The Highly Sensitive Person and the Temperament Trait Sensory Processing Sensitivity Therapy

Description of the Highly Sensitive Person

Sensory Processing Sensitivity is a temperament trait characterized by the acronym DOES (Aron, 2018):

• Depth of processing of environmental stimuli,
• Overstimulation
• Emotionality/Empathy as a result of deep processing, and
• Increased attention to Subtle Stimuli.

Individuals with this temperament trait represent about 20% of the population but comprise about 50% of those seeking professional counseling services (Aron, 2010). While most research to date studied individuals falling into one of two categories: high sensitivity or not high sensitivity, Lionetti and colleagues (2018) found evidence for high, medium, and low sensitivity among 1,136 psychology undergraduates in the United States and England. In general, researchers agree that those with this temperament trait, highly sensitive persons (HSPs), make up a minority group; however, without knowledge of this temperament, professional counselors are at risk for misdiagnosing or mistreating what is a healthy, inborn, and common trait.

The primary challenge for HSPs is overstimulation. Overstimulation becomes the foundation for emotional intensity, strong response to criticism, negative internalization, and the potential for low self-esteem. Overstimulation can be routine for HSPs when there is a mismatch between their needs and their work, home, and other environments. One key to differentiating challenges presented by living with the temperament and mental health disorders is the presence of distress in the absence of overstimulation, pointing to the need to further assess for disorders. It is quite possible for distressing symptoms to subside when highly sensitive clients become knowledgable about their trait and exercise agency to reduce overstimulation. Yet, all individuals with mental health disorders also have temperament traits, so it is possible to co-exist. 

Ellis and Boyce (2011) used the metaphor of the orchid and the dandelion to describe the impact of the environment on the HSP (orchid) in comparison to the rest of the population (dandelions). Just as orchids are quite challenging to grow in many climates, the HSP is at higher risk for maladaptation and negative developmental outcomes in adverse environments (poor fit), but thrive more (higher treatment response) when interacting with positive environments (Greven et al., 2019). In research investigating links between SPS, negative home environments, and negative outcomes, adverse home environments were characterized by the occurrence of stressful events, such as loss of family members, serious accidents and illnesses, frequent arguments among family members, divorce, and economic stress (Boterberg & Warreyn, 2016). Such conditions can lead to regular overstimuation for the HSP from numerous sensory stimuli (e.g., having many stressful events going on at once), sensory stimuli that is processed intensely (e.g., a parent who speaks forcefully to a highly sensitive child despite the child’s overstimulation), or messaging that high sensitivity is a defect.

Resources: Review of Aron’s (2010) text http://www.hochsensibel.org/dokumente/Aron-PsyTh_Review.pdf

Ellis, B. J., & Boyce, W. T. (2011). Differential susceptibility to the environment: Toward an understanding of sensitivity to developmental experiences and context. Development and Psychopathology, 23, 1-5. https://doi.org/10.1017/S095457941000060X

Assessment/Identification Strategies

The professional counselor can assist in the identification of the HSP trait through use of the Highly Sensitive Person Scale (HSPS) or the Highly Sensitive Child Scale (HSCS). As with all instruments, professional counselors should be knowledgeable about interpreting client responses and in assessing the client readiness for and meaning-making of, the information. The Highly Sensitive Person Scale (HSPS) includes an instrument originally designed for research use and another checklist designed as a self-test. The standard research version of the HSPS contains 27- items to which participants respond using a 7-point Likert-type rating scale: (1) not at all, (4) moderately, (7) extremely. Items include statements such as, “Do you seem to be aware of subtleties in your environment?” and “I have a rich, complex inner life” (Aron & Aron, 1997).

The self-test includes the same items in a checklist instead of the Likert-type scale, with guidance on how to self-assess. Smith, Sriken, and Erford (2019) found the original English version of the HSPS had adequate psychometric characteristics for a screening instrument. Internal consistency was α = .874 [CI95 = .845, .903], and most of the combined rs were clearly in the medium to large range, indicating some evidence for convergent validity. The HSPS total scale score correlated r = .50 to .90 with various proposed subscales.

Resources: Aron, E. (2019). Measurement scales for researchers. Retrieved from https://hsperson.com/research/measurement-scales-for-researchers/

Smith, H. L., Sriken, J., & Erford, B. T. (2019). Clinical and research utility of the Highly Sensitive Person Scale.

