object oriented research paper topics

Showing papers on "Object-oriented programming published in 2019"

The functional perspective.

36  citations

Hoobas: A highly object-oriented builder for molecular dynamics

23  citations

Invited: Actors Revisited for Time-Critical Systems

20  citations

Programmers do not favor lambda expressions for concurrent object-oriented code

19  citations

FluidSim: Modular, Object-Oriented Python Package for High-Performance CFD Simulations

13  citations

SDNSOC: Object Oriented SDN Framework

12  citations

A Brief Overview of Software Reuse and Metrics in Software Engineering

11  citations

Validating object-oriented software at design phase by achieving MC/DC

10  citations

Ant Lion optimizer for state based object oriented testing

Collaborative strategy for teaching and learning object-oriented programming course: a case study at mostafa stambouli mascara university, algeria.

9  citations

Object-oriented model of the seismic vulnerability of the fuel distribution network in coastal British Columbia

Lessons in persisting object data using object-relational mapping, on attributes of objects in object-oriented software analysis, an object-oriented semantic slam system towards dynamic environments for mobile manipulation, design decisions under object-oriented approach: a thematic analysis from the abstraction point of view, induction, coinduction, and fixed points in pl type theory., a new object-oriented framework for solving multiphysics problems via combination of different numerical methods, backus: comprehensive high-performance research software engineering approach for simulations in supercomputing systems., model based object-oriented software testing, godexpo: an automated god structure detection tool for golang, seamless object-oriented requirements, creation of biological databases using object-oriented system analysis, implementation of phpmailer with smtp protocol in the development of web-based e-learning prototype, does cyclic learning have positive impact on teaching object-oriented programming, to be, or not to be: that is the recursive question, an automatic and intelligent approach for supporting teaching and learning of software engineering considering design smells in object-oriented programming, on the students’ misconceptions in object-oriented language constructs, serialization in object-oriented programming languages, estimation of complexity by using an object oriented metrics approach and its proposed algorithm and models.

On the site

• Computer Systems Series

Research Directions in Object-Oriented Programming

Edited by Gul Agha , David Beech , Daniel G. Bobrow , Ole-Johan Dahl , Joseph A. Goguen , Brent Hailpern , Kenneth M. Kahn , Ole Lehrmann Madsen , David Maier , Andrea Skarra , Harold L. Ossher , Steven Reiss , Herbert Schwetman , Reid Smith , Alan Snyder , Peter Wegner and Stanley Zdonik

ISBN: 9780262192644

Pub date: October 9, 1987

• Publisher: The MIT Press
• 9780262192644
• Published: October 1987

Out of print

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• Description

Once a radical notion, object-oriented programming is one of today's most active research areas.

Once a radical notion, object-oriented programming is one of today's most active research areas. It is especially well suited to the design of very large software projects involving many programmers all working on the same project. The original contributions in this book will provide researchers and students in programming languages, databases, and programming semantics with the most complete survey of the field available. Broad in scope and deep in its examination of substantive issues, the book focuses on the major topics of object-oriented languages, models of computation, mathematical models, object-oriented databases, and object-oriented environments. The object-oriented languages include Beta, the Scandinavian successor to Simula (a chapter by Bent Kristensen, whose group has had the longest experience with object-oriented programming, reveals how that experience has shaped the group's vision today); CommonObjects, a Lisp-based language with abstraction; Actors, a low-level language for concurrent modularity; and Vulcan, a Prolog-based concurrent object-oriented language. New computational models of inheritance, composite objects, block-structure layered systems, and classification are covered, and theoretical papers on functional object-oriented languages and object-oriented specification are included in the section on mathematical models. The three chapters on object-oriented databases (including David Maier's "Development and Implementation of an Object-Oriented Database Management System," which spans the programming and database worlds by integrating procedural and representational capability and the requirements of multi-user persistent storage) and the two chapters on object-oriented environments provide a representative sample of good research in these two important areas.

Research Directions in Object-Oriented Programming is included in the Computer Systems series, edited by Herb Schwetman.

Gul Agha is Director of the Open Systems Laboratory at the University of Illinois at Urbana-Champaign and an Associate Professor in the Department of Computer Science.

Daniel G. Bobrow is a Research Fellow in the Intelligent Systems Laboratory, Xerox Palo Alto Research Center, editor-in-chief of the Journal of Artificial Intelligence , and Chair of the Governing Board of the Cognitive Science Society.

Reid Smith is Director of the Schlumberger Laboratory for Computer Science.

Peter Wegner is Professor in the Department of Computer Science at Brown University.

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2 Citations

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Ranking of problems and solutions in the teaching and learning of object-oriented programming

• Published: 08 February 2022
• Volume 27 , pages 7205–7239, ( 2022 )

Cite this article

• Luz E. Gutiérrez   ORCID: orcid.org/0000-0001-8229-7175 1 ,
• Carlos A. Guerrero   ORCID: orcid.org/0000-0001-8164-9650 2 &
• Héctor A. López-Ospina   ORCID: orcid.org/0000-0001-8144-6394 3  

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This study describes the most relevant problems and solutions found in the literature on teaching and learning of object-oriented programming (OOP). The identification of the problem was based on tertiary studies from the IEEE Xplore, Scopus, ACM Digital Library and Science Direct repositories. The problems and solutions identified were ranked through the multi-criteria decision methods DEMATEL and TOPSIS in order to determine the best solutions to the problems found and to apply these results in the academic context. The main contribution of this study was the categorization of OOP problems and solutions, as well as the proposal of strategies to improve the problem. Among the most relevant problems it was found: 1) difficulty in understanding, teaching and implementing object-orientation, 2) difficulties related to understanding classes and 3) difficulty in understanding object-oriented relationships. After doing the multicriteria analysis, it was found that the most important solutions to face the problems found in the teaching of OOP were: 1) use of active learning techniques and intrinsic rewards and 2) emphasize on basic programming concepts and introduce the object-oriented paradigm at an early point in the curriculum. As a conclusion, it was evidenced that there is coherence between the literary guarantee that gives support to the problems and solutions in the teaching of OOP presented in this study and the approaches that experts in the area of development highlight as relevant when they identify weaknesses in the process.

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1 Introduction

For Martins et al. ( 2018 ) programming is the basis of a professional on systems. For such reason, it is required that programming courses are based on a model that allows putting into practice all the proposed theoretical approach. According to Popat and Starkey ( 2019 ) programming skills are 21st-century competences every person should enhance.

Martins et al. ( 2018 ) state that a learning process in the programming area should allow the student to identify a real problem and transform it into a sequence of activities that will finally be translated into a language. According to Qian et al. ( 2020 ) the teacher is the one in charge of guiding the students in this process of problem transformation, making the complexity implicit in the programming decrease and motivate them to continue. In addition, Dorn et al. ( 2018 ) affirm that although the teachers are facilitators, knowing the difficulties of a programming teaching process can allow them to implement pedagogical strategies that help the students in their training process.

Now, for Azmi et al. ( 2016 ) facilitating the teaching of algorithm design and programming is an activity that not only requires technical knowledge from the teacher, but also skills to motivate the students to overcome the obstacles that arise in their training. According to Martins et al. ( 2018 ) a non-motivated student is likely to increase the dropout statistics.

Ismail et al. ( 2018 ) state that the current teaching processes are not the most adequate, as is the case of “Teaching based solely on referring to the books seen to fail to attract the students’ interest in learning”, the authors state that “every educator should practice effective teaching methods to produce optimum outcomes. The success of a student lies in the way of teaching. Thus, it is important for teachers to study appropriate teaching methods that suit with the targeted students." Therefore, according with Draz et al. ( 2016 ) and Sarkar et al. ( 2016 ) traditional methods can create resistance in the student that will eventually be transformed into fear of programming.

In the work by Yang et al. ( 2015 ) and Qian and Lehman ( 2017 ) concepts such as variables, cycles and conditional structures are challenges for a student in training. However, in programming the most critical points are in abstract thinking and object-oriented programming (Hadar, 2013 ; Jordine et al., 2015 ; Krpan et al., 2015 ). A wrong training process leads the students to take a reactive attitude and to develop the idea that they do not have the ability or competences to continue in software development (Dorn et al., 2018 ).

More recent research work suggests that a deep knowledge of the teaching programming problems could allow the establishment of processes based on emerging methodologies such as the case of video games (Guerrero et al., 2020 ). These new teaching processes seek that the student generates a commitment and motivation to address the topics of study (Piteira et al., 2017 ).

Several paradigms such as structural programming, object-oriented programming, aspect-oriented programming, and reactive programming are identified in the programming area. This article will focus primarily on the object-oriented paradigm OOP.

Therefore, it is important to explore what factors affect the teaching and learning process of OOP within the context of every student and their environment. Thus, the following research question arises: What solutions could be prioritized in the resolution of problems in the teaching and learning of OOP?

