjects in week 8 “how deep do you think the needles went into your skin?” The answer will be “deep”, “shallow” or “no penetration”. The subjects in the two groups whose answers are either “deep” or “shallow” will be considered to be blinded successfully, while “no penetration” unsuccessfully, and the proportions of them are going to be compared.Sample size will be decided by the primary outcome. According to our unpublished pilot study and literature review , the proP <0.05 with two-tailed test indicates statistical significance.For data analysis, statisticians and investigators will be blinded for the patients’ allocation. Statistical analysis will be performed using SPSS Ver.20  software. Enumeration data will be described as frequency and composition ratio. Continuous data will be presented by Mean ± Standard Deviation (M ± SD) if they meet normal distribution, otherwise they will be expressed as Medians ± Interquartile Range (M ± IQR). Categorical data will be presented by frequency and percentage. The analyses of efficacy will be based on the intention-to-treat (ITT) analysis set, which was defined as patients who receive at least one treatment. Missing data for the primary outcome will be treated by multiple imputation under chained equation, with m = 50 imputations. The covariates used to generate the multiple imputed data sets are age, sex, NAS scores of DPF, ESSDAI, ESSPRI, salivary flow rate, and Schirmer test score. For comparison with the baseline, a repeated measures data analysis of variance (ANOVA) or Wilcoxon signed rank test will be used for continuous data, whereas Chi-square test or Fisher exact test will be used for categorical data. In terms of comparison between the two groups, Chi-square test or Fisher exact test will be used for primary outcomes. For secondary outcomes, the analysis of covariance (ANCOVA) will be used if the residual are normal distributed, otherwise Wilcoxon rank sum test will be applied. To access the success of blinding, the proportion of subjects who are successfully blinded will be compared by Chi-square test or Fisher exact test. And nonparametric test will be used to analyze satisfaction. This trial is designed to assess the effects of acupuncture on DPF of pSS, with the alleviation of the symptoms as a clinical priority when severe complications absent in most cases. In this study, we will evaluate if the effect of acupuncture is not worse than that of sham; the characteristics of the patients who have better responses to acupuncture at the reasonable end points in multiple perspectives, covering the subjectivity and objectivity of patients’ feedback. The objective feedbacks are the structure and function of salivary glands, the disease activity, and complications of pSS. The subjective feedbacks include feelings of DPF and emotions.Inclusion criteria were held pragmatically to facilitate screening and recruitment. The symptom duration is set to be “less than 5 years” in the inclusion criteria, because the structure and function of the glands would be aggravated with the course of disease, which would be more difficult to be reversed  if it’s With a blunt end and achieving no skin penetration, the sham needle that we choose as a control procedure in this trial has the same appearance and gives a likely sense of penetration to a real one Fig. . In a crSince many of the subjects in China may have basic ideas of acupuncture, they would notice the difference between the needles used in this trial with plastic pads and the traditional ones applied clinically without Fig. . Thus, wBesides the details of sham needles and the inform strategy, there are a lot of other efforts we take to minimize the possible bias. We will give subjects acupuncture in one room and interview them in another, so that the physicians, the interviewer, the data collectors, and the statistics will be blind to the group allocations. What else, to ensure the consistency of manipulation in repeated courses of real/sham acupuncture, we will train the acupuncturist and write a standard operation procedure (SOP) and this acupuncturist will stick to SOP throughout the whole study. It is designed to be based on a specialists’ consensus, which is 3 times of acupuncture a week in the first 4 weeks followed by twice a week in the second 4 weeks. It obeys the acting rules of this traditional therapy. And the subjects will be followed up by another 16 weeks besides 8 weeks of acupuncture, in order to ensure the relatively long-term effects to be observed rather than only the short-term ones.When NAS scores are collected in CRF, a general pSS condition of the last 24 h will be asked to avoid temporary diverse interferences only existing during the interviews, such as mental relaxation in weekend, weather changing, and unexpected events in life, etc. Schirmer test, unstimulated salivary flow, and salivary grand ultrasound will be performed by the same technicians to maintain the consistency, before and after the 8-week intervention and during the follow-up, which also reduces bias.We selected acupoints based on the experiences of Professor Lu Zhizheng. The given acupoints will be a practical