Journal of Mental Health Counseling, 41, 221-241. http://doi.org/10.17744/mehc.41.3.03

The Highly Sensitive Child Scale (HSCS) includes a 12-item self-report measure and a parent reporting measure. Items include statements such as, “I notice it when small things have changed in my environment” and “I don’t like watching TV programs that have a lot of violence in them.” Children rate the statements on a scale from (1) not at all to (7) extremely. The parent reporting measure is based on the same items but rephrased for parent reporting on the child’s behavior.

Pluess and colleagues (2017) developed the scale, examining psychometric properties, associations with behavioral inhibition and activation, affect, temperament, and Big Five personality traits. Among adequate reliability and validity psychometrics, criterion-related validity showed that high scores demonstrated increased sensitivity to positive and negative parenting quality and increased positive responsiveness to psychological interventions.

Resources: Pluess, M., Assary, E., Lionetti, F., Lester, K. J., Krapohl, E., Aron, E. N., & Aron, A. (2017).

Environmental sensitivity in children: Development of the Highly Sensitive Child Scale and identification of sensitivity groups. Neuroscience and Biobehavioral Reviews, 98, 287-305. Retrieved from https://www.ncbi.nlm.nih.gov/pubmed/28933890

Healy, M. (2011). The highly sensitive child. Psychology Today. Retrieved from https://www.psychologytoday.com/us/blog/creative-development/201106/the-highly-sensitive-child

Differentiation among Other Constructs

Researchers have suggested that SPS is related to, yet separate from, other aspects of personality such as shyness, introversion, and neuroticism (Aron & Aron, 1997; Aron, Aron, & Davies, 2005). For instance, in one study (Aron et al., 2005) highly sensitive adults were more likely to be shy than less sensitive adults, but only when the highly sensitive individuals reported negative childhood experiences. Highly sensitive adults who reported positive childhood experiences exhibited adult shyness at levels similar to less sensitive individuals. These researchers posited that highly sensitive individuals who experience detrimental home environments as children could be more likely to develop higher levels of negative affect, such as anxiety and depression. These individuals might then become more attuned to past and present negative events and might begin to fear negative outcomes in social situations, leading to the development of shyness. In this way, SPS and shyness are separate constructs linked by negative affect from the interaction between SPS and adverse childhood environments.

Similarly, Aron and Aron (1997) found that SPS was linked to introversion, but that the two constructs are not identical. The researchers suggested that HSPs might engage in introverted behaviors more frequently as a strategy for coping with the large amounts of sensory information present in social situations. However, their studies showed that not all HSPs scored high in introversion and that not all individuals scoring high in introversion scored high in SPS, supporting the idea that the two constructs are related yet independent.

Finally, similar patterns emerged for the relationship between SPS and elements of neuroticism such as anxiety, fear, depression, and negative emotionality. In the studies mentioned previously, Aron and Aron (1997) found that the correlation between sensitivity and negative emotionality was strong (r = .65 in study 6), but that many highly sensitive individuals were also more likely to experience highly positive emotions, implying that not all highly sensitive individuals experience high levels of negative emotionality. Additionally, the researchers found that highly sensitive individuals who experienced negative childhood experiences displayed higher levels of negative emotionality, once again suggesting that highly sensitive individuals might be particularly influenced and aroused by sensory input from their environments, and thus more prone to develop elements of neuroticism when faced with negative home experiences.

Resources: Aron, E., Aron, A., & Davies, K. M. (2005). Adult shyness: The interaction of temperamental sensitivity and an adverse childhood environment. Personality and Social Psychology Bulletin, 31, 181-197. https://doi.org/10.1177/0146167204271419

Aron, E. N., & Aron, A. (1997). Sensory-processing sensitivity and its relation to introversion and emotionality.

