To date, developmental research on groups has focused mainly on in-group biases and intergroup relations. However, little is known about children’s general understanding of social groups and their perceptions of different forms of group. In this study, 5- to 6-year-old children were asked to evaluate prototypes of four key types of groups: an intimacy group (friends), a task group (people who are collaborating), a social category , and a loose association (people who coincidently meet at a tram stop). In line with previous work with adults, the vast majority of children perceived the intimacy group, task group, and social category, but not the loose association, to possess entitativity, that is, to be a ‘real group.’ In addition, children evaluated group member properties, social relations, and social obligations differently in each type of group, demonstrating that young children are able to distinguish between different types of in-group relations. The origins of the general group typology used by adults thus appear early in development. These findings contribute to our knowledge about children's intuitive understanding of groups and group members' behavior. Young children grow up in a complex social world in which they are constantly flooded with social information. Our social world is composed not only of individuals but of an array of different relationships and social groupings. One challenge for children is to decipher which of these social groupings are meaningful. People can appear to be a group from the outside, for example simply because they are in close proximity to each other, but they can be connected with each other at different levels: they can be kin or friends, be on the same sports or work team, be part of the same national or language group, or they can be associated with each other only briefly and loosely when, for instance, they take the same bus to get to the airport, or line up at a counter at the same time. Determining the type of group to which an association of people belongs is not only crucial for being able to understand individual group members’ behavior but can also be a short-cut to predicting how group members will relate to each other. For example, one can expect kin or friends to be loyal to each other, but one might not expect this about people who happen to be lining up at a counter at the same time. Another important form of predictions that can be drawn from social groupings, but which has been understudied in previous research , regardintimacy groups (such as families and friends), task groups (such as work or sports teams), social categories (such as women or U.S. citizens), and loose associations (such as people waiting in line at a counter). Participants associated different group characteristics with each group type, for example a long duration and high levels of interaction for intimacy groups, common goals and interaction in task groups, large size and member similarity for social categories, and short duration and low levels of similarity and common goals for loose associations . Relateiew, see –6. The eiew, see –5, 7. Liintimacy groups than in other types of groups. It has been argued that children do not develop a fully-fledged concept of these different relational models before nine or ten years of age [This group typology has received further support and validation from work in anthropology , 9. Intes of age , 9.Despite the theoretical importance of this group typology, very little research has investigated its origins in childhood. Instead, developmental research on group cognition in young children has focused mainly on children’s in-group biases, that is, their preference for members of their own group over members of other groups. Research in this tradition has shown that children prefer members of their own group on a variety of implicit and explicit measures –14. Anotsocial categories, thus limiting what we can conclude about children’s understanding of group relations more generally  than adults, who focused on more abstract features such as the importance of the group for its members [One exception to this general trend is a study conducted by Svirydzenka and colleagues . They fo members .Inspired by this study and Lickel and colleagues’ work , we inveThus our objective was to investigate whether, in addition to these preferences and expectations, children of this age also have a more general understanding of groups and different types of group–in other words, an early folk typology of groups. Several prominent theoretical accounts of the origins of intergroup psychology postulate substantial development between the age group in our study and the youngest age, so far, at which a group typology has been found, 10 years –26. Howeintimacy group, a task group, a social category, and a loose association as qualitatively different.As a first step, we measured children’s spontaneous definition of a group. We did this to investigate children’s naïve, spontaneous ideas about groups, before presenting them with different group types. We predicted that children would be able to give some appropriate examples of groups and were especially interested in whether they would focus on one particular example or definition when thinking about groups , or whether they would be able to give a more abstract definition . Second, because recent work has shown that 5-year-old children have comparable preferences for two types of group members–task group members and social category members –we invesIt was impossible, given the young age of our participants, to adopt the exact methods of previous studies, which used complex tasks such as sorting of examples of groups and rating multiple group characteristics for each example. To simplify the procedure so that young children would understand it, we thus created a prototype for each of the four types of groups and asked children to judge these prototypes on entitativity and 12 other group characteristics. These group characteristics were generally inspired by the characteristics Lickel et al.  and SvirThe present study strictly adhered to the legal requirements of the country in which it was conducted, and a detailed procedure was approved in advance by the Ethics Committee of the department in which it was conducted. In addition, parents of all children who participated in the study gave informed written consent.mean = 6 years, 0 months, 5 days; range = 5 years, 0 months, 3 days to 6 years, 10 months, 8 days) from a medium-sized city in Germany. Half of the participants were female. Children were tested in their kindergarten. One additional boy was tested but excluded from analyses due to extended interruption of his test session because of the distraction caused by the noise level outside the testing room.Participants were 48 5- to 6-year-olds  were counterbalanced across pictures.Children were presented with drawings (12.5 x 9.5 cm each) of four groups attached to a 30 x 21 cm piece of cardboard. Pictures were arranged in two rows; their positions were counterbalanced, using 12 different arrangements  “What is a group?” and, since piloting had revealed that most children understood the word “group” only as kindergarten group , the experimenter always asked (2) “And besides kindergarten groups, do you know any other groups?”Following this, still without any pictures present, children were asked, “What is a better example of a group: people who work together or people who are similar to each other?” The order of the two examples was counterbalanced.The four pictures were then brought out and introduced by the experimenter as follows (in the order in which they were displayed on the piece of cardboard):Intimacy group (friends): “These people here are friends. Look, they’re all just about to eat lunch.”Task group (people building a house): “These people here are building a house. Look, they’re all just about to go on working on it.”Social category : “These people here look alike. Look, they’re all wearing the same outfits.”People at the tram stop: “These people here are each waiting for a different tram. Look, they all happen to be waiting at the same tram stop.”Children then were asked to point at the pictures which showed a real group .The experimenter then asked questions about 12 group characteristics, asking children to point out the group that was most likely to have a particular feature. Children were asked about helping (“In which picture do people help each other most?”), sharing (“In which picture do people share their things with each other?”), loyalty (“In which picture should people not leave each other?”), liking (“In which picture do people like each other most?”), familiarity (“In which picture do people know each other best?”), interdependence (“In which picture do people need each other the most?”), joint goals , similarity (“In which picture are people most similar to each other?”), shared preferences (“In which picture do people like the same things?”), common knowledge (“In which picture do people know the same things?”), the groups’ low permeability (“In which picture can’t one join easily?”), and lack of continuance (“In which picture will the people not meet again?”). After each question, children were asked why they chose that group. Children were asked the 12 questions in counterbalanced order, using a 12 x 12 Latin square design; that is, there were 12 different order sets, with each question in each position exactly once. The 12 picture arrangements were randomly assigned to the 12 question order sets. Each combination was tested both with a male and a female participant.At the very end, children were again asked to point at the pictures which show a real group  to investigate whether the evaluation of the 12 group characteristics would influence participants’ entitativity ratings.Children’s responses were coded from videotape. Children’s combined answers to the first two questions about their definition of a group  were coded in one of three hierarchical categories from most abstract to most specific. The most abstract category was coded when children gave a general, overarching definition of a group as a social collective, that is, if they defined a group as a collection of people, . A middle category between the most abstract and specific definitions was coded when children defined a group as a collection of specific individuals, that is, as a collection of children, . Participants never gave definitions of a group as a collection of specific individuals other than children. The most specific category was coded if children gave one concrete example of a group . If children gave no answer or answers that fell in none of these categories  they were coded as the fourth category “other.” If children gave more than one answer, they were given credit for their most abstract definition.For the questions “Which ones are real groups?” , it was coded first which picture(s) were chosen. For a follow-up analysis, scores were then given for the order in which children chose the pictures they thought were groups. For each child, the picture that was chosen first was scored with the value 4, the second choice was scored with 3, the third with 2, and the fourth with 1. If a picture was not chosen by a child, it was scored zero.For the 12 group characteristics questions, it was coded which picture children chose. If children did not choose any picture, or said “I don’t know,” this choice was coded as blank (resulting in some N’s < 48).Twenty-five percent of the data (12 children) were randomly chosen to be independently coded by a second rater who was unaware of the aims of the study. Agreement between the two coders was