literary term synthesis

• University of Oregon Libraries
• Research Guides

How to Write a Literature Review

• 6. Synthesize
• Literature Reviews: A Recap
• Reading Journal Articles
• Does it Describe a Literature Review?
• 1. Identify the Question
• 2. Review Discipline Styles
• Searching Article Databases
• Finding Full-Text of an Article
• Citation Chaining
• When to Stop Searching
• 4. Manage Your References
• 5. Critically Analyze and Evaluate

Synthesis Visualization

Synthesis matrix example.

• 7. Write a Literature Review

• Synthesis Worksheet

About Synthesis

Approaches to Synthesis

You can sort the literature in various ways, for example:

How to Begin?

Read your sources carefully and find the main idea(s) of each source

Look for similarities in your sources – which sources are talking about the same main ideas? (for example, sources that discuss the historical background on your topic)

Use the worksheet (above) or synthesis matrix (below) to get organized

This work can be messy. Don't worry if you have to go through a few iterations of the worksheet or matrix as you work on your lit review!

Four Examples of Student Writing

In the four examples below, only ONE shows a good example of synthesis: the fourth column, or  Student D . For a web accessible version, click the link below the image.

Long description of "Four Examples of Student Writing" for web accessibility

• Download a copy of the "Four Examples of Student Writing" chart

Click on the example to view the pdf.

From Jennifer Lim

• << Previous: 5. Critically Analyze and Evaluate
• Next: 7. Write a Literature Review >>
• Last Updated: Aug 12, 2024 11:48 AM
• URL: https://researchguides.uoregon.edu/litreview

Contact Us Library Accessibility UO Libraries Privacy Notices and Procedures

1501 Kincaid Street Eugene, OR 97403 P: 541-346-3053 F: 541-346-3485

• Visit us on Facebook
• Visit us on Twitter
• Visit us on Youtube
• Visit us on Instagram
• Report a Concern
• Nondiscrimination and Title IX
• Accessibility
• Privacy Policy
• Find People

Literature Syntheis 101

How To Synthesise The Existing Research (With Examples)

By: Derek Jansen (MBA) | Expert Reviewer: Eunice Rautenbach (DTech) | August 2023

One of the most common mistakes that students make when writing a literature review is that they err on the side of describing the existing literature rather than providing a critical synthesis of it. In this post, we’ll unpack what exactly synthesis means and show you how to craft a strong literature synthesis using practical examples.

This post is based on our popular online course, Literature Review Bootcamp . In the course, we walk you through the full process of developing a literature review, step by step. If it’s your first time writing a literature review, you definitely want to use this link to get 50% off the course (limited-time offer).

Overview: Literature Synthesis

• What exactly does “synthesis” mean?
• Aspect 1: Agreement
• Aspect 2: Disagreement
• Aspect 3: Key theories
• Aspect 4: Contexts
• Aspect 5: Methodologies
• Bringing it all together

What does “synthesis” actually mean?

As a starting point, let’s quickly define what exactly we mean when we use the term “synthesis” within the context of a literature review.

Simply put, literature synthesis means going beyond just describing what everyone has said and found. Instead, synthesis is about bringing together all the information from various sources to present a cohesive assessment of the current state of knowledge in relation to your study’s research aims and questions .

Put another way, a good synthesis tells the reader exactly where the current research is “at” in terms of the topic you’re interested in – specifically, what’s known , what’s not , and where there’s a need for more research .

So, how do you go about doing this?

Well, there’s no “one right way” when it comes to literature synthesis, but we’ve found that it’s particularly useful to ask yourself five key questions when you’re working on your literature review. Having done so,  you can then address them more articulately within your actual write up. So, let’s take a look at each of these questions.

1. Points Of Agreement

The first question that you need to ask yourself is: “Overall, what things seem to be agreed upon by the vast majority of the literature?”

For example, if your research aim is to identify which factors contribute toward job satisfaction, you’ll need to identify which factors are broadly agreed upon and “settled” within the literature. Naturally, there may at times be some lone contrarian that has a radical viewpoint , but, provided that the vast majority of researchers are in agreement, you can put these random outliers to the side. That is, of course, unless your research aims to explore a contrarian viewpoint and there’s a clear justification for doing so. 

Identifying what’s broadly agreed upon is an essential starting point for synthesising the literature, because you generally don’t want (or need) to reinvent the wheel or run down a road investigating something that is already well established . So, addressing this question first lays a foundation of “settled” knowledge.

Need a helping hand?

2. Points Of Disagreement

Related to the previous point, but on the other end of the spectrum, is the equally important question: “Where do the disagreements lie?” .

In other words, which things are not well agreed upon by current researchers? It’s important to clarify here that by disagreement, we don’t mean that researchers are (necessarily) fighting over it – just that there are relatively mixed findings within the empirical research , with no firm consensus amongst researchers.

This is a really important question to address as these “disagreements” will often set the stage for the research gap(s). In other words, they provide clues regarding potential opportunities for further research, which your study can then (hopefully) contribute toward filling. If you’re not familiar with the concept of a research gap, be sure to check out our explainer video covering exactly that .

3. Key Theories

The next question you need to ask yourself is: “Which key theories seem to be coming up repeatedly?” .

Within most research spaces, you’ll find that you keep running into a handful of key theories that are referred to over and over again. Apart from identifying these theories, you’ll also need to think about how they’re connected to each other. Specifically, you need to ask yourself:

• Are they all covering the same ground or do they have different focal points  or underlying assumptions ?
• Do some of them feed into each other and if so, is there an opportunity to integrate them into a more cohesive theory?
• Do some of them pull in different directions ? If so, why might this be?
• Do all of the theories define the key concepts and variables in the same way, or is there some disconnect? If so, what’s the impact of this ?

Simply put, you’ll need to pay careful attention to the key theories in your research area, as they will need to feature within your theoretical framework , which will form a critical component within your final literature review. This will set the foundation for your entire study, so it’s essential that you be critical in this area of your literature synthesis.

If this sounds a bit fluffy, don’t worry. We deep dive into the theoretical framework (as well as the conceptual framework) and look at practical examples in Literature Review Bootcamp . If you’d like to learn more, take advantage of our limited-time offer to get 60% off the standard price.

4. Contexts

The next question that you need to address in your literature synthesis is an important one, and that is: “Which contexts have (and have not) been covered by the existing research?” .

For example, sticking with our earlier hypothetical topic (factors that impact job satisfaction), you may find that most of the research has focused on white-collar , management-level staff within a primarily Western context, but little has been done on blue-collar workers in an Eastern context. Given the significant socio-cultural differences between these two groups, this is an important observation, as it could present a contextual research gap .

In practical terms, this means that you’ll need to carefully assess the context of each piece of literature that you’re engaging with, especially the empirical research (i.e., studies that have collected and analysed real-world data). Ideally, you should keep notes regarding the context of each study in some sort of catalogue or sheet, so that you can easily make sense of this before you start the writing phase. If you’d like, our free literature catalogue worksheet is a great tool for this task.

5. Methodological Approaches

Last but certainly not least, you need to ask yourself the question: “What types of research methodologies have (and haven’t) been used?”

For example, you might find that most studies have approached the topic using qualitative methods such as interviews and thematic analysis. Alternatively, you might find that most studies have used quantitative methods such as online surveys and statistical analysis.

But why does this matter?

Well, it can run in one of two potential directions . If you find that the vast majority of studies use a specific methodological approach, this could provide you with a firm foundation on which to base your own study’s methodology . In other words, you can use the methodologies of similar studies to inform (and justify) your own study’s research design .

On the other hand, you might argue that the lack of diverse methodological approaches presents a research gap , and therefore your study could contribute toward filling that gap by taking a different approach. For example, taking a qualitative approach to a research area that is typically approached quantitatively. Of course, if you’re going to go against the methodological grain, you’ll need to provide a strong justification for why your proposed approach makes sense. Nevertheless, it is something worth at least considering.

Regardless of which route you opt for, you need to pay careful attention to the methodologies used in the relevant studies and provide at least some discussion about this in your write-up. Again, it’s useful to keep track of this on some sort of spreadsheet or catalogue as you digest each article, so consider grabbing a copy of our free literature catalogue if you don’t have anything in place.

Bringing It All Together

Alright, so we’ve looked at five important questions that you need to ask (and answer) to help you develop a strong synthesis within your literature review.  To recap, these are:

• Which things are broadly agreed upon within the current research?
• Which things are the subject of disagreement (or at least, present mixed findings)?
• Which theories seem to be central to your research topic and how do they relate or compare to each other?
• Which contexts have (and haven’t) been covered?
• Which methodological approaches are most common?

Importantly, you’re not just asking yourself these questions for the sake of asking them – they’re not just a reflection exercise. You need to weave your answers to them into your actual literature review when you write it up. How exactly you do this will vary from project to project depending on the structure you opt for, but you’ll still need to address them within your literature review, whichever route you go.

The best approach is to spend some time actually writing out your answers to these questions, as opposed to just thinking about them in your head. Putting your thoughts onto paper really helps you flesh out your thinking . As you do this, don’t just write down the answers – instead, think about what they mean in terms of the research gap you’ll present , as well as the methodological approach you’ll take . Your literature synthesis needs to lay the groundwork for these two things, so it’s essential that you link all of it together in your mind, and of course, on paper.

Psst… there’s more!

This post is an extract from our bestselling short course, Literature Review Bootcamp . If you want to work smart, you don't want to miss this .

excellent , thank you

Thank you for this significant piece of information.

This piece of information is very helpful. Thank you so much and look forward to hearing more literature review from you in near the future.

Submit a Comment Cancel reply

Your email address will not be published. Required fields are marked *

Save my name, email, and website in this browser for the next time I comment.

• Print Friendly

The Sheridan Libraries

• Write a Literature Review
• Sheridan Libraries
• Evaluate This link opens in a new window

Get Organized

• Lit Review Prep Use this template to help you evaluate your sources, create article summaries for an annotated bibliography, and a synthesis matrix for your lit review outline.

Synthesize your Information

Synthesize: combine separate elements to form a whole.

Synthesis Matrix

A synthesis matrix helps you record the main points of each source and document how sources relate to each other.

After summarizing and evaluating your sources, arrange them in a matrix or use a citation manager to help you see how they relate to each other and apply to each of your themes or variables.  

By arranging your sources by theme or variable, you can see how your sources relate to each other, and can start thinking about how you weave them together to create a narrative.

• Step-by-Step Approach
• Example Matrix from NSCU
• Matrix Template
• << Previous: Summarize
• Next: Integrate >>
• Last Updated: Jul 30, 2024 1:42 PM
• URL: https://guides.library.jhu.edu/lit-review

Library Guides

Literature reviews: synthesis.

• Criticality

Synthesise Information

So, how can you create paragraphs within your literature review that demonstrates your knowledge of the scholarship that has been done in your field of study?  

You will need to present a synthesis of the texts you read.  

Doug Specht, Senior Lecturer at the Westminster School of Media and Communication, explains synthesis for us in the following video:  

Synthesising Texts  

What is synthesis? 

Synthesis is an important element of academic writing, demonstrating comprehension, analysis, evaluation and original creation.  

With synthesis you extract content from different sources to create an original text. While paraphrase and summary maintain the structure of the given source(s), with synthesis you create a new structure.  

The sources will provide different perspectives and evidence on a topic. They will be put together when agreeing, contrasted when disagreeing. The sources must be referenced.  

Perfect your synthesis by showing the flow of your reasoning, expressing critical evaluation of the sources and drawing conclusions.  

When you synthesise think of "using strategic thinking to resolve a problem requiring the integration of diverse pieces of information around a structuring theme" (Mateos and Sole 2009, p448). 

Synthesis is a complex activity, which requires a high degree of comprehension and active engagement with the subject. As you progress in higher education, so increase the expectations on your abilities to synthesise. 

How to synthesise in a literature review: 

Identify themes/issues you'd like to discuss in the literature review. Think of an outline.  

Read the literature and identify these themes/issues.  

Critically analyse the texts asking: how does the text I'm reading relate to the other texts I've read on the same topic? Is it in agreement? Does it differ in its perspective? Is it stronger or weaker? How does it differ (could be scope, methods, year of publication etc.). Draw your conclusions on the state of the literature on the topic.  

Start writing your literature review, structuring it according to the outline you planned.  

Put together sources stating the same point; contrast sources presenting counter-arguments or different points.  

Present your critical analysis.  

Always provide the references. 

The best synthesis requires a "recursive process" whereby you read the source texts, identify relevant parts, take notes, produce drafts, re-read the source texts, revise your text, re-write... (Mateos and Sole, 2009). 

What is good synthesis?  

The quality of your synthesis can be assessed considering the following (Mateos and Sole, 2009, p439):  

Integration and connection of the information from the source texts around a structuring theme. 

Selection of ideas necessary for producing the synthesis. 

Appropriateness of the interpretation.  

Elaboration of the content.  

Example of Synthesis

Original texts (fictitious): 

Synthesis: 

Animal experimentation is a subject of heated debate. Some argue that painful experiments should be banned. Indeed it has been demonstrated that such experiments make animals suffer physically and psychologically (Chowdhury 2012; Panatta and Hudson 2016). On the other hand, it has been argued that animal experimentation can save human lives and reduce harm on humans (Smith 2008). This argument is only valid for toxicological testing, not for tests that, for example, merely improve the efficacy of a cosmetic (Turner 2015). It can be suggested that animal experimentation should be regulated to only allow toxicological risk assessment, and the suffering to the animals should be minimised.   

Bibliography

Mateos, M. and Sole, I. (2009). Synthesising Information from various texts: A Study of Procedures and Products at Different Educational Levels. European Journal of Psychology of Education,  24 (4), 435-451. Available from https://doi.org/10.1007/BF03178760 [Accessed 29 June 2021].

• << Previous: Structure
• Next: Criticality >>
• Last Updated: Nov 18, 2023 10:56 PM
• URL: https://libguides.westminster.ac.uk/literature-reviews

CONNECT WITH US

Literature Synthesis: Guide To Synthesise & Write Literature Review

Literature synthesis is a crucial skill for researchers and scholars, allowing them to integrate findings from multiple sources into a coherent analysis. Mastering literature synthesis will enhance your research and writing skills. 

This guide will walk you through the process of synthesising and writing a literature review, providing practical steps and insider tips. Learn how to:

• organise your sources,
• identify key themes, and
• create a cohesive narrative that highlights both agreements and disagreements within the existing literature.

Literature Synthesis vs Literature Review

You may be familiar with literature review, and the term literature synthesis may throw you off a bit. Are they a similar thing, or something different from each other?

If you are still unsure about how literature synthesis is different from literature review, here are a couple of points to think about: 

Approach To Sources

One difference is the approach to sources. In a literature review, you might describe each source separately, detailing its findings and contributions.

With synthesis, you combine the ideas from multiple sources to highlight relationships and gaps.

One example would be you may find that several studies agree on a particular theme but use different methodologies to reach their conclusions.

Organisation

A second difference is the organization. Literature reviews typically follow a structured format, summarizing each source in a new paragraph.

In contrast, synthesis requires organising sources around key themes or topics. This might involve using a synthesis matrix to align findings and theories from different sources into a cohesive analysis.

How To Evaluate Literature

Evaluating the literature also differs. When you write a literature review, you summarise and describe the existing research. Synthesis goes further by:

• critically evaluating the sources,
• identifying points of agreement and disagreement, and
• assessing the overall state of knowledge.

You need to address the methodological approaches used and how they relate to your research questions.

In terms of purpose, a literature review provides an overview of what’s known about a topic. It sets the stage for your research by summarising existing knowledge.

Synthesis, meanwhile, aims to create new insights by combining and contrasting different sources. This process helps you identify research gaps and questions that need further investigation.

Writing Process

Finally, the writing process differs. A literature review involves compiling summaries, often following a step-by-step guide.

With synthesis, you need to integrate:

• theories, and
• methodologies from various sources.

This involves weaving together different perspectives into a single, cohesive narrative that supports your research aims.

How To Perform Literature Synthesis?

Performing literature synthesis can be daunting, but by breaking it down step by step, you can create a comprehensive and coherent analysis of your topic.

Here’s a guide to help you through the process, with insider details and practical examples that will make your task easier.

Organise Your Sources

First, you need to gather and organise your sources. Start by conducting a thorough search of the existing literature on your topic, using

• research guides,
• library databases, and
• academic journals to find relevant sources.

There are plenty of AI tools that can help with process as well – make sure you check out my guide on best AI tools for literature review.

Record the main points of each source in a summary table. This table should include columns for:

• the author,
• publication year,
• key points,
• methodologies used, and

By organising your sources in this way, you’ll have a clear overview of the existing literature.

Identify Themes

Once you have your sources organised, it’s time to start synthesising the literature. This means combining the ideas and findings from multiple sources to create a cohesive analysis.

Begin by identifying the key themes that emerge from your sources. These themes will form the basis of your synthesis.

Suppose you are you’re researching job satisfaction, In this case, you might find recurring themes such as work-life balance, salary, and workplace environment.

Create A Synthesis Matrix

Next, create a synthesis matrix. This tool helps you organize the key points from each source under the identified themes.

Each row in the matrix represents a source, and each column represents a theme.

By filling in the matrix, you can see how different sources relate to each theme. This will help you identify similarities and differences between the sources.

Write Your Literature Synthesis

With your synthesis matrix in hand, you can start writing your literature synthesis.

Begin each paragraph with a clear topic sentence that identifies the theme you’re discussing. Then, weave together the findings from different sources, highlighting points of agreement and disagreement.

One way you may write this include: “While Franz (2008) found that salary is a major factor in job satisfaction, Goldstein (2012) argued that work-life balance plays a more significant role.”

Critically Evaluate Your Sources

Be sure to critically evaluate the sources as you synthesize the literature. This means assessing the methodologies used in each study and considering their impact on the findings.

Let’s say you found that most studies on job satisfaction used qualitative methods , you might question whether the findings would differ if quantitative methods were used. Addressing these methodological differences can help you identify research gaps and areas for further study.

Don’t Just Summarise

As you write your paragraphs, avoid simply summarising each source. Instead, combine the key points from multiple sources to create a more comprehensive analysis.

If we reuse Franz (2008) as example, rather than describing Franz’s study in one paragraph and Goldstein’s study in another, integrate their findings to show how they relate to each other.

This approach will make your synthesis more cohesive and easier to follow.

Address The Broader Context Of The Topic

To create a strong synthesis, you also need to address the broader context of your research. This means considering the theoretical frameworks and empirical evidence that underpin your topic.

If you’re researching job satisfaction, you might discuss how different theories of motivation relate to your findings. By integrating these broader perspectives, you can provide a more comprehensive overview of the current state of knowledge.

Keep Questioning Yourself

Throughout the writing process, keep the five key questions in mind:

• What’s broadly agreed upon within the current research?
• Where do the disagreements lie?
• Which theories are central to your research topic?
• Which contexts have been covered, and which haven’t?
• What types of research methodologies have been used?

Addressing these questions will help you create a more thorough and insightful synthesis.

Revise & Edit

Finally, revise and edit your work. This means checking for clarity, coherence, and logical flow. Make sure each paragraph has a clear topic sentence and that all sentences within the paragraph relate to that topic.

Remove any unnecessary information and ensure that your synthesis is well-organised and easy to follow.

Your Guide To Synthesise Literature

Performing literature synthesis may seem overwhelming, but by following this step-by-step guide, you can create a comprehensive and cohesive analysis of your topic.

Use tools like summary tables and synthesis matrices to organise your sources, and focus on combining the key points from multiple sources to create a strong synthesis.

With careful planning and critical evaluation, you can produce a literature synthesis that provides valuable insights into your field of study.

Dr Andrew Stapleton has a Masters and PhD in Chemistry from the UK and Australia. He has many years of research experience and has worked as a Postdoctoral Fellow and Associate at a number of Universities. Although having secured funding for his own research, he left academia to help others with his YouTube channel all about the inner workings of academia and how to make it work for you.

Thank you for visiting Academia Insider.

We are here to help you navigate Academia as painlessly as possible. We are supported by our readers and by visiting you are helping us earn a small amount through ads and affiliate revenue - Thank you!

2024 © Academia Insider

How to Synthesize Written Information from Multiple Sources

Shona McCombes

Content Manager

B.A., English Literature, University of Glasgow

Shona McCombes is the content manager at Scribbr, Netherlands.

Learn about our Editorial Process

Saul McLeod, PhD

Editor-in-Chief for Simply Psychology

BSc (Hons) Psychology, MRes, PhD, University of Manchester

Saul McLeod, PhD., is a qualified psychology teacher with over 18 years of experience in further and higher education. He has been published in peer-reviewed journals, including the Journal of Clinical Psychology.

On This Page:

When you write a literature review or essay, you have to go beyond just summarizing the articles you’ve read – you need to synthesize the literature to show how it all fits together (and how your own research fits in).

Synthesizing simply means combining. Instead of summarizing the main points of each source in turn, you put together the ideas and findings of multiple sources in order to make an overall point.

At the most basic level, this involves looking for similarities and differences between your sources. Your synthesis should show the reader where the sources overlap and where they diverge.

Unsynthesized Example

Franz (2008) studied undergraduate online students. He looked at 17 females and 18 males and found that none of them liked APA. According to Franz, the evidence suggested that all students are reluctant to learn citations style. Perez (2010) also studies undergraduate students. She looked at 42 females and 50 males and found that males were significantly more inclined to use citation software ( p < .05). Findings suggest that females might graduate sooner. Goldstein (2012) looked at British undergraduates. Among a sample of 50, all females, all confident in their abilities to cite and were eager to write their dissertations.

Synthesized Example

Studies of undergraduate students reveal conflicting conclusions regarding relationships between advanced scholarly study and citation efficacy. Although Franz (2008) found that no participants enjoyed learning citation style, Goldstein (2012) determined in a larger study that all participants watched felt comfortable citing sources, suggesting that variables among participant and control group populations must be examined more closely. Although Perez (2010) expanded on Franz’s original study with a larger, more diverse sample…

Step 1: Organize your sources

After collecting the relevant literature, you’ve got a lot of information to work through, and no clear idea of how it all fits together.

Before you can start writing, you need to organize your notes in a way that allows you to see the relationships between sources.

One way to begin synthesizing the literature is to put your notes into a table. Depending on your topic and the type of literature you’re dealing with, there are a couple of different ways you can organize this.

Summary table

A summary table collates the key points of each source under consistent headings. This is a good approach if your sources tend to have a similar structure – for instance, if they’re all empirical papers.

Each row in the table lists one source, and each column identifies a specific part of the source. You can decide which headings to include based on what’s most relevant to the literature you’re dealing with.

For example, you might include columns for things like aims, methods, variables, population, sample size, and conclusion.

For each study, you briefly summarize each of these aspects. You can also include columns for your own evaluation and analysis.

The summary table gives you a quick overview of the key points of each source. This allows you to group sources by relevant similarities, as well as noticing important differences or contradictions in their findings.

Synthesis matrix

A synthesis matrix is useful when your sources are more varied in their purpose and structure – for example, when you’re dealing with books and essays making various different arguments about a topic.

Each column in the table lists one source. Each row is labeled with a specific concept, topic or theme that recurs across all or most of the sources.

Then, for each source, you summarize the main points or arguments related to the theme.

The purposes of the table is to identify the common points that connect the sources, as well as identifying points where they diverge or disagree.

Step 2: Outline your structure

Now you should have a clear overview of the main connections and differences between the sources you’ve read. Next, you need to decide how you’ll group them together and the order in which you’ll discuss them.

For shorter papers, your outline can just identify the focus of each paragraph; for longer papers, you might want to divide it into sections with headings.

There are a few different approaches you can take to help you structure your synthesis.

If your sources cover a broad time period, and you found patterns in how researchers approached the topic over time, you can organize your discussion chronologically .

That doesn’t mean you just summarize each paper in chronological order; instead, you should group articles into time periods and identify what they have in common, as well as signalling important turning points or developments in the literature.

If the literature covers various different topics, you can organize it thematically .

That means that each paragraph or section focuses on a specific theme and explains how that theme is approached in the literature.

Source Used with Permission: The Chicago School

If you’re drawing on literature from various different fields or they use a wide variety of research methods, you can organize your sources methodologically .

That means grouping together studies based on the type of research they did and discussing the findings that emerged from each method.

If your topic involves a debate between different schools of thought, you can organize it theoretically .

That means comparing the different theories that have been developed and grouping together papers based on the position or perspective they take on the topic, as well as evaluating which arguments are most convincing.

Step 3: Write paragraphs with topic sentences

What sets a synthesis apart from a summary is that it combines various sources. The easiest way to think about this is that each paragraph should discuss a few different sources, and you should be able to condense the overall point of the paragraph into one sentence.

This is called a topic sentence , and it usually appears at the start of the paragraph. The topic sentence signals what the whole paragraph is about; every sentence in the paragraph should be clearly related to it.

A topic sentence can be a simple summary of the paragraph’s content:

“Early research on [x] focused heavily on [y].”

For an effective synthesis, you can use topic sentences to link back to the previous paragraph, highlighting a point of debate or critique:

“Several scholars have pointed out the flaws in this approach.” “While recent research has attempted to address the problem, many of these studies have methodological flaws that limit their validity.”

By using topic sentences, you can ensure that your paragraphs are coherent and clearly show the connections between the articles you are discussing.

As you write your paragraphs, avoid quoting directly from sources: use your own words to explain the commonalities and differences that you found in the literature.

Don’t try to cover every single point from every single source – the key to synthesizing is to extract the most important and relevant information and combine it to give your reader an overall picture of the state of knowledge on your topic.

Step 4: Revise, edit and proofread

Like any other piece of academic writing, synthesizing literature doesn’t happen all in one go – it involves redrafting, revising, editing and proofreading your work.