option for both domestic and international doctors and researchers for either their clinical prescriptions or studies. According to TCM theory, Taiyang (EX-HN5), Cuanzhu (BL2), and Sizhukong (SJ23) are functioning in the eye disorders. Chengjiang (RN24), Lianquan (RN23) and Jiache (ST6) take actions on dry mouth. Waiguan (SJ5) and Zhaohai (KI6), as the points in the corresponding meridians distal to the local areas, act not only on dryness of eyes and month, but also on pain and fatigue. Thus, with these acupoints mentioned above, this study is designed to evaluate the effect of acupuncture on symptoms of pSS patients since the acupoints work well in coordination theoretically and seemingly clinically.Limitations include the restricted sample size and single centre. Although the study takes place in GAM hospital in Beijing, it is not possible to limit subjects into only local citizens as there is a large number of people immigrating to Beijing from all over China and so do the patients. Thus, the differences of people in different areas of China may interfere the outcomes of the trial. Although we only accept subjects having less than 5-year of symptomatic pSS, different durations of having it may also interfere the outcomes. Besides, we can’t eliminate the medicine interferences from those who are taking other medicines during the study. We don’t know what the informing strategy would actually and exactly bring to subjects mentally by telling them we are researching on a “new” method of acupuncture, although our initial purpose of doing so is to make subjects to have the same expectations from their interventions. Another limitation is that the acupuncturist knows assignments and he conducts, in which case the communication between the acupuncturist and subjects may, more or less, change the expectations of subjects, which would cause bias. What’s more, the acupoints studied in this trial are constant. It is not the way of applying acupuncture clinically in TCM way, in which case we wouldn’t know how acupuncture would act if it’s done with Differentiation Method, a way of diagnosis in TCM, which also directs treatments. Finally, if there is a third group by standard care, the result would be more convincing; while, standard treatments based on the guideline of pSS had not been established yet before the start of this study, and our fund is not financially supportive to set a third group of cohort.


Mammals are defined by their similarities in bodies, behaviours and minds, where the mind is defined as the organized totality of mental processes. Mental similarities between related species, known as homologies, have largely been ignored by cognitive scientists since Darwin. Today, some behavioural scientists hold a series of beliefs which do not recognize them. However, people who have to do with animals daily have always recognized common mental traits they have with their animals. After 25 years of multi-disciplinary study, nine important mammalian mental homologies have been delineated: (1) All mammals have innate behaviour tendencies which are molded by the individual’s lifetime experiences. (2) They are sentient (that is they feel and have emotions) and consequently are conscious: awake and aware of the world. (3) They all learn in similar ways. (4) They all have to acquire ecological knowledge to live and reproduce. (5) They acquire social knowledge, have a social contract and can develop different traditions and cultures. (6) They have to know about others’ intentions to be social, that is they all have a “theory of mind”: an awareness that others have body/mind beings. (7) They are aware of their own body and feelings, thus they must be self-aware. (8) They are moral agents because they know when they have obeyed the social contract and when not. (9) They have a simple aesthetic sense because they like some things and dislike others. Sentience appears to be the power house behind these and other mental aptitudes which follow from them such as beliefs, decisions, episodic memory, imagination and mental time travel. In order to compare the “beings” (body-mine wholes) of different species and their world views, Conditional Anthropomorphism is proposed. This recognizes our common mental traits (anthropomorphism) takes into account different species specialties and examines the past experience of that individual to indicate how his/her world view is molded by lifetime experiences . Such studies are essential to improve their welfare and enriching our lives.Mammals’ mental homologies include that they look after their young, suckle and protect them; they acquire information about the world by learning. They have five types of sensory receptors and a brain to analyze the information and they feel: that is they are sentient. Mental homologies have been largely ignored by behavioural scientists since Darwin because of certain historical beliefs. This however has not been the case for people who have had to do with non-human mammals who have long recognized their mental similarities to humans. As a result, behavioural science has sponsored some inappropriate research (examples are given). The study of another mammal species epistemology, (knowledge and world view) requires a recognition of these mental homologies. The result of a 25 year multi-disciplinary study indicates that there are nine mammalian mental homologies which define mammals. These are discussed and reviewed and further mental aptitudes which logically follow from these are pointed out. A Conditional Anthropomorphic approach is proposed. By recognizing the body/mind, whole “being” homologies of mammals, we can advance in understanding other mammal species’ and individual’s epistemology (world view), and consequently better their welfare and enrich our own lives.  