excellent .n = 8/24) were more likely than boys (n = 2/24) to say that friends are interdependent. However, they did not do so significantly above 25% chance level, thus we consider this a minor difference. We thus collapsed across the factors gender and age for the analyses reported below.For all analyses, an equal split of the sample into a subset of 5- and a subset of 6-year-olds, as well as into boys and girls, revealed a similar pattern of results, with no significant differences between the age and gender groups except for a significant gender difference for the group characteristic question on interdependence. There, girls  “What is a group?” and (2) “Besides kindergarten groups, do you know any other groups?” were investigated see . The maip < .01; all reported p values are two-tailed).Next, we analyzed which of the two examples given children chose as the better example of a group. Most children (80.9%) chose “people who work together” as the better example of a group; the remaining 19.2% chose “people who are similar to each other.” This difference was significant  = 13.04, p < .01. The second trial at the end of the session revealed almost identical results  = 13.44, p < .01). Thus young children are able to accurately distinguish groups from mere collections of people.In the first entitativity trial we investigated which of the four pictures children perceived as depicting a “real group.” As predicted, most of the children perceived friends (85.4%), people building a house (81.3%), and people who look alike (85.4%) as real groups. In contrast, only 33.3% of children perceived people at the tram stop as a real group. This difference was significant, χ2 = 31.54, df = 3, p < 0.01). A post-hoc analysis using the R-package “pgirmess” [M score = 0.88, SD = 1.38) compared to each of the other three pictures. That is, “people at the tram stop” was least often chosen to be a real group or else was chosen later in the sequence. There were no pairwise differences between the pictures “friends” , “people building a house” , or “people who look alike” , showing that children did not choose any of these pictures more often, or earlier in the sequence, than the others. This suggests that children see these three categories as equally representative of a real group. Again, the same pattern of results was replicated for the second trial .In order to investigate whether children perceived any of the examples as more typical of a group than others, in a follow-up analysis we investigated the order in which children chose the pictures in the first trial. We reasoned that, if children view one type of group as a particularly good example of a ‘real’ group, then they should choose it first. A Friedman test revealed a significant difference between the four pictures’ scores  was estimated, revealing p = .001. The distribution of children’s choices in the original data thus differed significantly from a random distribution.Finally, children’s answers to the questions about the 12 remaining group characteristics were analyzed. Since the justifications children gave for their answers were often circular  or otherwise unhelpful, we focused on children’s choices. To avoid problems associated with multiple testing, we performed a downward analysis of the data before approaching the actual research question statistically . As a fip’s < 0.03). Thus children showed significant preferences for which pictures to choose in response to each particular question. This finding again allowed us to follow up and investigate which picture was chosen most often for each group characteristics question. Binomial tests for each individual choice were conducted . As predicted, there were systematic differences in how children expected members of the different types of groups to relate and interact. They expected friends to like each other, share with each other, and be loyal to each other. They expected people who build a house together to be interdependent, and to help each other. They expected people who look alike to be similar, familiar with each other, and to share common knowledge and similar preferences. In contrast, children characterized a collection of people who stand at the tram stop as low in permeability , and as not continuing in the future.After having established that participants’ responses were different from a random distribution, post-hoc analyses were conducted to investigate what was driving the differences . The firThis study investigated children’s general understanding of groups and their perceptions of different types of groups, a topic that so far has been understudied in developmental research. We investigated the naïve conceptions young children have about groups and examined whether children show distinct patterns of judgments and expectations regarding groups’ and group members’ characteristics across four different key types of groups.There were several interesting findings in this study. First, we found that when asked “What is a group,” only a small minority of children (8.3%) were able to define a group abstractly and generally as a collection of people. The vast majority of children defined a group as a collection of children or by giving an example of a kindergarten group. None of them could think of any concrete examples for a group beyond kindergarten groups. Thus, children do have some understanding of what a group is; however their understanding is limited in that other types of groups do not spontaneously come to mind for children as readily as they might for adults.Second, when asked to choose which is the better of two given examples of a group, a large majority of children chose people who work together over people who look similar. That is, although children generally assume group members to be similar to each other in third-party contexts , 32, wheintimacy group, a task group, and a social category to be real groups. The entitativity judgments for each of these groups were almost identical, that is, children thought that each of these three types of groups forms a coherent unit to the same degree. Only the loose association was judged as being significantly lower in entitativity, and thus as qualifying less as a real group. Adults and 10-year-olds in previous studies [loose associations to be lowest as well, but in contrast differentiated the entitativity levels of the first three group types: They rated entitativity highest for intimacy groups, followed by task groups, and social categories. This finding thus reveals an interesting developmental pattern suggesting that, compared to adults and older children, young children show a less fine-grained perception of group entitativity.Third, children’s judgments and expectations about four different types of groups and their group members were examined. We found that a large majority of children judged an  studies , 7 judgeintimacy group, task group, and social category as well as the loose association to have different patterns of group traits and they judged that group members of these different types of groups would have different kinds of characteristics, relationships, and obligations to one another. For example, children judged the intimacy and task group members to have social obligations and to behave prosocially towards one another. In particular, friends were judged to like, share with, and be loyal to each other, and people building a house together were perceived to be interdependent and help each other. Children’s judgments thus correspond well with adult intuitions about the members of these two types of groups, in that intimacy groups typically involve positive, long-lasting, reciprocal relationships [task groups possess basic qualities of cooperative interactions: interdependence and mutual help [intimacy group members [task group members [social category members to be familiar with each other and to possess properties marking fundamental similarities. In particular, people who look alike were perceived as being similar more generally. Interestingly, they were also thought to share similar preferences and common knowledge, indicating that children inferred similarities in various mental states from observing similarity in the way people look. These findings thus extend previous work showing that children perceive members of their own social categories as similar to themselves and expect them to share the same preferences [However, a fourth set of findings showed that children did have a relatively sophisticated understanding of the unique pattern of group characteristics associated with each group type. This is an important contribution to the literature, as it shows that children distinguish different types of in-group relations from each other. Children perceived the ionships  with a fionships , and tasual help , 41. In  members , 42, and members , 43 and  members , 45. Chiferences , 47 by dloose association to stand out with regard to its characteristics of a group as a whole. That is, people who happen to stand at the same tram stop were perceived to have a lack of continuance . In addition, they were expected to have low permeability, meaning children thought this group would be particularly difficult to join. At first glance this is somewhat surprising, as, according to Lickel and colleagues [Children judged the lleagues , such a intimacy groups as being interdependent with and similar to each other. Both the younger children in this study as well as the older children studied by Svirydzenka and colleagues [task group, or the similarity between members of a social category .These results suggest that children as young as 5 years of age show the origins of an intuitive group typology that is similar to that of adults. The set of group characteristics we chose to ask about was based broadly on previous studies with adults and 10-year-olds , 7, withintimacy groups), and the studies finding enhanced helping of and sensitivity to the interdependence of task group members used various examples of task group contexts [social category members  to be as similar to each other as in the current study. Previous studies show that children respond differently to different examples of social categories [In this study, we presented children with four types of groups, but it is possible that preschoolers might distinguish even more than these four basic types, or might have a more fine-grained perception of subtypes within these basic types. This needs to be examined in further studies. One limitation of this study is that for practical reasons we only asked about one prototype of each type of group. However, we would expect very similar findings on many of the group characteristics questions for other prototypes. For example, Olson and Spelke  have shocontexts , 50, 51.tegories , 52, so In summary, for 5- to 6-year-olds, not all groups are the same. By this age, children are beginning to distinguish the same four key types of groups as adults: They judge them to be different in nature, and associate different patterns of characteristics with each group type. This study thus demonstrates how deeply rooted our folk group typology is. Holding different intuitive theories about different types of groups likely influences not only how children perceive groups, but also how they behave within groups, and how they understand and predict both intra- and inter-group interactions. This study therefore casts new light on children's intuitive understanding of groups and group members' relationships and has implications for theoretical accounts of the origins of group psychology and thus the nature of the mature social mind.S1 Data(XLSX)Click here for additional data file.


