However, from the clients’ perspective, these tasks frequently represent novel challenges that can trigger anxiety and reluctance. Thus, a key element in therapy is the negotiation between therapist and client to move beyond such reluctance to potentially effective therapy activities and, at the same time, maintain positive relational affiliation between therapist and client. In this research we examined (1) a collection of therapist proposal/client response sequences that were geared toward recruiting participation in chair work and (2) sequences containing hesitation or instances where decisions to engage in chair work were deferred and related relational disaffiliation. Our goal was to identify the conversational resources  that worked to reject a proposed activity (or convey impending rejection) and examine the interactional practices directed at resolving client reluctance.Securing clients’ active and enthusiastic collaboration to participate in activities therapists would like to implement in therapy , questioning the authenticity of the task, or directly refusing. We identified specific therapist practices that facilitated engagement in “refusal-implicative” contexts such as proffering “or” alternatives, offering extended rationales for the activity (accounting), and elaborating on the proposals. We observed that the therapists’ deontic stance (mitigated and reduced claims to authority) and moderated epistemic positioning (deference to the client’s primacy of knowledge and information) played an important role in facilitating engagement.Our research highlights the kinds of interactional sequences in which clients and therapists are able to achieve alignment in mutually working toward chair work entry. Based on these observations, we offer some practical advice to therapists in formulating proposals to engage clients during in-therapy work. There is an accumulation of evidence that therapists and clients who can agree on the importance of the in-therapy activity proposed by the therapist, and actively collaborate in these tasks, have more successful outcomes than those who struggle to achieve such consensus . These fdeontics   that alldeontics , to bett1 In all instances, the goal is to bring the unresolved/split dynamics into the present, here-and-now, of the therapy session, and to help the client move toward resolution or accommodation of the conflictual elements  has been examined under the general rubric of deontics, and more specifically deontic stance and deontic status  claim that clients in Emotion-focused Therapy are often hesitant to engage in task-related activities such as chair work for a variety of reasons. They may be overly cautious when asked to experience their feelings, they may be scared of losing control, and they may find the proposed task awkward and artificial or not to be relevant. These reasons for the clients’ refusals of task-based activities are mainly taken from an “intrapersonal” perspective, what clients feel in certain situations. Our CA approach compliments this perspective by focusing on how opposition (whatever the etiology) is displayed publicly and interactively negotiated. We build on these findings gleaned from the application of CA research on discourses involving directives in general by here focusing particular attention to the relation between the therapist’s deontic stance and epistemic positioning and the degree of success or opposition in negotiating chair work.in vivo practices, rehearsals of physical behaviors , free association, etc. Each of these tasks has unique features that influence the structure of the interaction. In order to focus on the generic aspects of the process—how these negotiations are realized—we chose to focus on a single specific task and context: negotiating participation in chair work (CW) within the framework of Emotion-focused/Process Experiential Therapy  were made available to us. Four of the cases involved recovered clients and 4 were non-recovered. Cases were selected based on the following criteria: completeness of recordings  and quality of recordings .3 The 5 participating therapists  were experienced, trained and supervised in Emotion-focused Therapy/Process-Experiential treatment. For each case, we were supplied with three 1-h long videotaped psychotherapy sessions—from the beginning, middle and late phases of therapy—bringing our total number of sessions in our data to 21. Sessions from each phase were selected according to quality of recording and completeness (both audio and video recordings) rather than session number. Written informed consent was obtained from the participants for the publication of anonymized data. Persons referred to within therapy, including the client, have been given pseudonyms.The overarching goal in this study is to identify and analyze the interactional resources used in therapy to achieve cooperative engagement with respect to challenging in-therapy tasks. In clinical practice there are a great variety of tasks that therapists may wish to get clients to do, for example:  Therapy . Our dat Therapy .2 Eight transparency and validity  transcription conventions outlined in 4 We trace how the therapist interactionally manages to engage the client’s participation, especially in those contexts in which client agreement to engage in chair work is not immediately forthcoming or even contested. The method of identifying and selecting a corpus of directive sequences is taken from Prior research has found that entering chair work in Emotion-focused Therapy (EFT) is regularly accomplished through four distinct interlocking interactional phases: (1) formulating the client’s trouble; (2) recruiting participation in chair work; (3) readjusting the participation frame; (4) making contact . This cuproposals. These are actions that invite the recipient’s involvement as opposed to presupposing or demanding it , and client willingness: “would you be willing”, “you need”). Proposals often included a deictic that/this, indexing a shared understanding of what “work” is being done.From the directive sequences analyzed, it was found that most initiating directive actions functioned as nding it  and posinding it . With fe5 As such, by its very nature, it is potentially stress inducing and the client may be reluctant to consent to engage. The degree of ensuing reticence or opposition poses different levels of challenges and requires different interactive resources to resolve or overcome. To explicate the relation between the degrees of client opposition/reluctance and the kinds of conversational resources used by therapists we subdivided the available examples from our database into three broad categories: Smooth Entry; Mediated Entry; and Opposition to Entry. Smooth entry (n = 5) involves sequences in which the therapist’s proposal to do chair work around a specific conflict/emotion is followed by the client immediately endorsing the suggested project. Mediated entry (n = 15) is marked by delays in clients providing a response, prompting the therapist to do more interactional work to pursue eventual engagement in chair work. Opposition to entry sequences (n = 6) include client actions that challenge the value or validity of the intervention or that directly refuse participation in the activity. Although more than two-thirds of proposal attempts led to eventual engagement in chair work, in some cases chair work was abandoned following the client’s opposition.Chair work involves the recall and re-experiencing of, in the present, issues that the client has had difficulties with.In the smooth entry examples, there was only one attempted turn at proposing chair work before the client agreed. Proposals were designed in a highly contingent manner , orienting to the client’s greater entitlement to decide over the suggested course of action.•w- wudja be willing to do it?•↑d’yu wannu uhm•d like∗to try tuh (.) do:?>so is that< something that you’•↑wanna work with that today?•.h >so is that< something that you’d like to try tuh (.) do:? then is.hh at least try to (0.8) work toward:Additionally, in smooth entry, therapist proposal turns commonly feature either a deitic “that” only or “that conflict” as something to work on, displaying that the therapist and client have come to a clear, shared understanding of the in-the-moment conflict. This feature can also frequently be found in turns proceeding agreement, and after previous more extensive turns have been made in scenarios with dissent or rejection.•that some more today?so we can work with •that< something that you’d like ∗to try tuh (.) do:?>so is •that today?↑wanna work with •that conflict something that (.) we should (.) spend some time on?”.hhh is A sequence of smooth entry with the client Owen, who is a student that is also working part-time, is seen in a s′rta lo:nging,”. Following this, Owen affiliates with this formulation through verbal acknowledgement and nodding (line 7), leading the therapist to first confirm Owen’s acknowledgement and then, in line 11, to produce a proposal: “°m?°↑wanna work with that today?”