The second section of this article describes the methods and materials used to identify and prioritize the OOP problem. The results section presents the most important findings related to the problem. The discussion section relates the observations of experts involved in the research and analysis of the results. Finally, the conclusions consolidate the contributions of the study.

2 Material and methods

2.1 procedure for identifying oop problems and solutions.

A systematic literature review was carried out in order to identify the problems and solutions present in the teaching-learning process of object-oriented programming This review took as a reference the guidelines of the protocol proposed by Kitchenham et al. ( 2007 ). The PICOC strategy (Kitchenham & Charters, 2007 ) used in this research is presented below.

2.1.1 PICOC

According to Kitchenham and Charters ( 2007 ) the use of 5 criteria is suggested to define the research questions that will guide the search for the studies which will be part of the research: population, intervention, comparison, results, and context. These criteria are generally used in medicine and can be applied in the systems area. Population refers to the people affected by the intervention. The interventions which are usually a comparison between two or more alternative treatments. The outcomes are the clinical and economic factors that will be used to compare the interventions. The comparison refers to what the intervention is being compared with. The context refers to what is the context in which the intervention is delivered. The definition of each concept in the framework of this research is presented below:

Population: Corresponds to the literature related to topics that address the problems and solutions in the teaching-learning processes of object-oriented programming.

Intervention: The search string displayed in each one of the repositories made it possible to delimit the work to be done and established the field of intervention of the research.

Comparison: This concept was used in the present investigation when comparing the problems found.

Results: Identification of problems and solutions in the teaching-learning process of object-oriented programming.

Context: It is made up of the works that have as their foundation the study of object-oriented programming.

2.1.2 SLR Research Questions

The research questions proposed for carrying out the systematic literature review, which are supported by the PICOC criteria, are presented below.

Q1: What are the problems related to the learning and teaching of object-oriented programming?

Q2: What are the solutions to the problems found in the teaching and learning of object-oriented programming?

2.1.3 Search process

Once the research questions were defined and the keywords were identified, the generic search string was established to obtain the primary sources of the study. Fig. 1 presents the defined query string. This string is intended to identify tertiary papers that focus their studies towards teaching, learning or object-oriented paradigm skills. The "*" is used as a catch-all symbol to replace any combination of the words learn and teach, for example, it would apply learning and teaching.

Search string

The work carried out by Brereton et al. ( 2007 ) and Kitchenham and Charters ( 2007 ) was established as a reference for the selection of the search repositories. The selected repositories were IEEE Xplore, Scopus, ACM Digital Library and Science Direct.

3009 non-duplicate studies were found with the execution of the search string. For the Science Direct repository, an automatic filtering of the identified papers was performed with the VOSviewer tool (Van Eck & Waltman, 2010 ). The data obtained with the processing tool allowed to generate a term co-occurrence map that defines the most important topics for the present study in the Science Direct repository. The topics classified by the VOSviewer tool are shown in Fig. 2 .

Science Direct terms co-occurrence network map

Due to the limited number of papers, automatic processing was not performed with the VOSviewer tool in the IEEE, Scopus and ACM repositories. The automatic processing performed with VOSviewer significantly reduced the number of pre-selected studies, identifying 945 relevant investigations for the present study.

2.1.4 Selection and exclusion criteria

The following selection criteria were applied to the title and abstract metadata of the 945 articles preselected in the previous stage.

SC1: Studies that address problems in the teaching-learning of object-oriented programming.

SC2: Studies that reference bibliography where the problems of object-oriented programming are identified.

After applying the selection criteria 87 papers remained. Then, exclusion criteria were applied to these 87 papers. As a result of this process 56 studies remained which formed the conceptual basis of the present investigation. The applied exclusion criteria are shown below:

EC1: Incomplete studies that do not present the details of the research.

EC2: Articles that do not allow access to their information.

The complete process from definition of the search string, selection of repositories and selection and exclusion criteria application, is presented in Fig. 3 and Table 1 .

Search and selection process

2.2 Identified problems

A comparison matrix was made after analyzing the 56 selected studies. It allowed the identification of 14 problems related to the teaching and learning process of object-oriented programming. Each of these problems is described below.

Difficulty in understanding object and its dynamic nature (D01) . This problem is referred as the students’ conception of the term object as a simple record of a database. The students do not understand the aspect of behavior and variation as a function of the object’s state (Hadar, 2013 ; Jordine et al., 2015 ; Karahasanović et al., 2007 ; Moons & De Backer, 2009 ; Moussa et al., 2016 ; Olsson & Mozelius, 2015 ; Rajashekharaiah et al., 2016 ; Sajaniemi et al., 2007 ; Sanders et al., 2008 ; Sheetz, 2002 ; Sheetz et al., 1997 ; Sien & Chong, 2011 ; Tegarden & Sheetz, 2001 ; Thomasson et al., 2006 ; Xinogalos, 2015 ; Yang et al., 2018 ).

Difficulties related to understanding classes (D02). This difficulty is described as the complexity presented by the students when assimilating the static nature and depth of classes. It is challenging for them to understand the hierarchy and the identification of correct classes. The students even refer to the difficulty in distinguishing between class and object. They generally assimilate class as a collection of objects, rather than an abstraction (Benander et al., 2004 ; Biddle & Tempero, 1998 ; Gorschek et al., 2010 ; Hadar, 2013 ; Hubwieser & Mühling, 2011 ; Karahasanović et al., 2007 ; Lewis et al., 2004 ; Moons & De Backer, 2009 ; Moussa et al., 2016 ; Musil & Richta, 2017 ; Nelson et al., 1997 ; Rajashekharaiah et al., 2016 ; Sajaniemi et al., 2007 ; Sanders et al., 2008 ; Sheetz, 2002 ; Sheetz et al., 1997 , Sien, 2011 , Sien & Chong, 2011 , Tegarden & Sheetz, 2001 , Thomasson et al., 2006 ; Xinogalos, 2015 ; J. Yang et al., 2018 ).

Difficulty in understanding the concept of method (D03). In this case it is referred as the complexity presented when assimilating the concept of method, there is no clarity on how to make the method calls. The students do not know how to determine the number of methods needed or what labels or names to assign to them. They do not understand how to reuse methods or their proper placement (Berges et al., 2012 ; Gorschek et al., 2010 ; Hubwieser & Mühling, 2011 ; Karahasanović et al., 2007 ; Moons & De Backer, 2009 ; Moussa et al., 2016 ; Olsson & Mozelius, 2015 ; Sajaniemi et al., 2007 ; Sanders et al., 2008 ; Sheetz et al., 1997 ; Tegarden & Sheetz, 2001 ).

Difficulty in understanding, teaching and implementing object-orientation (D04). This problem is specified as the challenge of performing object-oriented analysis, design, and programming. The students present difficulties when adopting the object-oriented paradigm, because their initial formative process is generally based on purely structural programming. The modular nature of the object-oriented paradigm is conceived as a challenge for educators, since in this process it is common for students to assimilate erroneous conceptions and to present problems in understanding and implementing object-oriented standards (Abbasi et al., 2017 ; Anniroot & de Villiers, 2012 ; Arif, 2000 ; Barr et al., 1999 ; Benander et al., 2004 ; Black et al., 2013 ; Cetin, 2013 ; Dale, 2006 ; Fedorowicz & Villeneuve, 1999 ; García Perez-Schofield et al., 2008 ; Hadar, 2013 ; Hosanee & Panchoo, 2015 ; Hubwieser & Mühling, 2011 ; Hundley, 2008 ; Jordine et al., 2015 ; Tahat, 2014 ; Karahasanović et al., 2007 ; Kunkle & Allen, 2016 ; Lewis et al., 2004 ; Mazaitis, 1993 ; Moussa et al., 2016 ; Nelson et al., 1997 ; Pei et al., 2010 ; Rajashekharaiah et al., 2016 ; Sajaniemi et al., 2007 ; Sanders et al., 2008 ; Seng & Yatim, 2014 ; Sheetz, 2002 ; Sheetz et al., 1997 ; Sien, 2011 ; Sien & Chong, 2011 ; Streib & Soma, 2010 ; Tan et al., 2014 ; Tegarden & Sheetz, 2001 ; Thomasson et al., 2006 ; Turner et al., 2010 ; Xinogalos, 2015 ; J. Yang et al., 2018 ; Zhang et al., 2018 ).