Checklist for Synthesis

•   Do I introduce the paragraph with a clear, focused topic sentence?
•   Do I discuss more than one source in the paragraph?
•   Do I mention only the most relevant findings, rather than describing every part of the studies?
•   Do I discuss the similarities or differences between the sources, rather than summarizing each source in turn?
•   Do I put the findings or arguments of the sources in my own words?
•   Is the paragraph organized around a single idea?
•   Is the paragraph directly relevant to my research question or topic?
•   Is there a logical transition from this paragraph to the next one?

Further Information

How to Synthesise: a Step-by-Step Approach

Help…I”ve Been Asked to Synthesize!

Learn how to Synthesise (combine information from sources)

How to write a Psychology Essay

Literature Reviews

• Introduction
• Tutorials and resources
• Step 1: Literature search
• Step 2: Analysis, synthesis, critique
• Step 3: Writing the review

If you need any assistance, please contact the library staff at the Georgia Tech Library Help website . 

Analysis, synthesis, critique

Literature reviews build a story. You are telling the story about what you are researching. Therefore, a literature review is a handy way to show that you know what you are talking about. To do this, here are a few important skills you will need.

Skill #1: Analysis

Analysis means that you have carefully read a wide range of the literature on your topic and have understood the main themes, and identified how the literature relates to your own topic. Carefully read and analyze the articles you find in your search, and take notes. Notice the main point of the article, the methodologies used, what conclusions are reached, and what the main themes are. Most bibliographic management tools have capability to keep notes on each article you find, tag them with keywords, and organize into groups.

Skill #2: Synthesis

After you’ve read the literature, you will start to see some themes and categories emerge, some research trends to emerge, to see where scholars agree or disagree, and how works in your chosen field or discipline are related. One way to keep track of this is by using a Synthesis Matrix .

Skill #3: Critique

As you are writing your literature review, you will want to apply a critical eye to the literature you have evaluated and synthesized. Consider the strong arguments you will make contrasted with the potential gaps in previous research. The words that you choose to report your critiques of the literature will be non-neutral. For instance, using a word like “attempted” suggests that a researcher tried something but was not successful. For example: 

There were some attempts by Smith (2012) and Jones (2013) to integrate a new methodology in this process.

On the other hand, using a word like “proved” or a phrase like “produced results” evokes a more positive argument. For example:

The new methodologies employed by Blake (2014) produced results that provided further evidence of X.

In your critique, you can point out where you believe there is room for more coverage in a topic, or further exploration in in a sub-topic.

Need more help?

If you are looking for more detailed guidance about writing your dissertation, please contact the folks in the Georgia Tech Communication Center .

• << Previous: Step 1: Literature search
• Next: Step 3: Writing the review >>
• Last Updated: Apr 2, 2024 11:21 AM
• URL: https://libguides.library.gatech.edu/litreview

Reading & Writing Purposes

Reading & writing to synthesize, synthesis defined.

The concept of a “coherent whole” is essential to synthesis. When you synthesize in writing, you examine different types of information (ideas, examples, statistics, etc., from different sources) and different themes (perspectives and concepts) from different sources with the purpose of blending them together to help explain one main idea. So you have to look for relationships 1) among the sources’ themes and 2) between these themes and your own ideas in order to blend all of the pieces to make a coherent whole.

The concept of a “coherent whole” is important in terms of language, too. Once you examine content and choose the parts to synthesize, you need to express those parts in your own language in order to create a coherent whole in terms of writing style.

Synthesis is like combining different ingredients to make a stew. If you choose and combine carefully, with the end result (supporting your main idea) in mind, the ingredients will be both separate and well-blended, with all ingredients contributing as they should to the final taste.

View the following video for a basic definition of, and introduction to, the concept of synthesis.

As stated in the video, synthesis means combining similar information to create something new.  Reading and writing to synthesize means that you read information from many sources relating to a particular topic, question, insight, or assertion.  You extract appropriate pieces of information from each source, information that relates to your insight in some way (supporting it, negating it, offering additional detail).  You react to those pieces of information and relate them to your insight, to create something new–your own reasoned argument.

One standard example of reading and writing to synthesize is a research paper–a basic assignment in many college courses.  Skills that you develop in researching and synthesizing information also transfer to writing a business report or proposal. When you research a topic, you find information from many different sources which informs your personal thoughts and assertion about that topic.  However, reading and writing to synthesize involves more than just finding information and inserting it into an essay, report, or proposal.  You use the information you find to help create and support your own, unique thoughts.

Example of Synthesis in an Academic Setting

A research paper is the classic example of synthesis in an academic setting. You may be assigned to write a research paper in a sociology course, for example.  You may have read a number of selections dealing with different cultures, and the assignment asks you to synthesize information from these articles along with information from at least four other sources, to support your unique thesis. You start with a main idea in order to start the synthesis. You might create the following main idea: People within a culture have to both assimilate and adapt to their cultural and physical environments in order to thrive . You then might combine appropriate parts from different reading selections:

• definition and examples of assimilation from a chapter in a sociology textbook
• examples from researched articles on assimilation, cultural adaptation
• examples from interviews with people who have assimilated

Your research paper would blend themes from all of these sources to support your original insight and assertion (thesis) about assimilation and adaptation.

Example of  Synthesis in a Business Setting

After receiving more than ten different requests for flex time over the last year, you’ve decided that it makes sense to institute flexible hours for the fifty workers you supervise in your department.  You research a number of other businesses and examples of companies moving to flex time, quote or summarize those, and put them all into a document, which you send to your boss.  Your request is denied, because while your boss understood that flex time worked in other companies, she could not relate your research to the actual situation in your department. If you had offered your own analysis of how different companies’ strategies would benefit your own department, the outcome might have been different and your proposal approved.  It’s worth saying again: it’s important to blend the information you find with your own purpose, whether that is a proposal at work or an essay designed to offer your own, unique thoughts, supported by research.

Reading to Synthesize

Synthesis builds upon analysis.  You need to be able to read and analyze the quality of a text in order to decide whether you want to bring that text into the conversation. However, reading to synthesize moves in almost an opposite direction from analysis.  As you analyze, you break the text down into its parts in order to evaluate the text.  Analysis is like taking a puzzle apart and examining each piece, or analyzing a cake to find out what the ingredients are and how they work together.

On the other hand, as you read with the purpose of synthesizing, you search for thoughts about the same focused topic, thoughts which can be similar or different, in order to get a picture of the whole ongoing conversation about that topic. Then you decide if you agree or disagree with those thoughts–you join the conversation or discourse. Synthesis is like examining puzzle pieces with the purpose of putting the whole picture together, or baking a cake with ingredients that complement each other.

The process of reading to synthesize, in itself, blends or synthesizes many reading skills, which may include the following:

• skimming texts
• preview questions and answers
• reading for main idea (which may involve annotating, note taking, and more)
• summarizing
• analyzing the quality of the texts
• applying chosen texts to your insight
• reacting to the ideas in the texts

The main thing to remember as you read with the purpose of synthesizing is that your task is to find relationships among ideas.  Reading to synthesize does not merely consist of finding appropriate quotations and plugging them into an essay; instead, ideas from multiple texts need to be considered thoughtfully and linked with your own insights, reactions, and commentary.

Use an Idea Matrix to Synthesize Ideas

A idea matrix supports reading to synthesize, especially if you are reading multiple texts about a topic.  An idea matrix is a table that helps you identify and organize ideas from those texts according to their themes. It allows you to compare and contrast different insights about those themes. An idea matrix is a useful graphic, since one source may include ideas about many different themes.

Here’s one example of an idea matrix which synthesizes information from multiple sources around a specific focus.

Focus of Reading: Lessons Learned from the 1918 flu pandemic

To create an idea matrix, identify a topic around which your texts converge and state it clearly above the matrix. When you identify this focus, make sure it’s not too broad (e.g., pandemics – you’d have thousands of texts to read) or too narrow (e.g., number of U.S. deaths from the 1918 flu – you’d just need to consult one valid text for that information). The focus should be something that is part of a conversation happening among a manageable number of texts (e.g., lessons learned from the 1918 flu ).

The text column lists each source’s exact name.  It should also include the author, publication information for an eventual bibliography, url, and any other important identifying information.

The themes emerge from the sources you’ve read. You may choose to note them as paraphrases, summaries, and/or quotations.

Link to additional examples of idea matrices about different themes:

• Anxiety in Graduate Students from Ashford University’s Writing Center
• Thesis that makes an assertion about Democratic and Coaching Styles of Leadership

An idea matrix for reading can help you synthesize information from many texts, identify idea relationships within that information, and eventually help you formulate your own thoughts to add to the conversation.

Writing to Synthesize

Writing to synthesize involves taking those related ideas that you’ve extracted from multiple texts and incorporating them into a research paper, report, or proposal that’s structured around your own main insight, assertion, or thesis.

Don’t Do This:

In writing a document that synthesizes ideas from multiple texts, it’s the impulse of many students to summarize or paraphrase a paragraph or a whole article, insert the summary, and then move on to the next text and summary.  That’s not good practice, since it doesn’t link ideas in terms of their themes, and doesn’t focus on how those themes relate to your own ideas.

Instead , Do This:

Work from the idea matrix you built as you read different texts.  For a college research paper, turn your topic or focus statement at the top of the matrix into a thesis sentence , a sentence that makes an assertion or provides an insight offering your own informed views on the topic.  Offering your own perspective is key.  You’ll then structure the body of your essay using the groups of supporting ideas/themes you noted in the idea matrix, in whatever order you choose.  Each group gets its own topic sentence and unit of support.  And each group of supporting ideas includes your own thoughts, applications, and reactions to the texts included in that group.  One general rule is that you always structure “writing to synthesize” around your own ideas, and that you always offer your own ideas about information from each text used – that’s your contribution to the conversation.

The following video offers a clear discussion and examples to reinforce the concept of writing to synthesize.

This video about writing to synthesize researched sources incorporates information about using an idea matrix:

They Say/I Say Approach to Synthesis

Another way to think of synthesis is as though you’re joining a conversation; you’re listening to (reading) different texts, and bringing your own insight and experience to that conversation.  One good way of understanding synthesis in terms of reading and writing is to consider the “They Say/I Say” format created by Gerald Graff and Cathy Birkenstein, which helps you synthesize your own ideas with the text’s. The following video, although somewhat lengthy, provides a summary of Graff’s and Birkenstein’s text.

The video below explains how to write a synthesis applying the They Say/I Say framework. There’s a useful extended example showing how a writer incorporated appropriate pieces of different texts into an essay. (Note – don’t get too caught up in the MLA/APA format details at this point – focus on the concept of synthesis and how to synthesize texts in an essay.)

Summary: Reading & Writing to Synthesize

• Synthesis means that you’re coordinating different pieces (themes, ideas, types of information) to create a coherent and new whole.
• All of the pieces you synthesize in a piece of writing for college need to focus around your own insight/assertion/ thesis.
• Often, a research essay assignment will expect that you synthesize information to address and offer your unique insight about a debatable issue.
• Synthesis itself involves blending many reading and thinking skills, such as skimming, annotating, summarizing, and analyzing, among others.
• There are different approaches to synthesis that may help you read and write about multiple texts.  They Say/I Say helps you blend your own ideas with ideas in other texts.  An Idea Matrix helps you organize ideas from multiple texts around the focus of your own main idea.
• Reading & Writing to Synthesize. Authored by : Susan Oaks. Project : Introduction to College Reading & Writing. License : CC BY-NC: Attribution-NonCommercial
• video Synthesizing Information. Provided by : GCFLearnFree.org. Located at : https://www.youtube.com/watch?v=7dEGoJdb6O0 . License : Other . License Terms : YouTube video
• video They Say/I Say: The Moves that Matter in Academic Writing. Authored by : jilljitsu81. Located at : https://www.youtube.com/watch?v=2s8SWS-SZDw . License : Other . License Terms : YouTube video
• image of man's face on a puzzle, with one piece askew. Authored by : Richard Reid. Provided by : Pixabay. Located at : https://pixabay.com/photos/puzzle-jigsaw-jigsaw-puzzle-1487340/ . License : CC0: No Rights Reserved
• video Strategies for Synthesis. Authored by : Mary Lourdes Silva. Located at : https://www.youtube.com/watch?v=c7HtCHtQ9w0 . License : Other . License Terms : YouTube video
• video Synthesis: Definition and Examples. Provided by : WUWritingCenter. Located at : https://www.youtube.com/watch?v=sLhkalJe7Zc . License : Other . License Terms : YouTube video
• video Research Synthesis. Provided by : USU Libraries - Utah State University. Located at : https://www.youtube.com/watch?v=ObK6J7vGnw8 . License : Other . License Terms : YouTube video
• image of woman with laptop and pie chart showing relationship of parts to whole. Authored by : Tumisu. Provided by : p. Located at : https://pixabay.com/photos/analytics-charts-business-woman-3265840/ . License : CC0: No Rights Reserved

Privacy Policy

Literature Review How To

• Things To Consider
• Synthesizing Sources
• Video Tutorials
• Books On Literature Reviews

What is Synthesis

What is Synthesis? Synthesis writing is a form of analysis related to comparison and contrast, classification and division. On a basic level, synthesis requires the writer to pull together two or more summaries, looking for themes in each text. In synthesis, you search for the links between various materials in order to make your point. Most advanced academic writing, including literature reviews, relies heavily on synthesis. (Temple University Writing Center)  

How To Synthesize Sources in a Literature Review

Literature reviews synthesize large amounts of information and present it in a coherent, organized fashion. In a literature review you will be combining material from several texts to create a new text – your literature review.

You will use common points among the sources you have gathered to help you synthesize the material. This will help ensure that your literature review is organized by subtopic, not by source. This means various authors' names can appear and reappear throughout the literature review, and each paragraph will mention several different authors. 

When you shift from writing summaries of the content of a source to synthesizing content from sources, there is a number things you must keep in mind: 

• Look for specific connections and or links between your sources and how those relate to your thesis or question.
• When writing and organizing your literature review be aware that your readers need to understand how and why the information from the different sources overlap.
• Organize your literature review by the themes you find within your sources or themes you have identified. 
• << Previous: Things To Consider
• Next: Video Tutorials >>
• Last Updated: Nov 30, 2018 4:51 PM
• URL: https://libguides.csun.edu/literature-review

Report ADA Problems with Library Services and Resources

Literature Reviews

• 5. Synthesize your findings
• Getting started
• Types of reviews
• 1. Define your research question
• 2. Plan your search
• 3. Search the literature
• 4. Organize your results

How to synthesize

Approaches to synthesis.

• 6. Write the review
• Artificial intelligence (AI) tools
• Thompson Writing Studio This link opens in a new window
• Need to write a systematic review? This link opens in a new window

Contact a Librarian

Ask a Librarian

In the synthesis step of a literature review, researchers analyze and integrate information from selected sources to identify patterns and themes. This involves critically evaluating findings, recognizing commonalities, and constructing a cohesive narrative that contributes to the understanding of the research topic.

Here are some examples of how to approach synthesizing the literature:

💡 By themes or concepts

🕘 Historically or chronologically

📊 By methodology

These organizational approaches can also be used when writing your review. It can be beneficial to begin organizing your references by these approaches in your citation manager by using folders, groups, or collections.

Create a synthesis matrix

A synthesis matrix allows you to visually organize your literature.

Topic: ______________________________________________

Topic: Chemical exposure to workers in nail salons

• << Previous: 4. Organize your results
• Next: 6. Write the review >>
• Last Updated: Aug 12, 2024 11:35 AM
• URL: https://guides.library.duke.edu/litreviews

Services for...

• Faculty & Instructors
• Graduate Students
• Undergraduate Students
• International Students
• Patrons with Disabilities

• Harmful Language Statement
• Re-use & Attribution / Privacy
• Support the Libraries

We apologize for any inconvenience as we update our site to a new look.

• Walden University
• Faculty Portal

Using Evidence: Synthesis

Synthesis video playlist.

Note that these videos were created while APA 6 was the style guide edition in use. There may be some examples of writing that have not been updated to APA 7 guidelines.

Basics of Synthesis

As you incorporate published writing into your own writing, you should aim for synthesis of the material.

Synthesizing requires critical reading and thinking in order to compare different material, highlighting similarities, differences, and connections. When writers synthesize successfully, they present new ideas based on interpretations of other evidence or arguments. You can also think of synthesis as an extension of—or a more complicated form of—analysis. One main difference is that synthesis involves multiple sources, while analysis often focuses on one source.

Conceptually, it can be helpful to think about synthesis existing at both the local (or paragraph) level and the global (or paper) level.

Local Synthesis

Local synthesis occurs at the paragraph level when writers connect individual pieces of evidence from multiple sources to support a paragraph’s main idea and advance a paper’s thesis statement. A common example in academic writing is a scholarly paragraph that includes a main idea, evidence from multiple sources, and analysis of those multiple sources together.

Global Synthesis

Global synthesis occurs at the paper (or, sometimes, section) level when writers connect ideas across paragraphs or sections to create a new narrative whole. A literature review , which can either stand alone or be a section/chapter within a capstone, is a common example of a place where global synthesis is necessary. However, in almost all academic writing, global synthesis is created by and sometimes referred to as good cohesion and flow.

Synthesis in Literature Reviews

While any types of scholarly writing can include synthesis, it is most often discussed in the context of literature reviews. Visit our literature review pages for more information about synthesis in literature reviews.

Related Webinars

Didn't find what you need? Email us at [email protected] .

• Previous Page: Analysis
• Next Page: Citing Sources Properly
• Office of Student Disability Services

Walden Resources

Departments.

• Academic Residencies
• Academic Skills
• Career Planning and Development
• Customer Care Team
• Field Experience
• Military Services
• Student Success Advising
• Writing Skills

Centers and Offices

• Center for Social Change
• Office of Academic Support and Instructional Services
• Office of Degree Acceleration
• Office of Research and Doctoral Services
• Office of Student Affairs

Student Resources

• Doctoral Writing Assessment
• Form & Style Review
• Quick Answers
• ScholarWorks
• SKIL Courses and Workshops
• Walden Bookstore
• Walden Catalog & Student Handbook
• Student Safety/Title IX
• Legal & Consumer Information
• Website Terms and Conditions
• Cookie Policy
• Accessibility
• Accreditation
• State Authorization
• Net Price Calculator
• Contact Walden

Walden University is a member of Adtalem Global Education, Inc. www.adtalem.com Walden University is certified to operate by SCHEV © 2024 Walden University LLC. All rights reserved.

• Research Guides

Literature Review: A Self-Guided Tutorial

• 6. Synthesize
• Literature Reviews: A Recap
• Peer Review
• Reading the Literature
• Using Concept Maps
• Developing Research Questions
• Considering Strong Opinions
• 2. Review discipline styles
• Super Searching
• Finding the Full Text
• Citation Searching This link opens in a new window
• When to stop searching
• Citation Management
• Annotating Articles Tip
• 5. Critically analyze and evaluate
• How to Review the Literature
• Using a Synthesis Matrix
• 7. Write literature review

You can sort the literature in various ways, for example:

• << Previous: 5. Critically analyze and evaluate
• Next: How to Review the Literature >>
• Last Updated: Jul 30, 2024 4:12 PM
• URL: https://libguides.williams.edu/literature-review

Want to create or adapt books like this? Learn more about how Pressbooks supports open publishing practices.

Chapter 7: Synthesizing Sources

Learning objectives.

At the conclusion of this chapter, you will be able to:

• synthesize key sources connecting them with the research question and topic area.

7.1 Overview of synthesizing

7.1.1 putting the pieces together.

Combining separate elements into a whole is the dictionary definition of synthesis.  It is a way to make connections among and between numerous and varied source materials.  A literature review is not an annotated bibliography, organized by title, author, or date of publication.  Rather, it is grouped by topic to create a whole view of the literature relevant to your research question.

Your synthesis must demonstrate a critical analysis of the papers you collected as well as your ability to integrate the results of your analysis into your own literature review.  Each paper collected should be critically evaluated and weighed for “adequacy, appropriateness, and thoroughness” ( Garrard, 2017 ) before inclusion in your own review.  Papers that do not meet this criteria likely should not be included in your literature review.

Begin the synthesis process by creating a grid, table, or an outline where you will summarize, using common themes you have identified and the sources you have found. The summary grid or outline will help you compare and contrast the themes so you can see the relationships among them as well as areas where you may need to do more searching. Whichever method you choose, this type of organization will help you to both understand the information you find and structure the writing of your review.  Remember, although “the means of summarizing can vary, the key at this point is to make sure you understand what you’ve found and how it relates to your topic and research question” ( Bennard et al., 2014 ).

As you read through the material you gather, look for common themes as they may provide the structure for your literature review.  And, remember, research is an iterative process: it is not unusual to go back and search information sources for more material.

At one extreme, if you are claiming, ‘There are no prior publications on this topic,’ it is more likely that you have not found them yet and may need to broaden your search.  At another extreme, writing a complete literature review can be difficult with a well-trod topic.  Do not cite it all; instead cite what is most relevant.  If that still leaves too much to include, be sure to reference influential sources…as well as high-quality work that clearly connects to the points you make. ( Klingner, Scanlon, & Pressley, 2005 ).

7.2 Creating a summary table

Literature reviews can be organized sequentially or by topic, theme, method, results, theory, or argument.  It’s important to develop categories that are meaningful and relevant to your research question.  Take detailed notes on each article and use a consistent format for capturing all the information each article provides.  These notes and the summary table can be done manually, using note cards.  However, given the amount of information you will be recording, an electronic file created in a word processing or spreadsheet is more manageable. Examples of fields you may want to capture in your notes include:

• Authors’ names
• Article title
• Publication year
• Main purpose of the article
• Methodology or research design
• Participants
• Measurement
• Conclusions

  Other fields that will be useful when you begin to synthesize the sum total of your research:

• Specific details of the article or research that are especially relevant to your study
• Key terms and definitions
• Strengths or weaknesses in research design
• Relationships to other studies
• Possible gaps in the research or literature (for example, many research articles conclude with the statement “more research is needed in this area”)
• Finally, note how closely each article relates to your topic.  You may want to rank these as high, medium, or low relevance.  For papers that you decide not to include, you may want to note your reasoning for exclusion, such as ‘small sample size’, ‘local case study,’ or ‘lacks evidence to support assertion.’

This short video demonstrates how a nursing researcher might create a summary table.

7.2.1 Creating a Summary Table

  Summary tables can be organized by author or by theme, for example:

For a summary table template, see http://blogs.monm.edu/writingatmc/files/2013/04/Synthesis-Matrix-Template.pdf

7.3 Creating a summary outline

An alternate way to organize your articles for synthesis it to create an outline. After you have collected the articles you intend to use (and have put aside the ones you won’t be using), it’s time to identify the conclusions that can be drawn from the articles as a group.

  Based on your review of the collected articles, group them by categories.  You may wish to further organize them by topic and then chronologically or alphabetically by author.  For each topic or subtopic you identified during your critical analysis of the paper, determine what those papers have in common.  Likewise, determine which ones in the group differ.  If there are contradictory findings, you may be able to identify methodological or theoretical differences that could account for the contradiction (for example, differences in population demographics).  Determine what general conclusions you can report about the topic or subtopic as the entire group of studies relate to it.  For example, you may have several studies that agree on outcome, such as ‘hands on learning is best for science in elementary school’ or that ‘continuing education is the best method for updating nursing certification.’ In that case, you may want to organize by methodology used in the studies rather than by outcome.

Organize your outline in a logical order and prepare to write the first draft of your literature review.  That order might be from broad to more specific, or it may be sequential or chronological, going from foundational literature to more current.  Remember, “an effective literature review need not denote the entire historical record, but rather establish the raison d’etre for the current study and in doing so cite that literature distinctly pertinent for theoretical, methodological, or empirical reasons.” ( Milardo, 2015, p. 22 ).

As you organize the summarized documents into a logical structure, you are also appraising and synthesizing complex information from multiple sources.  Your literature review is the result of your research that synthesizes new and old information and creates new knowledge.

7.4 Additional resources:

Literature Reviews: Using a Matrix to Organize Research / Saint Mary’s University of Minnesota

Literature Review: Synthesizing Multiple Sources / Indiana University

Writing a Literature Review and Using a Synthesis Matrix / Florida International University

 Sample Literature Reviews Grid / Complied by Lindsay Roberts

Select three or four articles on a single topic of interest to you. Then enter them into an outline or table in the categories you feel are important to a research question. Try both the grid and the outline if you can to see which suits you better. The attached grid contains the fields suggested in the video .

Literature Review Table  

Test Yourself

• Select two articles from your own summary table or outline and write a paragraph explaining how and why the sources relate to each other and your review of the literature.
• In your literature review, under what topic or subtopic will you place the paragraph you just wrote?

Image attribution

Literature Reviews for Education and Nursing Graduate Students Copyright © by Linda Frederiksen is licensed under a Creative Commons Attribution 4.0 International License , except where otherwise noted.

Share This Book

Have a language expert improve your writing

Run a free plagiarism check in 10 minutes, generate accurate citations for free.

• Knowledge Base
• Working with sources
• Synthesizing Sources | Examples & Synthesis Matrix

Synthesizing Sources | Examples & Synthesis Matrix

Published on July 4, 2022 by Eoghan Ryan . Revised on May 31, 2023.

Synthesizing sources involves combining the work of other scholars to provide new insights. It’s a way of integrating sources that helps situate your work in relation to existing research.

Synthesizing sources involves more than just summarizing . You must emphasize how each source contributes to current debates, highlighting points of (dis)agreement and putting the sources in conversation with each other.

You might synthesize sources in your literature review to give an overview of the field or throughout your research paper when you want to position your work in relation to existing research.

Table of contents

Example of synthesizing sources, how to synthesize sources, synthesis matrix, other interesting articles, frequently asked questions about synthesizing sources.

Let’s take a look at an example where sources are not properly synthesized, and then see what can be done to improve it.

This paragraph provides no context for the information and does not explain the relationships between the sources described. It also doesn’t analyze the sources or consider gaps in existing research.