Species are classified as a result of cladistics  is also Placental mammals are defined as having an endo-skeleton with recognizably similar bones, internal organs and physiology. They are warm blooded  firsA recognition of sentience acknowledges that non-human mammals must have a “mind” since to feel, there must be something to feel with. Both Darwin , and JamBy contrast, the public recognition of human and non-human mammals’ mental similarities has its origins in centuries of contact with other mammals who were raised, handled, taught, helped in wars, worked on farms, used for transport, for entertainment and as companions and friends living by human firesides (Rollin ). Such kTherefore, unlike scientists, the general public did not ignore the presence of non-human mammalian minds and emotions, and consequently, their ability to suffer, even during the 19th century. The first animal protection law which recognized that cattle could suffer was passed in 1822 in the UK. Anna Sewell’s book Black Beauty (1877)  which deThus, long before “ethology” or “comparative psychology” was invented, humans recognized similar mental aptitudes, that is mental homologies, between themselves and non-humans. Today, this folk-knowledge  is oftenA brief summary of the history of ideas and beliefs  concerniOnce sentience  was finaThe study of learning by experimental psychologists did not undermine the belief that non-human behaviour was controlled genetically, that is in a sense robotically, because for the first half of the 20th century, learning was described as a type of neo-instinctive “conditioning” which allowed sentience, feeling or having emotions, as well other related mental attributes to be swept aside and dubbed “motivation”,  delegated to robotic status who behave because of their genes and instincts. This gave rise to the study of “ethology” It is believed that “good research” on mental attributes of a species, must be conducted from a tabula-rasa position that is, until it is proved that this species can do this mental task, it cannot be assumed, even though it is a mammal who by definition has this skill . This raises the question of what needs “proof”. An example of a discussion 30 years ago in Glasgow , was whether it was necessary to give ducks water . Logic dictates that a duck is, by its nature, that is by definition, a water bird, therefore it requires water, not just to drink but to swim on, bathe in, feed in etc. This is not something that needs to be tested, unless it is necessary to test whether the subject is, in fact, a duck! Similarly, a gnu is a plains living social quadruped who is a sophisticated visual communicator, runs fast and leaps and jumps around. Because he is who he is, a normal gnu requires to be able to do these things. It is not necessary to test this, any more than it is necessary to prove that a normal baby must have the opportunity to learn to walk on two legs.(2)(a)Negative experimental results. If that animal does not perform in that set of experimental conditions, it is concluded that the individual or the species, is incapable of that performance, but, this may be the result of a whole range of experimental conditions Inappropriate tests. Different species may see, hear, feel, smell, taste or manipulated things others do not. This must be properly understood before doing tests. For example, “self awareness” tests with a mirror concluded that as a result of an elephant’s performance, the elephant was not self aware (Povinelli [ovinelli ). On exaovinelli ); (ii) tovinelli ).Conclusions are rapidly drawn on the mental inabilities of non-human mammals as the result of:(3)not in line with evolutionary theory, but rather with special creationism and human theology and has long been debated  which, (4)Do non humans have a theory of mind”? It is often assumed that humans are mentally superior to all other species. . Do hum(6)conscious of that feeling, and consequently are conscious of being in the world. Sentience and consciousness of being in the world indicates that they have a subjectivity . To progress in an understanding of others’ mentality, and how to better their welfare, these beliefs need serious examination. The first step is to recognize what defines a mammalian being: an interactive mammalian body/mind. This investigation reviews, amalgamates and critically assesses information from any relevant source: evolutionary biology and systematics, physiology, anatomy, neurophysiology, environmental science and ethics, observational