. By targeting the client’s ‘willingness’ , the therapist orients to the client’s greater entitlement to decide over the suggested course of action. What is implied through this turn format is that Owen will not only play an agentive role in the impending action, but will also be a beneficiary of the action; that is, what is being suggested will have therapeutic gains for the client. Her granting Owen the prerogative to proceed or not is also designed in a highly contingent manner, involving hesitation, heightened pitch, rising intonation, and head tilting. Owen’s verbal response of “I think so yeah.”, while nodding (line 13), occurs smoothly and quickly and endorses the therapist’s proposal for chair work.In lines 1–5, the therapist orients to Owen’s dilemma by reformulating Owen’s description of his desire for and uncertainty about wanting a relationship as a source of conflict and connecting it to previous discussions as “Beginning chair work with a different client, Lisa, is shown in helpful) and the aim (t-to- bring (.) your parents, (0.2) °here.°) of chair work. Contingency is displayed via mitigation (might be) within turn pausing, a proffering gesture with the hand and head tilting. Agreement/compliance occurs in line 8, both vocally and non-vocally. Lisa’s response is pro-social, thus affiliative, and endorses or aligns with the activity in progress (leading up to chair work).In line 3, the therapist begins to put out her proposal while pointing to the empty chair, which provides some clarity regarding what the therapist will be directing the client to do. Then, in line 5, the therapist continues by mentioning the value (n = 2); (2) Providing an account (n = 6); (3) Elaborating on the conditions for proposing the activity (n = 4); and (4) Requesting confirmation (n = 3).For most proposal sequences examined, client compliance was not immediate, but deferred. This delay in responding was often signaled by pauses (silence) on the part of the client and by non-vocal actions that could be interpreted as a form of disengagement with the therapist’s suggested course of action. In contexts of silence following a proposal, we found that therapists would pursue compliance, not by immediately offering another version of the proposal cf. , but thrOr-prefaced alternative to their turn. This practice is seen in When confronted with a delay following a proposal, therapists had the option of appending an or onto her prior turn, which functions in a couple of ways. First, it treats Jennifer’s nod as insufficiently displaying acceptance and, second, it gives Jennifer an opportunity to suggest an alternative course of action–thus obviating the need for her to refuse the therapist’s proposal if need be–and downgrades the force of the proposal. Further, the extension of the therapist’s hands, as an open hand supine (OHS) gesture, toward the client may be seen as an offer  and this then immediately receives acceptance by Jennifer of the therapist’s original proposal of line 1.Following the therapist’s proposal (line 1), there is a significant 1.2 s pause during which Jennifer gives a shallow nod. The therapist then, in line 3, appends an an offer  and workor in these sequential environments would index a downgraded epistemic stance or “a lack of commitment to the expressed proposition” (p. 305). This is because this kind of turn format torques preference structure in favor of disconfirmation and opens the floor to possible alternatives. For proposal sequences, however, the orientation is not toward propositions or epistemics, but rather to deontics and the ‘orchestration of action’ in terms of offers, directives, requests, etc. But otherwise, the function appears to be similar. Or in these sequential environments, as shown in Or-prefaced alternative may ease up the pressure of complying, making it less difficult for clients, such as Jennifer, to deflect the challenging task of chair work.In a study of polar question sequences, accounting. These were found to come in two basic formats: Providing an explanation for how the proposal may benefit the client; Providing a justification that highlights the importance of doing chair work. In Another therapist practice dealing with delays in responding is experiment, modality of ability (couldessexpr), willingness (would you be willing to) and non-vocal actions . Following a brief pause in line 10, which signals potential rejection, the therapist continues with an account that indicates the benefits (ork…give you a chance< to w) and rationale .hh p) of chair work. There is a significant delay in Sofia’s response (line 14) and she also seems to bodily disengage from the therapist by gazing upward and away from the therapist. She then initiates an other-repair, requesting the therapist to clarify the details surrounding her proposal. It would appear that there remains some doubt regarding which painful feelings in relation to her father the therapist is referring to, leading Sofia to this other-repair request in which she seeks confirmation as to whether it was the event pertaining to her father’s death. After the repair sequence is resolved (not shown in the extract), Sofia does eventually concede to the proposal.The therapist’s proposal in lines 5 to 9 is packaged with many features of contingency: a beginning proposal that is self-repaired (line 5), formulating the activity as an An account that provides a justification for the importance of doing chair work is illustrated in I think that’s important) and then proceeds to indicate why it would be important to do. During this time, the client expresses token affiliation through repeated nods and, toward the end of the account, the therapist draws closer to the client, decreasing the physical space between them. Because proposals for chair work involve a fair degree of emotional commitment and involvement from the client, it may not always be easy for clients to readily comply. Thus, in contexts where clients appear hesitant or reluctant, further explanation and justification may be helpful in reassuring clients of the potential value or benefit of doing this activity.During the therapist’s proposal in line 7, Jennifer only partially bodily engages with the therapist by looking down and turning her face toward her. After a brief pause, the therapist provides a justification by first mentioning the significance of doing the activity  differentiating) and thus an orientation to the client’s greater entitlement to ratify the activity. Toward the end of the proposal, lines 5–6, the therapist pauses at points where the client could offer some form of non-vocal token affiliation  concerning the two sides that he had just previously described, but does not. Further, although the therapist references these two sides, he does not specify what they are. A silence occurs in line 7 that may imply an impending rejection, but the therapist grabs another turn-taking opportunity in order to elaborate on the two sides. First, the therapist adopts a downgraded deontic stance through evidential markers (hearingthat’s what I’m ) and by checking her understanding (if that fits with what you’re experiencing), thus allowing the client to take up upgraded epistemic and deontic rights. Next, the therapist adds more granularity to her prior description . The therapist also orients to contingency non-vocally in line 8 by animating her hands in a palm up position, suggesting that what she is proposing is a possibility and that the final decision (deontic authority) will rest with Ernie. The client then voices his confirmation of his inner conflict in line 12.The therapist is proposing two-chair work in which Ernie begins a dialog by acting out two different sides of himself. There are numerous expressions indexing contingency  observations on story telling, in which tellers make their descriptions more granular to provide recipients with more access to the event in question, thus allowing the recipient an opportunity to affiliate with the telling, so do therapists make their proposals more granular to better specify the conditions surrounding the proposal and help clients to better understand what will be required of them.kay?that’s o↑”, “is that alright?”, “at you think about that.wh”, “yeah?”