Research on the barriers to second language acquisition has primarily focused on age-related difficulties. Building on Lenneberg’s (1967) theory of a critical period of language acquisition, Johnson and Newport (1988) tested Lenneberg’s idea in the context of second language acquisition. Their research seemed to confirm that young learners acquire a second language more easily than older learners. Recent research has considered other potential barriers to language acquisition. Schepens, van Hout, and van der Slik (2022) have revealed that the difficulties of learning a second language at an older age are compounded by dissimilarity between a learner’s first language and the language they aim to acquire. Further research needs to be carried out to determine whether the difficulty faced by adult monoglot speakers is also faced by adults who acquired a second language during the “critical period.”

Prevent plagiarism. Run a free check.

To synthesize sources, group them around a specific theme or point of contention.

As you read sources, ask:

• What questions or ideas recur? Do the sources focus on the same points, or do they look at the issue from different angles?
• How does each source relate to others? Does it confirm or challenge the findings of past research?
• Where do the sources agree or disagree?

Once you have a clear idea of how each source positions itself, put them in conversation with each other. Analyze and interpret their points of agreement and disagreement. This displays the relationships among sources and creates a sense of coherence.

Consider both implicit and explicit (dis)agreements. Whether one source specifically refutes another or just happens to come to different conclusions without specifically engaging with it, you can mention it in your synthesis either way.

Synthesize your sources using:

• Topic sentences to introduce the relationship between the sources
• Signal phrases to attribute ideas to their authors
• Transition words and phrases to link together different ideas

To more easily determine the similarities and dissimilarities among your sources, you can create a visual representation of their main ideas with a synthesis matrix . This is a tool that you can use when researching and writing your paper, not a part of the final text.

In a synthesis matrix, each column represents one source, and each row represents a common theme or idea among the sources. In the relevant rows, fill in a short summary of how the source treats each theme or topic.

This helps you to clearly see the commonalities or points of divergence among your sources. You can then synthesize these sources in your work by explaining their relationship.

If you want to know more about ChatGPT, AI tools , citation , and plagiarism , make sure to check out some of our other articles with explanations and examples.

• ChatGPT vs human editor
• ChatGPT citations
• Is ChatGPT trustworthy?
• Using ChatGPT for your studies
• What is ChatGPT?
• Chicago style
• Paraphrasing

 Plagiarism

• Types of plagiarism
• Self-plagiarism
• Avoiding plagiarism
• Academic integrity
• Consequences of plagiarism
• Common knowledge

Don't submit your assignments before you do this

The academic proofreading tool has been trained on 1000s of academic texts. Making it the most accurate and reliable proofreading tool for students. Free citation check included.

Try for free

Synthesizing sources means comparing and contrasting the work of other scholars to provide new insights.

It involves analyzing and interpreting the points of agreement and disagreement among sources.

You might synthesize sources in your literature review to give an overview of the field of research or throughout your paper when you want to contribute something new to existing research.

A literature review is a survey of scholarly sources (such as books, journal articles, and theses) related to a specific topic or research question .

It is often written as part of a thesis, dissertation , or research paper , in order to situate your work in relation to existing knowledge.

Topic sentences help keep your writing focused and guide the reader through your argument.

In an essay or paper , each paragraph should focus on a single idea. By stating the main idea in the topic sentence, you clarify what the paragraph is about for both yourself and your reader.

At college level, you must properly cite your sources in all essays , research papers , and other academic texts (except exams and in-class exercises).

Add a citation whenever you quote , paraphrase , or summarize information or ideas from a source. You should also give full source details in a bibliography or reference list at the end of your text.

The exact format of your citations depends on which citation style you are instructed to use. The most common styles are APA , MLA , and Chicago .

Cite this Scribbr article

If you want to cite this source, you can copy and paste the citation or click the “Cite this Scribbr article” button to automatically add the citation to our free Citation Generator.

Ryan, E. (2023, May 31). Synthesizing Sources | Examples & Synthesis Matrix. Scribbr. Retrieved August 12, 2024, from https://www.scribbr.com/working-with-sources/synthesizing-sources/

Is this article helpful?

Eoghan Ryan

Other students also liked, signal phrases | definition, explanation & examples, how to write a literature review | guide, examples, & templates, how to find sources | scholarly articles, books, etc., get unlimited documents corrected.

✔ Free APA citation check included ✔ Unlimited document corrections ✔ Specialized in correcting academic texts

Purdue Online Writing Lab Purdue OWL® College of Liberal Arts

Synthesizing Sources

Welcome to the Purdue OWL

This page is brought to you by the OWL at Purdue University. When printing this page, you must include the entire legal notice.

Copyright ©1995-2018 by The Writing Lab & The OWL at Purdue and Purdue University. All rights reserved. This material may not be published, reproduced, broadcast, rewritten, or redistributed without permission. Use of this site constitutes acceptance of our terms and conditions of fair use.

When you look for areas where your sources agree or disagree and try to draw broader conclusions about your topic based on what your sources say, you are engaging in synthesis. Writing a research paper usually requires synthesizing the available sources in order to provide new insight or a different perspective into your particular topic (as opposed to simply restating what each individual source says about your research topic).

Note that synthesizing is not the same as summarizing.  

• A summary restates the information in one or more sources without providing new insight or reaching new conclusions.
• A synthesis draws on multiple sources to reach a broader conclusion.

There are two types of syntheses: explanatory syntheses and argumentative syntheses . Explanatory syntheses seek to bring sources together to explain a perspective and the reasoning behind it. Argumentative syntheses seek to bring sources together to make an argument. Both types of synthesis involve looking for relationships between sources and drawing conclusions.

In order to successfully synthesize your sources, you might begin by grouping your sources by topic and looking for connections. For example, if you were researching the pros and cons of encouraging healthy eating in children, you would want to separate your sources to find which ones agree with each other and which ones disagree.

After you have a good idea of what your sources are saying, you want to construct your body paragraphs in a way that acknowledges different sources and highlights where you can draw new conclusions.

As you continue synthesizing, here are a few points to remember:

• Don’t force a relationship between sources if there isn’t one. Not all of your sources have to complement one another.
• Do your best to highlight the relationships between sources in very clear ways.
• Don’t ignore any outliers in your research. It’s important to take note of every perspective (even those that disagree with your broader conclusions).

Example Syntheses

Below are two examples of synthesis: one where synthesis is NOT utilized well, and one where it is.

Parents are always trying to find ways to encourage healthy eating in their children. Elena Pearl Ben-Joseph, a doctor and writer for KidsHealth , encourages parents to be role models for their children by not dieting or vocalizing concerns about their body image. The first popular diet began in 1863. William Banting named it the “Banting” diet after himself, and it consisted of eating fruits, vegetables, meat, and dry wine. Despite the fact that dieting has been around for over a hundred and fifty years, parents should not diet because it hinders children’s understanding of healthy eating.

In this sample paragraph, the paragraph begins with one idea then drastically shifts to another. Rather than comparing the sources, the author simply describes their content. This leads the paragraph to veer in an different direction at the end, and it prevents the paragraph from expressing any strong arguments or conclusions.

An example of a stronger synthesis can be found below.

Parents are always trying to find ways to encourage healthy eating in their children. Different scientists and educators have different strategies for promoting a well-rounded diet while still encouraging body positivity in children. David R. Just and Joseph Price suggest in their article “Using Incentives to Encourage Healthy Eating in Children” that children are more likely to eat fruits and vegetables if they are given a reward (855-856). Similarly, Elena Pearl Ben-Joseph, a doctor and writer for Kids Health , encourages parents to be role models for their children. She states that “parents who are always dieting or complaining about their bodies may foster these same negative feelings in their kids. Try to keep a positive approach about food” (Ben-Joseph). Martha J. Nepper and Weiwen Chai support Ben-Joseph’s suggestions in their article “Parents’ Barriers and Strategies to Promote Healthy Eating among School-age Children.” Nepper and Chai note, “Parents felt that patience, consistency, educating themselves on proper nutrition, and having more healthy foods available in the home were important strategies when developing healthy eating habits for their children.” By following some of these ideas, parents can help their children develop healthy eating habits while still maintaining body positivity.

In this example, the author puts different sources in conversation with one another. Rather than simply describing the content of the sources in order, the author uses transitions (like "similarly") and makes the relationship between the sources evident.

• Literary Terms
• Synesthesia
• Definition & Examples
• When & How to Use Synesthesia

I. What is Synesthesia?

In literature, synesthesia (sin-uh s-thee-zhee-uh), (also spelled synaesthesia) is a rhetorical device that describes or associates one sense in terms of another, most often in the form of a simile. Sensations of touch, taste, see, hear, and smell are expressed as being intertwined or having a connection between them. The term is derived from the neurological condition of the same name, where some people experience an actual link between their senses, where one sense stimulates another—for instance, they may feel like they hear a color, smell a shape, or taste a texture. A person that experiences synesthesia is referred to as a synesthete . As a literary technique, synesthesia reflects this condition.

Synesthesia’s presence in literature is usually through a person or narrator that is characterized as being synesthete, which allows authors to uniquely express that character’s sensations and experiences. But, the feeling of synesthesia isn’t something that all authors are familiar with—on the contrary, it is more rare than common. So, it is actually a unique literary device that we don’t see in everyday writing.

II. Example of Synesthesia

The following sentences provide several examples of synesthesia:

• The bright field of wildflowers smelled like purple, magenta, yellow, white and green.
• The stars sounded like piles of diamonds.
• Her voice was as smooth as pudding.
• The scent of smoke burned my skin.
• The blueberry tasted round in my mouth, the same flavor as a circle.

III. Importance of Synesthesia

Synesthesia allows authors to deliver another level of description in literature. It challenges readers to think out of the box and reinterpret their senses as they know them. Most importantly, though, synesthesia is a unique device that very few authors employ, making it quite notable and distinctive when an author does use it.

IV. Examples of Synesthesia in Literature

The beloved children’s fantasy novel The Phantom Tollbooth is rich with descriptions that use synesthesia. The author Norton Juster is a synesthete, and he used his own sensory perceptions to inspire parts of the book, as you can see in the following passage from Chapter 10: A Colorful Symphony:

“I don’t hear any music,” said Milo. “That’s right,” said Alec; “you don’t listen to this concert—you watch it. Now, pay attention.” As the conductor waved his arms, he molded the air like handfuls of soft clay, and the musicians carefully followed his every direction. “What are they playing?” asked Tock, looking up inquisitively at Alec. “The sunset, of course. They play it every evening about this time.” “They do?” said Milo quizzically. “Naturally,” answered Alec; “and they also play morning, noon and night, when, of course, it’s morning, noon and night. Why, there wouldn’t be any color in the world unless they played it.”

Here, Juster uses synesthesia in the book’s fantasy world to express the idea of a connection between music and colors. Alec explains that the sunset they see every day is actually created by instruments that play colors instead of musical notes. He also tells Milo to “watch” the concert, rather than listen to it, because the instruments will create the colors of the sunset; and all of the colors in the world.

In Inferno of the epic poem The Divine Comedy, Dante uses synesthesia to emphasize a place’s harshness:

E’en such made me that beast withouten peace, Which, coming on against me by degrees Thrust me back thither where the sun is silent.

Here, Dante refers to a place “where the sun is silent.” Our perception of the sun is usually associated with our sense of sight (its brightness) and touch (its heat), but not with any sort of sound. By asserting that the sun is silent, Dante is highlighting the fact that it is absent from the place he is describing. His description has a greater impact than “the sun can’t be seen” or “there is no heat”—“silent” suggests a dark, lifeless, cold and colorless place that never sees the sun.

V. Examples of Synesthesia in Pop Culture

Synesthesia is a popular device in modern advertising, particularly in the food industry. Brands often relate the experience of eating or drinking their product to some other sensory experience—for instance, a brand of chewing gum may suggest that chewing their gum will make you feel a blast of icy cold air. The classic candy Skittles does this in the commercial below:

Skittles uses synesthesia as inspiration for their slogan “Taste the Rainbow.” As we know, a rainbow is an illusion in nature that we only experience through our sight. Skittles plays with the audience’s senses by tempting them to “taste the rainbow” rather than merely see it.

In the Pixar film Ratatouille, Remy is a rat with a very special talent for food. In the scene below, when Remy tastes food, he has an extraordinary sensory experience:

Here, Remy doesn’t just taste the flavors of the strawberries and the cheese. In fact, he doesn’t comment on the flavor at all—instead, each time he takes a bite he hears music and visualizes shapes and designs. When it comes to eating, Remy experiences synesthesia, which could be the secret to his skills.

VI. Conclusion

In conclusion, synesthesia is a unique rhetorical device not found in everyday writing and literature. It uses words to express a completely different form of sensory perception that forces audiences to step outside their normal understanding of taste, touch, sight, smell, and sound and imagine a relationship between them.

List of Terms

• Alliteration
• Amplification
• Anachronism
• Anthropomorphism
• Antonomasia
• APA Citation
• Aposiopesis
• Autobiography
• Bildungsroman
• Characterization
• Circumlocution
• Cliffhanger
• Comic Relief
• Connotation
• Deus ex machina
• Deuteragonist
• Doppelganger
• Double Entendre
• Dramatic irony
• Equivocation
• Extended Metaphor
• Figures of Speech
• Flash-forward
• Foreshadowing
• Intertextuality
• Juxtaposition
• Literary Device
• Malapropism
• Onomatopoeia
• Parallelism
• Pathetic Fallacy
• Personification
• Point of View
• Polysyndeton
• Protagonist
• Red Herring
• Rhetorical Device
• Rhetorical Question
• Science Fiction
• Self-Fulfilling Prophecy
• Turning Point
• Understatement
• Urban Legend
• Verisimilitude
• Essay Guide
• Cite This Website

Evidence Synthesis Service

• Starting a Review
• Meeting Request
• Intake Form
• Information for Students
• Other Library Resources

Relevant Guides

• Conducting a Literature Review by Ann Dyer Last Updated Aug 13, 2024 1960 views this year

Doing Diligence

The first step in any systematic review or other type of evidence synthesis project is to search the existing literature to identify what research, both primary and secondary, has already been conducted. As with any publication, your review will likely need to be original/novel in order to be of interest to editors and publications. In addition, duplicating a previously done study may not add new understandings to the body of evidence. Here are some questions for consideration:

• Has your research question already been answered?
• How recently has the existing secondary research been conducted/published?
• Does the existing secondary research need to be updated due to new original research that has been conducted after its publication?
• Is there existing secondary research that answers a different research question than the one you want to answer?
• How does your question, methodology, or timing differ from existing research?

All of these questions will help you identify  why  you would conduct this new study. It is disheartening (at best) to learn part way through an evidence synthesis project that the research has already been conducted.

Search Published Literature

Search for published studies that address your research question. This should be done in several different databases to ensure you have a solid sense of what has already been accomplished. It will also inform the way that you create your search strategy for this study, as you'll learn the types of words that are used to describe this research question, publications that have published these types of studies, and how the articles have been indexed within the databases. Below are a few databases that you might consider searching for health sciences publications.

• PubMed This link to PubMed is for those affiliated with WSU. PubMed comprises more than 30 million citations for biomedical literature from MEDLINE, life science journals and online books. Citations may include links to full-text content from PubMed Central and publisher web sites.
• EMBASE Embase is an abstract and Indexing (A & I) database covering over 8,500 journal titles, 30 million articles back to 1974, all disciplines of medicine and biomedical science, and includes substantial coverage of Allied Health subjects.
• CINAHL Complete (EBSCOHost) CINAHL Complete is the world's most comprehensive source of full-text for nursing & allied health journals, providing full text for more than 1,300 journals indexed in CINAHL.
• APA PsycInfo (ProQuest) This link opens in a new window An index with summaries of citations to articles in over 1,300 psychology research journals. Articles date from 1806 - present. Note: There are less than 146 records with publication dates prior to 1890. Updated weekly.

Search for Preregistrations

In addition to finding articles that have already been published, you will need to search registries to see if others are currently in the process of researching this topic/question, just as you would for clinical research. Here are a few repositories for you to search:

• Open Science Framework (OSF) Registries
• Cochrane Preregistrations
• Campbell Preregistrations

Identification of Review Type

While considering conducting a literature review, you should compare your draft research question to the different review types that can be used to explore the existing research. Some types, such as narrative reviews, do not consider the literature search as a formal methodology, while others such as Systematic Reviews view the literature search as a reproducible research methodology.

As a first step, search the literature for other published articles and studies that address the same or similar research question. The quantity, quality, and depth of existing research will be an important component in deciding on a review type.

Selection of the review type includes not only aspirations for what the review could accomplish, but also pragmatic limitations based on how much time the team has to devote to the project, how many team members are participating in the review, and deadlines for the review completion (such as the date of an upcoming conference). In addition, the breadth of the research question may result in a large number of search results; this should be considered in terms of the number of team members involved in the screening and abstraction of the included studies, as well as whether the research question should be narrowed or include more limitations/exclusion criteria in order to satisfy the practical limitations of the team.

Use the decision tree below from Cornell University to determine what type of review best suits your question/topic and available resources. The PDF is linked for you to view/download along with descriptions of the review types, with an image of the decision tree displayed on this page. To learn more about the different types, purposes, and methods of reviews, click the "Types of Reviews" link below the decision tree. 

Types of Reviews

• What Type of Review is Right For You? | Decision Tree

Reproduced from Grant, M. J. and Booth, A. (2009), A typology of reviews: an analysis of 14 review types and associated methodologies. Health Information & Libraries Journal, 26: 91–108. doi: 10.1111/j.1471-1842.2009.00848.x 

Develop a Searchable Question

When developing a searchable question, it helps to identify the key concepts of your research proposal. A clear and precise search question can be used to develop search terms during the literature searching process.

There are a number of frameworks available to use to help you break your question into its key concepts. Take a look at the frameworks below. 

• Evidence-Based Practice
• General Health
• Health Management

From BMJ Best Practice :

The PICO (Population, Intervention, Comparator and Outcomes) model captures the key elements and is a good strategy to provide answerable questions.

Population : who are the relevant patients or the target audience for the problem being addressed?      Example: In women with non-tubal infertility

Intervention : what intervention is being considered?     Example: …would intrauterine insemination…

Comparator : what is the main comparator to the intervention that you want to assess?      Example: …when compared with fallopian tube sperm perfusion…

Outcomes : what are the consequences of the interventions for the patient? Or what are the main outcomes of interest to the patient or decision maker?      Example: …lead to higher live birth rates with no increase in multiple pregnancy, miscarriage or ectopic pregnancy rates?

How to clarify a clinical question. (n.d.). BMJ Best Practice . Retrieved October 26, 2022, from https://bestpractice.bmj.com/info/us/toolkit/learn-ebm/how-to-clarify-a-clinical-question/

From "Formulating the Evidence Based Practice Question":

Setting : What is the context for the question? The research evidence should reflect the context or the research findings may not be transferable.

Perspective : Who are the users, potential users, or stakeholders of the service?

Intervention : What is being done for the users, potential users, or stakeholders?

Comparison : What are the alternatives? An alternative might maintain the status quo and change nothing.

Evaluation : What measurement will determine the intervention’s success? In other words, what is the result?

Davies, K. S. (2011). Formulating the Evidence Based Practice Question: A Review of the Frameworks. Evidence Based Library and Information Practice , 6 (2), Article 2. https://doi.org/10.18438/B8WS5N

From "How CLIP became ECLIPSE":

Expectation —what does the search requester want the information for (the original ‘I’s)? Client Group Location Impact:  what is the change in the service, if any, which is being looked for? What would constitute success? How is this being measured? Professionals Service:  for which service are you looking for information? For example, outpatient services, nurse-led clinics, intermediate care

Wildridge, V., & Bell, L. (2002). How CLIP became ECLIPSE: A mnemonic to assist in searching for health policy/management information. Health Information & Libraries Journal , 19 (2), 113–115. https://doi.org/10.1046/j.1471-1842.2002.00378.x

• << Previous: Home
• Next: Working with a Librarian >>
• Last Updated: Aug 14, 2024 1:22 PM
• URL: https://libguides.libraries.wsu.edu/evidencesynthesis

• Open access
• Published: 14 August 2024

Experiences of intensive treatment for people with eating disorders: a systematic review and thematic synthesis

• Hannah Webb 1 ,
• Maria Griffiths 1 &
• Ulrike Schmidt 2 , 3  

Journal of Eating Disorders volume  12 , Article number:  115 ( 2024 ) Cite this article

Metrics details

Eating disorders are complex difficulties that impact the individual, their supporters and society. Increasing numbers are being admitted to intensive treatment settings (e.g., for inpatient treatment, day-patient treatment or acute medical treatment). The lived experience perspectives of what helps and hinders eating disorder recovery during intensive treatment is an emerging area of interest. This review aims to explore patients’ perspectives of what helps and hinders recovery in these contexts.

A systematic review was conducted to identify studies using qualitative methods to explore patients’ experiences of intensive treatment for an eating disorder. Article quality was assessed using the Critical Appraisal Skill Programme (CASP) checklist and thematic synthesis was used to analyse the primary research and develop overarching analytical themes.

Thirty articles met inclusion criteria and were included in this review. The methodological quality was mostly good. Thematic synthesis generated six main themes; collaborative care supports recovery; a safe and terrifying environment; negotiating identity; supporting mind and body; the need for specialist support; and the value of close others. The included articles focused predominantly on specialist inpatient care and were from eight different countries. One clear limitation was that ethnicity data were not reported in 22 out of the 30 studies. When ethnicity data were reported, participants predominantly identified as white.

Conclusions

This review identifies that a person-centred, biopsychosocial approach is necessary throughout all stages of eating disorder treatment, with support from a sufficiently resourced and adequately trained multidisciplinary team. Improving physical health remains fundamental to eating disorder recovery, though psychological support is also essential to understand what causes and maintains the eating disorder and to facilitate a shift away from an eating disorder dominated identity. Carers and peers who instil hope and offer empathy and validation are valuable additional sources of support. Future research should explore what works best for whom and why, evaluating patient and carer focused psychological interventions and dietetic support during intensive treatment. Future research should also explore the long-term effects of, at times, coercive and distressing treatment practices and determine how to mitigate against potential iatrogenic harm.

Plain English summary

Some people with eating disorders will need intensive treatment (e.g., inpatient treatment, day-patient treatment or acute medical treatment) during the course of their illness. Understanding what helps and hinders eating disorder recovery during intensive treatment is an important part of developing effective interventions. This review summarises research exploring people with eating disorders’ perspectives of intensive treatment, with the aim of identifying what helps and hinders eating disorder recovery. We searched in scientific databases for all published qualitative studies that explored people with eating disorders’ perspectives of intensive treatment. Thirty studies meet the inclusion criteria of this literature review. The results sections of these studies were analysed by extracting relevant findings relating to eating disorder recovery. We found that a person-centred, holistic approach is necessary throughout all stages of eating disorder treatment, with support from healthcare professionals and carers with specialist knowledge of how to support people with eating disorders. Improving physical health is fundamental to eating disorder recovery. However, psychological support is also essential to help people with eating disorders to understand what causes and maintains the eating disorder and support them to move away from an eating disorder dominated identity. Areas for future research are outlined.

Introduction

Eating disorders (EDs) are a group of mental health disorders, such as anorexia nervosa (AN), bulimia nervosa (BN), and binge eating disorder (BED), that are characterised by severe disturbances of attitudes and behaviours related to food, weight, and shape, and that seriously impact mental and physical health [ 1 ]. ED onset is typically during late adolescence and early adulthood [ 2 ]. With the potential to impact every organ system, EDs can be life threatening, reportedly having the highest mortality rate of all mental health disorders [ 3 , 4 , 5 ]. EDs are burdensome to the individual, their supporters and society [ 6 ]. Covid-19 has only exacerbated this burden: increases in incidence rates, ED symptomatology and hospital admissions have been widely reported [ 7 , 8 , 9 ].

Treatment for people with eating disorders (PwEDs) depends on the severity and chronicity of difficulty [ 10 ]. Most PwEDs are first offered outpatient psychological therapy, which can be complemented with pharmacotherapy, medical monitoring, nursing and/or dietetic support [ 11 ]. For those who do not respond to outpatient treatment, or whose ED cannot be managed safely as an outpatient, intensive treatment may be offered. This typically ranges from day-patient treatment or partial hospitalisation to inpatient or residential treatment in an ED or general psychiatric unit. Though varied, these more intensive treatments typically involve greater multidisciplinary input and direct meal supervision [ 11 ]. Alongside specialist intensive treatments, increasing numbers of PwEDs are being admitted to general medical settings to manage the medical complications associated with EDs [ 12 , 13 ]. Care in medical settings is highly variable, with varying levels of specialist input [ 11 , 13 ]. Importantly, whilst the relative merits of each form of intensive treatment continue to be debated, demand appears to be rising internationally [ 14 , 15 , 16 ].

Clinicians supporting PwEDs encounter challenges due to the egosyntonic nature of the illness [ 17 ]. Many people attach positive value to their ED [ 18 ], as it gives a perceived sense of control, and means of obtaining identity and avoiding negative affect [ 19 , 20 ]. Consequently, PwEDs are often ambivalent towards treatment and display low motivation to change [ 21 , 22 ]. Current treatment efficacy is modest [ 23 ]. A recent rapid review suggested between 30% and 41% of PwEDs relapse within two years of receiving treatment and that less than half achieve recovery at long-term follow up [ 24 ]. Furthermore, across all EDs, 62–70% of people who have received inpatient treatment still meet full diagnostic criteria or have remaining ED symptoms at long-term follow-up [ 6 ].