and experimental behavioural and cognitive sciences including detailed observational and experimental research, philosophy of mind, folk knowledge and experiences, an examination of ones’ own feelings/emotional responses in similar situations with those of non-human mammals and, finally, detailed one to one research into the teaching of different mammalian species (Kiley-Worthington & Rendle-Worthington ). The result of this research spanning some 25 years, are the following mammalian mental homologies discussed in turn. Innate/Instinctive tendencies recognize how instinct and learning can unite to increase the knowledge and adaptability of the mammal. Von Uexkull  and lateStudies of learning followed a similar pattern. Pavlov  describeOver the next half century, some important discoveries were made concerning both instincts and learning in mammals, but their erratic, flexible, everyday behaviour was generally ignored. To confuse the issues further, elaborate jargons were developed which successfully cloak experimental psychologists’ and ethologists’ work in mystery, although “science” is supposed to deal in knowledge and facts, not mystery (further discussion Midgley )!when, whether, if, where, how s/he does this, is moulded by his/her lifetime experiences of his body/mind being. For example, humans have an” instinctive tendency” to walk on two legs, but if, when, where, whether and how they learn to do this, is the result of their lifetime experiences. If they have a damaged leg, they may hop, if raise by wolves, crawl  and learning  were recognised as involved in almost all human and non-human mammalian behaviours. The mammal has “instinctive tendencies” to do particular things as a result of the innate species predispositions, but Candland ). Bison,Candland  and PrinCandland ), but whCandland  AlthoughCandland ).One of the greatest evolutionary strengths of mammals is that much of their behaviour is genetically incorporated only as soft wired “tendencies” which can be moulded by lifetime experiences allowing the individual to acquire knowledge about the environment and adapt to it  characteristic of mammals and (ii) of that species. But if, ronment . There ronment  feels, then it is conscious of the feeling. “Conscious” is used here in the common sense meaning: awake and aware of what is around  thus, a Secondly, mammals have a variety of feelings or emotions in common: pain, fear, hot, cold, anger, happiness/pleasure, excitement, among others . Every But some species probably feel some emotions that other species cannot read so easily. This may be the result of their sensory systems, special bodies or special abilities. For example, a bat’s feeling when locating his prey by sonar; or the “snake face” of the stallion herding his own mares, or the feeling induced by smelling/touching/manipulating that an elephant must have with his trunk which combines senses and acts as a combined nose/mouth/hand. But, even here, we mammals have enough in common to be able to make an informed guess as to what that feeling might be like (Kiley-Worthington ).What exactly each feeling feels like may never be known by another, either of the same or a different species because it is a private feeling: my red may not spark the same feelings as when you see the same red . This “Sometimes the signs of different feelings in different mammals are so subtle that we cannot pick up the cues as our receptors are inadequate, such as many smells or tastes for humans. Human verbalizing can also be a handicap because it often takes priority and causes lack of attention or awareness to other cues such as visual, smell or taste. But, humans can learn to observe, smell, taste, feel and even hear non-verbal descriptions, just like the non-verbal dog/horse/elephant/lion who with close contact, can learn to listen to and interpret much of human language  as wellWhatever the subtleties of feelings, it is because mammals are able to read something about the feelings of others that they have, through evolution, been able to associate together or know when to avoid each other. It may also be why as a general rule we find it more difficult to get along with fish, reptiles and insects who may demonstrate their emotions differently, or have different ones. Communication conveys something about what the communicant is feeling to the recipient and what he is likely to do next. The recipient reads the communicator’s desires, as a result. All normal mammals convey “something about” their feelings to others which is understood by the recipient and acted on, consequently they all have a “theory of mind” (see below).It is these characteristic feelings or emotions which may be the powerhouse behind many of the other mammalian mental abilities (Goleman  below).Perhaps the greatest mammalian evolutionary achievement is the sophistication of their learning which allows flexible behaviour and the acquisition of an enormous amount of knowledge. This knowledge or information is acquired by having the “motivation”, that is “wanting” to learn what ever is needed, so the driving force behind all learning is also a feeling or an emotion.Learning