Difficulty in understanding object-oriented relationships (D05). It refers to the difficulty that the students have when understanding and implementing object-oriented relationships, such as association, dependency, generalization / specialization-inheritance, composition and aggregation. These problems are common due to the learners’ lack of experience in relation to the object-oriented programming paradigm. The students generally present difficulties in the process of modeling these relationships, and consequently in the implementation and application of concepts that are often conceived as complex (Barr et al., 1999 ; Benander et al., 2004 ; Berges et al., 2012 ; Biddle & Tempero, 1998 ; Dale, 2006 ; Gorschek et al., 2010 ; Hadar, 2013 ; Hosanee & Panchoo, 2015 ; Hundley, 2008 ; Karahasanović et al., 2007 ; Lewis et al., 2004 ; Moussa et al., 2016 ; Musil & Richta, 2017 ; Nelson et al., 1997 ; Olsson & Mozelius, 2015 ; Rajashekharaiah et al., 2016 ; Sheetz, 2002 ; Sheetz et al., 1997 ; Sien, 2011 ; Sien & Chong, 2011 ; Tegarden & Sheetz, 2001 ; Thomasson et al., 2006 ; J. Yang et al., 2018 ; Zhang et al., 2013 ).

Difficulty in understanding polymorphism and overload (D06). In this case it is indicated the high level of complexity the concepts of polymorphism and overload have at the moment of initiating a student into the programming area (Benander et al., 2004 ; Dale, 2006 ; Hosanee & Panchoo, 2015 ; Hundley, 2008 ; Lewis et al., 2004 ; Moussa et al., 2016 ; Rajashekharaiah et al., 2016 ; Sheetz, 2002 ; Sheetz et al., 1997 ; Tegarden & Sheetz, 2001 ; J. Yang et al., 2018 ).

Difficulty in understanding encapsulation (D07). This problem is related to the assimilation of several misconceptions related to understanding encapsulation, modularity and information hiding (Biddle & Tempero, 1998 ; Gorschek et al., 2010 ; Hubwieser & Mühling, 2011 ; Hundley, 2008 ; Karahasanović et al., 2007 ; Lewis et al., 2004 ; Moussa et al., 2016 ; Rajashekharaiah et al., 2016 ; Sanders et al., 2008 ; Sheetz, 2002 ; Sheetz et al., 1997 ; Sien & Chong, 2011 ; Tegarden & Sheetz, 2001 ; Turner et al., 2010 ; Xinogalos, 2015 ; J. Yang et al., 2018 ).

Complexity with the programming languages and tools used in the teaching and learning of object-orientation (D08). This problem is specified as the difficulty that students present with the use of debugging, navigation, testing and documentation tools. The change in technologies, paradigms and languages makes the learning process even more difficult (Barr et al., 1999 ; Benander et al., 2004 ; Bishop-Clark, 1995 ; García Perez-Schofield et al., 2008 ; Jiang et al., 2004 ; Jordine et al., 2015 ; Karahasanović et al., 2007 , Kiss, 2013 , Mazaitis, 1993 , Moons & De Backer, 2009 , Moons & De Backer, 2013 ; Nelson et al., 1997 ; Radenski, 2006 ; Rajashekharaiah et al., 2016 ; Sheetz, 2002 ; Sheetz et al., 1997 ; Tegarden & Sheetz, 2001 ; Thomasson et al., 2006 ; J. Yang et al., 2018 ; T.-C. Yang et al., 2015 ; Zainal et al., 2012 ; X. Zhang et al., 2018 ).

Difficulty in teaching and understanding general programming topics (D09). This difficulty refers to the challenges that the students face when understanding algorithms and basic programming concepts. Concepts such as variables, parameters, functions, and control structures are often considered difficult topics (Benander et al., 2004 ; Berges et al., 2012 ; Biddle & Tempero, 1998 ; Cetin, 2013 ; Dale, 2006 ; Govender, 2009 ; Hadar, 2013 ; Hubwieser & Mühling, 2011 ; Hundley, 2008 ; Jiang et al., 2004 ; Jordine et al., 2015 ; Karahasanović et al., 2007 ; Kiss, 2013 ; Krpan et al., 2015 ; Kunkle & Allen, 2016 ; Mazaitis, 1993 ; Moons & De Backer, 2009 ; Moons & De Backer, 2013 ; Moussa et al., 2016 ; Nelson et al., 1997 ; Olsson & Mozelius, 2015 ; Radenski, 2006 ; Sanders et al., 2008 ; Sheetz, 2002 ; Sheetz et al., 1997 ; Sien, 2011 ; Tan et al., 2014 ; Tegarden & Sheetz, 2001 ; Thomasson et al., 2006 ; T.-C. Yang et al., 2015 ; Zainal et al., 2012 ; J. Zhang et al., 2013 ).

Difficulty in developing abstract thinking (D10). This problem is related to the difficulty when understanding and solving real-world problems. The students frequently face processes where they must coordinate the acquired abstract thinking skills and the assimilated knowledge. This integration of skills and concepts challenges the student and, in many cases, makes the training process difficult (Anniroot & de Villiers, 2012 ; Biddle & Tempero, 1998 ; Black et al., 2013 ; Hadar, 2013 ; Hundley, 2008 ; Jordine et al., 2015 ; Karahasanović et al., 2007 ; Krpan et al., 2015 ; Olsson & Mozelius, 2015 ; Rajashekharaiah et al., 2016 ; Sheetz, 2002 ; Sheetz et al., 1997 ; Sien, 2011 ; Sien & Chong, 2011 ; Tegarden & Sheetz, 2001 ; Thomasson et al., 2006 ).

Difficulty in understanding software analysis and design (D11). It refers to the inability the students have to represent and design real-world problems. Students find challenges when using analysis and design techniques. They find it difficult to apply design concepts in Unified Modeling Language (UML) and to make use of related techniques and patterns (Anniroot & de Villiers, 2012 ; Biddle & Tempero, 1998 ; Bishop-Clark, 1995 ; Black et al., 2013 ; Hadar, 2013 ; Hundley, 2008 ; Tahat, 2014 ; Karahasanović et al., 2007 ; Lewis et al., 2004 ; Moons & De Backer, 2009 ; Rajashekharaiah et al., 2016 ; Sanders et al., 2008 ; Sheetz, 2002 ; Sheetz et al., 1997 ; Sien, 2011 ; Sien & Chong, 2011 ; Tegarden & Sheetz, 2001 ; Thomasson et al., 2006 ; Turner et al., 2010 ; J. Yang et al., 2018 ).

Difficulty in understanding reuse (D12) . This is a quite recurrent problem. The learners do not understand when and where to reuse and they confuse this concept with the tendency to copy code, generating redundancy and duplication of information (Karahasanović et al., 2007 ; Sheetz, 2002 ; Sheetz et al., 1997 ; Tegarden & Sheetz, 2001 ).

Difficulty with project administration and management methodologies and techniques (D13). This problem refers to understanding activities that include time and resource restrictions. It is confusing for the learners to know when to stop, advance or finish the project (Karahasanović et al., 2007 ; Sheetz, 2002 ; Sheetz et al., 1997 ; Tegarden & Sheetz, 2001 ).

Difficulty in software implementation and maintenance (D14). This last problem is related to the difficulty students have in starting the software and in adding, subtracting or modifying the code to be adapted. These challenges demand significant amounts of time and effort, which generally causes apathy and disinterest in the process (Karahasanović et al., 2007 ; Tegarden & Sheetz, 2001 ).

2.3 Identified solutions

According to the literature review, six possible solutions to the problems of teaching-learning of object-oriented programming were found. Each of the possible solutions is described below.

Use of tools that support knowledge transfer (S01). This solution is described as an emerging proposal where virtualization, animation, online sessions and more channels that support knowledge transfer are used. Additionally, it is emphasized on the use of game-related tools and more suitable languages for teaching (Abbasi et al., 2017 ; Govender, 2009 ; Jordine et al., 2015 ; Kiss, 2013 ; Mazaitis, 1993 ; Moons & De Backer, 2009 ; Moons & De Backer, 2013 ; Olsson & Mozelius, 2015 ; Radenski, 2006 ; Sajaniemi et al., 2007 ; Seng & Yatim, 2014 ; Sheetz et al., 1997 ; Tan et al., 2014 ; J. Yang et al., 2018 ; T.-C. Yang et al., 2015 ).

Emphasize basic programming concepts and introduce the object-oriented paradigm at an early point in the curriculum (S02). It is considered that introducing the object-oriented paradigm at an early point in the curriculum make the students better understand the associated concepts. In addition, the basic concepts, such as class and object, must be emphasized, because they tend to be confused (Biddle & Tempero, 1998 ; Hundley, 2008 ; Mazaitis, 1993 ; Sanders et al., 2008 ; Tegarden & Sheetz, 2001 ).

Make use of UML diagrams, design patterns and simplified methodologies (S03). The use of the unified modeling language helps the students visualize and formulate programming concepts (Hundley, 2008 ; Jiang et al., 2004 ; Moons & De Backer, 2013 ; Sheetz et al., 1997 ; J. Yang et al., 2018 ).

Minimize aspects of the problem mastery, while learning object-oriented fundamentals (S04). This solution refers to emphasizing the resolution and mastery of the problem, putting aside the complexity of programming languages or development environments (Tegarden & Sheetz, 2001 ).