To improve treatment outcomes for PwEDs, it is vital that we better understand the lived experiences of those who use ED services [ 25 , 26 ]. As such, emerging research explores lived experience perspectives of ED treatment. For example, Babb and colleagues [ 27 ] reviewed qualitative studies exploring PwEDs’ general experiences of ED treatment. This review called for more individualised care and psychological support. Whilst valuable, it did not specifically focus on recovery. It also only identified studies exploring inpatient and outpatient experiences. Yet, some studies have explored PwEDs’ perspectives of other treatment settings, such as day-patient or acute medical settings, which may add important insights. The lifespan approach taken in this review may also mean that a review focused on adult populations is warranted as there are differences in ED treatment accessibility and delivery between child, adolescent and adult services. For instance, the duration of untreated ED (DUED) varies strongly between age groups, with younger age groups seeing shorter DUEDs [ 28 ] and in child and adolescent ED treatment, greater emphasis is placed on family involvement [ 29 ].

Other reviews seek to conceptualise ED recovery from lived experience perspectives. These have led to recovery being described as a complex psychological process that requires commitment, responsibility, development of insight into the function and consequences of the ED, acceptance by others and of the self, and development of meaningful relationships [ 30 ]. Recovery has also been said to include remission of ED symptoms alongside psychological well-being and adaptability, and involves hope, reclaiming identity, meaning and purpose, empowerment and self-compassion as key components [ 31 , 32 , 33 ]. Whilst valuable findings, these reviews do not focus specifically on what aspects of treatment help or hinder recovery.

More recently, two qualitative reviews synthesised literature exploring the lived experiences of inpatient treatment for all EDs [ 34 ] and AN only [ 35 ] within ED-specific treatment settings. These reviews highlight the complex and multifaceted nature of inpatient experiences and the importance of person-centred treatment that involves medical and psychological intervention [ 34 , 35 ]. Undeniably, these reviews provide insight into a neglected area of research. However, they include differing all-age studies and exclude studies exploring different intensities and aspects of intensive treatment (such as the experience of involuntary admission). Yet, many PwEDs move through different intensive treatments, some outside ED-specific treatment settings, and all aspects of intensive treatment may relate to recovery.

ED recovery is a process rather than a singular event, which can begin before and continue beyond inpatient treatment. Therefore, this review aims to extend previous reviews exploring the lived experiences of inpatient treatment. With a focus on recovery, it aims to elucidate what helps and hinders recovery for adults with EDs across all types and aspects of intensive treatment and to provide recommendations for research and clinical practice.

Search strategy

This systematic review was conducted in line with Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines [ 36 ] and was pre-registered on PROSPERO (ID: CRD42023426052).

Systematic literature searches were carried out using electronic databases (EMBASE, MEDLINE, PsychINFO, and Web of Science), searched from conception to 6th June 2023. Search terms and inclusion and exclusion criteria were formed using the ‘Sample, Phenomenon of Interest, Design, Evaluation and Research type’ (SPIDER) tool [ 37 ], outlined in Table  1 . The search strategy employed was informed by preliminary internet searches and previous reviews. It covered four concepts: [ 1 ] EDs, [ 2 ] intensive treatment, [ 3 ] qualitative methodology, and [ 4 ] lived experiences. Various combinations of search terms were trialled before settling on a broad search strategy that explored all free text to maximise search sensitivity.

Study selection and eligibility criteria

The first author completed the literature search, which yielded 2590 articles. Duplicates were removed, and the titles and abstracts of the remaining articles were screened against predetermined inclusion and exclusion criteria, outlined in Table  2 . Qualitative or mixed method studies (if qualitative results were reported separately) that explored adults’ experiences or views of any aspect of intensive treatment directly related to an eating disorder diagnosis were considered for eligibility. Only studies originally published in English and in peer-reviewed journals were accepted. A decision was made not to search the grey literature due to time constraints and wanting to ensure adequate space and consideration was given to the included studies. Further, grey literature studies are not necessarily subject to the same rigorous academic peer-review processes as non-grey literature studies. Nonetheless, some potentially relevant studies may have been missed.

Eligibility screening resulted in 71 articles which were read in full. Full-text screening excluded a further 45 articles, resulting in a total of 26 articles. The first author also screened the reference lists of included manuscripts to identify other studies that may have met the inclusion criteria and conducted additional searches through Google Scholar throughout the review process. This resulted in an additional four articles, meaning that 30 articles were included in this review. Throughout this process, any discrepancies were discussed with the second author (MG) until a consensus was reached. The complete procedure is detailed in the PRISMA diagram (Fig.  1 ).

PRISMA Flow Diagram

Quality assessment

Though what constitutes “validity” or “quality” in qualitative research is debated, quality appraisal remains a crucial part of any qualitative review [ 38 ]. The Critical Appraisal Skill Programme (CASP) checklist, a commonly used research appraisal tool, offers ten questions that facilitate assessment of qualitative studies. The Cochrane Qualitative and Implementation Methods Group recommends to avoid providing numerical scores, as CASP is not recommended as an absolute score of quality [ 39 ]. Instead, studies are considered according to whether criteria are: “yes well addressed”; “can’t tell”; or “no not addressed”. In this review, “can’t tell” was chosen when insufficient information was reported to make a judgement, as quality issues may be due to poor methodology and/or inadequate reporting [ 40 , 41 ]. The first author conducted the quality assessment and any ambiguities were discussed with the review team until a consensus was reached.

Given the large number of studies in this review, whilst absolute scores were avoided, quality appraisal was used to organise the thematic synthesis, as has been recommended previously [e.g., 41 , 42 ]. This meant studies ( n  = 10) for which “yes” was chosen for all ten questions were first reviewed to generate the coding framework. This was used to code the remaining studies. When particularly meaningful, new codes were generated. No studies were deemed to be low quality, as all studies provided valuable contributions to a limited evidence base. If there had been low quality studies, no new codes would have been generated, though these studies would not have been excluded.

Method of synthesis

Thematic synthesis was chosen to integrate findings of multiple qualitative studies to answer a specific review question and extend what is already known [ 43 ]. All text from “results” or “findings” sections, and any findings in abstracts, were extracted and treated as data. Thematic synthesis followed three iterative stages. Stage one involved line-by-line coding of text according to meaning and content. Stage two involved grouping of codes into hierarchical structures, to develop descriptive themes that remained data-driven and close to the primary studies. Stage three involved the generation of analytical themes through inference of descriptive themes, which go beyond the primary studies to generate new interpretive explanations.

Reflexivity

Reflexivity, the conscious, collaborative appraisal and critique of how one’s subjectivity and context influence the research processes, is an essential component of qualitative research [ 44 , 45 ]. We, the three authors, have psychology/psychiatry and academic and clinical backgrounds. The first author is a trainee clinical psychologist with lived experience of an ED as well as academic and clinical experience in EDs/mental health. The second author is a clinical psychologist with academic and clinical experience in mental health, in particular with adults with experiences of psychosis. The third author is a consultant psychiatrist and expert in the field of EDs, with experience of developing national and international initiatives to improve ED policy and practice. One of us was an insider to the experience of ED treatment and we are all insiders to a culture of working in mental health services with often high levels of need and limited resource. We made every attempt to ensure potential biases (e.g., our combined clinical, academic and experiential understanding that intensive treatment can be challenging for many) were kept in awareness and endeavored to pay attention to the full range of findings. Coding extracts and theme developments were discussed with all authors to check for disagreements or uncertainties before being finalised. Additionally, the first and second author met for monthly supervision to discuss the review development and analysis, and to support a continuous process of self-reflection. This collaborative approach supported development of themes that captured important nuances in the lived experiences of ED treatment, for example identifying the tension between physical versus psychological support. Nonetheless, as with all qualitative research, a different group of researchers who sought to answer the same research question may have extracted different themes from the data.

Studies identified

Thirty papers were identified as relevant. These are summarised in Table  3 .

Included studies totalled 495 participants ranging from 17 to 56 years. 96% identified as female, 2% identified as male, 0.4% identified as non-binary and 0.6% were not reported. 65% of participants were diagnosed with AN, 6.3% with BN, 0.6% with BED, 9.1% with EDNOS, 0.4% with OSFED, and 18.6% as missing or not reported. Ethnicity data were not reported in 22 studies. When ethnicity data were reported, 98.9% of participants identified as white (94/95 participants in reporting studies) and 1% identified as Other.

Included studies were predominantly conducted in the United Kingdom ( N  = 17). Other countries included Australia ( N  = 4), Canada ( N  = 3), Sweden ( N  = 2), Denmark ( N  = 1), Israel ( N  = 1), Norway ( N  = 1) and the USA ( N  = 1). Most studies focused on specialist inpatient units only ( N  = 19), with three studies focusing on inpatient and day-patient settings and one study focusing on inpatient and general psychiatric units. Three studies focused on day-patient settings only and two studies focused on medical settings only. One study focused on intensive community treatment and one study did not report the setting (though it focused on experiences in intensive settings). Most (27/30) studies did not report length of stay and those that did reported a wide range of 0.14 to 27 months.

Recruitment was carried out using various methods, inviting both current and past receivers of treatment. A range of data analysis approaches were used, though half of the studies used thematic analysis. Most studies ( N  = 23) used semi-structured interviews. Other data collection methods included open-ended questions in discharge/feedback questionnaires, narrative interviews, focus groups, diary entries and medical documents.

Quality appraisal

Included studies were of variable quality, but none were considered inadequate (see Table  4 ). All studies provided clear statements of the aims and appropriateness of qualitative methodology. The research design was unclear in three studies [ 46 , 47 , 48 ] and one study [ 49 ] did not explain consideration of ethics. Ten studies did not describe their recruitment strategy and thirteen studies did not provide any/adequate consideration of the relationship between the researcher(s) and participants. This contrasted with many studies that provided clear descriptions of their recruitment strategy (e.g., [ 50 , 51 ]) and researcher reflexivity (e.g., [ 52 , 53 ]). In line with their study methodology, some studies provided more descriptive analyses (e.g., [ 54 , 55 ]) and others provided more in-depth analyses (e.g., [ 48 , 49 , 56 ]). Studies that did not provide sufficient qualitative data for the quality of their analysis to be considered and analysed as part of this review were excluded at the point of screening. All studies showed sufficient rigour, providing clear statements of findings and situating these within the wider literature.

Studies varied significantly in the time-point of data collection (e.g., during treatment, immediately after, retrospectively or a combination), with only some reflecting on the chosen time-point(s). Most studies focused on experiences relating to specialist inpatient treatment and only some adequately described the treatment setting. Moreover, several studies did not provide key participant characteristics, samples were not representative and no study focused exclusively on any ED other than AN.

Thematic synthesis

Six themes were generated from the data: Collaborative Care Supports Recovery; A Safe and Terrifying Environment; Negotiating Identity; Supporting Mind and Body; The Need for Specialist Support; and The Value of Close Others. Themes and subthemes are outlined in Table  5 and discussed below.

Theme 1: collaborative care supports recovery

Active involvement in treatment.

Collaborative care supported recovery across intensive settings. “ Working together ” [ 51 ] and supporting PwEDs to “ make their own decisions ” [ 50 ] strengthened participants’ motivation. However, collaboration was “ often felt to be absent ” [ 54 ]. Several studies identified that participants felt “ alienated from the decision-making process ” [ 55 ], especially those admitted involuntarily. Feeling unheard negatively impacted upon self-esteem and anxiety. Lack of transparency between PwEDs and treatment providers affected treatment experiences and subsequent recovery. Lack of clarity about ward rounds led to “power differences… and anxiety ” [ 57 ]. Participants in both studies exploring medical settings voiced not knowing who was chiefly responsible for their care and “ feeling deceived or given a punishment ” [ 55 ] when starting a refeeding protocol or being detained, due to lack of information. This negatively impacted upon treatment engagement. One study identified that providers should make expectations and regimes clearer and repeat them frequently “ to ensure patients have time to process and understand them ” [ 50 ]. In another study, the option to self-admit (to inpatient treatment) strengthened participants’ agency and motivation, and promoted partnership. However, for some, it risked too much decision-making power – “ too much say… it’ll be bad for me ” [ 56 ].

Collaboration was particularly key during transitions of care. Lack of information and “ uncertainty in what was going to happen ” [ 53 ] contributed to fear and feeling overwhelmed, hindering ongoing recovery. Many studies concurred that “ a graded and planned discharge helped… [re] integration ” [ 58 ]. This involved “ a phased , supportive approach ” [ 61 ], “ communication… with clear goals ” [ 54 ] and consideration of potential “ obstacles and challenges ” [ 63 ]. Several studies identified that treatment intensity dropped too quickly, that little or no further support was offered, or that participants were placed on lengthy outpatient waitlists. Continuity of support was essential.

Temporarily handing over responsibility

Whilst collaborative care generally supported recovery, there were instances in which, for short periods of time, participants found it helpful to not be so involved in care decisions. Several inpatient studies identified that, whilst challenging, many participants actually felt “ saved ” [ 58 ] when providers took responsibility (e.g., implementing clear boundaries around dietary change). “ Handing over” [ 59 ] control was sometimes viewed as a necessary step towards recovery. However, for some, sudden loss of control contributed to heightened distress and “ amped up the ED ” [ 50 ]. For those experiencing involuntary treatment in particular (e.g., forced nasogastric feeding) this led to disconnection from one’s care. One study identified that “ hopelessness and resentment ” [ 58 ] developed. As Fox and Diab [ 49 ] outlined, the ED “ gave participants a sense of control and a method of coping …” and “ refeeding… led to an intense feeling of losing control” – supporting participants to understand the reasons behind care decisions and to process the intensive emotions these activated appeared fundamental to recovery.

Theme 2: a safe and terrifying environment

A bubble that was hard to replicate.

For some, the safety and security afforded by intensive treatment supported recovery. Inpatient and day-patient treatment granted “ permission ” [ 53 , 58 ] to focus on recovery. Inpatients was described as a “ respite from overwhelming everyday demands ” [ 56 ]. Participants felt they “ belonged somewhere ” [ 64 ], finding “ comfort in predictable routines ” [ 65 ]. Inpatients also provided relief for carers. Several studies suggested non-negotiable boundaries supported change – “ completing meals was non-negotiable ” [ 66 ]. Two studies recognised when healthcare professionals (HCPs) made alterations to rules, it gave the ED “ leverage to pathologically negotiate ” [ 65 ]. Nonetheless, one participant identified that the existence of certain rules (e.g., prohibiting of water loading) alerted them to new possibilities.

It was recognised that the certainty and boundaries inpatients afforded was “ not easily replicated ” [ 52 ]. Their loss after discharge contributed to difficulties with continuing recovery. Indeed, inpatients was called a “ bubble ” [ 58 , 59 ], “ greenhouse ” [ 60 ] and “lab… [with] very exact and measured conditions ” [ 60 ]. It left participants “ frozen… and dependent on the unit ” [ 59 ]. Various studies identified that intensive treatment (particularly inpatient treatment) put “ life on hold ” [ 61 ]. For some, this contributed to dependence on treatment and the ED. As O’Connell [ 66 ] outlined, the ED became “ the standpoint from which I related to others ”. A few studies highlighted the importance of providers “ showcasing interest and highlighting aspects of patients’ lives outside of their ED ” [ 50 ] to provide relief from institutionalisation and support motivation. As PwEDs transitioned out of intensive treatment, returning to or beginning careers, relationships, leisure and personal development activities supported “ a sense of routine and purpose ” [ 61 ].

A punitive, distressing environment

Words such as “ miserable ”, “ horrific ”, “ hostile ”, “ traumatic ”, “ distressing ”, “ inhumane ”, “ terrifying ” and “ an assault ” were used to describe treatment (in inpatient and medical settings only) [ 48 , 49 , 54 , 60 , 64 ]. For some, feeling dehumanised, restricted or traumatised negatively impacted upon motivation, engagement and subsequent recovery. Several studies suggested participants felt “ under inspection ” [ 58 ] and treatment was described as “ doing time ” [ 67 ]. “ Exposure to… [and experiences of] distressing events ” [ 54 ] were difficult – described as “ something I’ll never forget ” [ 48 ]. Participants sometimes experienced “ corrective measures as punitive or disciplinary ” [ 65 ]. Moreover, across several studies, participants felt certain boundaries were arbitrary, employed without adequate explanation, or “ rigid and unable to be maintained ” [ 58 ], leaving them feeling disempowered.

Theme 3: negotiating identity

Separating the self and the ed.

Across many studies, attachment to the ED hindered recovery. The ED afforded safety, control and confidence in its success and provided “ emotional and physical detachment ” [ 62 ]. Intensive treatment “ created a state of internal coercion ” [ 48 ]. Several studies identified that a mismatch between treatment requirements and participants’ readiness to change could result in treatment refusal or termination, strengthening attachment to the ED. For those who experienced repeated admissions, lengthy stays or passing between services, “ feelings of hopelessness ” [ 49 ] and “ feelings of failure ” [ 56 ] were prevalent. Consequently, participants “ gripped more tightly onto AN ” [ 66 ] (and the ED identity).

Indeed, being “ reduced to a number and a disorder ” [ 55 ] in inpatient and medical settings hindered recovery. Various studies suggested participants disliked feeling defined by their illness and treated as “ a collective ” [ 60 ] or in accordance with “ an assumed group identity ” [ 68 ]. This “one-size-fits-all approach ” [ 67 ] left participants feeling “ misunderstood , invalidated and stereotyped ” [ 66 ]. There was a desire for “ different tracks for people with different needs ” [ 55 ] and a wish for providers to “ humanise the patient ” [ 50 ]. Indeed, personalised, flexible treatment supported recovery across intensive settings. Day-patients was viewed as more flexible than inpatients, though both groups desired a more “tailored approach ” [ 61 ] (e.g., better consideration of differences in sexuality, gender identity and comorbidities). Intensive community treatment was considered individualised, with “ specific and obtainable goals ” [ 62 ]. Moreover, several studies highlighted that, for some participants, being supported to externalise the ED as separate to their sense of self - recognising “ AN as pathology separate to who they were ” [ 65 ] - supported change and recovery.

Beginning to want something different

Indeed, ambivalence towards treatment, particularly initially, was common. Recovery required moving from ambivalence to acceptance and/or determination. Reflecting back, one participant suggested others should “ surrender a little bit … trust in the treatment ” [ 50 ]. For some, this was difficult. Several studies identified that compliance resulted in discharge, but not necessarily recovery. One participant “ humour [ed]” [ 63 ] providers and another aimed to “ eat their way out ” [ 58 ]. It was these participants where relapse was most likely. Self-criticism, shame, worthlessness and hopelessness kept participants stuck.

Conversely, several studies outlined the value of motivation. In their study exploring experiences of recovered versus relapsed PwEDs, participants’ “ own drive ” [ 63 ] was prevalent in the recovered group. One participant described eventually “ wanting something different ” [ 66 ] and another study noted EDs require “ extremely hard work to be fought against ” [ 62 ]. Key to recovery was self-acceptance, hopefulness, and awareness and insight into the ED: “ compassion… and self-care ” [ 58 ] and “ a sense of self ” [ 64 ] were necessary.

Theme 4: supporting mind and body

Weight restoration and dietary change.

Many participants retrospectively saw intensive treatment as “ saving lives ” [ 48 ], specifically regarding medical stabilisation. However, across inpatient and medical settings, participants struggled with discrepancy between “ normal [weight restored] bodies ” and continued “ anorexic thoughts ” [ 63 ], leading to other maladaptive behaviours or relapse. Overfocus on biological markers, for example “ micro-monitoring of the participant’s weight ” [ 67 ], negatively impacted recovery. Across studies, participants wished for a “ slow pace of change with focus on all aspects of their difficulties ” [ 62 ].

Nonetheless, across specialist settings (i.e., not general medical), support in understanding and implementing dietary changes facilitated recovery. Meal support, plans and routines developed “ behavioural patterns that supported recovery ” [ 52 ] and “ staff eating alongside ” [ 46 ] normalised mealtimes. Nutritional education was also valued. Learning about “ daily nutritional requirements” [ 52 ] and “ their bodies’ need for food ” [ 47 ] helped participants make dietary changes. Similarly, opportunities to engage in practical food groups (e.g., grocery shopping, outings to restaurants/cafes and meal preparation activities) were considered important and increased “confidence to attempt repeating the challenges outside” [ 69 ]. Practicing dietary related cognitive skills and coping strategies supported a “ gradual shift to more independent eating ” [ 70 ].

Psychological awareness and understanding

Understanding what caused and maintained the ED arose as integral to recovery, through individual and group therapy and wider psychological support. Individual therapy supported PwEDs to understand the ED and “ challenge… maladaptive thinking styles and behaviours ” [ 71 ]. A “ strong [therapeutic] connection ” [ 70 ] was essential. Similarly, a range of therapeutic groups, including Cognitive Behavioural Therapy, Dialectical Behavioural Therapy and the Maudsley Anorexia Nervosa Treatment for Adults groups, as well as perfectionism, mindfulness, and value-based groups, were appreciated. Many recognised “the importance of sharing experiences and learning from each other” [ 72 ], though for a minority, the perceived intensity of groups was challenging. A holistic therapy, acupuncture, was “ relaxing , both emotionally and physically ” [ 73 ] particularly after meals. Nonetheless, for some, therapy was “ too structured ” [ 74 ]. There was desire “ for more guidance and practice to help with real life application ” [ 71 ] and several studies identified a need for longer therapeutic intervention. One study identified insufficient psychological input in ward rounds, though one participant did not want their formulation shared due to it being “ very personal ” [ 57 ].

Learning to identify, express and manage emotions emerged as beneficial across intensive settings. For example, developing strategies to “ manage… and label emotions ” [ 74 ] and communicate one’s feelings supported recovery during and after treatment. Self-examination skills (e.g., journaling) helped PwEDs “ continue to work on recovery after discharge ” [ 52 ]. Several studies identified that emotional suppression and avoidance of negative affect limited progress.

Theme 5: the need for specialist support

Genuine care, alliance and trust.

Genuine care, trust and therapeutic alliance between PwEDs and HCPs was important for recovery. Participants wished to be treated with dignity and respect. They valued HCPs who were “ approachable and friendly ” [ 51 ], empathic and non-judgemental, and who validated and managed participants’ emotions. For some, feeling cared for involved nurses adopting a “ motherly or sisterly role ” [ 65 ] and HCPs who went “ beyond their roles ” [ 54 , 75 ]. Several studies noted the importance of strong therapeutic alliances with key workers, characterised by honesty, trust and openness. This promoted “ hope and optimism ” [ 75 ] and led participants to feel “ held or supported ” [ 62 ]. Without a good keyworker relationship “ challenges could feel insurmountable ” [ 51 ].

Correspondingly, across several studies, feeling uncared for negatively impacted recovery. Participants sometimes felt dismissed, patronised or ignored. They struggled with HCPs who “ failed to follow through with promises ” [ 58 ], “ overlooked [them] in comparison to newly admitted patients ” [ 59 ], or offered a “lack of a predictable response” [ 68 ]. Distrust between PwEDs and HCPs was “ an important precursor to some difficult interactions ” [ 67 ]. Described in several studies, conflict often led to further rebellion as the participant sought to “ retain their sense of control ” [ 46 ]. Poor connections resulted in increased anxiety and distrust, which impacted participants’ self-esteem, motivation, and desire to remain in treatment.

Skilled and well Resourced Multidisciplinary Care

Several studies outlined the importance of PwEDs being care for by a skilled and well resourced multidisciplinary team, with “ staff from different disciplines… contributing to residents’ recovery ” [ 70 ]. Changing teams, HCP shortages and use of non-permanent staff decreased standards of care and hindered recovery. Whereas, well trained and skilled HCPs displayed empathy, understanding, knowledge and clear boundaries. Indeed, “ trust and belief in practitioner’s expertise were… fundamentally important ” [ 49 ]. Skilled HCPs were able to separate the person from the ED, facilitate honesty and openness, and develop strong therapeutic alliances.

Theme 6: the Value of Close others

Peer support and comparison.

Peer support and comparison affected recovery. Across intensive settings, “ physical and behavioural comparisons ” [ 59 ] and competitiveness negatively affected “group cohesion and personal recovery ” [ 53 ]. Many found it distressing and triggering being admitted alongside others at various stages of recovery and with differing levels of illness severity. Indeed, participants were susceptible to adopting “new [unhelpful] ED practices ” [ 60 ]. Participants in two studies described comparing themselves (not under section) to those under section. This comparison increased participants’ guilt for choosing to eat and negatively impacted recovery. Correspondingly, participants in one study valued spending time with people without EDs who “ value aspects of life other than shape and weight ” [ 52 ].

In contrast, many of the same studies recognised that being alongside other PwEDs also supported recovery. Peers who understood and were non-judgmental were valued and contributed to connectedness, acceptance and belonging. Peer support “ increased knowledge of effective coping skills and hope for recovery ” [ 59 ]. Several studies noted participants made “ close and lasting friendships… through a sense of camaraderie ” [ 60 ]. Relatedly, one participant valued a peer mentor who had “ been there and got through ” [ 53 ].

Carer Support and understanding

Carer support and understanding during, and upon leaving, intensive treatment supported recovery. Across settings, participants desired for carers to “ provide love , a listening ear ” [ 50 ], particularly “ during the transition period ” [ 61 ]. Carer support groups were also valued. Returning home with “ insufficient or unhelpful social support ” [ 69 ], as well as “ continual emphasis on body weight and dieting within the family or social environment ” [ 63 ], hindered recovery.

Moving from loneliness to connection

Isolation hindered recovery. Particularly upon admission, participants described an emptiness, loneliness and difficulty trusting others. Difficulties developing and maintaining relationships contributed to negative attributions of the self and others and pushed participants further into their ED. Admissions sometimes exacerbated these difficulties as participants were removed from friends and family. Fostering “ meaningful connections after treatment ” [ 52 ] and moving from “ loneliness… to interpersonal connection ” [ 62 ] supported PwEDs to move towards recovery.