. Confirmation seeking is shown in The fourth way of dealing with delays following a proposal was the therapist practice of seeking confirmation after the delay. Confirmation seeking appears in various turn formats such as “kay?that’s o↑”, which is followed by a brief pause without any client acknowledgement and, in line 6, two more confirmation seeking expressions . Ernie, in line 7, produces overlapping acceptance. In >is that alright?), which receives immediate confirmation from the client Paula.In According to Stivers and Rossano (2010:27), directive actions such as requests and offers are “high in response relevance”, meaning that they strongly mobilize a response from the recipient. Further resources that consist of lexico-grammar, prosody, gaze and epistemic domain  play a crucial part in strengthening or weakening response relevance. Clients nonetheless sometimes delay their response and one therapist technique for increasing response relevance, as shown in do a refusal. Two practices of refusing were found in the data: Questioning the authenticity of the activity–refusal by implication–and direct refusals.A step up from delaying the response to a proposal, and thus expressing impending rejection, is to explicitly Participating in chair work requires that clients are ready to experience and engage with their emotions in the presence of an imagined other or conflicted self. According to Watson and Greenberg (2000: 181), “they [clients] may find the activities required of certain tasks too artificial and contrived, and feel silly performing them, for example, when asked to talk to an empty chair.” throw that out again as a possibility” (lines 1–2); “if that would yihknow work at some point” (line 7). The many pauses, the term “possibility”, the expression “where you feel you’re at” and conditional if all work together in constructing this proposal as highly contingent on the client’s acceptance, but also display a moment-by-moment orientation to his lack of affiliative displays. For instance, Ernie does not only refrain from accepting at numerous places where he could have, but he also delivers muted agreement that is accompanied by non-vocal actions that signal displeasure and disengagement (line 8) and a long whispered in-breath possibly displaying distress (line 10). In response, the therapist immediately follows up with one more attempt in which she orients to Ernie’s potential willingness (“wanna give that a whirl”). Following no response from Ernie, she then solicits an assessment (and confirmation) from him pertaining to her suggestion to do chair work (“at< you think about that.> I dunno wh”) and, later in line 15, provides more granularity  by offering a parallel claim of uncertainty about engaging in chair work (“I don’t know either”). In line 21, Ernie makes his discomfort explicit by pointing out the artificiality of the proposed task: “it seems a little contrived I-I-I-I °uh w° yihknow,”. In lines 22 and 25, the therapist displays affiliation with the client’s initial reluctance by a number of acknowledgement tokens (mm hm), nodding, smiling and then by producing a formulation that endorses Ernie’s unease concerning the artificial quality of the proposed activity . These therapist actions, which work to re-affiliate with the client’s opposing viewpoint, engender a movement toward realignment with the activity . This shift can work to facilitate the client’s explicit expression of his refusal to engage in chair work in the moment but, importantly, preserves the alliance (but [I mean I] I’m I’m open to anything) suggesting that the momentum in therapy, which was at risk, is not interrupted.At this point, Ernie’s refusal becomes more overt. He shakes his head in line 15 and then, following a few pauses and a “see also . The reaClients may also directly refuse a therapist’s proposal with an unadorned “no”, as illustrated in no:”) and then quickly laughs while smiling. The therapist, in line 5, returns Paula’s smile, repeats the “no” and then seeks an account from Paula that explains or justifies her refusal. After silences and hesitation, Paula provides an account and the talk turns toward the father and the difficulty that Paula has in facing him in the chair at this moment in time. Unlike some of the other proposals shown previously, this proposal format lacked a clear orientation to contingency and to the client’s greater entitlement to give assent, but it also seemed not to display an elaborately articulated description or reformulation of the client’s trouble with the father. But by pursuing an account from the client, although the therapist was not able to get Paula to engage in chair work, the conversation was still able to shift toward a clearer focus on the father and some of the emotional difficulties surrounding her relationship with her father.Following the therapist’s proposal to do chair work, lines 1–3, a silence ensues, which may be rejection implicative. The therapist smiles in line 4, which may be working to gain an affiliative return smile from the client , and theIn-therapy tasks form a ubiquitous component in diverse forms of psychological treatments. They may range from free association  and chaireasons clients might choose to contest therapists’ directives in different contexts  contexts, we found that successful negotiations involved therapists hoping to recruit clients to do chair work taking a flexible and appropriately responsive deontic stance. In smooth entries, the therapists’ proposals were developed using tentative, contingent forms such as “like to try”, “would you be willing to”, “wanna?”, “at least try”. Therapists also realized a distant non-authoritative position to the topic identified just prior to chair work using deictic forms such as “that” to refer to the topic. This served to downgrade the therapists’ epistemic stance and signaled deferment to the client’s authority and agency to formulate the content of chair work. To highlight and focus on the We provided examples of how silence, delay, or shifting of gaze can indicate opportunities for the therapist to engage with the clients’ subtly expressed opposition/reluctance. For example, in Our sample of proposal/response sequences was relatively limited in size. Although we have been able to identify a variety of ways in which clients (implicitly) contest therapist proposals and therapists manage such reluctance/opposition, there are likely other resources and actions that could be doing this kind of interactional work. We did not attempt to canvass the variety of in-therapy tasks, nor did our data cover diverse treatments or a variety of psychological problems. The goal of this research was to examine practices to overcome/negotiate opposition to a challenging in-therapy task in a somewhat typical context. We anticipate that different tasks in different treatments will have some unique features not evident in our examples. However, the focus of this initial investigation was on aspects of negotiating dissent that we felt are likely shared with a range of challenging in-therapy activities in other contexts.Working with active and passive reluctance/opposition has an enormous heritage in the literature, both theoretical and empirical. However, relatively little systematic research is available that focuses on how this dynamic is managed successfully as an interactive social achievement. The research we present offers an initial foray in identifying the conversational resources that are sequentially developed, both in clients taking a reluctant position and the ways in which such impasses may be resolved in therapy. A better understanding of how delayed engagement or refusals to perform in-therapy tasks are managed has a potential of making a practical contribution to therapist training and development.before proposing the directive to engage. Such clarity generates an opportunity to use the deictic “that” as a reference point in the proposal and clarifies the potential benefits of doing chair work, as well as the risks of engagement. Taking a tentative flexible deontic stance creates generous opportunities for the therapist to find a collaborative position wherein clients may assume an agentive role and makes the proposal work for them. Likewise, careful attention and respect to the clients’ epistemic authority, supporting their awareness and expertise of their own issues and capacities, creates a context where the therapist can advocate the activity while the client feels supported and entitled to make choices.Our sample of directives to engage in chair work essentially captured “cooperative” negotiations. Even when engagement in chair work was refused, therapists and clients were able to manage reluctance to engage, repair the drift in task consensus, and maintain a collaborative momentum in therapy. An essential clinical practice in successfully managing reluctance to do chair work seems to be the development of a clear and shared understanding of what the conflict is Collaborative negotiations are typically responsive and incremental. Therapists approach the proposal to do chair work in an open ended, flexible way by developing an “or” position, seeking ongoing confirmation as the negotiation proceeds and being open to elaborate on and account for the rationale. This flexible/responsive approach is not only more likely to be productive in terms of engagement in the proposed work but will more likely preserve the alliance and therapy momentum if the client refuses to engage in the activity. Our CA study focused on recurring practices that generalized across cases. Future research on this topic using larger data sets  might examine ‘typical’ practices occurring within a case and compare practices between cases and relate sequences of smooth vs. mediated entry (and opposition) with outcome and alliance measures.All datasets presented in this study are included in the article/supplementary material.The study involving human participants was reviewed and approved by the Simon Fraser University Research Ethics Board. Written informed consent was obtained from the participants to participate in the York I study and for the publication of anonymized data.PM wrote the analysis and produced the final edited manuscript. AH wrote Introduction and Conclusion. LC transcribed the chair work extracts, identified initial set of directive sequences, and provided copy editing. LA supplied the videorecorded sessions and helped to work on the content of the manuscript. All authors contributed to the article and approved the submitted version.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.