Use of active learning techniques and intrinsic rewards (S05). This solution is referred as the use of active learning techniques that involves peer tutoring, role-play activities, workshops, exemplifications, use of metaphors, and concept mapping (Jordine et al., 2015 ; Mazaitis, 1993 ; Moons & De Backer, 2013 ; Nelson et al., 1997 ; Sajaniemi et al., 2007 ; Sanders et al., 2008 ; Sien, 2011 ; Thomasson et al., 2006 ; T.-C. Yang et al., 2015 ; Zainal et al., 2012 ).

Change the way of teaching (S06). This solution refers to the change of teaching strategies, adapting the approach to the difficulties, achievements and mistakes of others. Thus, the learning is based on the students’ experiences (Govender, 2009 ; Moons & De Backer, 2013 ; Tan et al., 2014 ; Thomasson et al., 2006 ; T.-C. Yang et al., 2015 ).

2.4 Prioritization of the identified problems

The DEMATEL (Decision Making Trial and Evaluation Laboratory) multi-criteria method is used for the prioritization and classification of the most relevant OOP problems (Espinosa & Salinas, 2013 ; Jeong & Ramírez-Gómez, 2018 ; López-Ospina et al., 2017 ). This method allows finding the relationships between the problems of this study, as well as their hierarchization depending on the decision-making context. In other words, it is assumed that there is a relationship between the problems. DEMATEL is a method that is considered effective for identifying the key components of the cause-effect chain of a complex system. It seeks to evaluate the interdependent relationships between factors and find the most critical or relevant ones through a visual structural model. This method provided the causal relationship between OOP problems and their importance ranking (Alzahrani et al., 2018 ; Aldowah et al., 2020 ). The steps of the DEMATEL method that were carried out in the present study are detailed below.

2.4.1 Step 1: Generation of the direct relationship matrix

The evaluation of the direct relationships of the problems was carried out by three experts in the field of object-oriented programming. The selected profiles were those who met: 1) experience of more than 5 years in the academic environment, 2) experience of more than 5 years in application development in the business sector and 3) professionals from different universities. Table 2 describes the experts’ profiles.

The scale defined in Table 3 was used for the evaluation of the problems in order to find the influence relationship of the 14 problems identified in the teaching and learning of OOP. This scale is the one generally used in the applications of the DEMATEL method.

The 14 x 14 direct relationships matrix A was generated based on the information recorded by the experts (the problems have been described in section 2.2 Identified problems). Each expert evaluated the influence of each problem against the other ones to define the scale of influence among them. From this process, 3 evaluation matrices emerged, which later were averaged to generate the consolidated initial relationships matrix. Table 4 presents matrix A with the averages obtained.

2.4.2 Step 2: Normalization of the direct relationships matrix

The normalized matrix M was generated using equations ( 1 ) and ( 2 ). The objective of the transformation is to have a matrix with a norm less than 1. The results of M are presented in Table 5 .

2.4.3 Step 3: Obtaining the total relationship matrix

Subsequently, the total relationship matrix S was generated using equation ( 3 ). Table 6 presents the data of matrix S . It contains the direct and indirect relationships between the problems.

2.4.4 Step 4: Determine the cause group and effect group

Based on equations ( 4 ), ( 5 ) and ( 6 ) a vector with the sum of the elements per rows of the matrix S , named D , was generated; then a vector with the sum of the elements per columns of S , named R , was generated.

Table 7 presents the calculation values of D+R and D-R. The positive values of D-R represent causes and the negative values are interpreted as the problems that are effect. A problem that is a Cause is one that originates or initiates the problem, whereas if a problem is an Effect, it means that it is the consequence of another problem. These results can be seen in Table 8 .

2.4.5 Step 5: Set the threshold value and obtain the impact diagram

The threshold value was set at 0.2863 for matrix S based on equation ( 7 ).

The diagram in Fig. 4 shows the distribution of the matrix S values. The minimum value is 0.063, 1st quartile is 0.2154, 2nd quartile is 0.3027, 3rd quartile is 0.3586 and the maximum value is 0.5049. As it can be seen in Fig. 4 , there are no outliers of the S values. Additionally, the threshold value is less than the median and corresponds to the 41st percentile. It means that 41% of the scores are less than or equal to the threshold. This implies that 80 relationships among problems should be analyzed as key in the teaching-learning process. Given this number of relationships, it is proposed to do the aggregate causality analysis of Fig. 5 .

Box plot of matrix S

D+R vs D-R relationship

Fig. 5 describes the causal diagram is built with the horizontal axis (D + R) called "Prominence" and the vertical axis (D - R) called “Relation”. The horizontal axis shows the relative importance of each problem. On the other hand, vertical axis, splits problems into cause or effect. If (D - R) is positive, is a cause problem. Otherwise, it is an effect problem. For that reason, causal diagrams can visualize the causal relationships of problems into a visible structural model. According to the results obtained, D02’s problem is the cause factor with the highest importance. On the other hand, D10’s problem is the strongest effect factor and has a high weight. The problems classified as cause (D01, D02, D03, D06, D09, D12) have high weighting. However, some effect problems have a low importance.

2.4.6 Step 6: Weighting of problems

In this step, the problems that have the greatest weight in the teaching and learning process of OOP were identified. Equations ( 8 ) and ( 9 ) were used to weight the problems (Jeong & Ramírez-Gómez, 2018 ). The result of applying the equations is presented in Table 9 and Table 10 .

After applying the weighting and standardization coefficients, the problems with the greatest weight in the teaching and learning process of OOP were identified (see Table 11 ).

2.5 Selection of solutions strategies

It is important to identify the possible solutions for the problems found in the process of teaching and learning of OOP. There is evidence in the analyzed literature where authors such as Gómez et al. ( 2020 ); Zhang et al. ( 2019 ) and Yi and Fang ( 2018 ) presented significant results when selecting solution strategies through multi-criteria methods such as TOPSIS (Technique for Order Preference by Similarity to Ideal Solution). The TOPSIS method handles the concept of the ideal solution and the anti-ideal solution when choosing decision alternatives. Its premise is based on the fact that a given alternative is located at the shortest distance from a positive ideal solution and at the greatest distance from a negative ideal solution. An ideal solution is defined as an ideal set of levels with respect to all the considered attributes of a given problem, even when the ideal solution is usually impossible or not feasible to obtain (Sun et al., 2016 ). The steps used in the implementation of the TOPSIS method during the selection process of solution strategies analyzed in this study are listed below.

2.5.1 Step 1: Construction of the decision matrix

The same experts who supported the application process of the DEMATEL method were consulted for the evaluation of the matrix of solutions vs problems with the TOPSIS method. Each expert evaluated it based on the following guidelines: 1) identify how much influence a solution could have on each problem, 2) identify how much it could contribute to solving the problem and 3) how feasible it was to implement that solution. Each expert evaluated the influence of the solutions in each of the 14 problems, with values from 0 to 4, where 0 represents that there is no influence and 4 that there is a total influence of the solution to address the problem. The scale used is found in Table 3 . From this process 3 matrices emerge, one for each evaluator. These matrices are averaged and the decision matrix presented in Table 12 is obtained.

2.5.2 Step 2: Normalization of the decision matrix

Subsequently, the decision matrix was normalized based on Equation ( 10 ). Table 13 presents the results of the normalized matrix.

2.5.3 Step 3: Construction of the weighted normalized decision matrix

The weighting vector was obtained with the DEMATEL method. The weighted normalized decision matrix was calculated by multiplying each W j by each V ij . Where W is the weight vector for each problem (Table 14 ), and V is the normalized decision matrix (Table 13 ). The results of this calculation are presented in Table 15 .

2.5.4 Step 4: Determination of the ideal positive and negative solution

The objective of this step was to identify the positive and negative ideal solution, in order to calculate how close the OOP solutions were to the ideal ones. Formulas ( 11 ) and ( 12 ) were used for this process.

The results of Table 16 were obtained after applying formulas ( 11 ) and ( 12 ). For the case study of this article, the objective was to maximize the values of OOP solutions.

2.5.5 Step 5: Calculation of distance measurements

In this step the positive and negative distance measures were calculated for each solution applying formulas ( 13 ) and ( 14 ).

The results of this arithmetic procedure are presented in Table 17 .

2.5.6 Step 6: Calculation of relative proximity

The last step in the TOPSIS method was the calculation of relative proximity, a procedure based on equation ( 15 ).

Table 18 presents the results of the application of the relative proximity equation. Subsequently, the values were organized from the highest to the lowest weight, in order to identify the solutions that were closest to the solution ideal as described in Table 20 .