This review explored what helps and hinders recovery during intensive treatment for PwEDs. Participants acknowledged that intensive treatment was often necessary, particularly with regards to biomedical recovery. As higher discharge BMI predicts more positive outcomes (for AN) [ 76 ], promoting adequate weight restoration remains a priority. Nonetheless, consistent with existing literature [ 30 , 35 ], a biomedical focus often took precedence over addressing underlying psychosocial difficulties. Participants were weight-restored but not recovered and often discharged without a period of consolidation or without adequate step-down support, placing them at higher risk of relapse following discharge [ 31 ]. Providers should be careful to not over-focus on biological markers and should ensure pace of change is acceptable to the individual.

Correspondingly, a therapeutic milieu, comprising individual and group therapy and the wider care environment, was valued and necessary for recovery, though was not always present or sufficient. Consistent with existing literature [ 77 , 78 ], psychological interventions that supported PwEDs to understand the function and maintenance of their ED, as well as to identify, express and process emotions, facilitated recovery. Externalisation also arose as an important therapeutic technique across the wider care environment to foster separation from an illness identity [ 79 , 80 ].

Ambivalence, resistance to change and hopelessness hindered recovery. Commonly identified as barriers to recovery [ 81 , 82 , 83 ], if these factors were not attended to, change was difficult, and relapse was likely. Imposing actions (e.g., through boundaries and routines) may be necessary for an individual’s safety, but carry a risk of driving them further into their ED, increasing resistance and decreasing motivation and compliance [ 84 ]. These findings support research highlighting the role of holding and actively sharing hope [ 33 , 85 ] and of motivational interviewing [ 86 ].

Consistent dietary support should be embedded into intensive treatment. Across intensive settings (except in medical settings, where they were not mentioned), structured mealtimes, meal support, modelling normal eating, meal plans, nutritional education, and food groups supported PwEDs to move towards recovery. Supporting a small body of literature [ 87 , 88 ], dietary-related interventions allowed PwEDs to practice adaptive coping strategies, improve eating behaviours and self-efficacy, and address social challenges associated with eating.

Compassionate and yet boundaried HCPs were essential. Across intensive settings, collaborative, person-centred care strengthened hope and engagement. PwEDs desired active involvement in treatment, though for some, having responsibility removed initially was a necessary part of recovery. As clinicians have highlighted, balancing PwEDs’ desires with beneficence can be challenging [ 85 , 89 ], however the dominant medical paradigm, that positions HCPs as expert authorities, may harmfully limit choice, autonomy and opportunities for treatment participation. When PwEDs feel unheard or that their needs are not being met, premature treatment termination may result [ 90 ]. Whilst those in intensive settings are often at higher risk, where possible, it remains important to offer choice and clear information. Although few in number, studies exploring day-patient and intensive community settings suggested they afforded greater choice and collaboration, though this may be as these settings generally support less severe ED populations [ 91 ].

Experiences of care were highly individual. At times, intensive environments facilitated recovery. They were safe and supportive, due to firm boundaries, clear routines, and, in inpatient settings, escape from life stressors. Yet, consistent with ED clinicians’ concerns [ 85 ], intensive treatment (especially inpatient) also contributed to treatment dependence and estrangement from life outside. Transition out of intensive treatment was highlighted as a particularly vulnerable period. Day-patient and intensive community treatment discharges were experienced as somewhat more graded and skills learnt as more transferable, perhaps leading to a greater likelihood of maintenance. These findings underscore the value of intensive treatment but also the need for a gradual discharge process. Occupational therapists may be particularly well placed to support development of necessary skills for continuing recovery, supporting PwED’s to identify purpose outside of the ED, cope with external triggers and resume educational, vocational and/or family roles [ 87 ].

Intensive environments (in inpatient and medical settings only) were also experienced as restrictive and traumatising, due to experiences of coercion, scrutiny, and being subjected to, or witnessing of, distressing practices. These iatrogenic factors may hinder recovery and have long-lasting effects, contributing to more severe psychopathology and/or trauma-related symptoms. To date, limited work has explored what aspects render the experience of psychiatric hospitalisation distressing, though experiences of coercion, stress and trauma appear common and distressing [ 92 ]. Moreover, whilst compulsory treatment can be necessary to save lives, the long-term effects are largely unknown [ 93 ].

Adding to the growing literature base surrounding the value of carer support for adults with EDs [ 94 , 95 ], carer support was valued when carers were able to understand the ED and challenges of treatment and offer empathy and validation. Given that carers’ distress and ways of coping can inadvertently maintain or reinforce the ED [ 96 ], this finding affirms the necessity for carers to receive their own support [ 95 ]. Currently, a range of carer interventions show positive outcomes for PwEDs undergoing intensive treatment, though implementation is patchy, and research has predominantly focused on young people with AN and the experiences of mothers [ 95 ].

Peer comparison, competition and contagion were common in intensive settings and often reinforced the ED-dominant identity. Nonetheless, peer support and identification were also common, and frequently decreased isolation while motivating individuals towards recovery. One study also highlighted the value of a peer mentor. As a growing area of research and clinical practice, peer mentors may instil hope and increase motivation for treatment [ 97 ]. Treatment alongside other PwEDs being both helpful and hindering for recovery is a widely reported juxtaposition [ 27 , 85 ]. Helpful peer influence appears to depend on dis-identification with the ED-dominant identity and identification with a recovery identity. Indeed, a sense of shared identity with others in ED recovery promoted recovery in an online support group [ 98 ]. Specialist support is necessary and valued by PwEDs and this generally means PwEDs are treated alongside peers. Peer influence should therefore be considered as part of each individual’s formulation, to explore the potential for support and harm and how this may relate to the ED identity.

Clinical and research implications

To enhance likelihood of ED recovery, a multidisciplinary approach is required across intensive settings. Restoring physical health remains fundamental. However, psychological support is also necessary. Whilst several psychological treatments have evidence supporting use in outpatients, minimal evidence guides implementation of evidence-based practices in intensive settings [ 99 , 100 ]. Interventions that enhance motivation to change [ 86 , 101 ], foster separation from an ED-dominant identity [ 102 , 103 ] and support emotion recognition, regulation and expression [ 104 , 105 ] should be prioritised. Research must determine what works best for whom and why, tailoring processes to PwEDs’ unique needs, contexts and goals [ 30 ] and comorbidities [ 106 ].

Specialist dietetic support should also be employed. Dieticians possess unique skills and knowledge, but the extent to which they are involved in intensive treatment is largely unknown [ 88 ] and limited research guides the content of dietetic interventions or explores the effect of including dietetics [ 107 , 108 ]. Further research should explore what constitutes effective dietetic support across intensive settings [ 87 , 108 ].

Time to consolidate recovery gains alongside planned and phased discharges are vital for ED recovery. Research has begun to explore novel ways to support intensive treatment transitions [ 109 ] and intensive stepped-care treatment programs highlight the value of longer-term multidisciplinary care for PwEDs [ 110 , 111 ]. Further research must explore how to support maintenance of recovery, particularly as PwEDs return to daily life stressors.

Clinical practice guidelines recommend carer involvement in adult ED treatment [ 112 , 113 ] and carers and PwEDs recognise the value of carer support [ 96 , 114 ]. Current carer support is inconsistent, interventions vary, and a sufficient evidence base is lacking, particularly for adult ED populations [ 94 , 115 ]. Carer capacity, skill and knowledge vary and interventions need to be tailored accordingly [ 95 , 96 ]. To develop more routine and individualised care, research needs to elucidate which carer interventions works best for whom and why, taking consideration of different carer types, EDs other than AN, and stages of illness [ 94 , 96 ].

Perhaps most notably, this review highlights the complexity of intensive support for PwEDs. Findings highlight several dilemmas that HCPs face: helpful boundaries and containment versus restriction and coercion; peer support versus contagion; and physical versus psychological recovery. There is a clear need for sufficient resource, specialist training and opportunities for HCPs to engage in reflective spaces. Organisational pressures alongside client complexity mean HCPs can find working with PwEDs emotionally draining, leading to negative judgements, frustration, hopelessness and worry [ 99 , 116 ]. Perhaps it is these feelings that lead HCPs to strive for a practice of safe-certainty (e.g., administering standardised protocols) [ 116 ]. Time and space for reflection may support adoption of positions of safe-uncertainty, and consequently more flexible, person-centred approaches based on formulation and evidence-based interventions [ 116 ].

Specialist skills and knowledge, alongside trust and openness, reduce conflict and enhance therapeutic relationships and treatment engagement [ 117 , 118 , 119 ]. Within intensive settings, HCPs must balance firmness and empathy, communicating with clear boundaries to ensure certain behaviours are minimised whilst at the same time recognising and understanding the defensive nature of the ED and its adaptive function [ 22 ]. Future studies should explore what aspects of intensive treatment may be causing harm and any long-term effects. Moreover, there is need for specialist training and research in general medical settings, given the extent of negative experiences in this area.

Strengths and limitations

This review brings together 495 participants’ perspectives across thirty studies. Extending findings of previous reviews [ 34 , 35 ], this study explores what helps and hinders recovery across the spectrum of intensive treatment specifically for adults with EDs. A rigorous methodological process was employed in the selection, evaluation and interpretation of studies. To ensure findings remained contextualised, details of each included article’s aims, sample, setting, methods and methodological quality were included. However, a number of limitations must also be considered. As grey literature was not searched, some potentially relevant studies may have been missed. However, the sample is purposive rather than exhaustive, as this review aims to offer interpretive explanation and not prediction, therefore it may not be necessary to locate every available study [ 43 ]. The majority of included studies explored inpatient treatment experiences. Whilst the number of studies exploring lived experiences in non-inpatient settings is limited, the included studies offer a glimpse into experiences of these settings and highlight an important research gap. Further research is needed into lived experiences of intensive treatment settings other than specialist inpatient treatment for PwEDs (e.g., exploring lived experiences of day-patient treatment/partial hospitalisation, residential care, intensive community treatment, home-based treatments and acute medical admissions). Moreover, many studies also inadequately described the treatment setting. Given the diversity of intensive treatment approaches for PwEDs, authors should endeavour to describe treatment settings adequately to support transferability of findings [ 120 ]. Additionally, included studies omitted several key participant characteristics, and as has been identified previously, samples lacked ethnic, gender and diagnostic diversity. This limits the generalisability of findings to groups other than white women with AN. Researchers must include ethnicity data, as its absence further maintains underrepresentation. Research prioritising the treatment experiences of marginalised groups is urgently required [ 121 ].

This review explores what helps and hinders recovery during intensive treatment for PwEDs. A sufficiently resourced and adequately trained multidisciplinary service, which includes physical, psychological, dietetic and social support, supports ED recovery. Findings emphasised the vital role psychological support and understanding can have in supporting PwEDs to move from an ED-dominant identity to a sense of self outside of the illness and the value of carers and peers who instil hope and offer empathy and validation. Nonetheless, HCPs face several challenges when supporting PwEDs in intensive settings, as what is helpful for one person may be harmful for another. A person-centred, biopsychosocial approach is necessary throughout all stages of treatment. Further research must evaluate patient and carer focused psychological interventions and the role of dietetic support during intensive treatment. It must explore the long-term effects of, at times, coercive and distressing treatment practices and determine how to mitigate against potential iatrogenic harm.

Data availability

Data is provided within the manuscript. Further data is available on request.

American Psychiatric Association. Diagnostic and statistical manual of mental disorders. 5th ed. Washington, DC: American Psychological Association; 2022.

Book   Google Scholar  

Solmi M, Radua J, Olivola M, Croce E, Soardo L, Salazar de Pablo G, Il Shin J, Kirkbride JB, Jones P, Kim JH, Kim JY. Age at onset of mental disorders worldwide: large-scale meta-analysis of 192 epidemiological studies. Molecular Psychiatry. 2022;27(1):281–95. https://doi.org/10.1038/s41380-021-01161-7 .

Weigel A, Löwe B, Kohlmann S. Severity of somatic symptoms in outpatients with anorexia and bulimia nervosa. European Eating Disorders Review. 2019;27(2):195–204. https://doi.org/10.1002/erv.2643 .

Voderholzer U, Hessler-Kaufmann JB, Lustig L, Lage D. Comparing severity and qualitative facets of depression between eating disorders and depressive disorders: Analysis of routine data. Journal of Affective Disorders. 2019;257:758–64. https://doi.org/10.1016/j.jad.2019.06.029 .

Arcelus J, Mitchell AJ, Wales J, Nielsen S. Mortality rates in patients with anorexia nervosa and other eating disorders. Archives of General Psychiatry. 2011;68(7):724 – 31. https://doi.org/10.1001/archgenpsychiatry.2011.74 .

van Hoeken D, Hoek HW. Review of the burden of eating disorders: mortality, disability, costs, quality of life, and family burden. Current Opinion in Psychiatry. 2020;33(6):521–7. https://doi.org/10.1097/YCO.0000000000000641 .

Gilsbach S, Plana MT, Castro-Fornieles J, Gatta M, Karlsson GP, Flamarique I, Raynaud JP, Riva A, Solberg AL, van Elburg AA, Wentz E. Increase in admission rates and symptom severity of childhood and adolescent anorexia nervosa in Europe during the COVID-19 pandemic: data from specialized eating disorder units in different European countries. Child and Adolescent Psychiatry and Mental Health. 2022;16(1):46. https://doi.org/10.1186/s13034-022-00482-x .

Devoe D, Han A, Anderson A, Katzman DK, Patten SB, Soumbasis A, Flanagan J, Paslakis G, Vyver E, Marcoux G, Dimitropoulos G. The impact of the COVID-19 pandemic on eating disorders: A systematic review. International Journal of Eating Disorders. 2023;56(1):5–25. https://doi.org/10.1002/eat.23704 .

Katzman DK. The COVID-19 pandemic and eating disorders: a wake-up call for the future of eating disorders among adolescents and young adults. Journal of Adolescent Health. 2021;69(4):535–7. https://doi.org/10.1016/j.jadohealth.2021.07.014 .

Lemly DC, Dreier MJ, Birnbaum S, Eddy KT, Thomas JJ. Caring for adults with eating disorders in primary care. The Primary Care Companion for CNS Disorders. 2022;24(1). https://doi.org/10.4088/PCC.20nr02887 .

Hay PJ, Touyz S, Claudino AM, Lujic S, Smith CA, Madden S. Inpatient versus outpatient care, partial hospitalisation and waiting list for people with eating disorders. Cochrane Database of Systematic Reviews. 2019;. https://doi.org/10.1002/14651858.CD010827.pub2 .

Royal College of Psychiatrists. Medical emergencies in eating disorders (MEED) Guidance on recognition and management. 2022 May. https://www.rcpsych.ac.uk/improving-care/campaigning-for-better-mental-health-policy/college-reports/2022-college-reports/cr233 .

Turner P, De Silva A. Medical management of eating disorders. Medicine. 2023;51(7):493–7. https://doi.org/10.1016/j.mpmed.2023.04.011 .

Taquet M, Geddes JR, Luciano S, Harrison PJ. Incidence and outcomes of eating disorders during the COVID-19 pandemic. The British Journal of Psychiatry. 2022;220(5):262–4. https://doi.org/10.1192/bjp.2021.105 .

Hansen SJ, Stephan A, Menkes DB. The impact of COVID-19 on eating disorder referrals and admissions in Waikato, New Zealand. Journal of Eating Disorders. 2021;9(1). https://doi.org/10.1186/s40337-021-00462-0 .

Milliren CE, Richmond TK, Hudgins JD. Emergency department visits and hospitalisations for eating disorders during the COVID-19 pandemic. Pediatrics. 2023;151(1). https://doi.org/10.1542/peds.2022-058198 .

Gregertsen EC, Mandy W, Serpell L. The egosyntonic nature of anorexia: an impediment to recovery in anorexia nervosa treatment. Frontiers in Psychology. 2017;8. https://doi.org/10.3389/fpsyg.2017.02273 .

Denison-Day J, Appleton KM, Newell C, Muir S. Improving motivation to change amongst individuals with eating disorders: A systematic review. International Journal of Eating Disorders. 2018;51(9):1033–50. https://doi.org/10.1002/eat.22945 .

Frank GK, Roblek T, Shott ME, Jappe LM, Rollin MD, Hagman JO, Pryor T. Heightened fear of uncertainty in anorexia and bulimia nervosa. International Journal of Eating Disorders. 2012;45(2):227 – 32. https://doi.org/10.1002/eat.20929 .

Bryant E, Aouad P, Hambleton A, Touyz S, Maguire S. ‘In an otherwise limitless world, I was sure of my limit.’ experiencing anorexia nervosa: a phenomenological metasynthesis. Frontiers in Psychiatry. 2022;13. https://doi.org/10.3389/fpsyt.2022.894178 .

Halmi KA. Perplexities of treatment resistance in eating disorders. BMC Psychiatry. 2013;13(1):292. https://doi.org/10.1186/1471-244X-13-292 .

Abbate-Daga G, Amianto F, Delsedime N, De-Bacco C, Fassino S. Resistance to treatment and change in anorexia nervosa: a clinical overview. BMC Psychiatry. 2013;13(1):294. https://doi.org/10.1186/1471-244X-13-294 .

Monteleone AM, Pellegrino F, Croatto G, Carfagno M, Hilbert A, Treasure J, Wade T, Bulik CM, Zipfel S, Hay P, Schmidt U. Treatment of eating disorders: a systematic meta-review of meta-analyses and network meta-analyses. Neuroscience & Biobehavioral Reviews. 2022;142. https://doi.org/10.1016/j.neubiorev.2022.104857 .

Miskovic-Wheatley J, Bryant E, Ong SH, Vatter S, Le A, Touyz S, Maguire S. Eating disorder outcomes: findings from a rapid review of over a decade of research. Journal of Eating Disorders. 2023;11(1):85. https://doi.org/10.1186/s40337-023-00801-3 .

Tindall RM, Ferris M, Townsend M, Boschert G, Moylan S. A first-hand experience of co‐design in mental health service design: opportunities, challenges, and lessons. International Journal of Mental Health Nursing. 2021;30(6):1693–702. https://doi.org/10.1111/inm.12925 .

National Collaborating Centre for Mental Health. Working Well Together: Evidence and Tools to Enable Co-production in Mental Health Commissioning. London; 2019.

Babb C, Jones CRG, Fox JRE. Investigating service users’ perspectives of eating disorder services: A meta-synthesis. Clin Psychology & Psychotherapy. 2022;29(4):1276–96. https://doi.org/10.1002/cpp.2723 .

Austin A, Flynn M, Richards K, Hodsoll J, Duarte TA, Robinson P, Kelly J, Schmidt U. Duration of untreated eating disorder and relationship to outcomes: A systematic review of the literature. European Eating Disorders Review. 2021;29(3):329 – 45. https://doi.org/10.1002/erv.2745 .

Lock J. Family therapy for eating disorders in youth: current confusions, advances, and new directions. Current Opinion in Psychiatry. 2018;31(6):431–5. https://doi.org/10.1097/YCO.0000000000000451 .

Stockford C, Stenfert Kroese B, Beesley A, Leung N. Women’s recovery from anorexia nervosa: a systematic review and meta-synthesis of qualitative research. Eating Disorders. 2019;27(4):343–68. https://doi.org/10.1080/10640266.2018.1512301 .

Bardone-Cone AM, Hunt RA, Watson HJ. An overview of conceptualizations of eating disorder recovery, recent findings, and future directions. Current Psychiatry Reports. 2018;20(9):79. https://doi.org/10.1007/s11920-018-0932-9 .

de Vos JA, LaMarre A, Radstaak M, Bijkerk CA, Bohlmeijer ET, Westerhof GJ. Identifying fundamental criteria for eating disorder recovery: a systematic review and qualitative meta-analysis. Journal of eating disorders. 2017;5:1–4. https://doi.org/10.1186/s40337-017-0164-0 .

Wetzler S, Hackmann C, Peryer G, Clayman K, Friedman D, Saffran K, Silver J, Swarbrick M, Magill E, van Furth EF, Pike KM. A framework to conceptualize personal recovery from eating disorders: a systematic review and qualitative meta-synthesis of perspectives from individuals with lived experience. International Journal of Eating Disorders. 2020;53(8):1188–203. https://doi.org/10.1002/eat.23260 .

Peebles I, Cronje JL, Clark L, Sharpe H, Duffy F. Experiences of inpatient eating disorder admissions: A systematic review and meta-synthesis. Eating Behaviors. 2023 May 23:101753. https://doi.org/10.1016/j.eatbeh.2023.101753 .

Rankin R, Conti J, Ramjan L, Hay P. A systematic review of people’s lived experiences of inpatient treatment for anorexia nervosa: living in a bubble. Journal of Eating Disorders. 2023;11(1):95. https://doi.org/10.1186/s40337-023-00820-0 .

Page MJ, McKenzie JE, Bossuyt PM, Boutron I, Hoffmann TC, Mulrow CD, Shamseer L, Tetzlaff JM, Akl EA, Brennan SE, Chou R. The PRISMA 2020 statement: an updated guideline for reporting systematic reviews. BMJ. 2021 March 29;372. https://doi.org/10.1136/bmj.n71 .

Cooke A, Smith D, Booth A, Beyond PICO. the SPIDER tool for qualitative evidence synthesis. Qualitative Health Research. 2012;22(10):1435-43. https://doi.org/10.1177/1049732312452938 .

Garside R. Should we appraise the quality of qualitative research reports for systematic reviews, and if so, how? Innovation: The European Journal of Social Science Research. 2014;27(1):67–79. https://doi.org/10.1080/13511610.2013.777270 .

Noyes J, Booth A, Flemming K, Garside R, Harden A, Lewin S, Pantoja T, Hannes K, Cargo M, Thomas J. Cochrane Qualitative and Implementation Methods Group guidance series—paper 3: methods for assessing methodological limitations, data extraction and synthesis, and confidence in synthesized qualitative findings. Journal of Clinical Epidemiology. 2018;97:49–58. https://doi.org/10.1016/j.jclinepi.2017.06.020 .

Carroll C, Booth A, Lloyd-Jones M. Should we exclude inadequately reported studies from qualitative systematic reviews? an evaluation of sensitivity analyses in two case study reviews. Qualitative health research. 2012;22(10):1425-34. https://doi.org/10.1177/1049732312452937 .

Long HA, French DP, Brooks JM. Optimising the value of the critical appraisal skills programme (CASP) tool for quality appraisal in qualitative evidence synthesis. Research Methods in Medicine & Health Sciences. 2020;1(1):31–42. https://doi.org/10.1177/2632084320947559 .

Boeije HR, van Wesel F, Alisic E. Making a difference: towards a method for weighing the evidence in a qualitative synthesis. Journal of Evaluation in Clinical Practice. 2011;17(4):657 – 63. https://doi.org/10.1111/j.1365-2753.2011.01674.x .

Thomas J, Harden A. Methods for the thematic synthesis of qualitative research in systematic reviews. BMC medical research methodology. 2008;8:1 – 0. https://doi.org/10.1186/1471-2288-8-45 .

Olmos-Vega FM, Stalmeijer RE, Varpio L, Kahlke R. A practical guide to reflexivity in qualitative research: AMEE Guide No. 149. Medical Teacher. 2023;45(3):241–51. https://doi.org/10.1080/0142159X.2022.2057287 .

Jamieson MK, Govaart GH, Pownall M. Reflexivity in quantitative research: A rationale and beginner’s guide. Social and Personality Psychology Compass. 2023;17(4):e12735. https://doi.org/10.1111/spc3.12735 .

Long S, Wallis D, Leung N, Meyer C. All eyes are on you: anorexia nervosa patient perspectives of in-patient mealtimes. Journal of Health Psychology. 2012;17(3):419 – 28. https://doi.org/10.1177/1359105311419270 .

Solhaug C, Alsaker S. Treatment of eating disorders: voices from a ward. International Journal of Qualitative Studies on Health and Well-being. 2021;16(1):1983948. https://doi.org/10.1080/17482631.2021.1983948 .

Mac Donald B, Gustafsson SA, Bulik CM, Clausen L. Living and leaving a life of coercion: a qualitative interview study of patients with anorexia nervosa and multiple involuntary treatment events. Journal of Eating Disorders. 2023;11(1):40. https://doi.org/10.1186/s40337-023-00765-4 .

Fox JR, Diab P. An exploration of the perceptions and experiences of living with chronic anorexia nervosa while an inpatient on an Eating Disorders Unit: An Interpretative Phenomenological Analysis (IPA) study. Journal of Health Psychology. 2015;20(1):27–36. https://doi.org/10.1177/1359105313497526 .

Rienecke RD, Dimitropoulos G, Duffy A, Le Grange D, Manwaring J, Nieder S, Sauerwein J, Singh M, Watters A, Westmoreland P, Mehler PS. Involuntary treatment: A qualitative study from the perspectives of individuals with anorexia nervosa. European Eating Disorders Review. 2023;31(6):850 – 62. https://doi.org/10.1002/erv.3010 .

Sly R, Morgan JF, Mountford VA, Sawer F, Evans C, Lacey JH. Rules of engagement: Qualitative experiences of therapeutic alliance when receiving in-patient treatment for anorexia nervosa. Eating Disorders. 2014;22(3):233 – 43. https://doi.org/10.1080/10640266.2013.867742 .

Cockell SJ, Zaitsoff SL, Geller J. Maintaining change following eating disorder treatment. Professional Psychology: Research and Practice. 2004;35(5):527–534. https://doi.org/10.1037/0735-7028.35.5.527 .

Matthews K, Gordon L, van Beusekom J, Sheffield J, Patterson S. A day treatment program for adults with eating disorders: staff and patient experiences in implementation. Journal of Eating Disorders. 2019;7(1):21. https://doi.org/10.1186/s40337-019-0252-4 .

İnce B, Phillips MD, Zenasni Z, Shearer J, Dalton B, Irish M, Mercado D, Webb H, McCombie C, Au K, Kern N. Autopsy of a failed trial part 2: Outcomes, challenges, and lessons learnt from the DAISIES trial. European Eating Disorders Review. 2023 Dec 18. https://doi.org/10.1002/erv.3058 .