Patient and public involvement is essential in the design and implementation of research studies to ensure research remains relevant and in line with public priorities. Public views on a given area of research may be sought via platforms such as focus groups or surveys. Here, we present the use of an openly available Google search data query tool, which may be used alongside traditional forms of patient and public involvement in research to highlight public perceptions and priorities. We used an online search query tool (“AnswerThePublic.com”) to explore public Google searches relating to “arthritis,” and an exemplar rheumatic disease, “rheumatoid arthritis.” The most common searches relating to these diseases included quality of life, treatment, prognosis, as well as impacts on life, including work. However, they also reveal concerns that may be more difficult to elicit in face-to-face focus groups, such as questions on alcohol consumption in arthritis, and impacts on mental health. Using public search engine data in research, alongside the important traditional methods of patient and public involvement, is a cost-effective and time-efficient method of gauging public views and concerns on a given topic. It may facilitate broad scoping searches of public priorities and help to guide future research questions. Patient and public involvement (PPI) is integral to the design and prioritisation of research studies. The National Institute for Health Research (NIHR) defines public involvement in research as “research being carried out ‘with’ or ‘by’ members of the public rather than ‘to’, ‘about’ or ‘for’ them” . PPI areThere is ample evidence demonstrating that PPI is necessary to optimise research design and output –4. HowevThere is no replacement for PPI, for example in the form of stakeholder involvement, individual interviews, and focus groups, which will always be necessary to ensure adequate prioritisation and relevance of research. However, large-scale search query tools can overcome some of the issues described above. These openly available online tools are able to collate and display keyword suggestions and predictions based on searches within Google, which is used for 78% of internet searches. With 3.5 billion searches conducted per day through Google, summarising searches this way can provide an excellent overview of public concerns and queries on a given topic , which iIn healthcare, search query tools may not only serve to confirm prior knowledge from PPI and clinician perceptions, but also reveals searches on more sensitive topics, such as opioid dependence and psychological impact of rheumatic disease, which service-users may not necessarily wish to discuss face-to-face.We aimed to demonstrate the utility of a search query tool to complement PPI in the rheumatic diseases, using an exemplar rheumatic disease, rheumatoid arthritis.We used an openly available search query tool to collate and map Google searches for two separate terms: “arthritis” and “rheumatoid arthritis.” We opted to use “AnswerThePublic.com”, due to ease of use and the resulting visual format of the results. Data on searches performed in Google are presented in real-time, so results are up-to-date at the time of using the search query tool. Since the results at any given time are identical regardless of the individual conducting the search, one author conducted the search for the chosen terms. Search queries are based on Google searches in the region in which it is accessed (e.g. UK); therefore, factors such as the user’s own Google search history are irrelevant.We first explored public Google searches for “arthritis” to gauge a broad overview of public queries on one of the most commonly-used terms in rheumatology, also used by patients and public. We then assessed search suggestions for “rheumatoid arthritis,” as an exemplar rheumatic disease. Rheumatoid arthritis was selected as it is the most prevalent chronic inflammatory arthritis, and, therefore, likely to be a commonly-searched term in this field . All seaThe output of results for each of the above two queries were delivered in the following categories: questions on the term; prepositions ; comparisons . Results were presented in lists as well as data visualisation images. Search query data for the UK, English language only, were interrogated.Figure Subsequent searches are displayed in Tables Tables Public searches performed on these topics predominantly relate to impacts on quality of life, relief of debilitating features including pain, and prognosis. On review of questions asked on arthritis, approximately 30% referred to debilitating features or quality of life, while just over 20% were on treatment or prognosis. In the prepositions’ category, approximately 20% of searches were on debilitating features or quality of life, with a further 20% on treatment or prognosis.For on “rheumatoid arthritis” searches, approximately 20% of search questions were on debilitating features or quality of life, with approximately 30% on treatment or prognosis. Looking at searches on rheumatoid arthritis, by prepositions, approximately 15% were on debilitating features or quality of life, with 30% on treatment or prognosis. The remainder of searches for both arthritis and rheumatoid arthritis covered topics including but not limited to anatomical sites of symptoms, possible associations with other rheumatological diseases , investigations and diagnosis, and symptoms in animals.We used an openly available online tool to investigate Google searches for the terms “arthritis” and “rheumatoid arthritis,” conducted by the public. Our results reveal striking patterns in search themes, with a focus on treatment, prognosis, quality of life, and debilitating features, including impact on work. While some results were novel, consistencies were seen with previous research in these areas, such as quality of life and patient-reported outcomes. These similarities with traditional methods of PPI suggest a role for a search query tool in this area.One of the most common themes in searches for both arthritis and rheumatoid arthritis was on treatment. Specifically, some of the most frequently searched questions were “can arthritis be cured?”, “can arthritis be treated?”, “will arthritis go away?”, and “rheumatoid arthritis- can it be cured?”, as well as variations on these questions. This is consistent with previous studies on patient-reported health service needs. A recent scoping review identified that patients with inflammatory arthritis value discussions on treatment outside conventional medicine, such as alternative and complimentary therapies and dietary advice, as well as practical tools to help with daily activities . Indeed,Another common theme in the searches centred on quality of life, and debilitating aspects of arthritis relating to this. Some specific frequently-searched examples include “when arthritis becomes debilitating”, “will rheumatoid arthritis cripple me?”, and “what rheumatoid arthritis feels like”. Quality of life outcomes have been explored increasingly in recent years in the rheumatic diseases. This has sought to increase clinical awareness of the burden of disease on mental health and daily living, with recommendations for factors such as health-related quality of life and fatigue to be routinely assessed in those with conditions including rheumatoid arthritis –13. Our In addition, some specific frequent searches relating to quality of life, revealed public interest in aspects relating to work and arthritis. These included such examples as: “arthritis- can I claim PIP?”, “rheumatoid arthritis- can you work?”, and “is rheumatoid arthritis a disability?”