3.1 Influence relationship between the OOP problems

According to the DEMATEL results, Table 19 describes how much one problem affects another and how much it is affected by another. For the case of problem "D02 - Difficulties related to the understanding classes", it influences to a high degree problem "D04 - Difficulty in understanding, teaching and implementing object-orientation". This would be an expected result because, if a student does not handle the concept of classes correctly, it will be reflected when understanding the object-oriented paradigm.

Ten problems affect problem "D04 - Difficulty in understanding, teaching and implementing object orientation", indicating that this problem is the one that receives the most influence from the other factors. The problem that most affects the other problems is “D02 - Difficulties related to understanding classes”, with an occurrence of 11 out of 14.

3.2 Towards a generic framework

The construction of the Ranking allowed to define a framework for implementing solutions to problems in the object-oriented programming teaching. As a general contribution of this research, the steps to implement strategies that help in the object-oriented programming teaching-learning process are presented. Fig. 6 describes the stages and activities to be carried out for this purpose.

Generic framework

The validation stage is part of the next phase of this research in which instruments to evaluate the perception of students and teachers after applying the suggested strategies will be built. From this activity a feedback process will emerge for the proper calibration of such instruments and strategies.

3.3 Strategies to implement the best solutions

As it can be seen in Table 20 , the top ranked solutions is “S05 - Use of active learning techniques and intrinsic rewards”, followed by “S02 - Emphasize basic programming concepts and introduce the object-oriented paradigm at an early point in the curriculum”, and in the third position “S01 - Use of tools that support knowledge transfer”.

The solutions that are closest to the ideal are the best strategies to help minimize the 14 problems in this study (Table 20 ). Recommendations for the implementation of the solutions ranked in the top 3 positions are provided below.

3.3.1 Strategies for the use of active learning techniques and intrinsic rewards (S05)

For the implementation of the solution "Use of active learning techniques and intrinsic rewards", three strategies are proposed as it can be seen in Table 21 .

3.3.2 Strategies to emphasize basic programming concepts and introduce the object-oriented paradigm at an early in the curriculum (S02).

For the implementation of the solution "Emphasize basic programming concepts and introduce the object-oriented paradigm at an early point in the curriculum", four strategies are proposed as it can be seen in Table 22 .

3.3.3 Strategies for the use of tools that support knowledge transfer (S01).

For the implementation of the solution "Use of tools that support knowledge transfer", three strategies are proposed as it can be seen in Table 23 .

4 Discussion

The problems and solutions identified in the literature review phase present some suggestions by the panel of experts. For expert 1 problems D11, D13 and D14 are not part of the scope of OOP teaching and learning. Based on this statement, he recommends that these problems should not be taken into account in future research. He also mentions that there are relevant problems that were not explicitly identified in the findings, such as the programming language syntax requirement. By having a diversity of programming languages, each one will have its own statements and typing rules, making the teaching-learning process of OOP difficult. Another factor that influences the teaching of OOP is the pedagogical preparation of teachers. Instructors are usually experts in informatics or computer science; however, teaching methodology is not an area of their expertise.

On the other hand, expert 2 affirms that, although problems D13 and D14 are not directly related to the teaching and learning of OOP, it is important to evaluate them within the framework of a complete process of analysis of this problem. For expert 2, the problems identified group together the OOP universe.

Regarding the level of complexity of each problem, expert 3 states that the problems identified in the literature review are at different levels, it means that there are generic problems and other more specific ones. In this regard, he recommends working with problems D01 to D10.

Regarding the solutions found, Expert 1 considers that appropriate preparation in methodological and pedagogical issues is important in the teaching staff that guides programming topics.

Experts 1 and 2 suggest that ideally solution "S06 - Change the way of teaching" would be the optimal solution for the OOP teaching and learning problems. However, in the practice it is not feasible to implement it, because it implies the construction of individual and personalized teaching activities.

Expert 3 considers that solutions S01 and S05 have a great similarity in their concept, for this reason, they can be considered as the same solution when implementing them.

When analyzing the results of Table 11 , it is possible to see that the problem with the greatest weight is D04 “Difficulty in understanding, teaching and implementing object orientation”. According to the decision matrix of the TOPSIS method this problem may be solved by implementing S02 solution. This solution is very important, because the basis of OOP lies in understanding the concept of class and object; and as this research has proved these concepts are often confused.

The second most important problem was D02 “Difficulties related to understanding classes”. This problem, according to the matrix in Table 12 , can be addressed from 3 solutions: S02, S03 and S05 where only S03 did not appear in the ranking of solutions provided by the TOPSIS. However, it must be taken into account for this specific problem.

In general, the solutions of the ranking have in common that the change in the teaching and learning methodologies of OOP is prevailing. It is not advisable to maintain the same strategies for lectures and to present merely theoretical concepts. It is important to have students involved directly in the process and not continue thinking that they are actors who only receive information. As Ismail et al. ( 2018 ) well stated it, “This gamification approach to education is considered as one of the new teaching era that it is capable of improving students' achievement”.

5 Conclusions

This article presents an analysis of the OOP problem in 3 phases. The first phase of the study sought to identify the problems and solutions of OOP. This process of problem recognition was carried out through a systematic literature review in high-impact repositories. The second phase was the hierarchization of the OOP problems by means of the DEMATEL method; with this method, it was possible to identify the most relevant problems in the teaching-learning process of OOP and the relationship level between these problems. The third phase was the making up of the solutions ranking that was developed through the TOPSIS method, as well as the proposal of implementing strategies for each of the solutions located in the first three positions of the ranking. The contribution of this research can be focused on 3 aspects: 1) List of problems categorized from the greatest to the least relevance. 2) Ranking of solutions and 3) Strategies to implement the best solutions. The conclusions of this work according to the phases of the investigation are listed below.

It was possible to obtain information about the problems, causes and solutions of the teaching-learning process of object-oriented programming from the systematic literature review process carried out. These results show the interest of the academic community in presenting alternatives to implement strategies to improve this process.

According to the results obtained when applying the multicriteria techniques, the problem “D02 - Difficulties related to understanding classes” was identified as a cause in the DEMATEL method and had a high weighting value. This indicates the importance of emphasizing this subject in the classes, in order to generate adequate conceptual bases for programming students.

Based on the TOPSIS method results, it is found that the top ranked solution is "Strategies for the use of active learning techniques and intrinsic rewards". This finding reinforces the need for a change in OOP teaching strategies. For such reason, the use of tools related to computer games and the search for new teaching strategies that motivate students in their formative process can support the learning of object-oriented programming.

It was evidenced that there is coherence between the literary guarantee that supports the problems and solutions in the teaching of OOP presented in this study and the approaches that experts in the development area highlight as relevant when identifying weaknesses in the process.

The use of multi-criteria decision methods made it possible to identify the relationships between the OOP problems, as well as to prioritize the problems and solutions.

Taking into account the current world situation with the Covid-19 pandemic, the application of different teaching-learning strategies in all areas of study is imperative. In the case of OOP, strategies aimed at the use of tools that support knowledge transfer (S01) and the use of active learning techniques and intrinsic rewards (S05) are particularly important. It is because work mediated by technology and strengthening of individual skills is a priority with the current situation, where remote work and virtuality will be the new study scenarios.

6 Future research direction

This study laid the conceptual foundations in the identification of problems and solutions based on literature review. For this reason, it is necessary to carry out an analysis with a representative sample group, where OOP teachers and students of this subject help to identify which, from their experience, are the problems and solutions for the teaching of OOP by means of an evaluation instrument.

At the university where the authors belong, teacher evaluation processes are carried out twice each year, specifically, once for each academic semester. These results can feed the problems database that arise in the teaching of OOP.

The next phase of this research consists of implementing strategies to respond to the solution “Strategies for the use of active learning techniques and intrinsic rewards (S05)”. At this stage, a video game will be developed at the University of origin to teach concepts such as method, polymorphism, and encapsulation.

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Acknowledgements

This work was carried out with the assistance provided by Universidad Santo Tomás, Universidad del Norte and the program "Convocatoria de Doctorados Nacionales 785 de 2017". The authors would like to thank Universidad Santo Tomás and Universidad del Norte for allowing the articulation of an interdisciplinary team for the research project development. Thanks are extended to the experts who provided their valuable contributions.

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Gutiérrez, L.E., Guerrero, C.A. & López-Ospina, H.A. Ranking of problems and solutions in the teaching and learning of object-oriented programming. Educ Inf Technol 27 , 7205–7239 (2022). https://doi.org/10.1007/s10639-022-10929-5

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Inheritance and Its Type in Object Oriented Programming Using C++

13 Pages Posted: 18 Sep 2019

Dr Mehul Patel

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Date Written: September 10, 2019

Reusability is one of most important advantage of C++ programming language. C++ classes can be reused in several ways. Once the parent (Base) class has been written it can be modified by another programmer to suit their requirements. The main idea of inheritance is creating new classes, reusing the properties of the existing base class. The mechanism of deriving a new class (Child/Derived Class) from an Existing class (Base/Parent Class) is called inheritance. The old class is referred to as the base (Parent) class and the new class is called the derived class (Child) or subclass. A derived class includes all features of the generic base class and then adds qualities specific to the derived class. This paper reflects the study of the Inheritance concept and its types using C++ (oops).