comes in several types, Pavlovian Conditioning, Instrumental or Operant Conditioning, Associative, Social or Observational learning and Silent or Cognitive learning, (acquiring information without reinforcements) . requires decisions and choices: “to do or not to do”. This decision or choice, requires simple reasoning: “if I do this I will avoid that or obtain this”, thus, animals that learn voluntarily must take rational decisions, at least in the short term. But, voluntary instrumental learning  is recognized, the child or animal has a choice: “to do it or not to do it” and may get it right or wrong. Therefore, performing a voluntary act e Thorpe ) also inTo learn voluntarily a memory of what happened the last time is necessary. Something like “last time I had to do this to obtain that”, this memory involves beliefs and therefore it involves predictions of events in the future: “last time in this situation, that happened, so it may happen again” . HavingThe easiest way in which incidences may be remembered is by remembering particular episodes: episodic memory: “I remember/visualize what happened last time I was in exactly this situation”. Episodic memory is defined as the memory of autobiographical events, the collection of past personal experiences that occurred at a particular time and place . It is bA more important question than “proving” that mammals have episodic memory, is to ask to what degree and in what way, does the situation have to be similar before the same response is obtained? This may depend more on the individual’s past experience than a simple rule of thumb. For example, when a horse has been frightened by going through a particular gate, when does he recognize the same width, size, footing etc. of another gate as similar and therefore dangerous, and when is the gate sufficiently different for him not to worry about passing through? Such questions bring us nearer understanding his “concept” of gate, or trailer, e.g., , and theThe establishment of habits is one of the reasons why there is confusion concerning the necessary mental attributes associated with voluntary learning. Habits may be established after a behaviour has been learnt consciously and voluntarily when it is frequently repeated. When it becomes a “habit”, then it can be performed with no conscious decision making . natural geographers” to know their way around their home areas, find shelter, water, food, comfort. They must become “natural meteorologists” to know what the weather might do to avoid sever winds, avalanches, shelter from storms or sun; “natural geologist” to know where and when to dig, climb, walk . First:social contract”, that is the rules of that society . For exRousseau ), and thRousseau , Cooper Rousseau , Kiley-WRousseau  and HoroRousseau ).intentions and mood or feelings of others: is he going to attack or avoid me, be nice or nasty, playful or cross. To do this, each must recognize that others are beings, with bodies and minds: feelings and intentions.The social homologies that all species of mammal must have to breed and successfully raise their young are: (1) to learn to recognize their mother and when to suckle (2) recognize other members of their own species; (3) To discriminate males, females, and young from adults; and (4) to recognize individuals with whom they associate; (5) To recognize different species and learn something about their behaviours. Mammals raise their own young, so even solitary ones, have a level of social life and must read baseline mental aptitude for all live normal mammals. Some species or individuals, may predict what others will do better than others  but allcultures and traditions  then how can it have an organization, where each knows who to approach and when, who to avoid, and how to behave to remain in the group? The study of animal “social networks” (Krause & Croft 2015 ) takes tJablonka  and BonnJablonka ). not ignore others’ intentions, feelings or the social norms of that society, demonstrated by the fact they all have some social organization. The current belief among many cognitive ethologists, taking the reductionist approach, is that non human non-primates do not have a theory of mind until it is experimentally proven  protection from predators; (b) finding mates. But probably the most important reason for social living among mammals is Social facilitation or social synchronization  used a Whether they ponder or reflect on their feelings and themselves and decisions they have made, is not the same question as whether they are aware that they exist and that this foot/hoof/tongue is mine because I can feel it hurting (Stamp-Dawkins ). QuestiRecognizing moral agency  in non-hMany pets and working animals learn the rights and wrongs of what they are to do when living with humans. They exercise choice: to do the right or the wrong thing. Hence they are moral agents who can be held responsible for their actions like children, not just beings of moral consideration or moral standing.It is clear that many of us treat our dogs as moral agents: the individual is responsible for his actions and his desires are recognized and may be considered by others. They