Journal of Personality and Social Psychology, 73, 345-368. http://dx.doi.org/10.1037/0022-3514.73.2.345 Aron, E. (2012). Time Magazine: “The Power of (Shyness)” and High Sensitivity. Psychology Today. https://www.psychologytoday.com/us/blog/attending-the-undervalued-self/201202/time-magazine-the-power- shyness-and-high-sensitivity

Intervention Strategies

Because SPS is a normal, inborn variation within human beings, professional counselors would not focus on trying to change this aspect of clients; instead, counselors would assist clients in identifying their temperaments (e.g., through screening and psychoeducation), recognizing the unique advantages and susceptibilities, and tailoring self-care and lifestyle strategies that are most effective (Smith et al., 2019). Intervention should include strengths-based affirmation and psychoeducation, particularly positive information about the trait. Researched interventions for addressing susceptibilities have included mindfulness (e.g., meditation and mindfulness-based stress reduction), acceptance and commitment therapy, emotion regulation, and addressing implications for parenting.

Strengths-Based Affirmation

Knowledgeable counselors can reinforce the advantages of having the SPS trait. Chiefly among the advantages include higher sensitivity to the “good” facets of life. For example, positive social interactions may be experienced as highly positive or meaningful social interactions. Artistic, creative, or natural beauty is often particularly noticed, enjoyed, and appreciated. Highly sensitive persons have been found to possess higher sensitivity to social and emotional cues and often experience greater positive emotional arousal (Aron & Aron, 1997; Aron et al., 2005).

Highly sensitive children gained more benefit from depression-prevention and anti-bullying interventions than peers, again suggesting that highly sensitive individuals might be more receptive to positive influence from supportive environments (Nocentini, Menesini, & Pluess, 2018; Pluess & Boniwell, 2014).

Sharing neuronal and brain research studies with clients can help to affirm the temperament as a strength and one of research interest. For example, when exposed to emotional stimuli, individuals high in SPS displayed higher neural activity in areas of the brain supporting memory, physiological regulation, depth of processing, attention, action planning, awareness, empathy, and information integration (Acevedo et al., 2014; Acevedo, Jagiellowicz, Aron, Marhenke, & Aron, 2017). Meta-analysis revealed that individuals high in SPS showed increased activation in brain regions associated with reward processing, attention, reflective thinking, self-control, empathy, hormonal balance, and calmness (Acevedo, Aron, Pospos, & Jensen, 2018).

Jagiellowicz and colleagues (2011) found that individuals high in SPS exhibited greater activation in brain areas associated with visual attention when performing a visual change detection task. Researchers hypothesize that such heightened neural activity allows HSPs to integrate and store large amounts of sensory information (Acevedo et al., 2018).

Other advantages include the ability to process subtle stimuli and reflect on possible courses of action and consequences, leading to lower impulsivity and less risk-taking in potentially dangerous situations. One aspect of high sensitivity, called aesthetic sensitivity (a subscale of the HSPS) correlated with participants scoring higher levels of openness, strong communication skills, rich internal lives, and use of their sensitivity to subtleties as a strength (Liss et al., 2008; Smolewska et al., 2005.

Resources: Acevedo, B. P., Aron, E. N., Aron, A., Sangster, M. D., Collins, N., & Brown, L. L. (2014). The highly sensitive brain: An fMRI study of sensory processing sensitivity and response to others' emotions. Brain and Behavior, 4, 580-594. https://doi.org/10.1002/brb3.242

Nocentini, A., Menesini, E., & Pluess, M. (2018). The personality trait of environmental sensitivity predicts children's positive response to school-based anti-bullying intervention. Clinical Psychological Science, 6, 848-859. https://doi.org/10.1177/2167702618782194

Pluess, M., & Boniwell, I. (2014). Sensory-processing sensitivity predicts treatment response to a school-based depression prevention program: Evidence of vantage sensitivity. Personality and Individual Differences, 82, 40-45. https://doi.org/10.1016/j.paid.2015.03.011

Smoleska, K. A., McCabe, S. B., & Woody, E. Z. (2005). A psychometric evaluation of the Highly Sensitive Person Scale: The components of sensory processing sensitivity and their relation to the BIS/BAS and “Big Five.” Personality and Individual Differences, 40, 1269-1279. https://doi.org/10.1016/j.paid.2005.09.022

Susceptibilities

Much research has focused on the relationship between SPS and negative characteristics and outcomes (Aron & Aron, 1997; Benham, 2006; Liss et al., 2008). Because HSPs receive and process so much sensory information, they are more easily overstimulated by sensory input (Aron & Aron, 1997). High SPS is related to higher levels of stress, more self-reported symptoms of physical illness, anxiety, depression, and specific components of social anxiety, including agoraphobic avoidance and harm avoidance (Benham, 2006; Hoffman & Bitran, 2007; Liss et al., 2008). Highly sensitive children seem to face challenges as well, and researchers found these children had more internalizing problems, engaged in more crying, and reported more unexplained symptoms of ill health (Boterberg & Warreyn, 2016).