The Modern Synthesis envisions speciation through genetic changes in germ cells via random mutations, an “Egg first” scenario, but perhaps epigenetic inheritance mechanisms can transmit adaptive changes initiated in the soma (“Chicken first”).The article was reviewed by Dr. Eugene Koonin, Dr. Itai Yanai, Dr. Laura Landweber. In this commentary paper we wish to use the well-known “Chicken and Egg” paradox as a gateway for discussing different processes of evolution. While in the biological sense this is not a paradox at all, the metaphor is still useful because it allows examining of the distinction between Lamarckian and Darwinian evolution, and specifically, since it enables us to raise an important and unsolved question: “Can the phenotype affect the genotype?” or in other words, “can epigenetics translate into genetics”?e.g. “If there has been a first man he must have been born without father or mother – which is repugnant to nature” Aristotle), became synonymous with paradoxes in general, since it presents a classical catch: when two events appear to serve both as the cause and the effect of one another it is inconceivable to grasp that any one of them could have preceded the other.The “Chicken and the Egg Question” or “Which came first, the chicken or the egg?” is a well-known metaphorical paradox. The original and biologically-relevant question, which has been discussed already by ancient Greek philosophers , we ask - which came first? Let us start by defining what we mean when we use the metaphors,”Chicken” and “Egg”.While the question is not truly paradoxical, since an imagined “Egg” can precede a “Chicken” or Australopithecus mother who gave birth to a Homo child” ).There are several apparent “Chicken and Egg Paradoxes” in biology, most notably, the evolution of the translation system. The highly complicated translation system (RNAs and proteins) is needed for its own creation . We suggIs there evidence to suggest that inheritance of acquired traits has actually allowed “Chickens” to precede “Eggs”? How prevalent are such instances?This is an exciting and very active field of research, and a long road is ahead of us before the contribution of epigenetic processes to evolution could be assessed.Dr. Eugene Koonin. This is, by any account, an insightful essay. The parallelism between “chicken-or-egg”-type paradoxes and the Lamarckian vs Darwinian  is obvious once stated but I think has not been explicitly discussed before. The discussion in the paper centers on the interaction between germ line and soma but towards the end the authors notice that the complementarity between the two modalities of evolution is likely to be a general phenomenon relevant to all kinds of organisms. This rings true to me. I still wonder, though, how important are epigenetic phenomena in unicellular organisms. They definitely possess Lamarckian-type evolutionary mechanisms (CRISPR-Cas is the prime example) but do they have epigenetics sensu stricto? Perhaps, the authors could comment on that. A few highly relevant references seem to be missing: Koonin EV. Does the central dogma still stand? Biol Direct. 2012 Aug 23;7:27 (sorry to honk my own horn here but this paper does discuss explicit mechanisms whereby phenotypic changes could be assimilated in genomic mutations) Shapiro JA. How life changes itself: the Read-Write (RW) genome. Phys Life Rev. 2013 Sep;10(3):287–323.We thank Dr. Koonin for his helpful and generous comments. We did not elaborate in the paper regarding the relevancy of epigenetic mechanisms to evolution in unicellular organisms. However, we believe epigenetic inheritance could play a role in shaping the evolution of unicellular organisms as well. Indeed, while the CRISPR-cas system in bacteria (as mentioned by Dr. Koonin) is “Lamarckian”, it is not an “epigenetic” system par excellence. Nevertheless, other forms of epigenetic inheritance exist in single cell organisms, for example inheritance of prions in yeast, epigenetic inheritance of chromatin modifications that has been specifically studied in fission yeast, and inheritance of regulatory RNAs in ciliates. Whether this form of inheritance is important for their evolution is still an open question. We gladly added the additional references that Dr. Koonin rightly suggested.Dr. Itai Yanai. In this manuscript, Pilpel and Rechavi make the clever connection between Darwinian and Lamarckian mechanisms and the famous Chicken and Egg paradox. This allows them to nicely frame the question of where does novelty ultimately arise: in the germ line or in the soma? Since the Modern Synthesis a century ago, it has been held that novelty arises as mutations in the germ line, however exciting research over the past few years has provided evidence that changes occurring in the soma can also be heritable across generations. I commented on an earlier version of this manuscript and am even more pleased with its current state. One limitation of the analogy that may be worth pointing out again is that under the chicken-first scenario, really only one cell – and not the entire organism - has the ‘chicken-phenotype’.One issue that I feel is missing in the discussion is the role that any somatic epigenetic change plays in adaptation. In other words, are the changes necessarily of any consequence? If, through interaction with the environment, an adaptive somatic change may occur and become heritable, the details of such a mechanism would be extremely interesting. In a related note, the CRISPR system in bacteria can be said to be Lamarckian since the adaptive changes to the genome are inspire by the environment (the attacking viruses): did proto-chickens have a similar mechanism?Finally, in the two paths imagined by the authors, why does an epigenetic mutation precede a somatic mutation? It seems plausible that there is a third path that simply starts with a somatic genetic change and leads to a germline genetic change.We thank Dr. Yanai for his nice comments and suggestions. We think that an entire organism could have ‘chicken-phenotype’ due to a synchronized epigenetic response, which does not have to be limited to one particular cell. Synchronization of epigenetic responses could occur, in particular, if the epigenetic change takes place while the organism develops. For example, if a gene is epigenetically modified  early in development, and the silenced state would be maintained after cell division. Dr. Yanai asks in addition whether heritable epigenetic changes are necessarily of any consequence. We think that heritable epigenetic changes will be selected, much similarly to bone fide genetic changes, and thus non-adaptive changes, if significant enough, would be eliminated. Additionally, epigenetic changes, just as genetic mutations, that are neutral or that bear little phenotypic effect could be carried over by drift.Dr. Laura Landweber. This brief essay blends philosophy and history of science with recent review. One hypothesis is that some cases of speciation may result from epigenetic mutations, or alterations in the interpretation of the genome. This is, of course, consistent with a large body of literature documenting the importance of regulatory changes in evolution, but merging that field specifically withepigenetics seems a new proposal. Pilpel and Rechavi don’t have specific examples to offer yet, but propose this basic hypothesis. Epigenetics can certainly contribute quite a bit to variation, within and between species, but a few evolutionary biologists are just beginning to think about the layer of variation that epigenetics introduces. As to ciliate systems, an expertise of my lab, we have never observed mutations in the germline that correspond to mutations that first arise by manipulation of the somatic epigenome. Thus, like regulatory changes, the epigenetic changes are still at the level of the interpretation of the germline information in the soma.We thank Dr. Landweber for reviewing the paper, and specifically for providing insights regarding interactions between epigenetic inheritance and germline mutations in cilliates. Indeed it would be very exciting if evidence were found to support the theory that somatic epigenetic mutations can precede (and direct) germline mutations.


General practitioners (GPs) are considered to play a major role in detecting and managing substance abuse. However, little is known about how or why they decide to manage it. This study investigated the factors that influence GP behaviours with regard to the abuse of alcohol, illegal drugs, hypnotics, and tranquilisers among working Belgians.Twenty Belgian GPs were interviewed. De Vries’ Integrated Change Model was used to guide the interviews and qualitative data analyses.GPs perceived higher levels of substance abuse in urban locations and among lower socioeconomic groups. Guidelines, if they existed, were primarily used in Flanders. Specific training was unevenly applied but considered useful. GPs who accepted abuse management cited strong interpersonal skills and available multidisciplinary networks as facilitators.GPs relied on their clinical common sense to detect abuse or initiate management. Specific patients’ situations and their social, psychological, or professional dysfunctions were cited as cues to action.GPs were strongly influenced by their personal representations of abuse, which included the balance between their professional responsibilities toward their patients and the patients’ responsibilities in managing their own health as well the GPs’ abilities to cope with unsatisfying patient outcomes without reaching professional exhaustion. GPs perceived substance abuse along a continuum ranging from a chronic disease (whose management was part of their responsibility) to a moral failing of untrustworthy people. Alcohol and cannabis were more socially acceptable than other drugs. Personal experiences of emotional burdens (including those regarding substance abuse) increased feelings of empathy or rejection toward patients.Multidisciplinary practices and professional experiences were cited as important factors with regard to engaging GPs in substance abuse management. Time constraints and personal investments were cited as important barriers.Satisfaction with treatment was rare.Motivational factors, including subjective beliefs not supported by the literature, were central in deciding whether to manage cases of substance abuse. A lack of theoretical knowledge and training were secondary to personal attitudes and motivation. Personal development, emotional health, self-awareness, and self-care should be taught to and fostered among GPs to help them maintain a patient-centred focus. Health authorities should support collaborative care. The social and economic effects of alcohol and other drugs on society are substantial, but they largely depend on the type of drug. In 2010, alcohol use was the third leading risk factor for global disease burden. In addiIn Belgium, 10% of alcohol consumers aged 15 or older are problematic drinkers. In 2008General practitioners (GPs) are considered to play a major role in detecting and managing the problems related to substance abuse, regardless of its legality. However, previous work by Glanz, Gabbay and Deehan in the United Kingdom demonstrated that GPs view alcohol or drug misusers as undesirable patients-11. DiffThis study is part of the “Up to Date” research project seeking to describe the approaches of GPs and occupational physicians (OPs) to the detection and management of the abuse of alcohol, illegal drugs, hypnotics, and tranquilisers among the Belgian population and to recommend