Keywords: Base (Parent) class, Reusability, Sub (Derived/Child) Class, Visibility Modes and Types of Inheritance

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Introduction

Objects and object oriented programing, classes, structures and unions, inheritance, polymorphism.

Object oriented programming (OOP) is a programming concept that was invented to solve limitations of earlier programming paradigms. Therefore, it may be argued that OOP is a new approach to developing software. Whether OOP is an old or modern idea is open for debate. However, this paper focuses on the concepts that make up object oriented programming. It summarizes the relationship between structures, classes and unions, and OOP, and mentions the concepts of inheritance, objects, and polymorphism in OOP.

In the programming world, things are often viewed into two perspectives – data and actions or operations on these data. This viewpoint is inherent in object oriented programing. However, in OOP and unlike in a procedural programming approach, data and actions on data are further organized into modular units. These modular units are what is often referred to as objects. To develop a complete program, a programmer has to connect these objects. Therefore, the basic aspect of OOP design involves objects and interactions of these objects.

An object in OOP can be described simply as a group of data and operations on these data. As Horton (2010, p.507) has highlighted, an object is a data structure. An object in OOP sense is more or less like a physical or real-world object. Keogh, Keogh, and Giannini, (2004, p.230 ) have mentioned that an object is characterized by both state and behaviour. This similarities of objects to real things makes OOP a very powerful programming approach (Keogh, Keogh and Giannini, 2004, p.123).

The term objects can also be very confusing to persons with little knowldge of object oriented programing. According to Oracle (1995), an object is a software bundle having similar state or data and behaviour. Classes, structures and unions are examples of objects in OOP. However, instances of a class have often been reffered to as objects (Keogh, Keogh, and Giannini, 2004, p.210), an aspect that can be a source of confusion.

An understanding of object oriented programing must include knowledge of classes, structures and unions. Classes, structures and unions are core concepts of object oriented programming. A class is simply a data type. It provides a blueprint from which to create specific objects. A class can describe real-world or abstract objects to solve specific problems. Horton (2010, p.508) has mentioned further that a class defines “the objects to which” a program relate. We can describe a class as an entity defining the features of a specific set of things that are identified by similar set of operations and parameters.

Structures and union are also custom data types. Barnett, O’Cull, and Cox, (2006, p.54) have described a structure as “a method of creating a single data object from one or more variables” or members that do not have to be of same data type. Classes, structures, and unions are often defined by a user depending on requirements of a program.

A union is more or less like a structure. Their format and purposes are the same. Actually, the declaration of a union is similar to that of a structure. The difference between the two is that unlike a structure, a union allows its members to share a common memory space. Members of a union begins at the same memory location such that a member is overwritten when another is updated. The ability of a union variable to store values is limited to only a single member at a time. To create real-life objects and store large amount of data, a structure is more valuable and prefferable than a union.

classes, unions and structures can all have data objects of different data types. This aspect is in contrast to arrays, which are usually characterized by elements of the same data type.

The difference between classes, and structures and unions is clear. In a class, the members are automatically set to private while in unions and structures they are set to public. Keogh, Keogh and Giannini (2004, p.243) have highlighted that a C++ complier often converts a structure (or rather a struct) into a class.

Inheritance is also a main feature of OOP. It is simply a feature that describes the link between types of objects. In C++, for instance, a class can inherit the behaviour and state of other classes. Therefore, because of inheritance a child class can be extracted from the parent class.

Polymorphism is also an inherent aspect of OOP. It is a feature of object oriented programming languages that allows objects to be processed differently according to their class or data type. In other words, polymorphism make it possible to redefine derived classes’ methods. Horton (2010, p, 535) has pointed out that any true OOP language must be be characterised by polymorphism. The polymorphism feature of OOP languages makes it possible to manipulate values of varying data types through a similar interface.

This paper has exained the concepts of object oriented programming. It has summarized the relationships between structures, classes and unions, and object oriented programming as well as touched on the concepts of inheritance, objects, and polymorphism. These aspects of OOP makes it a very powerful programming approach.

Barnett, R.H., O’Cull, L., Cox, S. (2006 ). Embedded C programming and the Atmel AVR. Clifton park, New York: Cengage Learning.

Horton, I. (2010). Ivor Horton’s Beginning Visual C++ 2010 . Indianapolis, Indiana: John Wiley and Sons.

Keogh,J., Keogh, J.E., & Giannini, M. (2004). OOP demystified .Emeryville, Califrnia: McGraw-Hill Professional.

Oracle. (1995). Lesson: Object-Oriented Programming Concepts. Web.

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IRJET- Research Paper on Object-Oriented Programming (OOP

2020, IRJET

For the growth of software industry in future and the advance of software engineering, use of object-oriented programming (OOP) has increased in the software real world. Some the important features that's know is compulsory and that's features are important to study the depth knowledge of object-oriented programming in this paper, we study the concept of object-oriented programming and its features, advantages, disadvantages, and we also know the constructor and destructors

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Mirko Viroli

Today's large scale software systems are typically designed and implemented using the concepts of the object-oriented (OO) paradigm. However, there is still a need for existing OO languages and architectures to continuously adapt in response to demands for new features and innovative approaches. These new features, to name a few, include unanticipated software evolution, security, safety, distribution, and interoperability.

IJSRD - International Journal for Scientific Research and Development

Object Oriented Programming (OOP) utilizes an alternate arrangement of programming language than old procedural programming dialects (C, Pascal, and so forth.). It is a methodology which is essentially centered on the way objects collaborate to convey and share the data. It changed the utilization of procedural oriented programming, where the attention was on the methodology of execution. The object oriented methodology brought another way, giving more significance to the items. There are four basic concepts which are to be emphasized. The first concept is that of an Object. It is the basic building block of any programming language. It represents the way you can describe anything in the programming world. The next is Class; a class in OOP is the principle body of any system. The classes frame the fundamental improvement unit of any system. Third factor is Inheritance, where we can create a new class known as derived class from the parent base class. This helps in reducing the time for coding and the derived class is error free. The last factor is Polymorphism, which means the capacity to ask for that the same operations be performed by an extensive variety of diverse sorts of things.

Dr. Ifeanyi S Nwokoro

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Pierre America

Nikoleta Razkova

Since the first design concept of computers came into the world, many different methods of communication with these machines have been developed (Wu, 2010, p. 2). This paper discusses first, second, and third generations of programming languages. Several paradigms are defined and further compared with insight into their advantages and disadvantages.

International Journal for Research in Applied Science and Engineering Technology -IJRASET

IJRASET Publication

In a software development process, designing the software plays an important role. Thus, the use of object oriented system has widely used for its advantages such as reusability, and providing security to the software. These features are implemented using various features of object oriented system. In this paper, we study the various pillars of object oriented system i.e. abstraction, encapsulation, inheritance and polymorphism.

International Journal of Scientific Research in Computer Science, Engineering and Information Technology

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Object oriented programming has become a very important programming CONCEPT of our times.The time it was brought into existence by Simula. It directly support the object notions of classes, inheritance, information hiding, and dynamic binding. There is a variety of implementations for each of these concepts, and there is no general agreement as to how a particular concept must be interpreted. This survey takes a detailed look at the concepts which are fundamental to object-orientation, namely inheritance and polymorphism. Different aspects of inheritance and polymorphism are implemented in various popular Object oriented program language. We conclude that there is still lot of work to be done to reach a common ground for these to achieve features of OOPs. This survey presents a comparison of Java, C++, C# , Eiffel, Smalltalk, Ruby and Python in terms of their inheritance and polymorphism implementations. The paper also presents a compilation of the observations made by several surveys [1].

Chintan Varnagar

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Clinical and scientific review of severe and enduring anorexia nervosa in intensive care settings: introducing an innovative treatment paradigm

• Joseph A Wonderlich 1 , 2 ,
• Dorian R Dodd 1 , 2 ,
• Cindy Sondag 2 ,
• Michelle Jorgensen 2 ,
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• Stephen A Wonderlich 1  

Journal of Eating Disorders volume  12 , Article number:  131 ( 2024 ) Cite this article

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Anorexia nervosa is a serious and potentially lethal psychiatric disorder. Furthermore, there is significant evidence that some individuals develop a very long-standing form of the illness that requires a variety of different treatment interventions over time.

The primary goal of this paper was to provide a review of treatment strategies for severe and enduring anorexia nervosa (SE-AN) with the particular focus on treatments involving hospital care. Additionally, we wish to highlight a contemporary approach to such care and provide qualitative reactions to this model from both staff and patients.