Scrimin et al. (2018) found that children high in environmental sensitivity who also experienced childhood adversity reported lower physical comfort and lower self-efficacy for social interaction. Highly sensitive children with supportive home environments exhibited greater self- efficacy. It is important to note, however, that some researchers found SPS to predict anxiety and depression beyond parental care, and others found HSPs to be susceptible to negative environments, but not to positive environments, suggesting that SPS might still be a risk factor for negative outcomes independent from childhood experience (Booth et al., 2015, Liss et al., 2008).

Highly sensitive clients who are unaware of the trait of SPS often know they are different, but not why. Their overstimulation and distress can be due to attempts to live like those who are not highly-sensitive, and resulting self-judgment when they cannot (e.g., “what is wrong with me?”). Highly sensitive clients can also be misunderstood when describing distressing symptoms.

Professional counselors who are unaware of SPS and problems with overstimulation, can erroneously diagnose disorders based upon temporary symptoms that may seem like Autism, attention deficit hyperactivity disorder (ADHD), mood disorders, agoraphobia, post-traumatic stress disorder (PTSD), and others. Lastly, the name Sensory Processing Sensitivity, while a distinct construct, is sometimes confused with the Diagnostic and Statistical Manual for Mental Disorders (DSM-5; APA, 2013) categorizations of similarly named constructs (e.g., sensory processing disorder).

Resources: Benham, G. (2006). The highly sensitive person: Stress and physical symptom reports. Personality and Individual Differences, 40, 1433-1440. https://doi.org/10.1016/j.paid.2005.11.021

Hofmann, S. G., & Bitran, S. (2007). Sensory-processing sensitivity in social anxiety disorder: Relationship to harm avoidance and diagnostic subtypes. Journal of Anxiety Disorders, 21, 944-954. https://doi.org/10.1016/j.janxdis.2006.12.003

Liss, M., Mailloux, J., & Erchull, M. J. (2008). The relationship between sensory processing sensitivity, alexithymia, autism, depression, and anxiety. Personality and Individual Differences, 45, 255-259. https://doi.org/10.1016/j.paid.2008.04.009

Researched Interventions

Experimental evidence exists supporting the effectiveness of mindfulness-based stress reduction (MBSR) interventions for HSPs (Soons, Brouwers, & Tomic, 2010). Researchers found that, HSPs) who received an 8-week MBSR intervention showed significantly lower levels of stress and anxiety and significantly higher levels of empathy, self-acceptance, personal growth, and self-transcendence. The results were maintained at a four-week follow-up. The researchers hypothesized that the mindfulness techniques emphasized in this program, including body scans, yoga, and meditation, help HSPs cope with and accept constant streams of sensory input, rather than becoming overwhelmed by stimuli.

There are potential benefits of acceptance for individuals high in SPS. Bakker and Moulding (2012) found that SPS was only associated with greater anxiety and depression when individuals scored low on measures of mindfulness and acceptance. Both mindfulness and acceptance mediated the relationship between SPS and anxiety and depression. However, acceptance accounted for a greater part of the interaction, especially for anxiety. ACT techniques aimed at increasing acceptance by emphasizing the non-judgmental, non-evaluative noticing of sensory stimuli have the potential to reduce the stress and anxiety that might occur when highly sensitive individuals attempt to make meaning of and evaluate all incoming information. Furthermore, individuals who scored higher in SPS tended to score lower in mindfulness and acceptance, suggesting that while HSPs could potentially benefit from these practices, conscious interventions to increase mindfulness and acceptance might be needed.

Emotion regulation strategies are potentially effective for decreasing symptoms of depression for HSPs. Brindle et. al. (2015) showed that lack of emotion regulation strategies partially mediated the relationship between high SPS and depressive symptoms. HSPs who exhibited limited emotion regulation strategies, as well as heightened awareness and limited acceptance of negative emotions, were more likely to experience depressive symptoms. The researchers hypothesized that HSPs who tend to be prone to negative emotional states might be exposed to such negative states repeatedly, thus increasing their awareness of these emotions and lowering their self-efficacy for emotion regulation as well as their acceptance of feelings of distress.