Matthews-Rensch K, Young A, Cutmore C, Davis A, Jeffrey S, Patterson S. Acceptability of using a nasogastric refeeding protocol with adult patients with medically unstable eating disorders. Journal of Evaluation in Clinical Practice. 2023;29(1):49–58. https://doi.org/10.1111/jep.13718 .

Strand M, Bulik CM, von Hausswolff-Juhlin Y, Gustafsson SA. Self‐admission to inpatient treatment for patients with anorexia nervosa: the patient’s perspective. International Journal of Eating Disorders. 2017;50(4):398–405. https://doi.org/10.1002/eat.22659 .

Yim SH, Jones R, Cooper M, Roberts L, Viljoen D. Patients’ experiences of clinical team meetings (ward rounds) at an adult in-patient eating disorders ward: mixed-method service improvement project. BJPsych Bulletin. 2023;47(6):316 – 22. https://doi.org/10.1192/bjb.2023.14 .

Seed T, Fox J, Berry K. Experiences of detention under the mental health act for adults with anorexia nervosa. Clinical Psychology & Psychotherapy. 2016;23(4):352 – 62. https://doi.org/10.1002/cpp.1963 .

Smith V, Chouliara ZO, Morris PG, Collin PA, Power K, Yellowlees AL, Grierson D, Papageorgiou E, Cook M. The experience of specialist inpatient treatment for anorexia nervosa: a qualitative study from adult patients’ perspectives. Journal of Health Psychology. 2016;21(1):16–27. https://doi.org/10.1177/1359105313520336 .

Eli K. Between difference and belonging: Configuring self and others in inpatient treatment for eating disorders. PLoS One. 2014;9(9):e105452. https://doi.org/10.1371/journal.pone.0105452 .

Bryan DC, Macdonald P, Cardi V, Rowlands K, Ambwani S, Arcelus J, Bonin EM, Landau S, Schmidt U, Treasure J. Transitions from intensive eating disorder treatment settings: qualitative investigation of the experiences and needs of adults with anorexia nervosa and their carers. BJPsych open. 2022;8(4):e137. https://doi.org/10.1192/bjo.2022.535 .

Hannon J, Eunson L, Munro C. The patient experience of illness, treatment, and change, during intensive community treatment for severe anorexia nervosa. Eating disorders. 2017;25(4):279 – 96. https://doi.org/10.1080/10640266.2017.1318626 .

Federici A, Kaplan AS. The patient’s account of relapse and recovery in anorexia nervosa: A qualitative study. European Eating Disorders Review: The Professional Journal of the Eating Disorders Association. 2008;16(1):1–10. https://doi.org/10.1002/erv.813 .

Ross JA, Green C. Inside the experience of anorexia nervosa: A narrative thematic analysis. Counselling and Psychotherapy Research. 2011;11(2):112-9. https://doi.org/10.1080/14733145.2010.486864 .

Zugai JS, Stein-Parbury J, Roche M. Therapeutic alliance, anorexia nervosa and the inpatient setting: A mixed methods study. Journal of advanced nursing. 2018;74(2):443 – 53. https://doi.org/10.1111/jan.13410 .

O’Connell L. Being and doing anorexia nervosa: an autoethnography of diagnostic identity and performance of illness. Health. 2023;27(2):263 – 78. https://doi.org/10.1177/13634593211017190 .

Holmes S, Malson H, Semlyen J. Regulating untrustworthy patients: constructions of trust and distrust in accounts of inpatient treatment for anorexia. Feminism & Psychology. 2021;31(1):41–61. https://doi.org/10.1177/0959353520967516 .

Pemberton K, Fox JR. The experience and management of emotions on an inpatient setting for people with anorexia nervosa: a qualitative study. Clinical Psychology & Psychotherapy. 2013;20(3):226 – 38. https://doi.org/10.1002/cpp.794 .

Biddiscombe RJ, Scanlan JN, Ross J, Horsfield S, Aradas J, Hart S. Exploring the perceived usefulness of practical food groups in day treatment for individuals with eating disorders. Australian occupational therapy journal. 2018;65(2):98–106. https://doi.org/10.1111/1440-1630.12442 .

Williams KD, O’Reilly C, Coelho JS. Residential treatment for eating disorders in a Canadian treatment centre: clinical characteristics and treatment experiences of residents. Canadian Journal of Behavioural Science. 2020;52(1):57. https://doi.org/10.1037/cbs0000143 .

Whitney J, Easter A, Tchanturia K. Service users’ feedback on cognitive training in the treatment of anorexia nervosa: a qualitative study. International Journal of Eating Disorders. 2008;41(6):542 – 50. https://doi.org/10.1002/eat.20536 .

Larsson E, Lloyd S, Westwood H, Tchanturia K. Patients’ perspective of a group intervention for perfectionism in anorexia nervosa: a qualitative study. Journal of Health Psychology. 2018;23(12):1521-32. https://doi.org/10.1177/1359105316660183 .

Hedlund S, Landgren K. Creating an Opportunity to Reflect: Ear Acupuncture in Anorexia Nervosa–Inpatients’ Experiences. Issues in Mental Health Nursing. 2017;38(7):549 – 56. https://doi.org/10.1080/01612840.2017.1303858 .

Money C, Genders R, Treasure J, Schmidt U, Tchanturia K. A brief emotion focused intervention for inpatients with anorexia nervosa: a qualitative study. Journal of health psychology. 2011;16(6):947 – 58. https://doi.org/10.1177/1359105310396395 .

Wright KM, Hacking S. An angel on my shoulder: a study of relationships between women with anorexia and healthcare professionals. Journal of Psychiatric and Mental Health Nursing. 2012;19(2):107 – 15. https://doi.org/10.1111/j.1365-2850.2011.01760.x .

Glasofer DR, Muratore AF, Attia E, Wu P, Wang Y, Minkoff H, Rufin T, Walsh BT, Steinglass JE. Predictors of illness course and health maintenance following inpatient treatment among patients with anorexia nervosa. Journal of Eating Disorders. 2020;8(1):69. https://doi.org/10.1186/s40337-020-00348-7 .

Thompson-Brenner H, Brooks GE, Boswell JF, Espel‐Huynh H, Dore R, Franklin DR, Gonçalves A, Smith M, Ortiz S, Ice S, Barlow DH. Evidence‐based implementation practices applied to the intensive treatment of eating disorders: summary of research and illustration of principles using a case example. Clinical Psychology: Science and Practice. 2018;25(1):e12221. https://doi.org/10.1111/cpsp.12221 .

Solmi M, Wade TD, Byrne S, Del Giovane C, Fairburn CG, Ostinelli EG, De Crescenzo F, Johnson C, Schmidt U, Treasure J, Favaro A. Comparative efficacy and acceptability of psychological interventions for the treatment of adult outpatients with anorexia nervosa: a systematic review and network meta-analysis. The Lancet Psychiatry. 2021;8(3):215 – 24. https://doi.org/10.1016/S2215-0366(20)30566-6 .

Heywood L, Conti J, Hay P. Paper 1: a systematic synthesis of narrative therapy treatment components for the treatment of eating disorders. Journal of Eating Disorders. 2022;10(1):137. https://doi.org/10.1186/s40337-022-00635-5 .

Dawson L, Rhodes P, Touyz S. Doing the impossible the process of recovery from chronic anorexia nervosa. Qualitative Health Research. 2014 March 4;24(4):494–505. https://doi.org/10.1177/1049732314524029 .

Ali K, Farrer L, Fassnacht DB, Gulliver A, Bauer S, Griffiths KM. Perceived barriers and facilitators towards help-seeking for eating disorders: a systematic review. International Journal of Eating Disorders. 2016;50(1):9–21. https://doi.org/10.1002/eat.22598 .

Lindgren BM, Enmark A, Bohman A, Lundström M. A qualitative study of young women’s experiences of recovery from bulimia nervosa. Journal of advanced nursing. 2015 March 4;71(4):860-9. https://doi.org/10.1111/jan.12554 .

Nordbø RH, Espeset EM, Gulliksen KS, Skårderud F, Geller J, Holte A. Reluctance to recover in anorexia nervosa. European Eating Disorders Review. 2012;20(1):60 – 7. https://doi.org/10.1002/erv.1097 .

Krebs P, Norcross JC, Nicholson JM, Prochaska JO. Stages of change and psychotherapy outcomes: A review and meta-analysis. Journal of clinical psychology. 2018;74(11):1964-79. https://doi.org/10.1002/jclp.22683 .

Webb H, Dalton B, Irish M, Mercado D, McCombie C, Peachey G, Arcelus J, Au K, Himmerich H, Louise Johnston A, Lazarova S. Clinicians’ perspectives on supporting individuals with severe anorexia nervosa in specialist eating disorder intensive treatment settings. Journal of eating disorders. 2022;10(1):3. https://doi.org/10.1186/s40337-021-00528-z .

Weiss CV, Mills JS, Westra HA, Carter JC. A preliminary study of motivational interviewing as a prelude to intensive treatment for an eating disorder. Journal of Eating Disorders. 2013;1(34). https://doi.org/10.1186/2050-2974-1-34 .

Mack RA, Kelleher K, Bhattarai JJ, Spence T. Individuals with eating disorders’ perspectives on a meal preparation intervention. Occupational Therapy in Mental Health. 2023 Sep 28:1–20. https://doi.org/10.1080/0164212X.2023.2262761 .

Jeffrey S, Heruc G. Balancing nutrition management and the role of dietitians in eating disorder treatment. Journal of Eating Disorders. 2020;8(1):64. https://doi.org/10.1186/s40337-020-00344-x .

Walker DC, Heiss S, Donahue JM, Brooks JM. Practitioners’ perspectives on ethical issues within the treatment of eating disorders: Results from a concept mapping study. International Journal of Eating Disorders. 2020;53(12):1941-51. https://doi.org/10.1002/eat.23381 .

Vinchenzo C, Lawrence V, McCombie C. Patient perspectives on premature termination of eating disorder treatment: a systematic review and qualitative synthesis. Journal of Eating Disorders. 2022;10(1):39. https://doi.org/10.1186/s40337-022-00568-z .

Irish M, Dalton B, Potts L, McCombie C, Shearer J, Au K, Kern N, Clark-Stone S, Connan F, Johnston AL, Lazarova S. The clinical effectiveness and cost-effectiveness of a ‘stepping into day treatment’approach versus inpatient treatment as usual for anorexia nervosa in adult specialist eating disorder services (DAISIES trial): a study protocol of a randomised controlled multi-centre open-label parallel group non-inferiority trial. Trials. 2022;23(1):500. https://doi.org/10.1186/s13063-022-06386-7 .

Ward-Ciesielski EF, Rizvi SL. The potential iatrogenic effects of psychiatric hospitalization for suicidal behavior: A critical review and recommendations for research. Clinical Psychology: Science and Practice. 2021;28(1):60–71. https://doi.org/10.1111/cpsp.12332 .

Elzakkers IF, Danner UN, Hoek HW, Schmidt U, van Elburg AA. Compulsory treatment in anorexia nervosa: a review. International Journal of Eating Disorders. 2014;47(8):845 – 52. https://doi.org/10.1002/eat.22330 .

Fleming C, Le Brocque R, Healy K. How are families included in the treatment of adults affected by eating disorders? A scoping review. International Journal of Eating Disorders. 2021;54(3):244 – 79. https://doi.org/10.1002/eat.23441 .

Hannah L, Cross M, Baily H, Grimwade K, Clarke T, Allan SM. A systematic review of the impact of carer interventions on outcomes for patients with eating disorders. Eating and Weight Disorders-Studies on Anorexia, Bulimia and Obesity. 2021; 27: 1953-62. https://doi.org/10.1007/s40519-021-01338-7 .

Treasure J, Nazar BP. Interventions for the carers of patients with eating disorders. Current Psychiatry Reports. 2016;18:1–7. https://doi.org/10.1007/s11920-015-0652-3 .

Lewis HK, Foye U. From prevention to peer support: a systematic review exploring the involvement of lived-experience in eating disorder interventions. Mental Health Review Journal. 2022;27(1):1–17. https://doi.org/10.1108/MHRJ-04-2021-0033 .

McNamara N, Parsons H. ‘Everyone here wants everyone else to get better’: The role of social identity in eating disorder recovery. British Journal of Social Psychology. 2016;55(4):662 – 80. https://doi.org/10.1111/bjso.12161 .

Thompson-Brenner H, Brooks GE, Boswell JF, Espel‐Huynh H, Dore R, Franklin DR, Gonçalves A, Smith M, Ortiz S, Ice S, Barlow DH. Evidence‐based implementation practices applied to the intensive treatment of eating disorders: Summary of research and illustration of principles using a case example. Clinical Psychology: Science and Practice. 2018;25(1). https://doi.org/10.1111/cpsp.12221 .

Chen EY, Kaye WH. We are only at the tip of the iceberg: A commentary on higher levels of care for anorexia nervosa. Clinical psychology: a publication of the Division of Clinical Psychology of the American Psychological Association. 2018;25(1). https://doi.org/10.1111/cpsp.12225 .

Macdonald P, Hibbs R, Corfield F, Treasure J. The use of motivational interviewing in eating disorders: a systematic review. Psychiatry research. 2012;200(1):1–11. https://doi.org/10.1016/j.psychres.2012.05.013 .

Schmidt U, Wade TD, Treasure J. The Maudsley Model of Anorexia Nervosa Treatment for Adults (MANTRA): development, key features, and preliminary evidence. Journal of cognitive psychotherapy. 2014;28(1):48–71. https://doi.org/10.1891/0889-8391.28.1.48 .

Heywood L, Conti J, Hay P. Paper 1: a systematic synthesis of narrative therapy treatment components for the treatment of eating disorders. Journal of Eating Disorders. 2022;10(1). https://doi.org/10.1186/s40337-022-00635-5 .

Oldershaw A, Startup H. Building the healthy adult in eating disorders: a schema mode and emotion-focused therapy approach for anorexia nervosa. In: Oldershaw A, Startup H, editors. Creative methods in schema therapy. PLACE: Routledge; 2020. pp. 287–300.

Chapter   Google Scholar  

Harrison A, Stavri P, Tchanturia K. Individual and group format adjunct therapy on social emotional skills for adolescent inpatients with severe and complex eating disorders (CREST-A). Neuropsychiatrie. 2021;35:163 – 76. https://doi.org/10.1007/s40211-020-00375-5 .

Hambleton A, Pepin G, Le A, Maloney D, Touyz S, Maguire S. Psychiatric and medical comorbidities of eating disorders: findings from a rapid review of the literature. Journal of eating disorders. 2022;10(1). https://doi.org/10.1186/s40337-022-00654-2 .

McMaster CM, Wade T, Franklin J, Hart S. A review of treatment manuals for adults with an eating disorder: nutrition content and consistency with current dietetic evidence. Eating and Weight Disorders-Studies on Anorexia, Bulimia and Obesity. 2021;26:47–60. https://doi.org/10.1007/s40519-020-00850-6 .

Yang Y, Conti J, McMaster CM, Hay P. Beyond refeeding: the effect of including a dietitian in eating disorder treatment. A systematic review. Nutrients. 2021;13(12). https://doi.org/10.3390/nu13124490 .

Adamson J, Cardi V, Kan C, Harrison A, Macdonald P, Treasure J. Evaluation of a novel transition support intervention in an adult eating disorders service: ECHOMANTRA. International Review of Psychiatry. 2019;31(4):382 – 90. https://doi.org/10.1080/09540261.2019.1573721 .

Dalle Grave R. Multistep cognitive behavioral therapy for eating disorders: theory, practice, and clinical cases. Jason Aronson; 2013.

Ibrahim A, Ryan S, Viljoen D, Tutisani E, Gardner L, Collins L, Ayton A. Integrated enhanced cognitive behavioural (I-CBTE) therapy significantly improves effectiveness of inpatient treatment of anorexia nervosa in real life settings. Journal of Eating Disorders. 2022;10(1):98. https://doi.org/10.1186/s40337-022-00620-y .

National Institute for Health and Care Excellence. Eating disorders: recognition and treatment NG69. London: NICE. 2017. https://www.nice.org.uk/guidance/ng69 .

Hay P, Chinn D, Forbes D, Madden S, Newton R, Sugenor L, Touyz S, Ward W. Royal Australian and New Zealand College of Psychiatrists clinical practice guidelines for the treatment of eating disorders. Australian & New Zealand Journal of Psychiatry. 2014;48(11):977–1008. https://doi.org/10.1177/0004867414555814 .

Bezance J, Holliday J. Mothers’ experiences of home treatment for adolescents with anorexia nervosa: an interpretative phenomenological analysis. Eating Disorders. 2014;22(5):386–404. https://doi.org/10.1080/10640266.2014.925760 .

Fleming C, Byrne J, Healy K, Le Brocque R. Working with families of adults affected by eating disorders: uptake, key themes, and participant experiences of family involvement in outpatient treatment-as-usual. Journal of Eating Disorders. 2022;10(1):88. https://doi.org/10.1186/s40337-022-00611-z .

Graham MR, Tierney S, Chisholm A, Fox JR. The lived experience of working with people with eating disorders: A meta-ethnography. International Journal of Eating Disorders. 2020;53(3):422 – 41. https://doi.org/10.1002/eat.23215 .

Hartley S, Raphael J, Lovell K, Berry K. Effective nurse–patient relationships in mental health care: A systematic review of interventions to improve the therapeutic alliance. International Journal of Nursing Studies. 2020;102:103490. https://doi.org/10.1016/j.ijnurstu.2019.103490 .

Gulliksen KS, Espeset EM, Nordbø RH, Skårderud F, Geller J, Holte A. Preferred therapist characteristics in treatment of anorexia nervosa: the patient’s perspective. International Journal of Eating Disorders. 2012;45(8):932 – 41. https://doi.org/10.1002/eat.22033 .

Johns G, Taylor B, John A, Tan J. Current eating disorder healthcare services–the perspectives and experiences of individuals with eating disorders, their families and health professionals: systematic review and thematic synthesis. BJPsych open. 2019;5(4):e59. https://doi.org/10.1192/bjo.2019.48 .

Treharne GJ, Riggs DW. Ensuring quality in qualitative research. In: Rohleder P, Lyons A, editors. Qualitative Research in clinical and Health psychology. Bloomsbury; 2017. pp. 57–73.

Goel NJ, Jennings Mathis K, Egbert AH, Petterway F, Breithaupt L, Eddy KT, Franko DL, Graham AK. Accountability in promoting representation of historically marginalized racial and ethnic populations in the eating disorders field: a call to action. International Journal of Eating Disorders. 2022;55(4):463-9. https://doi.org/10.1002/eat.23682 .

Download references

Acknowledgements

Not applicable.

There was no direct funding for this project. The first author completed the systematic review as part of a Doctorate in Clinical Psychology at the Salomons Institute for Applied Psychology whilst employed by Surrey and Borders Partnership NHS Foundation Trust. US receives salary support from the NIHR Biomedical Research Centre for Mental Health, South London and Maudsley NHS Foundation Trust and Institute of Psychiatry, Psychology and Neuroscience, King’s College London.

Author information

Authors and affiliations.

Salomons Institute for Applied Psychology, Canterbury Christ Church University, Tunbridge Wells, TN1 2YG, UK

Hannah Webb & Maria Griffiths

Centre for Research in Eating and Weight Disorders, Institute of Psychiatry, Psychology & Neuroscience, King’s College London, London, UK

Ulrike Schmidt

South London and Maudsley NHS Foundation Trust, Maudsley Hospital, Denmark Hill, London, SE5 8AZ, UK

You can also search for this author in PubMed   Google Scholar

Contributions

HW conducted the review and analysed data, and was a major contributor in writing the manuscript; MG supervised the project, provided qualitative expertise during analysis and reviewed the manuscript; US supervised the project and reviewed the manuscript. All authors approved the final manuscript.

Corresponding author

Correspondence to Hannah Webb .

Ethics declarations

Ethics approval and consent to participate, competing interests.

The authors declare no competing interests.

Consent for publication

Additional information, publisher’s note.

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Rights and permissions

Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article’s Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article’s Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/ . The Creative Commons Public Domain Dedication waiver ( http://creativecommons.org/publicdomain/zero/1.0/ ) applies to the data made available in this article, unless otherwise stated in a credit line to the data.

Reprints and permissions

About this article

Cite this article.

Webb, H., Griffiths, M. & Schmidt, U. Experiences of intensive treatment for people with eating disorders: a systematic review and thematic synthesis. J Eat Disord 12 , 115 (2024). https://doi.org/10.1186/s40337-024-01061-5

Download citation

Received : 17 April 2024

Accepted : 09 July 2024

Published : 14 August 2024

DOI : https://doi.org/10.1186/s40337-024-01061-5

Share this article

Anyone you share the following link with will be able to read this content:

Sorry, a shareable link is not currently available for this article.

Provided by the Springer Nature SharedIt content-sharing initiative

• Anorexia nervosa, bulimia nervosa
• Eating disorders
• Intensive treatment
• Qualitative research
• Day patient
• Patient perspective

Journal of Eating Disorders

ISSN: 2050-2974

• General enquiries: [email protected]

Maintenance work is planned from 21:00 BST on Sunday 18th August 2024 to 21:00 BST on Monday 19th August 2024, and on Thursday 29th August 2024 from 11:00 to 12:00 BST.

During this time the performance of our website may be affected - searches may run slowly, some pages may be temporarily unavailable, and you may be unable to log in or to access content. If this happens, please try refreshing your web browser or try waiting two to three minutes before trying again.

We apologise for any inconvenience this might cause and thank you for your patience.

Faraday Discussions

A critical reflection on attempts to machine-learn materials synthesis insights from text-mined literature recipes.

Synthesis of predicted materials is the key and final step needed to realize a vision of computationally-accelerated materials discovery. Because so many materials have been previously synthesized, one would anticipate that text-mining synthesis recipes from the literature would yield a valuable dataset to train machine learning models that can predict synthesis recipes to new materials. Between 2016 and 2019, the corresponding author (Wenhao Sun) participated in efforts to text-mine 31,782 solid-state synthesis recipes and 35,675 solution-based synthesis recipes from the literature. Here, we characterize these datasets and show that they do not satisfy the “4 Vs” of data-science—that is: volume, veracity, variety, and velocity. For this reason, we believe that machine-learned regression or classification models built from these datasets will have limited utility in guiding the predictive synthesis of novel materials. On the other hand, these large datasets provided an opportunity to identify anomalous synthesis recipes—which in fact did inspire new hypotheses on how materials form, that we later validated by experiment. Our case study here urges a re-evaluation on how to extract the most value from large historical materials science datasets.

• This article is part of the themed collection: Data-driven discovery in the chemical sciences

Article information

Download Citation

Permissions.

W. Sun and N. David, Faraday Discuss. , 2024, Accepted Manuscript , DOI: 10.1039/D4FD00112E

This article is licensed under a Creative Commons Attribution-NonCommercial 3.0 Unported Licence . You can use material from this article in other publications, without requesting further permission from the RSC, provided that the correct acknowledgement is given and it is not used for commercial purposes.

To request permission to reproduce material from this article in a commercial publication , please go to the Copyright Clearance Center request page .

If you are an author contributing to an RSC publication, you do not need to request permission provided correct acknowledgement is given.

If you are the author of this article, you do not need to request permission to reproduce figures and diagrams provided correct acknowledgement is given. If you want to reproduce the whole article in a third-party commercial publication (excluding your thesis/dissertation for which permission is not required) please go to the Copyright Clearance Center request page .

Read more about how to correctly acknowledge RSC content .

Social activity

Search articles by author.

This article has not yet been cited.

Advertisements

• Research article
• Open access
• Published: 15 August 2024

The impact of adverse childhood experiences on multimorbidity: a systematic review and meta-analysis

• Dhaneesha N. S. Senaratne 1 ,
• Bhushan Thakkar 1 ,
• Blair H. Smith 1 ,
• Tim G. Hales 2 ,
• Louise Marryat 3 &
• Lesley A. Colvin 1  

BMC Medicine volume  22 , Article number:  315 ( 2024 ) Cite this article

Metrics details

Adverse childhood experiences (ACEs) have been implicated in the aetiology of a range of health outcomes, including multimorbidity. In this systematic review and meta-analysis, we aimed to identify, synthesise, and quantify the current evidence linking ACEs and multimorbidity.

We searched seven databases from inception to 20 July 2023: APA PsycNET, CINAHL Plus, Cochrane CENTRAL, Embase, MEDLINE, Scopus, and Web of Science. We selected studies investigating adverse events occurring during childhood (< 18 years) and an assessment of multimorbidity in adulthood (≥ 18 years). Studies that only assessed adverse events in adulthood or health outcomes in children were excluded. Risk of bias was assessed using the ROBINS-E tool. Meta-analysis of prevalence and dose–response meta-analysis methods were used for quantitative data synthesis. This review was pre-registered with PROSPERO (CRD42023389528).

From 15,586 records, 25 studies were eligible for inclusion (total participants = 372,162). The prevalence of exposure to ≥ 1 ACEs was 48.1% (95% CI 33.4 to 63.1%). The prevalence of multimorbidity was 34.5% (95% CI 23.4 to 47.5%). Eight studies provided sufficient data for dose–response meta-analysis (total participants = 197,981). There was a significant dose-dependent relationship between ACE exposure and multimorbidity ( p  < 0.001), with every additional ACE exposure contributing to a 12.9% (95% CI 7.9 to 17.9%) increase in the odds for multimorbidity. However, there was heterogeneity among the included studies ( I 2  = 76.9%, Cochran Q  = 102, p  < 0.001).

Conclusions

This is the first systematic review and meta-analysis to synthesise the literature on ACEs and multimorbidity, showing a dose-dependent relationship across a large number of participants. It consolidates and enhances an extensive body of literature that shows an association between ACEs and individual long-term health conditions, risky health behaviours, and other poor health outcomes.