A selective and strategic review of the treatment literature for SE-AN was conducted for the current paper. Emphasis was placed on clinical or scientific papers related to hospital-based care. Additionally, staff who work on a specific inpatient eating disorder unit with a substantial treatment program for SE-AN, along with a number of SE-AN patients were surveyed regarding their experiences working on, or receiving treatment on the unit. Importantly, the staff of this unit created a specific treatment protocol for individuals receiving hospital care. The results of the highlight both advantages and challenges of a hospital-based protocol oriented toward emphasizing quality of life, medical stability, and a health-promoting meal plan.

While there is general inconsistency with the type of treatment that is best suited to individuals with SE-AN, this is particularly true for higher levels of care that rely on inpatient hospital units or residential treatment settings. This is a highly significant clinical topic in need of further clinical and scientific examination.

Plain English summary

Anorexia nervosa is a serious illness which often persists for decades. Treatments for persistent anorexia nervosa are not well defined and there is considerable debate in the field about appropriate types of treatment strategies for these individuals. Such clinical uncertainty is particularly noteworthy in terms of the most appropriate types of care for these patients when they are hospitalized, which happens relatively frequently. Greater efforts are needed to develop inpatient programs for SE-AN that take into consideration their unique clinical needs.

Anorexia Nervosa (AN) is a serious and potentially lethal psychiatric disorder that is most typically seen in girls and young women, with a lifetime prevalence of 2–4% [ 1 , 2 ]. While AN is rare in some countries (e.g., Africa and Latin America) it is most prevalent in Europe, North America, and Australasia. AN is considered one of the most lethal psychiatric disorders with a crude mortality rate of 5% per decade and a standardized mortality ratio of around 6 [ 2 , 3 ].

Prospective longitudinal studies have consistently identified a subset of AN patients who have long-standing eating disorders, characterized by minimal improvement and significant impairment over decades (e.g. [ 4 , 5 ]). However, there has been significant variability across studies in terms of rates of remission and recovery from AN. Eddy and colleagues [ 5 ], suggested that the longer the duration of follow up in such prospective longitudinal designs, the greater the rates of recovery. Steinhausen [ 6 ] reported that in studies with follow up to four years since index diagnosis, recovery was approximately 33%, while studies with follow-ups ranging from 4 to 10 years average 47% recovered, and studies longer than 10 years in duration revealed recovery rates over 70%. Robinson [ 7 ] examined the same literature and concluded that rates of recovery after 10 years seemed to be declining compared to follow-ups ranging from 4 to 10 years. Eddy et al., [ 5 ] suggest that studies beyond 20 years of follow-up are not only limited, but the findings are even more inconsistent. For example, Theander [ 8 ] reported outcomes over 33 years of follow-up with 76% achieving recovery. However, two other studies [ 9 , 10 ] found that approximately 20 years after an initial hospitalization, around 50% of the sample of AN individuals was recovered. Ratnasuriya [ 11 ] reported that 20 years after hospitalization only 30% of the patients had a good outcome. Similarly, a study with a large sample of individuals treated for AN revealed that the longer the duration of the eating disorder, the lower the chance of recovery [ 12 ]. These findings are further supported by a recent systematic review on the treatment of eating disorders that showed that 40% of AN cases had partial or no remission of symptoms [ 13 ].

However, another important longitudinal study, by Eddy et al., [ 5 ] relied on a well-characterized and regularly assessed sample of both individuals with AN and bulimia nervosa (BN) over 22 years. In this study, the authors found that at the end of the first decade of illness, approximately 31% of the individuals with AN and 68% of the individuals with BN were recovered. Thus, BN appeared to be a much more remitting illness than AN. However, approximately two decades after the initial diagnosis, there was significant proportional change. At this point, approximately 63% of the individuals with AN and 68% of the individuals with BN had recovered. Approximately half of those with AN who had not recovered in the first decade did recover in the second decade. Interestingly, the recovery rate of BN did not change significantly over that decade. Thus, the study by Eddy and colleagues [ 5 ] suggests that recovery from AN may continue for decades after onset, but importantly, well over a third of the AN sample continued to have very significant AN moving into the third decade of the illness.

During the timeframe when many of these longitudinal studies were being conducted, clinicians were actively attempting to outline treatment strategies for long-term, persistent, and minimally remitting AN. Wonderlich and colleagues [ 14 ] summarized these clinical strategies, which were wide ranging and infrequently tested empirically. Overall, the collection of strategies reflected the informed experience of clinicians who had treated numerous patients with long-standing AN and served as a repository of clinical wisdom accrued largely during the 80s and 90s. Numerous recommendations and suggestions from these individuals still inform contemporary treatment strategies for SE-AN, such as establishing clear guidelines, the value of a team-oriented approach, the importance of meaningful treatment collaboration, inclusion of the patient’s family, avoidance of aggressive change-oriented techniques, and the potential value of psychiatric rehabilitation models of intervention. Additionally, Williams and colleagues [ 15 ] described an integrated treatment program which included staff from hospital-based eating disorder program along with a community-based mental health rehabilitation team and demonstrated some degree of efficacy.

An important point in the treatment literature for long-standing AN was the randomized controlled trial conducted by Touyz and colleagues [ 16 ]. This study compared the efficacy of 30 outpatient sessions of an adapted form of cognitive behavioral therapy (CBT) to an adapted form of specialist supportive clinical management (SSCM). Both treatments had a modified primary focus on enhancing quality of life and promoting harm reduction, rather than weight gain and symptom reduction. Both treatments had excellent retention of participants, with attrition rates under 15%. Comparisons between the two treatments revealed minimal differences in outcome. Furthermore, secondary analyses found a series of meaningful predictors of good response and revealed that quality of the therapeutic alliance was associated with positive responses, broadly [ 17 ]. Thus, this study offers support for the treatment of SE-AN and developing treatments that optimize patient engagement.

Several other empirical studies preliminarily have examined the impact of evidence-based, shorter-term treatments on SE-AN. Some of these studies suggested that treatments, such as CBT appear equally effective when delivered to individuals with AN versus individuals with SE-AN [ 18 ]. Similarly, two studies found that duration of illness was not a significant predictor of the outcome in structured treatment such as CBT and MANTRA [ 19 , 20 ]. However, in another study, which relied on practice guideline-based treatments, there was a significant difference in outcome between early stage versus SE-AN patients. Specifically, the SE-AN patients were less likely to improve in areas of work and social adjustment than the early stage patients and the SE-AN patients were more likely to access intensive services following treatment [ 21 ]. There are an increasing number of empirical studies with SE-AN patients which could ultimately impact effective treatment deliveries, however at this point in time, the number of these studies remains relatively limited and frequently constrained by sample size issues. Thus, there is a significant need for additional strategies to be tested with individuals, displaying long-standing and serious forms of AN.

Wonderlich and colleagues [ 22 ] outline a number of innovative treatment strategies which have been tested, at least preliminarily, in individuals with long-standing SE-AN. They highlight that there are new behavioral strategies (e.g., exposure paradigms [ 23 ], habit-oriented interventions [ 24 ], cognitive remediation therapy [ 25 ]), along with novel pharmacologic interventions, (e.g., ketamine [ 26 ], and dronabinol [ 27 ]) which may have potential value in treating longer standing forms of AN. Additionally, there are brain stimulation interventions (e.g., rTMS [ 28 ], DBS [ 29 ]) which continue to be tested in individuals with SE-AN and show either reasonable tolerability or preliminary efficacy. Also, there are system-oriented strategies that are being looked at, such as stepped-care treatment models [ 30 ] and novel “self-admission” approaches [ 31 ] to inpatient care. Again, preliminary data suggests these strategies may have value.

However, despite these newer developments, we agree with the general idea that the lack of understanding of SE-AN and the associated dearth of treatments represent a serious deficit in the eating disorder field. Moreover, we believe that this dearth of empirically supported treatments for SE-AN patients is even more of an urgent situation for higher levels of care in hospital based and residential treatment settings as many of these patients repeatedly utilize a higher level of care. The primary aim of this paper is to highlight that empirically informed treatments for SE-AN patients are particularly limited in higher levels of care, such as inpatient units, partial hospitals, and residential treatment centers. Furthermore, we want to highlight the significance of this dilemma and the impact it has on SE-AN patients, and the clinical teams who attempt to treat them in these environments. In the next section, we will provide an overview of this situation and describe an innovative program, which has recently been developed based on clinical need and expertise, to provide quality care for SE-AN patients and also support the treatment teams who are attempting to provide the intervention.