Interventions to increase individuals’ self-efficacy of emotion regulation and acceptance of negative emotional states may be especially useful.

Resources: Bakker, K., & Moudling, R. (2012). Sensory-processing sensitivity, dispositional mindfulness and negative psychological symptoms. Personality and Individual Differences, 53, 341-346. https://doi.org/10.1016/j.paid.2012.04.006

Brindle, K., Moulding, R., Bakker, K., & Nedeljkovic, M. (2015). Is the relationship between sensory- processing sensitivity and negative affect mediated by emotional regulation? Australian Journal of Psychology, 67, 214-221. https://doi.org/10.1111/ajpy.12084

Soons, I., Brouwers, A., & Tomic, W. (2010). An experimental study of the psychological impact of a mindfulness-based stress reduction program on highly sensitive persons. Europe’s Journal of Psychology, 6(4), 148-169. https://doi.org/10.5964/ejop.v6i4.228

Implications for Parenting

As discussed previously, multiple researchers suggested that while highly sensitive children (HSC) might be more sensitive to adverse home environments, these same children might also benefit significantly from positive, supportive home environments (Aron & Aron, 1997; Pluess & Belsky, 2010; Scrimin et al., 2018). Additionally, negative childhood experiences in other studies were characterized by negative or hostile interactions with caregivers, the subjective feeling of unhappiness during childhood, parental over-reactivity, parental power assertion, inconsistent disciplinary practices, and parental ignoring of children (Booth et al., 2015; Slaght, Dubas, & Ellis, 2018). On the other hand, these researchers also used the presence of caring adults, high parental responsiveness, encouragement of children’s autonomy, and positive parent-child interactions as markers of positive home environments that support the positive development of highly sensitive children (Scrimin et al., 2018; Slaght et al., 2018).

Parents of HSC may first present in counseling with fear or concern that their child is not developing normally or adaptively to certain contexts (e.g., school or peer groups). Symptoms should be assessed as described earlier in regard to overstimulation but with developmentally-specific behaviors, such as excessive crying or emotionality, inability to focus or make decisions, desire to interact with fewer peers during play, or aversion to destructive-themed media, games or overly-aggressive play. Professional counselors can provide positive information about the trait and psychoeducation for parenting a HSC. Supportive parenting includes waiting until the child is no longer overstimulated to provide corrective feedback on behavior, teaching the child how to express their basic emotions and consistently validating them when they do express their emotions, teaching HSC how to prevent and manage overstimulation, and noticing how the child’s sensitivity is of benefit to others on a regular basis. Parents, teachers, professional counselors and other caregivers hold tremendous power to support HSC (and later, highly sensitive adults) to share their gifts with the world.

Acevedo, B. P., Aron, E. N., Aron, A., Sangster, M. D., Collins, N., & Brown, L. L. (2014). The highly sensitive brain: An fMRI study of sensory processing sensitivity and response to others' emotions. Brain and Behavior, 4, 580-594. https://doi.org/10.1002/brb3.242

Acevedo, B., Aron, E., Pospos, S., & Jessen, D. (2018). The functional highly sensitive brain: A review of the brain circuits underlying sensory processing sensitivity and seemingly related disorders. Philosophical Transactions of the Royal Society B, 373, 1-5. https://doi.org/10.1098/rstb.2017.0161

Acevedo, B. P., Jagiellowicz, J., Aron, E., Marhenke, R., & Aron, A. (2017). Sensory processing sensitivity and childhood quality's effects on neural responses to emotional stimuli. Clinical Neuropsychiatry, 14, 359-373.

American Psychiatric Association. (APA). (2013). Diagnostic and statistical manual of mental disorders (5th ed.).Arlington,  VA: Author.

Aron, E. N. (2010). Psychotherapy and the highly sensitive person: Improving outcomes for that minority of people who are the majority of clients. New York, NY: Routledge.