ways to promote multidisciplinary collaborative care for these patients. This paThis qualitative survey sought to answer the following question: “What are the experiences, attitudes, perspectives, and decision-making skills of GPs with regard to the abuse of alcohol, illegal drugs, hypnotics, and tranquilisers?” The survey sought to understand GPs’ points of view. The representations of substance abuse were considered a “guide to action”,18; thusWe used de Vries’ model as a conceptual framework Figure 19]. Th. Th19]. Working with the I-Change model allowed us to distinguish between the factors that underlie GP decisions to care for patients with a problematic alcohol or drug use  and the factors resulting in differences between intentions and behaviours . The major obstacles can be identified by deconstructing the process of intention into separate units  and searching for the links between them. This article presents the results as a synthesis of the main results, and the results are classified according to the I-Change Model units.Chairs of the local “GP Circles” and “Local Quality Evaluation Group” of the provinces of Antwerp and Liege connected us with GPs. These recruited GPs did not necessarily possess particular expertise in substance abuse; on the contrary, GPs working in specialised abuse clinics were excluded. First, the GPs were invited to complete a short questionnaire regarding their experience in the field and their practice profile. Second, the respondents were sampled to retrieve a variety of clinical profiles based on sex, age, reported experience in substance abuse management, practice location , and type of practice (single or group).Ten GPs working in the Dutch-speaking province of Antwerp and ten working in the French-speaking province of Liege were selected. Their sociodemographic characteristics are summarised in Table In Belgium, GPs work in the context of a liberal healthcare system. The fee-for-service payment system predominates. However, GPs working in one of the 100 multidisciplinary primary healthcare centres  are paid on a capitation basis. These centres, whose patients are bound by a contract of care, serve 3% of the population, primarily in urban and deprived areas.Trained interviewers  conducted the dialogues at the GPs’ practices in the second half of 2012. A semi-structured interview guide, initiated from a clinical case, based on the I-Change Model and created via consensus between the researchers, was used  foreigners. I do not have a single drug addict among my patients. There are no secrets; we deal with people who are clever and live in satisfactory socioeconomic conditions”. GP 16, Female (F), 35 year (y), French-speaking (Fr)Abuse was mentioned among patients with low socioeconomic level, young age, psychiatric problems, social and professional dysfunctions, private life problems, social and ethnic origin (migrants from northern Africa), unemployment, relationship problems, and child protection problems.“Unfortunately, I think that more alcohol abuse occurs in less privileged environments, although in certain privileged backgrounds alcohol abuse also exists, and, in my opinion, even more so…. There is also a problem of medication abuse among families who are a little less privileged; this is the feeling that I have”. GP14, Male (M), 62 y, FrSome GPs cited the facilitating role of the capitation payment system because it allows extended consultation times. However, it was also thought to improve access among illegal drug and alcohol abusers, increase the referral rate from addiction treatment centres, and increase the number of addicted patients.“Expertise is increasing in the medical homes because it is well known that we work in multidisciplinary teams; there is more global care, better accessibility, [and] therefore, naturally, [one cares for] people who withdraw from therapy or leave the Alpha centre etc…. The [social] workers… will maybe say to themselves… that a medical home will be more suitable because [it is a] more integrated… type of care than service providers who are on their own”. GP17, M, 37 y, FrIn contrast, the fee-for-service system and individual practices were mentioned as being less in favour of substance abuse management. Specifically, the GPs mentioned difficulties with regard to refusing prescriptions for hypnotics and tranquilisers.“If a patient only comes for a prescription, which is common because it is fee-for-service, then it is sometimes difficult to say, ‘I am not going to prescribe [that drug]’. And then the patient stands there asking, ‘Will I have to pay, then?’ Yes, actually; but that does make it difficult, ethically speaking. In our community health centre, I simply tell them, ‘I’m sorry. We can’t do that’. We can easily refuse”. GP 9, F, 29 y, Dutch-speaking (Nl)GPs did not use peer-reviewed literature to support their practices. GPs, especially those in Flanders, mentioned the lack of guidelines regarding illicit drugs. GPs who supervised trainees in their practice more easily accessed such information.“Mr. X reported that he occasionally uses cocaine. I think that is okay, but is it really okay? I would like to [review] the guideline; that [might] help me. [Then], if he comes back another time, I [would] know exactly what I should ask so that there is less guess work.... It does not have to be a novel or anything like that; something short… a consensus text, a guide… [that helps] you proceed with someone who reports [drug abuse]”. GP10, F, 43 y, NlThe classifications of “misuse,” “addiction,” or “problematic use” were rarely known or used. The recommended maximum intake for alcoholic beverages by the World Health Organisation (WHO) was much better known than that for illicit drugs. Few GPs used screening tests for patients at risk, and some used the CAGE-test. GPs did“Yes. Imagine that you have come for a consultation for the first time, and you have [dysmenorrhea]. Should I ask whether you use drugs? Yes, I am somewhat reluctant to ask that of everyone as a standard question.... No, I do not do that. Maybe I should; I do not know…” GP 2, M, 51 y, Nlconditio sine qua non to manage these types of patients. These skills included motivational interviewing, cognitive behavioural therapy, and systems thinking. GPs described patient management as a package of tailored and flexible interventions, built around shared and realistic objectives, appropriate to the real world.A confident relationship based on strong interpersonal skills and a patient-centred approach seemed to predict the successful management of substance abuse. Although this competency was central, it seemed to be due to the personalities of the GPs in Wallonia; specific training to encourage this behaviour rarely occurred. In Flanders, GPs more often considered communication skills training as “That depends on the objectives that you set [for] yourself: Is it to reduce risk, or is it to put an end to substance abuse? It is important to define that at the beginning”. GP17, M, 37 y, Fr“Yes, the first thing is to open it [up] for discussion. They have to feel that they can discuss anything here. And that it can be discussed in a non-normative manner, now and in the future.… I frame it as a dilemma. You have to be able to come up with your own agenda. And I should not be able to determine your agenda; that is one ideal”. GP 2, M, 51 y, NlImportant differences in training among the GPs were reported. Those who were most involved in substance abuse management had undertaken Continuous Professional Development (CPD) or network collaborations concerning this topic. Young Flemish GPs trained in communication skills specifically expressed that this training was particularly helpful for substance abuse management.“You see, I guess you could say that I was trained before the war. We read a bit of theory about substance [abuse], but we did not know anything about conversational techniques. And that is what you need: how you should address it with this person or that person”. GP 8, M, 59 y, NlThe GPs discussed how their attitudes changed as a result of becoming more experienced. Starting from an idealistic or anxious point of view, feeling intrusive, with little life experience and only their education, some of them gradually moved toward a more pragmatic method of addressing abuse without antagonising the patient.“For example, with a 60-year-old man with an alcohol problem… because of my age and the comfortable life that I lead, you almost feel guilty pointing fingers and saying, ‘You have a problem,’ you see. I cannot imagine it; I say that as well”. GP 1, F, 29 y, NlPersonal, familial, or professional experiences of substance abuse were mentioned as influencing GPs’ behaviours toward patients who exhibited these behaviours. Some GPs refused to treat these patients, whereas others cared for them with increased empathy and consideration. Personal histories, deep emotions, or emotional burdens influenced the GP’s choices with regard to addressing and managing patients who abuse substances. The balance between caring for one’s patients and caring for oneself seemed to directly affect GPs’ behaviour.“I fell into a depression then as well. I learned a lot from it personally, but I certainly use it in my daily work as well. And I think that I can sense very quickly if someone is not feeling mentally up to par; I can recognise it quickly. The personal experience makes me more sensitive, I think. It certainly plays a role”. GP 3, F, 35 y, NlBecause substance abuse management can be challenging and stressful, the GPs said they had to identify, assess, and control their own emotions when dealing with it. With experience, certain skills are developed and additional self-care strategies are adopted. Even when their motivations  were highly positive, the fear of not being able to personally or emotionally cope might cause GPs to refrain from becoming involved.“Is it artificial [to find a meaning in becoming involved with these patients]… to hold on and be happy in my job, even if it does not pay dividends? Or is it therapeutically useful? Well, that is my question”. GP 18, F, 32 y, FrThe GPs’ perceived self-efficacy depended on positive physician-patient relationships, confidence in their own skills, and positive emotions. Time constraints and personal involvement were cited as important barriers for managing patients who required more time, especially when the chances for success are limited.“No. That is not very easy for me. It is a sort of intimacy, like when you are talking about sex. Or… it has a normative character… or something like, “How dare you ask me that?”… I think that I project that onto the patient. I do not know whether the patient thinks that. Perhaps the patient thinks that it is a normal medical question”. GP 2, M, 51 y, NlWhen treating addicted patients face-to-face, two attitudes emerged: The GPs either considered substance abuse as a chronic disease  or they expressed moral judgements about these patients, highlighting their faults and responsibilities with regard to clinical and social damages, and considering them untrustworthy. This second attitude reduced GPs’ willingness to manage substance abuse.“I cannot stand drug addicts because they are liars, and I do not like liars; alcoholics are liars too, but the former are the worse, especially because of substitution therapies…. Drug addicts are utter and complete liars, and I believe that [caring for them is not my responsibility], it is the medical centres’”. GP 19, M, 58 y, FrGPs perceived a primary responsibility to manage substance abuse. Some GPs were strongly engaged in their coaching role, supporting patients with regard to accepting their responsibilities and providing strength to allow them to face life’s difficulties.