. We know from previous studies and patient-reported outcomes that productivity at work, as well as presenteeism and absenteeism, are affected by all forms of arthritis –16. HowePatient and public involvement, in rheumatology and elsewhere, has repeatedly highlighted the value placed on their relationship with health professionals, including ease of communication and approachability , 17. ConThe co-existence of fibromyalgia with other rheumatic diseases has become more apparent in recent years, associated with poorer clinical outcomes in inflammatory arthritis , 19. SomSome searches did not follow a theme, or revealed unexpected patterns of search behaviour. One of the commonest phrases was “rheumatoid arthritis and COVID”, consistent with the time at which we conducted this study . Other commons searches were on the genetics of rheumatoid arthritis (“is rheumatoid arthritis hereditary?” and “rheumatoid arthritis-is it genetic?”). This perhaps demonstrates a sensitive area which clinicians may not routinely address in clinic, but of importance to the patient. On a similar theme, searches such as “arthritis and alcohol” and “arthritis and sex” reveal similar sensitive topics which may prove potentially embarrassing for the patient to ask, leading them to seek answers on the Internet and online forums.Our use of a search query tool to explore searches conducted on “arthritis” and “rheumatoid arthritis” reveal known concerns from patients and the public, but also demonstrate areas of concern which may not be immediately apparent to researchers and clinicians. There is, therefore, scope to apply this tool as an adjunct to traditional methods of PPI, for example, when planning research in sensitive fields, such as opioid addiction and medication side-effects, for example, corticosteroids. It may also enhance and encourage research in areas including the impact of rheumatic disease on mental health. In the era of COVID-19 and telemedicine, such a tool provides a quick method of ascertaining public concerns and questions on its use, not only in rheumatology, but also other fields. Finally, as our internet and social media habits change, search query tools which are able to capture phrases used on social media may provide additional information on patient perceptions on healthcare-related topics. This has already been done through applications which are able to capture increased social media activity in relation to disease activity, including pain, but there is scope to extend further to incorporate use of specific phrases .A key limitation of such a tool is the inability to attribute all searches to a patient body. However, the tool can provide broad indications of public perceptions of a topic, within a given geographical region, e.g. UK. Furthermore, while searches on a topic such as arthritis may not change significantly from one day to another, searches conducted in Google on current and fast-changing situations may do so, which will affect the output from search query tools if conducted at two separate times. A prime example of this is search terms relating to COVID-19. In addition, as described above, search query tools are currently limited in number and can only capture data from the most commonly-used search engine, Google. Search query tools are complimentary, but not identical, to online platforms such as Google Trends which is able to display volumes and patterns of searches on a given topic, but no granularity on the nature of these searches. It is this additional information on extended phrases and questions entered into search engines which may enable their use as an adjunct to traditional PPI. As their utility grows in areas outside marketing, including in healthcare, possibly so too will their scope, including in areas such as social media.PPI is, and must continue to be, an essential part of research, from inception, to implementation, and dissemination of results. However, we have demonstrated the utility of a search query tool to complement traditional methods of PPI, for example, to conduct scoping searches at a project’s inception, or in addition to PPI, particularly at present, when focus groups may be difficult to convene due to social distancing regulations. Not only are the searches revealed by this tool consistent with known priorities of patients and the public, but they also demonstrate areas which benefit from user anonymity, such as concerns regarding the impact of arthritis on relationships, lifestyle, and work. This has the potential to guide future research questions, increasing the alignment of research priorities with those of the public.


Conclusions: Physically active parents have active children. To promote PA among children and adolescents with DS, it is important to promote and pay attention to the parents’ and siblings’ PA behavior, as children with DS are dependent on support from the family.From a public health perspective, it is important that children with Down syndrome (DS) lay the foundations of physical activity (PA) early in life to keep active in school, as teenagers and as adults. The aims were to investigate PA patterns in children and adolescents with DS, as well as their parents’ and siblings’ PA patterns. Methods: A survey was performed among 310 families with children with DS (54% boys and 46% girls) aged 8–18 years  in Sweden. Chi-squared tests and multiple logistic regression were carried out. Results: Nineteen percent of children and adolescents with DS and 34% of the parents were active three or more times per week. The child’s PA level was significantly associated with parents’ PA (OR = 5.5), siblings’ PA (OR = 5.1) and the child’s locomotion ability (OR = 3.5). Physically active parents had active children to a greater extent than inactive parents (59% vs. 29%;  Down syndrome (DS) is the most common genetic cause of intellectual disability (ID). The physiological characteristics associated with DS can impact an individual’s ability to participate in physical activity (PA). Despite difficulties being active, it is important that children with DS are physically active as the long-term consequences of their inactivity can lead to serious health problems. It is important to understand and design appropriate interventions for this group of children. DS accounts for 8% of all registered cases of congenital anomalies in Europe. The overall prevalence of DS in the world is 10 per 10,000 live births. In recent years, the prevalence of DS has been increasing, though it varies between different countries [DS is a genetic condition that causes delays in both physical and intellectual development. A non-disjunction and division of cells have taken place. Instead of having the typical two copies of the 21st chromosome, people with DS have three copies. Physical and mental disabilities vary in terms of severity. A set of anatomical, physiological, cognitive and psycho-social attributes predispose them to limitations regarding PA and fitness .It is important that children with DS develop routines for PA and exercise early in life to establish a healthy lifestyle and to maintain a life-long functional level of physical fitness , especiaChildren and adolescents in general sit more, walk less frequently and do less PA than children did some decades ago ,25,26. IAs there are few studies addressing PA among children with DS and, to our knowledge, no such studies carried out in Sweden, the purpose of this study was to investigate PA patterns in children and adolescents with DS, as well as to investigate their parents’ and siblings’ PA patterns.n = 310). More than half of the children (56%) had siblings, 32% of the older and 24% younger full siblings, 20% had older and 1% had younger half-siblings. Thirty-two percent of the children with DS had one sibling, 24% had two, 24% had three and 20% had four siblings. Data were obtained using a questionnaire completed by the parents. All information about the children with DS and their siblings was received from their parents. Thus, the sample consisted of 310 families. The families were recruited through state rehabilitation centers or by a non-profit membership-based association for children with DS, where information on the study was advertised on the associations’ website. The non-profit membership-based association for children with DS had about 3000 members at the time for the performance of the study. The parents who were interested in participating send an email to the researchers and received a letter with information and a personal invitation to participate. The response rate of questions in the survey ranged from 98% to 100%. The number of respondents for each question will be presented in parenthesis in the following text.The study design was a cross-sectional survey. The study included 310 children and adolescents with DS  between 8 and 18 years old; the average age was 14.04 years (SD = 3.18). The inclusion criteria for participation in the study was families with children with diagnosed DS in the age of 8–18 years. The participating families came from all parts of Sweden, from north to south, urban and rural areas. Forty-three percent of the participating families lived in cities, 37% in small villages and 20% in the countryside. The habitation was 71% in single-family homes, while 19% lived in apartment blocks and 10% on farms or in cottages .The survey included 54 questions on demographics, PA patterns of the children and adolescents with DS, participation in any sports activities, the parents’ and any siblings’ PA patterns, the DS child’s sedentary behavior, the parents’ perceptions and experiences of barriers and facilitators for PA for the child with DS and the child’s ability to perform different movement skills. In addition to the questions presented in “How important do you think PA/exercise is in general?” With four response items: “Very important; Quite important; Not very important; Not at all important.”