Aron, E. N. (2018). Sensory processing sensitivity: Review of the research. Retrieved from http://hsperson.com/research/summaries-of-research-easy-reads/

Aron, E. N., & Aron, A. (1997). Sensory-processing sensitivity and its relation to introversion and emotionality. Journal of Personality and Social Psychology, 73, 345-368. http://dx.doi.org/10.1037/0022-3514.73.2.345

Bakker, K., & Moudling, R. (2012). Sensory-processing sensitivity, dispositional mindfulness and negative psychological symptoms. Personality and Individual Differences, 53, 341-346. https://doi.org/10.1016/j.paid.2012.04.006

Benham, G. (2006). The highly sensitive person: Stress and physical symptom reports. Personality and Individual Differences, 40, 1433-1440. https://doi.org/10.1016/j.paid.2005.11.021

Booth, C., Standage, H., & Fox, E. (2015). Sensory-processing sensitivity moderates the association between childhood experiences and adult life satisfaction. Personality and Individual Differences, 87, 24-29. https://doi.org/10.1016/j.paid.2015.07.020

Boterberg, S., & Warreyn, P. (2016). Making sense of it all: The impact of sensory processing sensitivity on daily functioning of children. Personality and Individual Differences, 92, 80-86. https://doi.org/10.1016/j.paid.2015.12.022

Brindle, K., Moulding, R., Bakker, K., & Nedeljkovic, M. (2015). Is the relationship between sensory- processing sensitivity and negative affect mediated by emotional regulation? Australian Journal of Psychology, 67, 214-221. https://doi.org/10.1111/ajpy.12084

Ellis, B. J., & Boyce, W. T. (2011). Differential susceptibility to the environment: Toward an understanding of sensitivity to developmental experiences and context. Development and Psychopathology, 23, 1-5. https://doi.org/10.1017/S095457941000060X

Greven, C. U., Lionetti, F., Booth, C., Aron, E. N., Fox, E., Schendan, H. E.…Homberg, J. (2019). Sensory processing sensitivity in the context of environmental sensitivity: A critical review and development of research agenda. Neuroscience and Biobehavioral Reviews, 98, 287-305. https://doi.org/10.1016/j.neubiorev.2019.01.009

Hofmann, S. G., & Bitran, S. (2007). Sensory-processing sensitivity in social anxiety disorder: Relationship to harm avoidance and diagnostic subtypes. Journal of Anxiety Disorders, 21, 944-954. https://doi.org/10.1016/j.janxdis.2006.12.003

Jagiellowicz, J., Xu, X., Aron, A., Aron, E., Cao, G., Feng, T., & Weng, X. (2011). The trait of sensory processing sensitivity and neural responses to changes in visual scenes. Social Cognitive Affective Neuroscience, 6, 38-47. https://doi.org/10.1093/scan/nsq001

Lionetti, F., Aron, A., Aron, E. N., Burns, G. L., Jagiellowicz, J., & Pluess, M. (2018). Dandelions, tulips, and orchids: Evidence for the existence of low-sensitive, medium-sensitive, and high-sensitive individuals. Translational Psychiatry, 8(24), 1-11.

Liss, M., Mailloux, J., & Erchull, M. J. (2008). The relationship between sensory processing sensitivity, alexithymia, autism, depression, and anxiety. Personality and Individual Differences, 45, 255-259. https://doi.org/10.1016/j.paid.2008.04.009

Nocentini, A., Menesini, E., & Pluess, M. (2018). The personality trait of environmental sensitivity predicts children's positive response to school-based anti-bullying intervention. Clinical Psychological Science, 6, 848-859. https://doi.org/10.1177/2167702618782194

Pluess, M., Assary, E., Lionetti, F., Lester, K. J., Krapohl, E., Aron, E. N., & Aron, A. (2017). Environmental sensitivity in children: Development of the Highly Sensitive Child Scale and identification of sensitivity groups. Developmental Psychology, 54, 1-97. http://dx.doi.org/10.1037/dev0000406

Pluess, M., & Belsky, J. (2010). Children’s differential susceptibility to effects of parenting. Family Science, 1, 14-15. https://doi.org/10.1080/19424620903388554

Pluess, M., & Boniwell, I. (2014). Sensory-processing sensitivity predicts treatment response to a school-based depression prevention program: Evidence of vantage sensitivity. Personality and Individual Differences, 82, 40-45. https://doi.org/10.1016/j.paid.2015.03.011

Scrimin, S., Osler, G., Pozzoli, T., & Moscardino, U. (2018). Early adversities, family support, and child well-being: The moderating role of environmental sensitivity. Child Care Health Development, 44, 885-891. https://doi.org/10.1111/cch.12596