“When [I] treat an alcoholic who drinks and knocks someone over, I feel personally responsible…“. GP 11, M, 51 y, FrSome GPs also reported having a positive attitude with regard to this aspect of their job. In fact, many said that these responsibilities are what being a GP is all about.“I always find it rewarding [to see] an alcoholic who is no longer dependent, who moves forward in life, who is more autonomous than before, who has a better quality of life in the broad sense. It is his life, it is his quality of life; but I think that if I, at any given moment, have been able to help him to reach this autonomy, well, that is good. […] I think that this is our role as doctors”. GP 13, M, 43 y, FrHowever, satisfaction with regard to dealing with addicted patients was rare. Substance abuse was described as a complex problem that requires long-term, staged follow-up assessments that proceed at the patient’s pace and are associated with many relapses without any outcome certainties. GPs often considered abstinence to be a long-term goal. Negative past experiences gave some GPs a feeling of impotence.“There is weariness with regard to morally supporting people. We must accept  that we may not be able to cure them, but that we are there to help them…. It is difficult to unceasingly return [to] a problem that one cannot solve; it is not very rewarding on a medical level; it is easier to cure people…” GP 12, F, 55 y, FrSome GPs considered the use of all illegal drugs as abuse, whereas others considered this use as abuse only when it affected the patient’s health or social life. Cannabis was often tolerated for recreational use and was considered common among young people. Alcohol was much more socially acceptable than other substances; moreover, alcoholism was easier to address than psychotropic drug abuse. Some GPs were more tolerant of psychotropic drug abuse (particularly among elderly people), whereas others considered it to be a growing problem, and some of them felt partly responsible for initiating psychotropic treatment among patients looking for help with critical life events.The GPs were concerned about possible breakdowns in the therapeutic relationship; therefore, they often delayed the beginning of interventions until they perceived an opportunity to discuss the abuse with their patient. After the problem was broached, the patients were made aware that the GP’s door was open for additional dialogue. This behaviour was part of the contemplation stage.During the preparation stage, the GPs sought opportunities to broach the subject with the patient, for example, when both parties had sufficient time and when the context was appropriate .“Sometimes you ask about [the drug abuse], and you know that they are lying. Then you know, [now] is certainly not the time to go into any depth because the patient does not want to hear about it.... Then you just leave it alone for a while. In many cases, these are the types of patients who will be back. You just know that”. GP 1, F, 29 y, NlGPs relied on their clinical competence, and various reasons were used as opportunities to broach the problem of abuse, including repeated requests for sickness-absence certificates or drug prescriptions, physical stigmas and symptoms of acute trauma, social malfunctioning reported by either the patient (sometimes) or his or her relatives (more often), or simple intuition .“The family also puts pressure on us, especially the parents. There are parents who beg us to do something, really; and then we initially see the parents 3-4 times before seeing the child because the latter does not want to see us at all”. GP 14, M, 62 y, FrThe GPs expressed their need to collaborate with other caregivers in multidisciplinary networks, primarily for psychological and social reasons. The opportunity to collaborate easily with other professionals was perceived as an advantage of multidisciplinary teams. Some GPs asked about a place for information and peer exchange for support in case of pitfalls and feelings of impotence. Others asked for financial and organisational incentives. In group practices, electronic medical records provide the opportunity to share information and alert GPs to possible drug abuse or patients at risk for aggression.Referrals to psychiatrists or psychologists were difficult and often too expensive for most patients. The waiting list at specialised care centres was a major concern among the GPs.“If you have a patient who has been addicted for a very long time, [then it is frustrating] once you have finally gotten him motivated to go into detox, and there is nothing available. People often drop out then, you know. They say, ‘I just don’t care anymore’ or ‘I don’t want it anymore’ or ‘I can solve my own problems’. And it is with precisely these people that you need to strike while the iron is hot, so to speak. This is the ideal time to admit someone. But then the moment is gone, and it is actually too late”. GP 7, M, 39 y, NlA significant number of disparities exist among GPs with regard to their willingness to manage patients who abuse substances. The motivation to engage primarily depended on their personal attitudes, the available resources, and their training level. A striking feature of the analysis was that the vast majority of the statements ended up in the “attitude” portion of the I-Change Model. This portion of the model considered pros and cons that were crucial to determining the intentions and actions of substance abuse management, particularly with regard to its workability and manageability.Another important finding was that the topic strongly affected all GPs, but these physicians were also highly concerned about protecting themselves as individuals and professionals because managing these patients requires time and energy. The fears of exhaustion and burnout were tangible and justified a demand for support, including exchange meetings or effective and accessible collaborations with specialised care centres.Collaborative management was a prerequisite for GPs who sought support and a desire to share expertise, especially with regard to illegal drug users. Mental health care (at least its accessibility) was depicted as insufficient. Local collaboration within multidisciplinary practices might be an interesting solution.This study highlighted a great variety of behaviours linked to GPs’ personal histories and reflexivity with regard to treating patients with substance abuse, and these behaviours matched attitude and self-efficacy, as motivational factors. ManaginAlcohol and psychotropic drugs are well known and more accepted by GPs; conversely, more reticence was expressed with regard to illegal drugs. It is not surprising that the opinions concerning these patients were more negative given the possible stereotypical views regarding substance use, as various authors have mentioned,14,30,31The various representations and social acceptability of different substances most likely depends partly on their legal status  and partly on their prevalence .Older GPs with more professional experience tended to be more involved. Furthermore, perceptions of a clear role and defined limits with regard to their responsibilities protected GPs against feelings of frustration, disillusionment, and perceived impotence. However, attitudes can also be improved through communication skills training, peer exchange, and support. A strong difference existed between Dutch-speaking and French-speaking GPs concerning communication skills training.The existing literature does not completely support the differences in prevalence between practice locations revealed in the interviews. The linth component of patient-centeredness as defined by Mead and Bower, which concerns a self-awareness of the influence of their personal qualities on the way they practice medicine[GPs’ attitudes concerning substance abuse, their perceptions of their role and their opinions concerning substance abuse as well as their lack of theoretical knowledge and training in this area are important determinants of their behaviours. The central effect of a physician’s personal qualities with regard to dealing with emotions, his or her personal life history/experience, self-care, and self-awareness in treating patients has been acknowledged previously. Bombeke et al. introduced the “doctor-as-a-person” model as a key determinant in the development of patient-centred behaviour among medical students. Using tmedicine.Given the rich data that coincide with this “doctor-as-a-person” model, interventions that address self-reflection, coaching, or tutoring to improve self-care are advisable. Several participants suggested the need for this type of support, which can strengthen the ability factors of GPs. Specific skills are needed to maintain the delicate confidential doctor-patient relationship. Mutual respect is the appropriate attitude for helping these patients. Personal development, dealing with emotions and personal suffering, self-awareness, and self-care were submitted as key qualities that must be taught, guided, and fostered to maintain a patient-centred focus among GPs. Thus, tutorship and coaching are as important as theoretical and practical workshops in undergraduate education and continuous professional development programs, as various authors have mentioned over the past two decades,37-42. CAddiction is a complex phenomenon that, according to WHO's definition of health, includes medical, social, and psychological aspects. CollaboThis qualitative exploratory study preliminarily analysed the determinants of GPs’ involvement in substance abuse management from the GPs’ points of view. This study cannot provide reliable information regarding influences at the macro-social level . Moreover, this study was conducted within a purposive sample with a limited number of participants.This inductive phase should now be followed by a deductive phase. A quantitative survey will be conducted to measure the importance and prevalence of determinants of substance abuse management. The results might contribute to the implementation of policies that aim to support current practices. De Vries’ I-Change Model provided us with a complementary and continuous approach between the current qualitative portion and the upcoming quantitative portion of this study.This exploratory study highlighted major aspects of addiction management in the general practices of two Belgian provinces. The personal determinants of behaviour are most likely homogenous in culturally similar western nations.Improving GP practice is often depicted as a matter of training or developing new tools to help physicians. Guidelines and implementation tools are of limited interest for those who do not favour personal involvement. Our study showed that GPs do not act as a homogeneous group. GP behaviours are strongly influenced by their opinions of substance abuse. Moral judgments and various fears were present in the therapeutic relationship. This point should be accounted for in the initial training of physicians. Support workshops and groups aiming to exchange best practices in a safe environment should also be considered for those who treat patients with substance abuse. This practice will help to break the isolation of GPs and reduce the risk of developing burnout, which is frequent among these professionals-46.Improving substance abuse management in primary care is also a matter of policy as well as improving clinical competencies, as has been depicted for other mental health problems.The Ethics committees of the Universities of Antwerp and Liege approved this study (Belgian Nr: 12/41/315 for Antwerp and B707201214939 for Liege).The authors declare that there are no competing interests.All authors participated in the design of the study and construction of the interview guide.FK, LS, ML and MV conducted the interviews; FK, LS and ML analysed the results with the help of LP and MV. FK drafted the manuscript. MV was the coordinator of the Up to Date research project, which includes this study. All authors read and approved the final manuscript.The pre-publication history for this paper can be accessed here:http://www.biomedcentral.com/1471-2296/15/119/prepubInterview guide.Click here for file