“Are you satisfied with the child’s PA level?” With four response items: “Yes, very satisfied; Yes, quite satisfied; No, not very satisfied; No, not at all satisfied.”“Do you perceive that the child is satisfied with its own PA level?” with four response items: “Yes, very satisfied; Yes, quite satisfied; No, not very satisfied; No, not at all satisfied.”“Does the child voluntarily want to do PA?” with four response items: “Yes, most of the time; Yes, quite often; No, not very often; No, never.”The child’s involvement in PA of various intensities was assessed by the question: “To what extent does the child exercise, do sports- or outdoor activities in his or her leisure time in low, moderate or high-intensity PA for more than 20 min of activity at a time? Please assess the number of occasions per week in the three different intensity levels.” With five response items for each intensity: “Never; Very seldom; Once a week; Twice a week; Three times or more a week.”The range of sports activities for the child with DS was assessed by the question: “Does the child participate in any sports activities every week in his/her free time during the season? If the child practices one or more sports regularly, please write which one or which ones.”The parents were asked to assess the child’s motor skills, balance skills and endurance capacity in comparison with other children’s skills. “Do you experience that the child’s motor ability differs from other children’s? with nine response items: “No differences; Movements are slower; Balance is less good; Reaction time is slower; Endurance skills are lower, Fitness is lower; Movements are faster; Balance is better; Reaction time is faster; Endurance skills are higher; Fitness is higher.”The child’s movement ability/inability was assessed by the question: “According to your experience, what type of movements/activities has the child problems to perform or to participate in?” with nine response items: Ball games together with other children; Ball games together with other children but with a personal helping adult; Swimming; Fast running in short distances; Running with changes of directions; Endurance activities; Cross movements where the centerline of the body is crossed; Fine motor skills such as threading beads, tying, embroidering.”The child’s physical fitness was assessed by the question: “Do you experience that the child’s physical fitness differs from other children’s? with five response items: “Much better; Better; Neither better nor worse; Worse; Much worse.”The parents were asked to assess if the DS child was physically active according to the World Health Organization (WHO) recommendations by the question: “Based on the WHO’s recommendation of at least 60 min of daily heart rate-enhancing PA (MVPA), do you feel that your child is achieving this?” With four response items: “Yes, most often; Yes, quite often; No not often; No never.”The child’s sedentary behavior was assessed by the question: “Do you think that your child is more sedentary and sits still more compared to other children, also compared to children without disabilities?” With five response items: “Much more, More, Neither more nor less, Less, Much less.”2 test [p < 0.05. Adjusted estimates and their 95% confidence intervals, as well as the p-value, were used.Statistical analyses were performed using the statistical package IBM SPSS Statistics for Windows Version 23.0 . First, descriptive statistics with frequencies were used to summarize the characteristics of the cohort. Second, the Chi-square test was used to determine the significance of differences when comparing groups of children and adolescents. Third, a multiple linear regression was carried out using a logistic regression model (method: enter) with the DS children’s PA as the dependent variable. Independent variables included in the model were gender, parents’ PA, siblings’ PA, living region, child’s locomotion ability, transportation to activities, child’s membership in a sports club, parents’ membership in a sports club, child’s willingness to exercise and child’s involvement in high-intensity PA . The Hos2 test  were usen = 307) had regular physiotherapy every week and 18% had regular special training in school or daycare. All the children and adolescents had physical education (PE) in school; 26% once a week, 59% had PE lessons twice a week and 12% three times a week. About 99% of the parents thought that PA was very or quite important for health. Endurance activities, changing directions in locomotion, sprint and swimming were perceived difficult to manage for the children with DS. A summarize of the parents’ perceptions of the children’s difficulties, health, PA patterns, sedentary behavior, fitness and physical abilities are shown in A total of 7% of the children and adolescents with DS (n = 308) and a wide variety of sports was mentioned: football, swimming, floor hockey, dancing, ice hockey, riding, rugby, archery, wrestling, karate, running, cycling, gymnastics, orienteering, bowling, spinning, tennis, cross-fit, alpine skiing, cross country skiing, track and field, volleyball, handball, basketball, yoga, climbing, diving, parkour, water aerobics, badminton, table tennis, golf, canoeing, motocross, skateboard, biathlon, boxing, aerobics and cheerleading.About 69% of the children with DS were reported to be active in any sports activity (n = 308) of the children and adolescents with DS were reported to be physically active, so they became sweaty and short of breath , while the amount of physically active parents was 34% .A correlation between parent and child PA level was found. The physically active parents had active children to a greater extent than inactive parents had . The children’s ability to move the distance 3 km in relation to age groups are shown in Table 5. PA patterns and sedentary behavior in relation to age groups are also shown in The parents assessed the children’s and adolescents’ ability to walk, jog or run the distance of 3 km. About 10% of the children and adolescents with DS were reported not to be able to walk 3 km at all, 24% could walk the distance if they could stop and rest, 38% could walk the distance without stops, 20% could walk at a moderate speed, 6% could jog the distance slowly and 2% could run at a moderate speed  stated that PA was important for health; however, only a third of the parents were physically active themselves. There are likely many reasons why the parents were not active though they thought PA was important; we did not investigate the reasons. Most parents had positive attitudes towards PA; however, the transmission of attitudes and habits from parent to a child became more efficient when it comes to parents’ actions. Children do not do as parents tell the children to do; children do as parents do. The children are subjects to the transmission of parental beliefs and values towards PA. The transmission from parents might be even more important for children and adolescents with DS as they are less attached to peers and more referred to as their parents and siblings. Sometimes the DS children are at risk of becoming socially isolated as they, compared to their mainstream peers, show less frequent peer interaction . ChildreAccording to Barr and Shields (2011), the family setting was number one as a facilitator and number two as a barrier for PA . Thus, bThough the influence of parents’ behavior on children’s behavior is strong, the child’s physical ability is decisive for the PA patterns. In our study, the children’s locomotion ability was associated with the children’s PA level. It was also shown that children who were able to perform PA with high intensity were more active. Many sports have elements of high-intensity PA and endurance, which limit the possibility for children and adolescents with DS to participate , as a seThe locomotion skills were assessed via a question about the child’s ability to walk, jog or run the distance of 3 km. About 10% of the children and adolescents with DS could not walk the distance at all and a quarter had difficulties doing so. Less than 10% could jog or run the distance slowly and about 80% could walk at different speeds with or without stops. Thus, many of the children and adolescents had difficulties moving a distance, especially when it came to jogging or running. A significant difference in ability to move the distance was seen in relation to the age of the children. A higher percentage of the older children was able to move the distance than the younger. The ability to move the distance is dependent of the development of motor competence. The development of motor competence during childhood is dependent by the growth and maturity characteristics of the child interacting with the