Peer Review reports

In recent years, adverse childhood experiences (ACEs) have been identified as factors of interest in the aetiology of many conditions [ 1 ]. ACEs are potentially stressful events or environments that occur before the age of 18. They have typically been considered in terms of abuse (e.g. physical, emotional, sexual), neglect (e.g. physical, emotional), and household dysfunction (e.g. parental separation, household member incarceration, household member mental illness) but could also include other forms of stress, such as bullying, famine, and war. ACEs are common: estimates suggest that 47% of the UK population have experienced at least one form, with 12% experiencing four or more [ 2 ]. ACEs are associated with poor outcomes in a range of physical health, mental health, and social parameters in adulthood, with greater ACE burden being associated with worse outcomes [ 1 , 2 , 3 , 4 , 5 , 6 , 7 , 8 ].

Over a similar timescale, multimorbidity has emerged as a significant heath challenge. It is commonly defined as the co-occurrence of two or more long-term conditions (LTCs), with a long-term condition defined as any physical or mental health condition lasting, or expected to last, longer than 1 year [ 9 ]. Multimorbidity is both common and age-dependent, with a global adult prevalence of 37% that rises to 51% in adults over 60 [ 10 , 11 ]. Individuals living with multimorbidity face additional challenges in managing their health, such as multiple appointments, polypharmacy, and the lack of continuity of care [ 12 , 13 , 14 ]. Meanwhile, many healthcare systems struggle to manage the additional cost and complexity of people with multimorbidity as they have often evolved to address the single disease model [ 15 , 16 ]. As global populations continue to age, with an estimated 2.1 billion adults over 60 by 2050, the pressures facing already strained healthcare systems will continue to grow [ 17 ]. Identifying factors early in the aetiology of multimorbidity may help to mitigate the consequences of this developing healthcare crisis.

Many mechanisms have been suggested for how ACEs might influence later life health outcomes, including the risk of developing individual LTCs. Collectively, they contribute to the idea of ‘toxic stress’; cumulative stress during key developmental phases may affect development [ 18 ]. ACEs are associated with measures of accelerated cellular ageing, including changes in DNA methylation and telomere length [ 19 , 20 ]. ACEs may lead to alterations in stress-signalling pathways, including changes to the immune, endocrine, and cardiovascular systems [ 21 , 22 , 23 ]. ACEs are also associated with both structural and functional differences in the brain [ 24 , 25 , 26 , 27 ]. These diverse biological changes underpin psychological and behavioural changes, predisposing individuals to poorer self-esteem and risky health behaviours, which may in turn lead to increased risk of developing individual LTCs [ 1 , 2 , 28 , 29 , 30 , 31 , 32 ]. A growing body of evidence has therefore led to an increased focus on developing trauma-informed models of healthcare, in which the impact of negative life experiences is incorporated into the assessment and management of LTCs [ 33 ].

Given the contributory role of ACEs in the aetiology of individual LTCs, it is reasonable to suspect that ACEs may also be an important factor in the development of multimorbidity. Several studies have implicated ACEs in the aetiology of multimorbidity, across different cohorts and populations, but to date no meta-analyses have been performed to aggregate this evidence. In this review, we aim to summarise the state of the evidence linking ACEs and multimorbidity, to quantify the strength of any associations through meta-analysis, and to highlight the challenges of research in this area.

Search strategy and selection criteria

We conducted a systematic review and meta-analysis that was prospectively registered in the International Prospective Register of Systematic Reviews (PROSPERO) on 25 January 2023 (ID: CRD42023389528) and reported using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines.

We developed a search strategy based on previously published literature reviews and refined it following input from subject experts, an academic librarian, and patient and public partners (Additional File 1: Table S1). We searched the following seven databases from inception to 20 July 2023: APA PsycNET, CINAHL Plus, Cochrane CENTRAL, Embase, MEDLINE, Scopus, and Web of Science. The search results were imported into Covidence (Veritas Health Innovation, Melbourne, Australia), which automatically identified and removed duplicate entries. Two reviewers (DS and BT) independently performed title and abstract screening and full text review. Discrepancies were resolved by a third reviewer (LC).

Reports were eligible for review if they included adults (≥ 18 years), adverse events occurring during childhood (< 18 years), and an assessment of multimorbidity or health status based on LTCs. Reports that only assessed adverse events in adulthood or health outcomes in children were excluded.

The following study designs were eligible for review: randomised controlled trials, cohort studies, case–control studies, cross-sectional studies, and review articles with meta-analysis. Editorials, case reports, and conference abstracts were excluded. Systematic reviews without a meta-analysis and narrative synthesis review articles were also excluded; however, their reference lists were screened for relevant citations.

Data analysis

Two reviewers (DS and BT) independently performed data extraction into Microsoft Excel (Microsoft Corporation, Redmond, USA) using a pre-agreed template. Discrepancies were resolved by consensus discussion with a third reviewer (LC). Data extracted from each report included study details (author, year, study design, sample cohort, sample size, sample country of origin), patient characteristics (age, sex), ACE information (definition, childhood cut-off age, ACE assessment tool, number of ACEs, list of ACEs, prevalence), multimorbidity information (definition, multimorbidity assessment tool, number of LTCs, list of LTCs, prevalence), and analysis parameters (effect size, model adjustments). For meta-analysis, we extracted ACE groups, number of ACE cases, number of multimorbidity cases, number of participants, odds ratios or regression beta coefficients, and 95% confidence intervals (95% CI). Where data were partially reported or missing, we contacted the study authors directly for further information.

Two reviewers (DS and BT) independently performed risk of bias assessments of each included study using the Risk Of Bias In Non-randomized Studies of Exposures (ROBINS-E) tool [ 34 ]. The ROBINS-E tool assesses the risk of bias for the study outcome relevant to the systematic review question, which may not be the primary study outcome. It assesses risk of bias across seven domains; confounding, measurement of the exposure, participant selection, post-exposure interventions, missing data, measurement of the outcome, and selection of the reported result. The overall risk of bias for each study was determined using the ROBINS-E algorithm. Discrepancies were resolved by consensus discussion.

All statistical analyses were performed in R version 4.2.2 using the RStudio integrated development environment (RStudio Team, Boston, USA). To avoid repetition of participant data, where multiple studies analysed the same patient cohort, we selected the study with the best reporting of raw data for meta-analysis and the largest sample size. Meta-analysis of prevalence was performed with the meta package [ 35 ], using logit transformations within a generalised linear mixed model, and reporting the random-effects model [ 36 ]. Inter-study heterogeneity was assessed and reported using the I 2 statistic, Cochran Q statistic, and Cochran Q p -value. Dose–response meta-analysis was performed using the dosresmeta package [ 37 ] following the method outlined by Greenland and Longnecker (1992) [ 38 , 39 ]. Log-linear and non-linear (restricted cubic spline, with knots at 5%, 35%, 65%, and 95%) random effects models were generated, and goodness of fit was evaluated using a Wald-type test (denoted by X 2 ) and the Akaike information criterion (AIC) [ 39 ].

Patient and public involvement

The Consortium Against Pain Inequality (CAPE) Chronic Pain Advisory Group (CPAG) consists of individuals with lived experiences of ACEs, chronic pain, and multimorbidity. CPAG was involved in developing the research question. The group has experience in systematic review co-production (in progress).

The search identified 15,586 records, of which 25 met inclusion criteria for the systematic review (Fig.  1 ) [ 40 , 41 , 42 , 43 , 44 , 45 , 46 , 47 , 48 , 49 , 50 , 51 , 52 , 53 , 54 , 55 , 56 , 57 , 58 , 59 , 60 , 61 , 62 , 63 , 64 ]. The summary characteristics can be found in Additional File 1: Table S2. Most studies examined European ( n  = 11) or North American ( n  = 9) populations, with a few looking at Asian ( n  = 3) or South American ( n  = 1) populations and one study examining a mixed cohort (European and North American populations). The total participant count (excluding studies performed on the same cohort) was 372,162. Most studies had a female predominance (median 53.8%, interquartile range (IQR) 50.9 to 57.4%).

Flow chart of selection of studies into the systematic review and meta-analysis. Flow chart of selection of studies into the systematic review and meta-analysis. ACE, adverse childhood experience; MM, multimorbidity; DRMA, dose–response meta-analysis

All studies were observational in design, and so risk of bias assessments were performed using the ROBINS-E tool (Additional File 1: Table S3) [ 34 ]. There were some consistent risks observed across the studies, especially in domain 1 (risk of bias due to confounding) and domain 3 (risk of bias due to participant selection). In domain 1, most studies were ‘high risk’ ( n  = 24) as they controlled for variables that could have been affected by ACE exposure (e.g. smoking status) [ 40 , 41 , 43 , 44 , 45 , 46 , 47 , 48 , 49 , 50 , 51 , 52 , 53 , 54 , 55 , 56 , 57 , 58 , 59 , 60 , 61 , 62 , 63 , 64 ]. In domain 3, some studies were ‘high risk’ ( n  = 7) as participant selection was based on participant characteristics that could have been influenced by ACE exposure (e.g. through recruitment at an outpatient clinic) [ 45 , 48 , 49 , 51 , 53 , 54 , 58 ]. The remaining studies were deemed as having ‘some concerns’ ( n  = 18) as participant selection occurred at a time after ACE exposure, introducing a risk of survivorship bias [ 40 , 41 , 42 , 43 , 44 , 46 , 47 , 50 , 52 , 55 , 56 , 57 , 59 , 60 , 61 , 62 , 63 , 64 ].

Key differences in risk of bias were seen in domain 2 (risk of bias due to exposure measurement) and domain 5 (risk of bias due to missing data). In domain 2, some studies were ‘high risk’ as they used a narrow or atypical measure of ACEs ( n  = 8) [ 40 , 42 , 44 , 46 , 55 , 56 , 60 , 64 ]; others were graded as having ‘some concerns’ as they used a broader but still incomplete measure of ACEs ( n  = 8) [ 43 , 45 , 48 , 49 , 50 , 52 , 54 , 62 ]; the remainder were ‘low risk’ as they used an established or comprehensive list of ACE questions [ 41 , 47 , 51 , 53 , 57 , 58 , 59 , 61 , 63 ]. In domain 5, some studies were ‘high risk’ as they failed to acknowledge or appropriately address missing data ( n  = 7) [ 40 , 42 , 43 , 45 , 51 , 53 , 60 ]; others were graded as having ‘some concerns’ as they had a significant amount of missing data (> 10% for exposure, outcome, or confounders) but mitigated for this with appropriate strategies ( n  = 6) [ 41 , 50 , 56 , 57 , 62 , 64 ]; the remainder were ‘low risk’ as they reported low levels of missing data ( n  = 12) [ 44 , 46 , 47 , 48 , 49 , 52 , 54 , 55 , 58 , 59 , 61 , 63 ].

Most studies assessed an exposure that was ‘adverse childhood experiences’ ( n  = 10) [ 41 , 42 , 50 , 51 , 53 , 57 , 58 , 61 , 63 , 64 ], ‘childhood maltreatment’ ( n  = 6) [ 44 , 45 , 46 , 48 , 49 , 59 ], or ‘childhood adversity’ ( n  = 3) [ 47 , 54 , 62 ]. The other exposures studied were ‘birth phase relative to World War Two’ [ 40 ], ‘childhood abuse’ [ 43 ], ‘childhood disadvantage’ [ 56 ], ‘childhood racial discrimination’ [ 55 ], ‘childhood trauma’ [ 52 ], and ‘quality of childhood’ (all n  = 1) [ 60 ]. More than half of studies ( n  = 13) did not provide a formal definition of their exposure of choice [ 42 , 43 , 44 , 45 , 49 , 52 , 53 , 54 , 57 , 58 , 60 , 61 , 64 ]. The upper age limit for childhood ranged from < 15 to < 18 years with the most common cut-off being < 18 years ( n  = 9). The median number of ACEs measured in each study was 7 (IQR 4–10). In total, 58 different ACEs were reported; 17 ACEs were reported by at least three studies, whilst 33 ACEs were reported by only one study. The most frequently reported ACEs were physical abuse ( n  = 19) and sexual abuse ( n  = 16) (Table  1 ). The exposure details for each study can be found in Additional File 1: Table S4.

Thirteen studies provided sufficient data to allow for a meta-analysis of the prevalence of exposure to ≥ 1 ACE; the pooled prevalence was 48.1% (95% CI 33.4 to 63.1%, I 2  = 99.9%, Cochran Q  = 18,092, p  < 0.001) (Fig.  2 ) [ 41 , 43 , 44 , 46 , 47 , 49 , 50 , 52 , 53 , 57 , 59 , 61 , 63 ]. Six studies provided sufficient data to allow for a meta-analysis of the prevalence of exposure to ≥ 4 ACEs; the pooled prevalence was 12.3% (95% CI 3.5 to 35.4%, I 2  = 99.9%, Cochran Q  = 9071, p  < 0.001) (Additional File 1: Fig. S1) [ 46 , 50 , 51 , 53 , 59 , 63 ].

Meta-analysis of prevalence of exposure to ≥ 1 adverse childhood experiences. Meta-analysis of prevalence of exposure to ≥ 1 adverse childhood experience. ACE, adverse childhood experience; CI, confidence interval

Thirteen studies explicitly assessed multimorbidity as an outcome, and all of these defined the threshold for multimorbidity as the presence of two or more LTCs [ 40 , 41 , 42 , 44 , 46 , 47 , 50 , 55 , 57 , 60 , 61 , 62 , 64 ]. The remaining studies assessed comorbidities, morbidity, or disease counts [ 43 , 45 , 48 , 49 , 51 , 52 , 53 , 54 , 56 , 58 , 59 , 63 ]. The median number of LTCs measured in each study was 14 (IQR 12–21). In total, 115 different LTCs were reported; 36 LTCs were reported by at least three studies, whilst 63 LTCs were reported by only one study. Two studies did not report the specific LTCs that they measured [ 51 , 53 ]. The most frequently reported LTCs were hypertension ( n  = 22) and diabetes ( n  = 19) (Table  2 ). Fourteen studies included at least one mental health LTC. The outcome details for each study can be found in Additional File 1: Table S5.

Fifteen studies provided sufficient data to allow for a meta-analysis of the prevalence of multimorbidity; the pooled prevalence was 34.5% (95% CI 23.4 to 47.5%, I 2  = 99.9%, Cochran Q  = 24,072, p  < 0.001) (Fig.  3 ) [ 40 , 41 , 44 , 46 , 47 , 49 , 50 , 51 , 52 , 55 , 57 , 58 , 59 , 60 , 63 ].

Meta-analysis of prevalence of multimorbidity. Meta-analysis of prevalence of multimorbidity. CI, confidence interval; LTC, long-term condition; MM, multimorbidity

All studies reported significant positive associations between measures of ACE and multimorbidity, though they varied in their means of analysis and reporting of the relationship. Nine studies reported an association between the number of ACEs (variably considered as a continuous or categorical parameter) and multimorbidity [ 41 , 43 , 46 , 47 , 50 , 56 , 57 , 61 , 64 ]. Eight studies reported an association between the number of ACEs and comorbidity counts in specific patient populations [ 45 , 48 , 49 , 51 , 53 , 58 , 59 , 63 ]. Six studies reported an association between individual ACEs or ACE subgroups and multimorbidity [ 42 , 43 , 44 , 47 , 55 , 62 ]. Two studies incorporated a measure of frequency within their ACE measurement tool and reported an association between this ACE score and multimorbidity [ 52 , 54 ]. Two studies reported an association between proxy measures for ACEs and multimorbidity; one reported ‘birth phase relative to World War Two’, and the other reported a self-report on the overall quality of childhood [ 40 , 60 ].

Eight studies, involving a total of 197,981 participants, provided sufficient data (either in the primary text, or following author correspondence) for quantitative synthesis [ 41 , 46 , 47 , 49 , 50 , 51 , 57 , 58 ]. Log-linear (Fig.  4 ) and non-linear (Additional File 1: Fig. S2) random effects models were compared for goodness of fit: the Wald-type test for linearity was non-significant ( χ 2  = 3.7, p  = 0.16) and the AIC was lower for the linear model (− 7.82 vs 15.86) indicating that the log-linear assumption was valid. There was a significant dose-dependent relationship between ACE exposure and multimorbidity ( p  < 0.001), with every additional ACE exposure contributing to a 12.9% (95% CI 7.9 to 17.9%) increase in the odds for multimorbidity ( I 2  = 76.9%, Cochran Q  = 102, p  < 0.001).

Dose–response meta-analysis of the relationship between adverse childhood experiences and multimorbidity. Dose–response meta-analysis of the relationship between adverse childhood experiences and multimorbidity. Solid black line represents the estimated relationship; dotted black lines represent the 95% confidence intervals for this estimate. ACE, adverse childhood experience

This systematic review and meta-analysis synthesised the literature on ACEs and multimorbidity and showed a dose-dependent relationship across a large number of participants. Each additional ACE exposure contributed to a 12.9% (95% CI 7.9 to 17.9%) increase in the odds for multimorbidity. This adds to previous meta-analyses that have shown an association between ACEs and individual LTCs, health behaviours, and other health outcomes [ 1 , 28 , 31 , 65 , 66 ]. However, we also identified substantial inter-study heterogeneity that is likely to have arisen due to variation in the definitions, methodology, and analysis of the included studies, and so our results should be interpreted with these limitations in mind.

Although 25 years have passed since the landmark Adverse Childhood Experiences Study by Felitti et al. [ 3 ], there is still no consistent approach to determining what constitutes an ACE. This is reflected in this review, where fewer than half of the 58 different ACEs ( n  = 25, 43.1%) were reported by more than one study and no study reported more than 15 ACEs. Even ACE types that are commonly included are not always assessed in the same way [ 67 ], and furthermore, the same question can be interpreted differently in different contexts (e.g. physical punishment for bad behaviour was socially acceptable 50 years ago but is now considered physical abuse in the UK). Although a few validated questionnaires exist, they often focus on a narrow range of ACEs; for example, the childhood trauma questionnaire demonstrates good reliability and validity but focuses on interpersonal ACEs, missing out on household factors (e.g. parental separation), and community factors (e.g. bullying) [ 68 ]. Many studies were performed on pre-existing research cohorts or historic healthcare data, where the study authors had limited or no influence on the data collected. As a result, very few individual studies reported on the full breadth of potential ACEs.

ACE research is often based on ACE counts, where the types of ACEs experienced are summed into a single score that is taken as a proxy measure of the burden of childhood stress. The original Adverse Childhood Experiences Study by Felitti et al. took this approach [ 3 ], as did 17 of the studies included in this review and our own quantitative synthesis. At the population level, there are benefits to this: ACE counts provide quantifiable and comparable metrics, they are easy to collect and analyse, and in many datasets, they are the only means by which an assessment of childhood stress can be derived. However, there are clear limitations to this method when considering experiences at the individual level, not least the inherent assumptions that different ACEs in the same person are of equal weight or that the same ACE in different people carries the same burden of childhood stress. This limitation was strongly reinforced by our patient and public involvement group (CPAG). Two studies in this review incorporated frequency within their ACE scoring system [ 52 , 54 ], which adds another dimension to the assessment, but this is insufficient to understand and quantify the ‘impact’ of an ACE within an epidemiological framework.

The definitions of multimorbidity were consistent across the relevant studies but the contributory long-term conditions varied. Fewer than half of the 115 different LTCs ( n  = 52, 45.2%) were reported by more than one study. Part of the challenge is the classification of healthcare conditions. For example, myocardial infarction is commonly caused by coronary heart disease, and both are a form of heart disease. All three were reported as LTCs in the included studies, but which level of pathology should be reported? Mental health LTCs were under-represented within the condition list, with just over half of the included studies assessing at least one ( n  = 14, 56.0%). Given the strong links between ACEs and mental health, and the impact of mental health on quality of life, this is an area for improvement in future research [ 31 , 32 ]. A recent Delphi consensus study by Ho et al. may help to address these issues: following input from professionals and members of the public they identified 24 LTCs to ‘always include’ and 35 LTCs to ‘usually include’ in multimorbidity research, including nine mental health conditions [ 9 ].

As outlined in the introduction, there is a strong evidence base supporting the link between ACEs and long-term health outcomes, including specific LTCs. It is not unreasonable to extrapolate this association to ACEs and multimorbidity, though to our knowledge, the pathophysiological processes that link the two have not been precisely identified. However, similar lines of research are being independently followed in both fields and these areas of overlap may suggest possible mechanisms for a relationship. For example, both ACEs and multimorbidity have been associated with markers of accelerated epigenetic ageing [ 69 , 70 ], mitochondrial dysfunction [ 71 , 72 ], and inflammation [ 22 , 73 ]. More work is required to better understand how these concepts might be linked.

This review used data from a large participant base, with information from 372,162 people contributing to the systematic review and information from 197,981 people contributing to the dose–response meta-analysis. Data from the included studies originated from a range of sources, including healthcare settings and dedicated research cohorts. We believe this is of a sufficient scale and variety to demonstrate the nature and magnitude of the association between ACEs and multimorbidity in these populations.

However, there are some limitations. Firstly, although data came from 11 different countries, only two of those were from outside Europe and North America, and all were from either high- or middle-income countries. Data on ACEs from low-income countries have indicated a higher prevalence of any ACE exposure (consistently > 70%) [ 74 , 75 ], though how well this predicts health outcomes in these populations is unknown.

Secondly, studies in this review utilised retrospective participant-reported ACE data and so are at risk of recall and reporting bias. Studies utilising prospective assessments are rare and much of the wider ACE literature is open to a similar risk of bias. To date, two studies have compared prospective and retrospective ACE measurements, demonstrating inconsistent results [ 76 , 77 ]. However, these studies were performed in New Zealand and South Africa, two countries not represented by studies in our review, and had relatively small sample sizes (1037 and 1595 respectively). It is unclear whether these are generalisable to other population groups.

Thirdly, previous research has indicated a close relationship between ACEs and childhood socio-economic status (SES) [ 78 ] and between SES and multimorbidity [ 10 , 79 ]. However, the limitations of the included studies meant we were unable to separate the effect of ACEs from the effect of childhood SES on multimorbidity in this review. Whilst two studies included childhood SES as covariates in their models, others used measures from adulthood (such as adulthood SES, income level, and education level) that are potentially influenced by ACEs and therefore increase the risk of bias due to confounding (Additional File 1: Table S3). Furthermore, as for ACEs and multimorbidity, there is no consistently applied definition of SES and different measures of SES may produce different apparent effects [ 80 ]. The complex relationships between ACEs, childhood SES, and multimorbidity remain a challenge for research in this field.

Fourthly, there was a high degree of heterogeneity within included studies, especially relating to the definition and measurement of ACEs and multimorbidity. Whilst this suggests that our results should be interpreted with caution, it is reassuring to see that our meta-analysis of prevalence estimates for exposure to any ACE (48.1%) and multimorbidity (34.5%) are in line with previous estimates in similar populations [ 2 , 11 ]. Furthermore, we believe that the quantitative synthesis of these relatively heterogenous studies provides important benefit by demonstrating a strong dose–response relationship across a range of contexts.

Our results strengthen the evidence supporting the lasting influence of childhood conditions on adult health and wellbeing. How this understanding is best incorporated into routine practice is still not clear. Currently, the lack of consistency in assessing ACEs limits our ability to understand their impact at both the individual and population level and poses challenges for those looking to incorporate a formalised assessment. Whilst most risk factors for disease (e.g. blood pressure) are usually only relevant within healthcare settings, ACEs are relevant to many other sectors (e.g. social care, education, policing) [ 81 , 82 , 83 , 84 ], and so consistency of assessment across society is both more important and more challenging to achieve.

Some have suggested that the evidence for the impact of ACEs is strong enough to warrant screening, which would allow early identification of potential harms to children and interventions to prevent them. This approach has been implemented in California, USA [ 85 , 86 , 87 ]. However, this is controversial, and others argue that screening is premature with the current evidence base [ 88 , 89 , 90 ]. Firstly, not everyone who is exposed to ACEs develops poor health outcomes, and it is not clear how to identify those who are at highest risk. Many people appear to be vulnerable, with more adverse health outcomes following ACE exposure than those who are not exposed, whilst others appear to be more resilient, with good health in later life despite multiple ACE exposures [ 91 ] It may be that supportive environments can mitigate the long-term effects of ACE exposure and promote resilience [ 92 , 93 ]. Secondly, there are no accepted interventions for managing the impact of an identified ACE. As identified above, different ACEs may require input from different sectors (e.g. healthcare, social care, education, police), and so collating this evidence may be challenging. At present, ACEs screening does not meet the Wilson-Jungner criteria for a screening programme [ 94 ].

Existing healthcare systems are poorly designed to deal with the complexities of addressing ACEs and multimorbidity. Possibly, ways to improve this might be allocating more time per patient, prioritising continuity of care to foster long-term relationships, and greater integration between different healthcare providers (most notably primary vs secondary care teams, or physical vs mental health teams). However, such changes often demand additional resources (e.g. staff, infrastructure, processes), which are challenging to source when existing healthcare systems are already stretched [ 95 , 96 ]. Nevertheless, increasing the spotlight on ACEs and multimorbidity may help to focus attention and ultimately bring improvements to patient care and experience.

ACEs are associated with a range of poor long-term health outcomes, including harmful health behaviours and individual long-term conditions. Multimorbidity is becoming more common as global populations age, and it increases the complexity and cost of healthcare provision. This is the first systematic review and meta-analysis to synthesise the literature on ACEs and multimorbidity, showing a statistically significant dose-dependent relationship across a large number of participants, albeit with a high degree of inter-study heterogeneity. This consolidates and enhances an increasing body of data supporting the role of ACEs in determining long-term health outcomes. Whilst these observational studies do not confirm causality, the weight and consistency of evidence is such that we can be confident in the link. The challenge for healthcare practitioners, managers, policymakers, and governments is incorporating this body of evidence into routine practice to improve the health and wellbeing of our societies.