When we buy food, we’re often buying packaging, too. From cherries to Cheez-It® crackers, modern foods are processed, transported, stored, and sold in specialized materials that account, on average, for half the cost of the item, according to Joseph Hotchkiss, a professor in Michigan State University’s School of Packaging. Consumer-level food packaging serves a wide range of functions, such as providing product information, preventing spoilage, and protecting food during the journey from production to retail to pantry, fridge, or freezer. That’s why food producers lavish so much time and money on it.,,,But what happens when these valuable and painstakingly engineered containers leach chemicals and other compounds into the food and drink they’re designed to protect? Such contamination is nearly ubiquitous; it happens every day, everywhere packaged food is found, with all common types of packaging, including glass, metal, paper, and plastic.Even as awareness of the issue grows, large-scale solutions that are scientifically and financially viable remain out of reach. The challenges in reaching them are many. Yet some of the world’s leading health authorities and largest food producers are working toward fixes , despite the absence of scientific consensus or regulatory requirements around most food-packaging chemicals of concern.Due primarily to consumer demand, health concerns represent the largest force driving innovation within the food-packaging industry today, Hotchkiss says. “I believe the safety issues will continue to grow, and those who can assure consumers that they are concerned about it and are doing what they can to address it will be rewarded in the marketplace,” he says. “Those that don’t will be punished in the marketplace.”,,People around the world are familiar with bisphenol A (BPA) and concerns about its migration into food and drink from plastic bottles, metal cans, and other consumer products. To date U.S. and European authorities have concluded, based on the available evidence, that the levels of BPA that currently occur in foods are safe for all consumers.Beyond our borders, several other countries have banned BPA from some infant products, including Canada, the European Union, South Africa, China, Malaysia, Argentina, Brazil, and Ecuador.The BPA debate illuminates many of the challenges involved in stemming chemical migration. As France recognized with its ban, prohibitions for baby products alone don’t address the fact that BPA exists in countless consumer products and food-packaging materials to which infants and expectant mothers,,,BPA is just one of many known or suspected endocrine disruptors commonly found in food packaging that can migrate into food and drink.For these reasons, Laura Vandenberg, an assistant professor of environmental health at the University of Massachusetts Amherst, believes most existing bans on BPA do little to ensure food safety. “This was a very empty victory, I think, to focus on BPA and baby bottles,” she says.Sure enough, in some applications BPA was replaced with other bisphenols, including BPS and BPF, which laboratory experiments indicate have estrogenic effects at least as pronounced as those of BPA.Chemists are now on the hunt for effective alternatives to BPA. To date no one has identified any drop-in fixes that will work in all the same applications, for the same or a lesser cost, with an established lack of estrogenic activity (now known in the marketplace as “EA-free”). But partial solutions are beginning to appear.One of the most widely available is a polymer called Tritan that can replace traditional polycarbonate in clear, hard plastics used for water and baby bottles. According to its manufacturer, Eastman Chemical Company, Tritan is free of estrogenic activity within the human body.Not everyone agrees. In 2011 a pair of affiliated firms called PlastiPure and CertiChem published a study showing the potential for endocrine disruption in Tritan.Tritan is still used widely in hard-plastic bottles sold by Nalgene, CamelBak, Nathan, and other brands, while PlastiPure and CertiChem continue to support the development of other alternative plastics and products, including food packaging, says chief economic officer Mike Usey. In addition to testing and consulting, the sister companies will soon expand into product development, Usey says. “We’ve had so much interest in the last year and a half from consumers for safer products, and a lack of traction with manufacturers, that we’ve decided to spin off a product company.”But full-scale solutions remain at least a few iterations away, says John Warner of the Warner Babcock Institute for Green Chemistry. “Something like reinventing plastic isn’t going to happen in a day, a month, or a year,” he says. “This isn’t a matchmaking game. It’s not like the solutions are out there, if only the companies could be matched up with those solutions. I really feel we are inventions away from success.”Much of Warner’s personal research centers on developing biobased plastics  that are safer, cheaper, and as effective as traditional fossil-fuel plastics for food packaging. However, plant-based plastics still may contain some of the same harmful additives and manufacturing by-products  that can migrate into food and drink.These plastics do offer one distinct advantage, Warner says: “Because bioplastics are new, they have less of an incumbent history, so designers, inventors, and developers can create a better formulation of additives that have less impact on human health and the environment.” In other words, although it doesn’t guarantee success, there may be more opportunity for creativity and innovation around bioplastics than with traditional plastics that are more entrenched in industry, he speculates.Beyond reusable hard plastic bottles, the most prominent source of BPA in food-contact materials is the ubiquitous metal can. The BPA-based epoxy resin linings of cans serve a dual purpose by protecting the container from acidic or otherwise corrosive elements in foods as well as protecting food and drink from the can’s metallic taste.Within this sector of the food-packaging industry, researchers have worked for years to identify a replacement for standard BPA-containing epoxies that performs just as well across the same range of food and beverage types.Valspar Corporation, a Minneapolis-based manufacturer that bills itself as the number-one global supplier of coatings for metal packaging, is motivated to develop an EA-free can lining for use with a wide variety of foods. And staff toxicologist Mark Maier, who’s leading the company’s efforts, thinks he’s found it. He says Valspar has developed a replacement coating that several academic laboratories have shown to be EA-free. But even if testing validates Valspar’s invention, that doesn’t guarantee economic viability. “The supply chain challenge may be bigger than the safety challenge,” he says. “It doesn’t matter how good your technology is—if it costs too much, nobody’s going to buy it.”Daniel Schmidt, an associate professor in the Department of Plastics Engineering at the University of Massachusetts Lowell, is leading another group in search of a new can lining. Schmidt’s lab has already made an epoxy from 2,2,4,4-tetramethyl-1,3-cyclobutanediol (CBDO), the same monomer that is at the heart of Tritan,As to whether Schmidt’s design will ultimately show any estrogenic activity, which CertiChem’s tests on Tritan suggest it could, he admits there’s some uncertainty. “We do need to do more to ensure that everything is okay in all respects,” he says. “One of the main reasons we chose CBDO was for its structure, which bears little or no resemblance to known endocrine disruptors. This doesn’t guarantee success, but it’s a good place to start.”Other large corporations including Dow Chemical have also alluded to their own efforts to develop safer drop-in can-lining solutions.Amy’s, for example, gives no information on its website as to what alternative formulation it is using, although it does say that low levels of BPA are still migrating into its food.Nestlé Corporation, the world’s largest food producer with thousands of brands selling nearly any prepackaged food one can imagine, must manage the entire spectrum of food-packaging materials and their potential risks. It therefore has a considerable incentive to ensure the safety of its packaging.The Swiss company’s food-packaging safety program got its start after a huge 2005 recall caused by the discovery that traces of isopropyl thioxanthone, a chemical used to cure packaging inks, was migrating through paper cartons into ready-to-drink baby formula sold by the company.“Nestlé got burned and said, ‘That will never happen again,’” says Stephen Klump, the company’s head of packaging quality and safety. “That was a big wake-up call for the industry.” Eventually Nestlé published guidance for inks that prohibits more than 50 acrylates, solvents, photoinitiators, and pigments.The company also has a policy against food contact with BPA, phthalates, and recycled paperboard, which can contain harmful chemicals derived from sources not originally intended for use in food packaging—such as newspaper ink or BPA-/BPS-containing thermal receipts that are added to recycling bins. In addition, Klump says Nestlé aims to phase out BPA from all its can linings and polycarbonate plastics by the end of 2015, but he did not specify which alternatives the company is embracing. In February of this year, Nestlé announced it is developing guidance on packaging adhesives in order to clarify its position on additional substances of concern.The company asks suppliers to formally declare compliance with its guidances as part of their contract, but does not enforce them; Klump says it can be hard to verify total compliance. Nevertheless, through these directives, Nestlé can use its sheer size to spur innovation within the food-packaging industry, and companies selling safer inks and adhesives can tout their compliance with Nestlé’s guidance as a benchmark, as SPGPrints has done with its new line of low-migration ultraviolet inkjet inks.Other large food producers hold similar sway, says Jane Muncke, managing director and chief scientific officer of the Switzerland-based Food Packaging Forum, a nonprofit foundation formed in 2012 to communicate information about food packaging and health. “They have such big buying power they’ll just switch suppliers if they’re not happy with the product.”,In this sense, the onus is often on packaging suppliers to make their products safer, which many are trying to do. A number of manufacturers have introduced new barrier films for dry foods such as pasta, cereal, and rice, among them Clondalkin Flexible Packaging,While it’s clear that a number of packaging manufacturers are eager to switch to