environment such as opportunities and restraints for movement, which interact with the biological substrates of growth and maturation to determine the mobility capacity of the child .Children with DS have lower running performance than mainstream peers but also compared with children with other disabilities . DifficuThe parents were asked to assess the number of PA occasions the children with DS were involved in three different intensity levels: low, moderate and high intensity. A small proportion of the children, about 8%, was active in high-intensity PA three times or more a week and 7% in moderate intensity. Thus, less than a fifth of the children were active in moderate to vigorous PA (MVPA) three times or more a week. We asked about MVPA sessions for at least 20 min, which is far less than the recommended daily amount of PA . AccordiPhysical inactivity and sedentary behavior are a serious threat to health and wellbeing ,16,26 anThe study design was cross-sectional, which limits conclusions about causality. The children’s, siblings’ and parents’ PA were reported and not measured, which is a limitation. A combination of self-reported and measured PA by accelerometers would have been optimal ,63. HoweAll variables included in the study were reported by the parents and could be affected by their perceptions. We recruited the families through a non-profit membership-based association for children with DS, where information on the study was advertised on the associations’ website and parents who wanted to attend contacted us. This could have caused a predominantly positive selection of families with parents positively committed to PA and the results might have a skewness to the positive side. The prevalence of inactive children with DS is probably higher, which has been shown in other studies ,24. In oThe study has strengths that are worth mentioning. The sample included more than 300 families with children with DS, which gives a good picture of PA habits for this group of children. To the best of our knowledge, there are very few, if any, research about PA among children and adolescents in Sweden. The questionnaire consisted of several questions about the PA patterns to get a picture of habits, amount of PA and intensity of PA among children and adolescents with DS. The results show the great importance of the family setting where the parents’ attitudes and actions are vital for the children’s PA behavior.The interest, attitudes and habits of PA are carried over, from parent to child. To promote PA among children with DS, it is vital to pay attention to their parents’ and siblings’ PA behavior and to provide parents with support in their upbringing of physically active children. This is vital for all children and parents; however, even more, pronounced for children with DS because they are more dependent on guidance and support high up in age. Parents need support from sports coaches, child health care and physical education (PE) teachers and it is crucial that these categories have adequate knowledge about DS and facilitators and barriers for PA connected with DS. The benefits of PA for health are well known but the information about the PA patterns among DS children and adolescents is limited and many parents often feel incapable of how to increase PA and how to train the children’s fundamental movement skills. From a public health perspective, it is important to pay attention to PA in the whole family and not just the child with DS solely. Information on PA habits of children and adolescents with DS in Sweden is low and the perceptions of their parents would help to guide the development and design of needed support and strategies to promote PA in this group of children. This study contributes to the current knowledge of PA behavior in families with DS children. The number of children and adolescents with DS who accumulate periods of satisfactory PA levels is low. The study provides results that active children with DS have active parents and that the interest, habits and attitudes are carried over, from parent to child, as well as among children with DS.


Many neuropsychologists are of the opinion that the multitude of cognitive tests may be grouped into a much smaller number of cognitive domains. However, there is little consensus on how many domains exist, what these domains are, nor on which cognitive tests belong to which domain. This incertitude can be solved by factor analysis, provided that the analysis includes a broad range of cognitive tests that have been administered to a very large number of people. In this article, two such factor analyses were performed, each combining multiple studies. However, because it was not possible to obtain complete multivariate data on more than the most common test variables in the field, not all possible domains were examined here. The first analysis was a factor meta-analysis of correlation matrices combining data of 60,398 healthy participants from 52 studies. Several models from the literature were fitted, of which a version based on the Cattell-Horn-Carroll (CHC) model was found to describe the correlations better than the others. The second analysis was a factor analysis of the Advanced Neuropsychological Diagnostics Infrastructure (ANDI) database, combining scores of 11,881 participants from 54 Dutch and Belgian studies not included in the first meta-analysis. Again, the model fit was better for the CHC model than for other models. Therefore, we conclude that the CHC model best characterizes both cognitive domains and which test belongs to each domain. Therefore, although originally developed in the intelligence literature, the CHC model deserves more attention in neuropsychology.The online version of this article (10.1007/s11065-019-09423-6) contains supplementary material, which is available to authorized users. Neuropsychological tests are designed to measure cognitive functions, which may be impaired by brain disorders like Alzheimer’s or Parkinson’s disease, traumatic brain injury, or stroke. The tests neuropsychologists use are often assigned to various cognitive domains such as executive function, memory, or attention.There are many reasons for establishing domains of cognitive functions and for assigning tests to these domains. The first reason may be that a clinician suspects problems in a specific cognitive domain for a particular patient and wants to select tests from this domain to administer. For example, if a patient comes in with subjective memory complaints, memory could be investigated further by selecting tests from this domain. The second reason may be that a clinician wants to qualify whether a particular patient is suffering from impairment on a single domain or on multiple domains. In the literature on mild cognitive impairment (MCI), for example, single-domain or multi-domain MCI are considered separate diagnoses, which have separate prognoses , in which one has to draw a line from labeled circles 1 to A to 2 to B to 3 and so on, is one test that is particularly difficult to assign. Because it involves drawing with a pencil and the outcome measure is the time to completion, one could assign it to the domain of psychomotor speed along with tests like the Grooved Pegboard. However, because Trail Making Test B performance depends for a large part on how attentive the person is, one could assign it to the domain of attention as well, along with tests like the Continuous Performance Test. Moreover, because it involves shifting back and forth between letters and numbers, one could assign it to the domain of executive functions along with the Stroop Interference test.There is also a lack of consensus on how many domains there are. For example, there are many tests that aim to assess memory in neuropsychology. Whether a single memory domain is sufficient, or whether more domains are necessary, is a matter of debate  fewer than two tests of interest were used, b) an adult sample was not studied, c) they were published before 1997, d) a cognitively healthy sample was not studied, e) test administration was manipulated or otherwise differed from typical administration, f) they were included in the ANDI database. Criterion c was chosen because for many datasets, extra information would be required from the original authors. Criterion d entailed that we did not include groups with psychiatric or neurological disorders , with disorders that could interfere with test administration , or with conditions that were studied for their cognitive implications . Criterion e excluded studies in which manipulations  were applied to participants during testing, or in which novel, often computerized, versions of test batteries were used. This last choice was made because these novel versions are less familiar and less