Availability of data and materials

No additional data was generated for this review. The data used were found in the referenced papers or provided through correspondence with the study authors.

Abbreviations

Adverse childhood experience

Akaike information criterion

CONSORTIUM Against pain inequality

Confidence interval

Chronic pain advisory group

Interquartile range

Long-term condition

International prospective register of systematic reviews

Preferred reporting items for systematic reviews and meta-analyses

Risk of bias in non-randomised studies of exposures

Socio-economic status

Hughes K, Bellis MA, Hardcastle KA, Sethi D, Butchart A, Mikton C, et al. The effect of multiple adverse childhood experiences on health: a systematic review and meta-analysis. Lancet Public Health. 2017;2:e356–66.

Article   PubMed   Google Scholar  

Bellis MA, Lowey H, Leckenby N, Hughes K, Harrison D. Adverse childhood experiences: retrospective study to determine their impact on adult health behaviours and health outcomes in a UK population. J Public Health Oxf Engl. 2014;36:81–91.

Article   Google Scholar  

Felitti VJ, Anda RF, Nordenberg D, Williamson DF, Spitz AM, Edwards V, et al. Relationship of childhood abuse and household dysfunction to many of the leading causes of death in adults. The Adverse Childhood Experiences (ACE) Study. Am J Prev Med. 1998;14:245–58.

Article   CAS   PubMed   Google Scholar  

Maniglio R. The impact of child sexual abuse on health: a systematic review of reviews. Clin Psychol Rev. 2009;29:647–57.

Yu J, Patel RA, Haynie DL, Vidal-Ribas P, Govender T, Sundaram R, et al. Adverse childhood experiences and premature mortality through mid-adulthood: a five-decade prospective study. Lancet Reg Health - Am. 2022;15:100349.

Wang Y-X, Sun Y, Missmer SA, Rexrode KM, Roberts AL, Chavarro JE, et al. Association of early life physical and sexual abuse with premature mortality among female nurses: prospective cohort study. BMJ. 2023;381: e073613.

Article   PubMed   PubMed Central   Google Scholar  

Rogers NT, Power C, Pereira SMP. Child maltreatment, early life socioeconomic disadvantage and all-cause mortality in mid-adulthood: findings from a prospective British birth cohort. BMJ Open. 2021;11: e050914.

Hardcastle K, Bellis MA, Sharp CA, Hughes K. Exploring the health and service utilisation of general practice patients with a history of adverse childhood experiences (ACEs): an observational study using electronic health records. BMJ Open. 2020;10: e036239.

Ho ISS, Azcoaga-Lorenzo A, Akbari A, Davies J, Khunti K, Kadam UT, et al. Measuring multimorbidity in research: Delphi consensus study. BMJ Med. 2022;1:e000247.

Barnett K, Mercer SW, Norbury M, Watt G, Wyke S, Guthrie B. Epidemiology of multimorbidity and implications for health care, research, and medical education: a cross-sectional study. Lancet Lond Engl. 2012;380:37–43.

Chowdhury SR, Das DC, Sunna TC, Beyene J, Hossain A. Global and regional prevalence of multimorbidity in the adult population in community settings: a systematic review and meta-analysis. eClinicalMedicine. 2023;57:101860.

Noël PH, Chris Frueh B, Larme AC, Pugh JA. Collaborative care needs and preferences of primary care patients with multimorbidity. Health Expect. 2005;8:54–63.

Chau E, Rosella LC, Mondor L, Wodchis WP. Association between continuity of care and subsequent diagnosis of multimorbidity in Ontario, Canada from 2001–2015: a retrospective cohort study. PLoS ONE. 2021;16: e0245193.

Article   CAS   PubMed   PubMed Central   Google Scholar  

Nicholson K, Liu W, Fitzpatrick D, Hardacre KA, Roberts S, Salerno J, et al. Prevalence of multimorbidity and polypharmacy among adults and older adults: a systematic review. Lancet Healthy Longev. 2024;5:e287–96.

Albreht T, Dyakova M, Schellevis FG, Van den Broucke S. Many diseases, one model of care? J Comorbidity. 2016;6:12–20.

Soley-Bori M, Ashworth M, Bisquera A, Dodhia H, Lynch R, Wang Y, et al. Impact of multimorbidity on healthcare costs and utilisation: a systematic review of the UK literature. Br J Gen Pract. 2020;71:e39-46.

World Health Organization (WHO). Ageing and health. 2022. https://www.who.int/news-room/fact-sheets/detail/ageing-and-health . Accessed 23 Apr 2024.

Franke HA. Toxic stress: effects, prevention and treatment. Children. 2014;1:390–402.

Parade SH, Huffhines L, Daniels TE, Stroud LR, Nugent NR, Tyrka AR. A systematic review of childhood maltreatment and DNA methylation: candidate gene and epigenome-wide approaches. Transl Psychiatry. 2021;11:1–33.

Ridout KK, Levandowski M, Ridout SJ, Gantz L, Goonan K, Palermo D, et al. Early life adversity and telomere length: a meta-analysis. Mol Psychiatry. 2018;23:858–71.

Elwenspoek MMC, Kuehn A, Muller CP, Turner JD. The effects of early life adversity on the immune system. Psychoneuroendocrinology. 2017;82:140–54.

Danese A, Baldwin JR. Hidden wounds? Inflammatory links between childhood trauma and psychopathology. Annu Rev Psychol. 2017;68:517–44.

Brindle RC, Pearson A, Ginty AT. Adverse childhood experiences (ACEs) relate to blunted cardiovascular and cortisol reactivity to acute laboratory stress: a systematic review and meta-analysis. Neurosci Biobehav Rev. 2022;134: 104530.

Teicher MH, Samson JA, Anderson CM, Ohashi K. The effects of childhood maltreatment on brain structure, function and connectivity. Nat Rev Neurosci. 2016;17:652–66.

McLaughlin KA, Weissman D, Bitrán D. Childhood adversity and neural development: a systematic review. Annu Rev Dev Psychol. 2019;1:277–312.

Koyama Y, Fujiwara T, Murayama H, Machida M, Inoue S, Shobugawa Y. Association between adverse childhood experiences and brain volumes among Japanese community-dwelling older people: findings from the NEIGE study. Child Abuse Negl. 2022;124: 105456.

Antoniou G, Lambourg E, Steele JD, Colvin LA. The effect of adverse childhood experiences on chronic pain and major depression in adulthood: a systematic review and meta-analysis. Br J Anaesth. 2023;130:729–46.

Huang H, Yan P, Shan Z, Chen S, Li M, Luo C, et al. Adverse childhood experiences and risk of type 2 diabetes: a systematic review and meta-analysis. Metabolism. 2015;64:1408–18.

Lopes S, Hallak JEC, de Machado Sousa JP, de Osório F L. Adverse childhood experiences and chronic lung diseases in adulthood: a systematic review and meta-analysis. Eur J Psychotraumatology. 2020;11:1720336.

Hu Z, Kaminga AC, Yang J, Liu J, Xu H. Adverse childhood experiences and risk of cancer during adulthood: a systematic review and meta-analysis. Child Abuse Negl. 2021;117: 105088.

Tan M, Mao P. Type and dose-response effect of adverse childhood experiences in predicting depression: a systematic review and meta-analysis. Child Abuse Negl. 2023;139: 106091.

Zhang L, Zhao N, Zhu M, Tang M, Liu W, Hong W. Adverse childhood experiences in patients with schizophrenia: related factors and clinical implications. Front Psychiatry. 2023;14:1247063.

Emsley E, Smith J, Martin D, Lewis NV. Trauma-informed care in the UK: where are we? A qualitative study of health policies and professional perspectives. BMC Health Serv Res. 2022;22:1164.

ROBINS-E Development Group (Higgins J, Morgan R, Rooney A, Taylor K, Thayer K, Silva R, Lemeris C, Akl A, Arroyave W, Bateson T, Berkman N, Demers P, Forastiere F, Glenn B, Hróbjartsson A, Kirrane E, LaKind J, Luben T, Lunn R, McAleenan A, McGuinness L, Meerpohl J, Mehta S, Nachman R, Obbagy J, O’Connor A, Radke E, Savović J, Schubauer-Berigan M, Schwingl P, Schunemann H, Shea B, Steenland K, Stewart T, Straif K, Tilling K, Verbeek V, Vermeulen R, Viswanathan M, Zahm S, Sterne J). Risk Of Bias In Non-randomized Studies - of Exposure (ROBINS-E). Launch version, 20 June 2023. https://www.riskofbias.info/welcome/robins-e-tool . Accessed 20 Jul 2023.

Balduzzi S, Rücker G, Schwarzer G. How to perform a meta-analysis with R: a practical tutorial. Evid Based Ment Health. 2019;22:153–60.

Schwarzer G, Chemaitelly H, Abu-Raddad LJ, Rücker G. Seriously misleading results using inverse of Freeman-Tukey double arcsine transformation in meta-analysis of single proportions. Res Synth Methods. 2019;10:476–83.

Crippa A, Orsini N. Multivariate dose-response meta-analysis: the dosresmeta R Package. J Stat Softw. 2016;72:1–15.

Greenland S, Longnecker MP. Methods for trend estimation from summarized dose-response data, with applications to meta-analysis. Am J Epidemiol. 1992;135:1301–9.

Shim SR, Lee J. Dose-response meta-analysis: application and practice using the R software. Epidemiol Health. 2019;41: e2019006.

Arshadipour A, Thorand B, Linkohr B, Rospleszcz S, Ladwig K-H, Heier M, et al. Impact of prenatal and childhood adversity effects around World War II on multimorbidity: results from the KORA-Age study. BMC Geriatr. 2022;22:115.

Atkinson L, Joshi D, Raina P, Griffith LE, MacMillan H, Gonzalez A. Social engagement and allostatic load mediate between adverse childhood experiences and multimorbidity in mid to late adulthood: the Canadian Longitudinal Study on Aging. Psychol Med. 2021;53(4):1–11.

Chandrasekar R, Lacey RE, Chaturvedi N, Hughes AD, Patalay P, Khanolkar AR. Adverse childhood experiences and the development of multimorbidity across adulthood—a national 70-year cohort study. Age Ageing. 2023;52:afad062.

Cromer KR, Sachs-Ericsson N. The association between childhood abuse, PTSD, and the occurrence of adult health problems: moderation via current life stress. J Trauma Stress. 2006;19:967–71.

England-Mason G, Casey R, Ferro M, MacMillan HL, Tonmyr L, Gonzalez A. Child maltreatment and adult multimorbidity: results from the Canadian Community Health Survey. Can J Public Health. 2018;109:561–72.

Godin O, Leboyer M, Laroche DG, Aubin V, Belzeaux R, Courtet P, et al. Childhood maltreatment contributes to the medical morbidity of individuals with bipolar disorders. Psychol Med. 2023;53(15):1–9.

Hanlon P, McCallum M, Jani BD, McQueenie R, Lee D, Mair FS. Association between childhood maltreatment and the prevalence and complexity of multimorbidity: a cross-sectional analysis of 157,357 UK Biobank participants. J Comorbidity. 2020;10:2235042X1094434.

Henchoz Y, Seematter-Bagnoud L, Nanchen D, Büla C, von Gunten A, Démonet J-F, et al. Childhood adversity: a gateway to multimorbidity in older age? Arch Gerontol Geriatr. 2019;80:31–7.

Hosang GM, Fisher HL, Uher R, Cohen-Woods S, Maughan B, McGuffin P, et al. Childhood maltreatment and the medical morbidity in bipolar disorder: a case–control study. Int J Bipolar Disord. 2017;5:30.

Hosang GM, Fisher HL, Hodgson K, Maughan B, Farmer AE. Childhood maltreatment and adult medical morbidity in mood disorders: comparison of unipolar depression with bipolar disorder. Br J Psychiatry. 2018;213:645–53.

Lin L, Wang HH, Lu C, Chen W, Guo VY. Adverse childhood experiences and subsequent chronic diseases among middle-aged or older adults in China and associations with demographic and socioeconomic characteristics. JAMA Netw Open. 2021;4: e2130143.

Mendizabal A, Nathan CL, Khankhanian P, Anto M, Clyburn C, Acaba-Berrocal A, et al. Adverse childhood experiences in patients with neurologic disease. Neurol Clin Pract. 2022. https://doi.org/10.1212/CPJ.0000000000001134 .

Noteboom A, Have MT, De Graaf R, Beekman ATF, Penninx BWJH, Lamers F. The long-lasting impact of childhood trauma on adult chronic physical disorders. J Psychiatr Res. 2021;136:87–94.

Patterson ML, Moniruzzaman A, Somers JM. Setting the stage for chronic health problems: cumulative childhood adversity among homeless adults with mental illness in Vancouver. British Columbia BMC Public Health. 2014;14:350.

Post RM, Altshuler LL, Leverich GS, Frye MA, Suppes T, McElroy SL, et al. Role of childhood adversity in the development of medical co-morbidities associated with bipolar disorder. J Affect Disord. 2013;147:288–94.

Reyes-Ortiz CA. Racial discrimination and multimorbidity among older adults in Colombia: a national data analysis. Prev Chronic Dis. 2023;20:220360.

Sheikh MA. Coloring of the past via respondent’s current psychological state, mediation, and the association between childhood disadvantage and morbidity in adulthood. J Psychiatr Res. 2018;103:173–81.

Sinnott C, Mc Hugh S, Fitzgerald AP, Bradley CP, Kearney PM. Psychosocial complexity in multimorbidity: the legacy of adverse childhood experiences. Fam Pract. 2015;32:269–75.

Sosnowski DW, Feder KA, Astemborski J, Genberg BL, Letourneau EJ, Musci RJ, et al. Adverse childhood experiences and comorbidity in a cohort of people who have injected drugs. BMC Public Health. 2022;22:986.

Stapp EK, Williams SC, Kalb LG, Holingue CB, Van Eck K, Ballard ED, et al. Mood disorders, childhood maltreatment, and medical morbidity in US adults: an observational study. J Psychosom Res. 2020;137: 110207.

Tomasdottir MO, Sigurdsson JA, Petursson H, Kirkengen AL, Krokstad S, McEwen B, et al. Self reported childhood difficulties, adult multimorbidity and allostatic load. A cross-sectional analysis of the Norwegian HUNT study. PloS One. 2015;10:e0130591.

Vásquez E, Quiñones A, Ramirez S, Udo T. Association between adverse childhood events and multimorbidity in a racial and ethnic diverse sample of middle-aged and older adults. Innov Aging. 2019;3:igz016.

Yang L, Hu Y, Silventoinen K, Martikainen P. Childhood adversity and trajectories of multimorbidity in mid-late life: China health and longitudinal retirement study. J Epidemiol Community Health. 2021;75:593–600.

Zak-Hunter L, Carr CP, Tate A, Brustad A, Mulhern K, Berge JM. Associations between adverse childhood experiences and stressful life events and health outcomes in pregnant and breastfeeding women from diverse racial and ethnic groups. J Womens Health. 2023;32:702–14.

Zheng X, Cui Y, Xue Y, Shi L, Guo Y, Dong F, et al. Adverse childhood experiences in depression and the mediating role of multimorbidity in mid-late life: A nationwide longitudinal study. J Affect Disord. 2022;301:217–24.

Liu M, Luong L, Lachaud J, Edalati H, Reeves A, Hwang SW. Adverse childhood experiences and related outcomes among adults experiencing homelessness: a systematic review and meta-analysis. Lancet Public Health. 2021;6:e836–47.

Petruccelli K, Davis J, Berman T. Adverse childhood experiences and associated health outcomes: a systematic review and meta-analysis. Child Abuse Negl. 2019;97: 104127.

Bethell CD, Carle A, Hudziak J, Gombojav N, Powers K, Wade R, et al. Methods to assess adverse childhood experiences of children and families: toward approaches to promote child well-being in policy and practice. Acad Pediatr. 2017;17(7 Suppl):S51-69.

Bernstein DP, Stein JA, Newcomb MD, Walker E, Pogge D, Ahluvalia T, et al. Development and validation of a brief screening version of the Childhood Trauma Questionnaire. Child Abuse Negl. 2003;27:169–90.

Kim K, Yaffe K, Rehkopf DH, Zheng Y, Nannini DR, Perak AM, et al. Association of adverse childhood experiences with accelerated epigenetic aging in midlife. JAMA Network Open. 2023;6:e2317987.

Jain P, Binder A, Chen B, Parada H, Gallo LC, Alcaraz J, et al. The association of epigenetic age acceleration and multimorbidity at age 90 in the Women’s Health Initiative. J Gerontol A Biol Sci Med Sci. 2023;78:2274–81.

Zang JCS, May C, Hellwig B, Moser D, Hengstler JG, Cole S, et al. Proteome analysis of monocytes implicates altered mitochondrial biology in adults reporting adverse childhood experiences. Transl Psychiatry. 2023;13:31.

Mau T, Blackwell TL, Cawthon PM, Molina AJA, Coen PM, Distefano G, et al. Muscle mitochondrial bioenergetic capacities are associated with multimorbidity burden in older adults: the Study of Muscle, Mobility and Aging (SOMMA). J Gerontol A Biol Sci Med Sci. 2024;79(7):glae101.

Friedman E, Shorey C. Inflammation in multimorbidity and disability: an integrative review. Health Psychol Off J Div Health Psychol Am Psychol Assoc. 2019;38:791–801.

Google Scholar  

Satinsky EN, Kakuhikire B, Baguma C, Rasmussen JD, Ashaba S, Cooper-Vince CE, et al. Adverse childhood experiences, adult depression, and suicidal ideation in rural Uganda: a cross-sectional, population-based study. PLoS Med. 2021;18: e1003642.

Amene EW, Annor FB, Gilbert LK, McOwen J, Augusto A, Manuel P, et al. Prevalence of adverse childhood experiences in sub-Saharan Africa: a multicounty analysis of the Violence Against Children and Youth Surveys (VACS). Child Abuse Negl. 2023;150:106353.

Reuben A, Moffitt TE, Caspi A, Belsky DW, Harrington H, Schroeder F, et al. Lest we forget: comparing retrospective and prospective assessments of adverse childhood experiences in the prediction of adult health. J Child Psychol Psychiatry. 2016;57:1103–12.

Naicker SN, Norris SA, Mabaso M, Richter LM. An analysis of retrospective and repeat prospective reports of adverse childhood experiences from the South African Birth to Twenty Plus cohort. PLoS ONE. 2017;12: e0181522.

Walsh D, McCartney G, Smith M, Armour G. Relationship between childhood socioeconomic position and adverse childhood experiences (ACEs): a systematic review. J Epidemiol Community Health. 2019;73:1087–93.

Ingram E, Ledden S, Beardon S, Gomes M, Hogarth S, McDonald H, et al. Household and area-level social determinants of multimorbidity: a systematic review. J Epidemiol Community Health. 2021;75:232–41.

Darin-Mattsson A, Fors S, Kåreholt I. Different indicators of socioeconomic status and their relative importance as determinants of health in old age. Int J Equity Health. 2017;16:173.

Bateson K, McManus M, Johnson G. Understanding the use, and misuse, of Adverse Childhood Experiences (ACEs) in trauma-informed policing. Police J. 2020;93:131–45.

Webb NJ, Miller TL, Stockbridge EL. Potential effects of adverse childhood experiences on school engagement in youth: a dominance analysis. BMC Public Health. 2022;22:2096.

Stewart-Tufescu A, Struck S, Taillieu T, Salmon S, Fortier J, Brownell M, et al. Adverse childhood experiences and education outcomes among adolescents: linking survey and administrative data. Int J Environ Res Public Health. 2022;19:11564.

Frederick J, Spratt T, Devaney J. Adverse childhood experiences and social work: relationship-based practice responses. Br J Soc Work. 2021;51:3018–34.

University of California ACEs Aware Family Resilience Network (UCAAN). acesaware.org. ACEs Aware. https://www.acesaware.org/about/ . Accessed 6 Oct 2023.

Watson CR, Young-Wolff KC, Negriff S, Dumke K, DiGangi M. Implementation and evaluation of adverse childhood experiences screening in pediatrics and obstetrics settings. Perm J. 2024;28:180–7.

Gordon JB, Felitti VJ. The importance of screening for adverse childhood experiences (ACE) in all medical encounters. AJPM Focus. 2023;2: 100131.

Finkelhor D. Screening for adverse childhood experiences (ACEs): Cautions and suggestions. Child Abuse Negl. 2018;85:174–9.

Cibralic S, Alam M, Mendoza Diaz A, Woolfenden S, Katz I, Tzioumi D, et al. Utility of screening for adverse childhood experiences (ACE) in children and young people attending clinical and healthcare settings: a systematic review. BMJ Open. 2022;12: e060395.

Gentry SV, Paterson BA. Does screening or routine enquiry for adverse childhood experiences (ACEs) meet criteria for a screening programme? A rapid evidence summary. J Public Health Oxf Engl. 2022;44:810–22.

Article   CAS   Google Scholar  

Morgan CA, Chang Y-H, Choy O, Tsai M-C, Hsieh S. Adverse childhood experiences are associated with reduced psychological resilience in youth: a systematic review and meta-analysis. Child Basel Switz. 2021;9:27.

Narayan AJ, Lieberman AF, Masten AS. Intergenerational transmission and prevention of adverse childhood experiences (ACEs). Clin Psychol Rev. 2021;85: 101997.

VanBronkhorst SB, Abraham E, Dambreville R, Ramos-Olazagasti MA, Wall M, Saunders DC, et al. Sociocultural risk and resilience in the context of adverse childhood experiences. JAMA Psychiat. 2024;81:406–13.

Wilson JM, Jungner G. Principles and practice of screening for disease. World Health Organisation; 1968.

Huo Y, Couzner L, Windsor T, Laver K, Dissanayaka NN, Cations M. Barriers and enablers for the implementation of trauma-informed care in healthcare settings: a systematic review. Implement Sci Commun. 2023;4:49.

Foo KM, Sundram M, Legido-Quigley H. Facilitators and barriers of managing patients with multiple chronic conditions in the community: a qualitative study. BMC Public Health. 2020;20:273.

Download references

Acknowledgements

The authors thank the members of the CAPE CPAG patient and public involvement group for providing insights gained from relevant lived experiences.

The authors are members of the Advanced Pain Discovery Platform (APDP) supported by UK Research & Innovation (UKRI), Versus Arthritis, and Eli Lilly. DS is a fellow on the Multimorbidity Doctoral Training Programme for Health Professionals, which is supported by the Wellcome Trust [223499/Z/21/Z]. BT, BS, and LC are supported by an APDP grant as part of the Partnership for Assessment and Investigation of Neuropathic Pain: Studies Tracking Outcomes, Risks and Mechanisms (PAINSTORM) consortium [MR/W002388/1]. TH and LC are supported by an APDP grant as part of the Consortium Against Pain Inequality [MR/W002566/1]. The funding bodies had no role in study design, data collection/analysis/interpretation, report writing, or the decision to submit the manuscript for publication.

Author information

Authors and affiliations.

Chronic Pain Research Group, Division of Population Health & Genomics, School of Medicine, University of Dundee, Ninewells Hospital, Dundee, DD1 9SY, UK

Dhaneesha N. S. Senaratne, Bhushan Thakkar, Blair H. Smith & Lesley A. Colvin

Institute of Academic Anaesthesia, Division of Systems Medicine, School of Medicine, University of Dundee, Dundee, UK

Tim G. Hales

School of Health Sciences, University of Dundee, Dundee, UK

Louise Marryat

You can also search for this author in PubMed   Google Scholar

Contributions

DS and LC contributed to review conception and design. DC, BT, BS, TH, LM, and LC contributed to search strategy design. DS and BT contributed to study selection and data extraction, with input from LC. DS and BT accessed and verified the underlying data. DS conducted the meta-analyses, with input from BT, BS, TH, LM, and LC. DS drafted the manuscript, with input from DC, BT, BS, TH, LM, and LC. DC, BT, BS, TH, LM, and LC read and approved the final manuscript.

Corresponding author

Correspondence to Dhaneesha N. S. Senaratne .

Ethics declarations

Ethics approval and consent to participate.

Not applicable.

Consent for publication

Competing interests.

The authors declare that they have no competing interests.

Additional information

Publisher’s note.

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Supplementary Information

12916_2024_3505_moesm1_esm.docx.

Additional File 1: Tables S1-S5 and Figures S1-S2. Table S1: Search strategy, Table S2: Characteristics of studies included in the systematic review, Table S3: Risk of bias assessment (ROBINS-E), Table S4: Exposure details (adverse childhood experiences), Table S5: Outcome details (multimorbidity), Figure S1: Meta-analysis of prevalence of exposure to ≥4 adverse childhood experiences, Figure S2: Dose-response meta-analysis of the relationship between adverse childhood experiences and multimorbidity (using a non-linear/restricted cubic spline model).

Rights and permissions

Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/ . The Creative Commons Public Domain Dedication waiver ( http://creativecommons.org/publicdomain/zero/1.0/ ) applies to the data made available in this article, unless otherwise stated in a credit line to the data.

Reprints and permissions

About this article

Cite this article.

Senaratne, D.N.S., Thakkar, B., Smith, B.H. et al. The impact of adverse childhood experiences on multimorbidity: a systematic review and meta-analysis. BMC Med 22 , 315 (2024). https://doi.org/10.1186/s12916-024-03505-w

Download citation

Received : 01 December 2023

Accepted : 14 June 2024

Published : 15 August 2024

DOI : https://doi.org/10.1186/s12916-024-03505-w

Share this article

Anyone you share the following link with will be able to read this content:

Sorry, a shareable link is not currently available for this article.

Provided by the Springer Nature SharedIt content-sharing initiative

• Adverse childhood experiences
• Childhood adversity
• Chronic disease
• Long-term conditions
• Multimorbidity

BMC Medicine

ISSN: 1741-7015

• Submission enquiries: [email protected]
• General enquiries: [email protected]