also respond as moral agents as children do. They learn the rights and wrongs of their behavior and act accordingly, and may treat us as moral agents . Interesting philosophical, ethological or evolutionary questions can now be asked on what aesthetic sense does that species  have particularly well developed. It is possible that if humans appreciate in more depth different aesthetic values, they could enrich their own.Proving any of the above mental attributes in any non-human mammal does not further our understanding of that species cognition because they define what a mammal is. Logic dictates that they all must have them as part of the mammalian package, although some species may or may not have specialized in one or the other.A recognition of these basic mental homologies in mammals is the starting point for a serious appraisal of general mammalian epistemology  ThereaftSome have attempted to outline the epistemology of some species . The secondly step is a critical assessment of how these are specialized or modified in a particular species because of his body & mind. The third step is the assessment of how that individual of that species, develops and modifies his mammalian homologies as a result of his individual genetic constitution and lifetime experiences. This three tier approach  is calle(1)By recognizing mammalian mental homologies, we can escape from asking irrelevant questions and begin to unravel non-human mammals mental similarities and differences with greater speed and rationality.(2)a life of quality for species or individuals whether in nature reserves, any form of captivity, domestic, on farms, pets, used for recreation, human therapy or working.Further knowledge has implications for the family, species and individuals’ welfare and needs. Only in this way can we begin to provide (3)Recognising non human mental homologies leads to recognizing that all mammals have other mental dependent attributes for example: reasoning, anticipating and predicting, beliefs, mental time travel, episodic memory, making judgments, having concepts and imagination and acquiring a vast amount of ecological and social information.(4)It raises many questions concerning different worlds, free will and species and individual epistemology.(5)An understanding of another species or individual’s epistemology makes us think in new and different ways and appreciate different things. It can mould our world view and enrich our lives. We might learn something about how to live or die better, and could solve some of the worlds threatening problems created by the present homocentric world view.There are both pure and applied scientific and philosophical reasons why such a study is important:We no longer need to throw up our hands and assume that the mental world of another species is impossible to comprehend or even imagine, (Nagel 1974 ). We neeThe study of animal minds and cognition has been greatly fettered by historical and cultural beliefs and the rise of humanism (Gray ). But, tWe are in the curious position today, that species we have relatively little information about such as cetaceans, primates and elephants (which have only been studied for some decades and no one lives with), are believed to be more mentally able than any animal on our farm or by our fireside, although things may be changing as dog cognition (mans’ best friend) is now receiving attention .Because they are sentient: feel, they are all conscious of being awake and in the world, and self conscious of their own body/mind beings. To survive and breed, they learn about their world and therefore have experiences and acquire knowledge about the environment and the social norms and have traditions and cultures. They have a social contract and therefore are moral agents, and they like and dislike things, therefore, have a simple aesthetic sense. All of this indicates that they have a subjective point of view: an epistemology and a personhood. The driving force behind these mental homologies appears to be sentience/feelings/emotions. Of course, different species develop one or other of these mental attributes differently, but all mammals have them. As a result of recognizing these mental homologies in mammals it is not clear why, or if, humans mental attributes and trivial interests, should always trump those of non-humans. I hope this paper will stimulate further discussion about the beliefs that colour the opinions and science of cognitive and animal welfare scientists, philosophers and animal welfare activitists debates. To ignore what defines a mammal’s whole being, makes little sense and throws out the baby with the bathwater if we want to find out more about their epistemology. We should give the other mammal the benefit of any doubt that we may have, as we have no time left. We are loosing mammals fast. It is predicted that by 2050 there will be a 68% extinction of animal species from 1970 . They aThe way forward is to develop a multi-disciplinary approach to understanding another’s epistemology, we have suggested Conditional Anthropomorphism. This paper addresses the first stage: what common mental attributes do all mammals have.