thoroughly validated than the common versions. Criterion f preserved the independence of the analyses done in study 1 and study 2 of the present article.A complete list of variables that were considered of interest is given in Appendix With a few exceptions  model as described by Jewsbury, Bowden, and Duff . The CHCThe factors for the included tests were the same across the two variants of the CHC model: “Acquired knowledge or crystallized ability,” “Processing speed,, “Long-term memory encoding and retrieval,” “Working memory,“ and “Word fluency,. In the first variant, Trail Making Test B measures “Processing speed.” In the second variant, Trail Making Test B measures both “Processing speed” and “Working memory.”All factor model specifications are given in Table Each factor model consisted of factor loadings describing the relationship between the tests and the latent variables, residual variances of the test variables, and covariances between latent variables, which were all freely estimated. The covariances between latent variables can be interpreted as correlations, because all latent variable variances were fixed to 1.From the literature search, 3259 sources were identified. After deduplication, 2520 distinct sources remained. These were judged against the exclusion criteria by inspection of the title, abstract, and description of the tests and measures that is provided in PsycINFO. After this step, 330 articles were selected of which the full-texts were obtained. Seven articles were excluded because the full-text could not be could not be retrieved, so a total of 323 were eligible for inclusion. After e-mailing the corresponding authors, 60 correlation matrices were obtained from 57 studies. A list of contributing studies is provided in the From these correlation matrices, tests were selected that were administered together in multiple studies. This limited the number of tests to the twelve described in the methods section. Five studies did not include any or just one of the selected tests and were not included in the final analysis , except for the one factor model, where the RMSEA value indicates acceptable fit (RMSEA <0.08). The SRMR values indicate a lack of fit for the five simplest models (SRMR >0.10), and acceptable fit for the CHC model and the model by Larrabee (SRMR >0.05). The CFI values indicate a lack of fit for the one factor model (CFI < 0.95), acceptable fit for the model used by Gross et al. (CFI < 0.97), and good fit for the other models (CFI > 0.97).The best-fitting CHC model is depicted in Fig. From this factor meta-analysis, we can conclude that the two CHC models provide the best fit. The two CHC models themselves do not differ by much, but all fit measures agree that the second model, with the extra cross-loading of Trail Making Test B on “Working memory,” fits better.Therefore, we conclude that for the tests used here, the correlations between test variables are best described by five cognitive domains, namely “Acquired knowledge or crystallized ability,” “Processing speed,” “Long-term memory encoding and retrieval,” “Working memory,” and “Word fluency.” We also conclude that some test variables load on multiple domains.The factor meta-analysis framework has several advantages in that it allows for the analysis of a large number of tests and a very large number of participants. Using the partial correlation matrices rather than the raw correlation matrices allowed us to correct for the effects of age, sex, and level of education.However, there are a number of limitations to this analysis. First, different versions of tests were used as if they are parallel. This choice was made to arrive at a greater degree of test overlap between studies. Whether a test with a different name constitutes a different version or a different test altogether is to some degree subjective. For some tests, there is empirical evidence that there is a high correlation between test scores which makes it reasonable for the present goal to consider them versions of the same test. For example, the sum scores of the California Verbal Learning Test (CVLT), the Hopkins Verbal Learning Test (HVLT), and the Auditory Verbal Learning Test (AVLT) are highly correlated  Table . For theThe models were fitted using Mplus , except for the one factor model, for which the RMSEA indicates acceptable fit (RMSEA <0.08). The SRMR values indicate a lack of fit for the one factor, Gross, and Hoogland models (SRMR >0.10), and acceptable fit for the Lezak, Larrabee, and CHC models (SRMR >0.05). The CFI values indicate a lack of fit for all models (CFI < 0.95), except for the CHC model, for which fit was good (CFI > 0.97).Next, we compared the CHC model fitted in study 2 to the CHC model fitted in study 1 to determine whether the factor structure was stable across the two analyses. The methods used in the two studies were dissimilar, that is, correlation matrices served as the outcome measure in study 1 and actual test scores were the outcome measure in study 2. Because the scale of factor loadings and residual variances is dependent on the scale of the outcome measure, it is not warranted to compare factor loadings or residual variances between studies. However, the correlations between latent variables can be compared. To make the models comparable, the CHC model without the “Working Memory” latent variable from study 2 was fitted to the meta-analytic data from study 1 without Digit Span Forwards and Digit Span Backwards. The model is depicted in Fig. In this article, we sought to establish the cognitive domains that are measured by neuropsychological tests. Cognitive domains are used by neuropsychologists to make decisions on which tests to administer to a particular patient, to determine whether a disorder affects a single domain or multiple domains, to calculate composite scores of different tests belonging to the same domain, and to validate new tests that are designed to measure a particular cognitive function.We compared several neuropsychological factor models that have been formulated in the literature. First, we performed a factor meta-analysis of correlation matrices, using the meta-analytic structural equation modeling framework  or are considered “Executive Functioning” tests . In the CHC model as formulated by Jewsbury, Bowden, and Duff , a separIn our analyses of the CHC model, the Boston Naming Test was the only measure that was an indicator of only “Acquired knowledge or crystallized ability”, since Story Recall also functions as an indicator for “Long-term memory encoding and retrieval”. However, the Boston Naming Test is not a pure measure of crystallized ability in Jewsbury, Bowden, and Duff  their spOne caveat concerning the goodness-of-fit of the CHC model is its number of cognitive domains relative to the number of variables that were included. If there are many latent variables, and each latent variable has only indicators from a single measurement instrument, this latent variable may not represent a cognitive domain and may simply represent the variance that is unique to that particular method. In each of the models examined in this article, two test variables that belong to the same test were always assumed to measure the same latent variable. Therefore, this issue, sometimes called method variance, is not unique to the CHC model. In fact, no factor in the CHC model has only indicators belonging to a single instrument. Therefore, of the models specified here, in combination with this selection of variables, the CHC results should be relatively less determined by method variance. However, more data from a broader selection of tests is imperative.The present article lends support to the recent endorsement of the CHC model by Jewsbury, Bowden, and Duff . Their sThe fact that the CHC model fits better than other models has a number of consequences for neuropsychology. First, a consequence of the cross-loadings in the CHC model is that it corroborates the view that tests generally measure more than one domain. For test selection, this does not mean that these are bad tests to administer, but rather that they can be informative for multiple domains at once. For example, if a low score on Trail Making Test Part B is observed, this could indicate impairment of “Processing speed” if observed with a low score on Trail Making Test Part A, or indicate impairment of “Working memory” if observed with a low score on Digit Span.Second, the result has implications for the distinction between single-domain and multi-domain disorders. These disorders have typically been defined referring to the domains based on expert opinion, that is, “Executive Functions”, “Memory”, “Attention”, and so on  model best describes the structure of neuropsychological test domains.ESM 1(DOCX 15 kb)ESM 2(PDF 399 kb)