alternative packaging whether required to or not, progress to date has been incremental at best. “The unqualified success may be out there, and I really do hope that these companies are developing them, but for the most part what I have seen are just-barely-studied alternatives,” says Vandenberg. Many researchers and innovators in the field who believe they’re on the right track have yet to see their eureka moment, if indeed it’s coming.Still, change is happening. Consumer demand in Europe contributed to the development and rollout of the world’s first PVC- and plasticizer-free glass-jar lid by German packaging manufacturer Pano, says Rolf Rohrkasse, manager of product and material development for the company. Since 2011 Pano has sold 450 million of its BLUESEALÆ lids in Europe, but it has yet to break into the U.S. market. However, Pano is in discussions with Coca-Cola, Unilever, and Nestlé, among others, to expand its global reach.The caps still contain a plastic seal—a polyolefin-based elastomer called Provalin®.However, like relying on dry-food barriers to reduce migration rather than eliminating the harmful chemicals in the first place, Muncke sees Pano’s lids as only a small step in the right direction. “It’s kind of a half-solution,” she says. “It doesn’t solve the whole issue.”Some nongovernmental organizations are taking steps to get specific chemicals removed from food packaging.Maricel Maffini, a consultant and former senior scientist with the NRDC, is concerned that the development of safer alternatives is being hampered by a lack of regulatory incentives and oversight. “There is no regulatory pressure for innovation,” she says. “And when [manufacturers] do take the initiative to go for an alternative, we don’t know the safety profile of that alternative, we don’t know the exposure, we don’t know if it gets metabolized when it gets into the environment. So there are still a lot of systemic improvements that we need.”Schmidt points out that even if consumer packaging is totally free of harmful substances, there are still many opportunities during processing and handling for foods and beverages to become contaminated, even before they are packaged. As an illustration, he points to a study of phthalates in olive oil, which found contamination in every sample tested, but no significant difference in the degree of contamination between oils packaged in glass, plastic, or metal.“Packaging is important,” he says, “but the issue is even bigger still. Make the packaging perfect, and you’ve still got [contamination] coming from further up the supply chain.”Muncke, for one, is prepared to concede that a true food-packaging panacea may not be anywhere around the next bend—especially when one takes into account the environmental impacts of producing and discarding so much packaging, and the carbon footprint of the global food system. “If you want to preserve food by using packaging, then you have to make compromises,” she says. “There is no packaging that is perfect.”As migration concerns drive chemists, food producers, and packaging manufactures to seek out and market new chemicals and materials, the threshold for deeming a substance “safe” is likely to become more hotly contested. Although traditional toxicity tests can be used to evaluate some outcomes of concern, endocrine disruption poses a particular challenge due to the fact that such chemicals may produce effects in experimental models at very low doses.Some of the field’s leading figures in the United States, including Pete Myers of Environmental Health Sciences, Terry Collins of the Institute for Green Science at Carnegie Mellon University, and Jerrold Heindel and Thaddeus Shug of the National Institute of Environmental Health Sciences, have developed an endocrine-disruption detection system known as TiPED that is designed to help chemists formulate safer chemicals.in silico and in vitro tiered structure that foregoes any animal testing.Meanwhile, a European program known as LIFE-EDESIA—designed to identify three to five EA-free alternatives each for bisphenols, phthalates, and parabens—has developed a simpler


Narrative, the creation of imaginative projects and experiences displayed in expressions of movement and voice, is how human cooperative understanding grows. Human understanding places the character and qualities of objects and events of interest within stories that portray intentions, feelings, and ambitions, and how one cares about them. Understanding the development of narrative is therefore essential for understanding the development of human intelligence, but its early origins are obscure. We identify the origins of narrative in the innate sensorimotor intelligence of a hypermobile human body and trace the ontogenesis of narrative form from its earliest expression in movement. Intelligent planning, with self-awareness, is evident in the gestures and motor expressions of the mid-gestation fetus. After birth, single intentions become serially organized into projects with increasingly ambitious distal goals and social meaning. The infant imitates others’ actions in shared tasks, learns conventional cultural practices, and adapts his own inventions, then names topics of interest. Through every stage, in simple intentions of fetal movement, in social imitations of the neonate, in early proto-conversations and collaborative play of infants and talk of children and adults, the narrative form of creative agency with it four-part structure of ‘introduction,’ ‘development,’ ‘climax,’ and ‘resolution’ is present. We conclude that shared rituals of culture and practical techniques develop from a fundamental psycho-motor structure with its basic, vital impulses for action and generative process of thought-in-action that express an integrated, imaginative, and sociable Self. This basic structure is evident before birth and invariant in form throughout life. Serial organization of single, non-verbal actions into complex projects of expressive and explorative sense-making become conventional meanings and explanations with propositional narrative power. Understanding the root of narrative in embodied meaning-making in this way is important for practical work in therapy and education, and for advancing philosophy and neuroscience. The individual-as-agent extends forward in time through movement, self-generating a world of actions and contingent perceptual responses. These responses are appraised as a threat or benefit to the vitality of the organism, giving a self-related affective valence to each act and it consequences. Figure 1). Each unit in the hierarchy of intended action, from unit components to the whole project, comprises both a physical pole and a mental one – the act in motor expression, and its attendant psychological qualities of intention, perceptual guidance, and affective evaluation. These combine in a deliberate form of movement appreciated privately or subjectively, and perceptually available to others intersubjectively . They constitute the beginnings of conceptual development accumulating motor memories and associated responses, affects and plans to achieve the goals of ‘projects of activity.’To approach an environmental goal with an independently mobile body many action units must be coordinated together in an intended future . Serial Serial organization of effective movements by an infant, requiring ‘action chaining’ in imaginative projects  is not win utero. It must (i) initiate toward that future, (ii) develop in its progression over time and through space with sensory feedback and adaptive anticipatory response charged with memories, and (iii) reach its target before (iv) resolving into a quiet state again, the effects of that action now appropriated into the recollected state of the organism. Each step carries the organism purposefully in time and space to a set of relations with new affordances, and new meaning in what Margaret Donaldson calls the ‘line mode’ of thought .We can trace the development in the first year of infancy toward projects of practical communication: from primary intersubjectivity in dialog, through games with expressions, then games with objects, to secondary intersubjectivity to share the project of a task using objects . HallidaEach stage of the development of conscious control of actions is sustained by the affective regulation of ‘vitality dynamics’ in body movement . These aPerformance of more distal, more ambitious goals requires serial organization of movement-with-awareness into ‘projects of projects of action units.’ Enterprises like cooking dinner, building a tower of blocks, or winning at chess, require coordinating a number of sub-projects, each with their own goals. Such achievements of creative practical and social action must be conceived within an imaginative ‘present moment’ drawing on memories of past skills as it looks to achieve a desired future .When babies become toddlers and are able to master a rich repertoire of projects, they take delight in mimicking the complex projects of adults, learning the styles and patterns of a culture. Cooking dinner is one such project, and the children’s play kitchen is always a favorite in the nursery classroom. Nursery children aged 2–4 take special joy in cooking and preparing dinner with toy utensils and foods, organizing the projects of grasping, cutting, mixing, and so on into larger structures with higher intentional perspective. Over the next years their motor and cognitive precision will improve to allow them to do just that, replacing toys for the genuine article. From two to five the child takes up and transforms words to recount ingenious understanding of purposes and experiences .Young children join in the rituals of the day , showing“Narratives of individual experience and of companionship are built from the units of pulse and quality found in the jointly created gestures of vocalizations and bodily movement. Narratives are the very essence of human companionship and communication. Narratives allow two persons to share a sense of passing time, and to create and share the emotional envelopes that evolve through this shared time. They express innate motives for sharing emotion and experience with other persons and for creating meaning in joint activity with others”, p. 45.introduction, development, climax, and resolution, with rhyming vowels at key points, to all of which the infants engage with anticipation , the rhythm of which relates to autonomic or visceral processes that give the internal ‘psychic time’ (Table 2) of an integrated Self to arousal of sequences of cognitive elements, intentional acts, and the affective, interpersonal power of expressions in communication .A narrative’s nature exists in its internal dimensions of feeling and form as well as in its rhythmic, shared, and co-created form between two or more persons, “There are certain aspects of the so-called ‘inner life’—physical or mental—which have formal properties similar to those of music— patterns of motion and rest, of tension and release, of agreement and disagreement, preparation, fulfillment, excitation, sudden change, etc.,” , p. 223.When the narrative is finished, the experience of its creation will remain with each of the partners, and between them they may hold its special memory – a memory of a unique, shared experience, the co-creation of which imbues the memory with ‘meaning.’ The conclusion of a narrative episode is followed by a disengagement, which allows the two partners to consider renewing their mutual focus, ready to begin building a new narrative cycle, or they may separate. We illustrate the primary psychological events and their synthesis to generate mutual interest, shared excitement, and reflective satisfaction with a micro-analysis of a 30 second dialog between a premature newborn and his affectionate mother. Many forms of expressive movement are displayed, intersubjective contact being mediated by complementary modalities of voice and gesture. The two human beings compensate for their very different levels of development in intimate collaboration, the mother coming close to her infant in rhythm and sympathy with musical intonation of her speech, and the infant animating his feelings in seductive ways in response to her encouragements.Baby B, was born prematurely at 27 weeks gestational age with his monozygotic twin brother. The boys received intensive care in the hospital neonatal unit, and their mother visited every day for sessions of body to body ‘kangaroo’ care and for social support. When the recording was made, the mother and her infants had been in hospital for 8 weeks with regular opportunity for interaction, and B was at 34–36 weeks before term. Both babies were due for discharge that week and their health was considered stable.Figure 3), and a second camera recorded a frontal view of his mother. Their vocalizations  were recorded by two microphones. B’s arm movements were tracked by attaching a reflective marker to his wrists. A six-camera motion capture system  recorded in 3D the coordinate position of the markers 500 times per second, with a spatial resolution of less than 1 mm. Displacements of his left and right wrists were recorded as tangential velocity or speed, disregarding direction of travel .B was lying on a quilted tabletop with his mother seated in a chair at his feet, leaning over him. An overhead video camera provided a vertical view of B . His left hand is held shut by his head and his right hand is lying back on the bed, open. He makes a small vocalization just before she says, “Good afternoon!” She makes a gesture to touch his side with her right index finger then points to her mouth in rhythmic synchrony with speech before laying her hand gently on the bed beside him. B closes his mouth with his tongue between his lips, then turns away, making a sleepy jerk to face his right hand, with eyes closed. His left hand makes a rapid movement up and to the right to follow the head, and his right hand moves up a little the fingers opening as his mother starts to say, “Good afternoon, wee B” and she turns left to face him, placing her right index beside B. His right hand opens and shuts synchronously with the word “B” – he is listening (C). At 7 s as his mother says “How are you doin?”, B’s right hand moves slightly forward, closes index then opens and closes again gently, again in synchrony with her speech (D). She withdraws the right index as she says “Eh?”, as her voice rises, B smiles and his right hand shuts. He is clearly listening and shadowing his mother’s speaking with his right hand, and signaling his appreciation with a smile.In the first 3 s  the baby, who had been asleep, is stirring gently as his mother attempts to arouse him, saying, “Oorh, look at that big smile!” with a cheerful teasing expression of pleasure, and she pulls her head back and touches the bed with her right index. B may be swallowing after the attempt to vocalize. After smiling, he pauses a moment. His mother turns right to look at the monitor behind her to check his physiological indices and says, to herself, with different intonation, “Oh, that’s all great!” B reaches up with his right hand and opens his eyes in synchrony with this phrase (F), then as she pronounces the word “great” he makes a chewing movement and looks toward his hand. At 15 s his right hand opens and closes and his wrist turns out away from his face (G). He may be feeling the mattress with the back of his hand. His mother touches him to tickle his thigh gently, and then as she says to him, with lift of intonation, “Look at that big smile!” her index goes down to touch the blanket. B’s right hand waves back to touch the bed, then is pulled in his cheek. He smiles and his eyes close in rhythm with the mother’s speech, then they open at 17 s (H).Still smiling, B makes a small vocalization at 10 s (E) His mouth opens and then shuts quickly as his mother says “Hi-ya,” he stretches his head up to look forward, turning his right hand back at the wrist in a waving gesture, opens his mouth wide, and smiles (I). Then he turns quickly to face his mother, vocalizes with a rough sound and gestures, smiling and grimacing with the effort. At 19–20 s when his mother says, “Hello there!”, both his hands are pulled up, back and out in a big rowing gesture . As mother’s voice glides dramatically down through an octave from C5 to C4 between 20 and 21 s, B opens his mouth very wide and closes it with a smile in synchrony with fast forward and back down and pulled back rowing movements of his two hands. His eyes open and he coughs at 20 s (L). At 22 s B makes a second rowing cycle and his mouth shuts. As his mother finishes the vocal glide and turns to her right, his hands are at his shoulders and his tongue is visible in an open mouth.As B’s mother says “Oh, you’re kicking your Mum!” (B is pushing his foot against his mother’s stomach). He turns his head up, and with the word “Mum!” (M), his eyes close and his right hand goes up, opens and moves slowly out, then his eyes open to look at his hand. His mouth is half open with the tongue visible. His mother glances to her right to the monitor as she says “Mum!”, then she turns back and gives a little tickle to his side with her right index, saying, “Are you kickin’ me?” (N). At 26 s B clasps his right hand quietly and moves it down as his mouth opens. His mother says, “Eh?” (O). A moment later, at 29 s, B turns back to face his mother, his mouth opens wide and his eyes close. His left hand is up beside his face and his right hand is back and half closed, with index extended and his tongue protruded in a wide-open mouth (P). His mother responds with a vigorous teasing at low pitch, “Have a big wriggle, then.” In these last 5 s  B has become active, but he is performing with little sign of awareness of his mother, or her playful actions. He appears to be disengaged from her and perhaps is recollecting his excitement of 10 s previously  in a ‘coda.’ He does not smile or vocalize.At 23 s, having finished his display of excitement and delight, shared intimately in rhythm with his mother’s speaking, B pulls his hands in and turns away from his mother, eyes half closed, mouth half open and shutting with tongue visible as she says with a deep ironic tone “B displayed his awakening experience of his mother’s voice and touches by becoming still, to listen. And then he slowly began a story of self-aware movements that harmonized with her repeating calls of speech, turning his head, gesturing expressively with his hands, making subtle movements with his mouth, holding his right hand up and looking at it, recognizing his mother’s encouragements with smiles and attempts to vocalize. He became a collaborator, linking his increasing interest and effort at self-expression to his mother’s responses, gaining fluency and vigor in synchrony with her rhythms until he excited both of them with big cyclic movements of both arms together and wide open mouth with effort to vocalize. His mother’s dramatic pitch glide shared this triumph and brought their shared excitement to a close. And then he withdrew and rested before making some movements for his own pleasure, which show little attention to his mother’s observations about what he was doing. Altogether they traced a narrative form of arousal, affect, and intention with its four distinct phases, co-creating its ‘story.’B’s shared narrative with his mother appears to have become an object in his memory, holding a process of learned meaning composed with evolving affective value and patterns of self- and other-regulation of arousal, interest, and intentions expressed in the form and qualities of body movement. He repeats this pattern in the short coda after the event, recalling the embodied, shared schema of feeling in action and expression. This object now held in his memory becomes available for future events, setting a template of possible action with its expectations of affect-laden social interest and intention from the others, as well as its preparatory autonomic anticipations . This isThe story made by Baby B and his mother demonstrates the dual aspect of narrative as embodied in physical and emotional experience of the actor, and as a semiotic experience for consensual understanding. Mother and baby shared a human ‘tide of vitality’ in arousal, interest and expression over the four-part structure of what All narratives are rooted and expressed in body movement, for communication. Human cultural narratives, beginning in proto-conversations and the rituals of games with infants , become The theory of the prospective organization of embodied narrative in interpersonal meaning-making is supported by evidence of disruption in the prospective timing and affective integration of motor intentions in individuals with socio-emotional disorder. For example, errors in sensorimotor capacity to efficiently enact desired intentions characterize autism spectrum disorders, regularly thwarting success, creating distress and isolation, and consequent social and emotional compensations . When rhIn this paper we trace the origin of narrative form in communication to a primary motivation for conscious understanding enacted and structured through purposeful movement. These lively self-generated engagements with awareness of the world place events in a time and space of vital meaning for the embodied experience of the Self, as well as for communication with other persons. The form of this generative process is found to be invariant across development, from the simple motor capacities of the young fetus through pre-verbal proto-conversation in infancy, and into linguistic meaning-making in childhood and later human life.initiation seeking a goal, (ii) a development in the strategy of its progression, usually through repeated cycles of ‘testing’ by expression and adaptation until, (iii) a climax of excitation and achievement is attained, before (iv) that particular plan of action comes to an end, or resolution, and the direction of interest changes.Meaning-making in movement and its co-creation in dialog arise within a basic, four-part organization common to all levels in the embodied action of a purposeful agent, with (i) an We have shown how the future-oriented, generative and rhythmic structure of the human will-to-move is organized from the start by the psycho-motor dynamics of an articulated, hypermobile body together with its internal self-preserving, visceral autonomic rhythms, that is, with purpose and with emotion. The coordinated temporal patterns of action and vitality of the Self-As-Agent structure forms of effort that generate meaningful concern for the individual as he or she, in solitary or in social projects patterned over many seconds, tens of seconds, minutes, and hours, engages with a world of objects and people. The rhythms of engagement expand in scope and ambition as the imagination of adult life envisages years of achievement and understanding that will be stored and named as beliefs, rituals, and techniques. Thus life stories with their intrinsic narrative vitality create a store of experience, memories, understanding and purpose – the culture of a cooperative society.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.