Higher levels of care and SE-AN

Historically, there has been some debate about the most preferred treatment setting for patients with SE-AN. Some individuals clearly suggest that outpatient treatment is appropriate if medical stability is maintained [ 32 ]. However, Strober [ 33 ] advocates for inpatient hospitalization for SE-AN and suggests that comprehensive coordinated care is best provided in such a setting. Woodside [ 34 ] provides broad strategy for SE-AN patients when hospitalized, which happens relatively frequently. He notes that many SE-AN patients cannot realistically conceive of recovery but are interested in incremental improvements in their eating disorder. Others are interested in pursuing enhanced quality of life or improving their overall condition. He highlights the importance of collaborative goal setting that is realistic and tailored to each individual patient. There are no minimum standards for goals, virtually any change is promoted. Woodside does not provide high levels of detail about the operations of the program over the course of a hospital stay, but does conclude that there is an urgent need for increased dialogue about the issues regarding inpatient care and SE-AN.

Banford et al. [ 35 ] offer comments about the idea that eating disorder treatment programs, both outpatient and inpatient, often pursue treatment goals that are inconsistent with SE-AN patient motivation. Furthermore, many of these programs are oriented toward more acute cases of AN, often of younger ages than many of the SE-AN patients. Thus, the authors highlight the possible problems for SE-AN patients when they are in traditional eating disorder programs. They emphasize that when SE-AN patients are integrated into recovery focused partial hospital programs with younger, more acute patients, problems may emerge and they recommend that SE-AN patients are best treated in a separate program with individualized goals and interventions. They highlight that there are very few descriptions of SE-AN specific hospital units in the eating disorder literature, but note that such patients are frequently admitted. They highlight that in an ideal SE-AN hospital unit, goals might include harm reduction, improved quality of life, achieving stabilization, reducing medical risk and decreasing crisis hospital dependency. Overall, they highlight an approach that is characterized by clinical flexibility, creativity, and adaptability for higher levels of care for SE-AN.

A recent systematic review of treatment interventions for SE-AN suggests that hospital-based care for SE-AN is not well understood and varies significantly across studies [ 36 ]. The evidence suggests that inpatient treatment for SE-AN may have a beneficial impact on eating disorder symptoms, but the evidence is unclear about whether or not such gains are maintained. Importantly, however, the five trials that are included in this review relied on a heterogenous collection of treatment strategies for these patients. Some programs were clearly oriented around cognitive behavioral therapy (CBT) while others were only partly based on CBT. Some programs included well defined nutrition plans, while others did not. Some programs relied on antidepressants while others did not. The length of the programs varied significantly, ranging from 3 to 5 months, which is a substantial variation. We would suggest that the clinical variability reported across the hospital-based programs in this review is representative of hospital programs broadly that treat individuals with SE-AN. In fact, this review provides support for the fundamental argument in the present paper, that there is a need for increased scientific and clinical attention to treatment protocols for SE-AN at higher levels of care.

Considerations for developing a treatment of SE-AN in higher levels of care

The Sanford Eating Disorders Unit in Fargo, North Dakota, is one of a declining number of hospital-based eating disorder programs with inpatient, partial hospital and intensive outpatient programming in the United States. In this program, we provide care annually to approximately 250 patients ranging in age from early adolescence throughout the life span. Additionally, we are one of a limited number of programs that openly accepts public insurance in the U.S. As such, we regularly provide care to individuals turned away from other treatment centers due to high medical complexity or insurance policies not covered by other programs. Typically, these individuals display SE-AN. Over time, the unit has attempted to develop a humane and effective approach to care for these individuals. In the hospital setting, we were forced to grapple with several ethical questions, such as whether we should provide care focused on full-weight restoration for a given SE-AN patient, when there is evidence to suggest that this approach has not worked well with the patient previously. Alternatively, should SE-AN patients be allowed to be admitted to the hospital without an active weight restoration based treatment plan, given the long-term risks of premature death in SE-AN? Thus, we sought to develop a treatment program that provides medical stabilization, promotes quality of life, and retains the possibility that one could, in fact, recover after years or decades of serious SE-AN [ 5 ].

In developing a standardized treatment approach for individuals with SE-AN, addressing the challenges associated with hospital-based care for individuals who vary significantly in terms of their desire or ability to restore weight was crucial. The heterogeneity of individuals with eating disorders is a significant issue in general but is even more significant in the shared space afforded by hospital treatment units. Thus, the typical hospital program for eating disorders must try to develop clinical programming to accommodate a wide variety of individuals. This may become particularly challenging when we consider that there is marked variability in the age of patients, the number of previous inpatient treatment episodes, and the total length of time they have been treated. In the case of AN, hospital programs must provide treatment programming for first-episode patients who are often adolescents and have significant family involvement, as well as long-standing patients with AN who may be significantly older, without family support.

Furthermore, there may be significant differences among SE-AN patients in terms of the degree to which the primary focus should be on weight-based recovery, or one that prioritizes a goal of maintaining medical stability and promoting quality of life. Importantly, these significant differences may, at times, be complicated for treatment teams in the hospital who are actively promoting weight-based recovery in one patient and maintaining medical stability and quality of life, or palliative or hospice care in another. Clearly, the complexity of patient experiences in a hospital environment with shared treatment programming and physical space limitations between patients is noteworthy, and a significant challenge for clinicians.

Another challenge for hospital-based programs is the impact of such diversity of patient characteristics on the distribution of valuable clinical resources. Hospital staff must repeatedly, and frequently, make decisions about who will be admitted when there is an opening for care. Should the opening be allocated to more acute, recent onset cases of AN in teenagers versus individuals with long-standing AN who have been hospitalized multiple times and not established significant weight restoration?

Furthermore, as we have noted previously, all of this clinical diversity and complexity in the hospital environment is increased because there is no well-defined, structured intervention for individuals with SE-AN in the hospital setting. As a result, there is often confusion about whether treatment goals for such individuals should focus on weight-based recovery versus medical stabilization with enhancement of quality of life. There is also uncertainty about what treatment approaches may be beneficial to SE-AN patients. For example, in the hospital, what type of psychological intervention may be most beneficial for individuals with SE-AN? Should dietary interventions be modified for such individuals? What is the role of pharmacotherapy in the treatment of SE-AN?

Given these challenges, and the lack of any clear guidance in the literature, we created an active treatment program track for hospitalized individuals with SE-AN. Due to the need to capitalize on existing resources, the SE-AN track was developed entirely integrated within our traditional eating disorder inpatient program. This means that all patients, regardless of whether they are on the SE-AN track, take part in group therapy and eat in the dining room together. In an effort to reduce potential conflicts arising in treatment as a result of a mixed milieu, some adjustments to therapeutics and dining room rules were implemented. These are described in more detail below.

When developing the SE-AN track, our primary goal was to help our SE-AN patients improve their quality of life, primarily by reducing the duration and frequency of hospitalizations and creating a more personalized treatment approach. Second, we aimed to provide transparency between patients and clinical staff regarding the rationale and procedures for treating individuals with SE-AN. Third, we sought to establish a highly collaborative agreement early in treatment between a patient and clinical staff regarding structured goals to reduce future long-term hospitalizations. Fourth, we aim to actively engage with the patient regarding discharge planning at the start of treatment. The primary objectives of the program are to maintain gains established during the hospital stay, develop an outpatient treatment plan with explicit targets, and provide a clear understanding of the procedures utilized in the long-term treatment plan (which may include repeated short-term, return hospital visits).

A description of a SE-AN treatment program at a higher level of care

In deciding to change treatment outcomes for SE-AN patients in the hospital, it became crucial to re-examine the treatment approaches generally used on the unit, given that they were designed for traditional treatment targets (e.g., full weight restoration). Changes were made across almost all therapeutic modalities (e.g., psychotherapy, psychiatric interventions, and nutritional rehabilitation). For example, our goal was no longer primarily focusing on three to four pounds of weight restoration a week in the hospital. We wondered what this would mean for dietitians working with SE-AN patients or when determining the length of hospitalization. Furthermore, in a patient’s psychotherapy, if quality of life is the outcome being measured, what should a therapist focus on in a session? Though specific quality of life interventions were not clear in the existing literature, what became clear to our team was the need to reduce the length and frequency of hospitalizations. We did not believe that a high-quality life could be achieved moving from hospital admission to hospital admission. However, SE-AN patients also often require significant time and support from providers at higher levels of care due to their high medical acuity arising from complications of their SE-AN. Thus, any quality of life focused treatment for individuals with SE-AN at higher levels of care must find a way to reduce time spent in the hospital by the patients, while also providing them significant ongoing support. This perspective (i.e., reducing frequency and length of hospitalizations while supporting the patients) became an overarching goal across all aspects of the SE-AN program. Below, we outline the fundamental procedures for the program.

Admission procedures and initiation of SE-AN treatment

As previously stated, one of the primary goals of the SE-AN program is to provide transparency and collaborative goal setting between patients and clinical staff. As such, discussing the SE-AN program goals should be started immediately, but not prescriptively. We believe the best approach for goal-setting is through collaborative formulation process among the treatment team and the patient, as this is one of the best ways to ensure adherence to treatment and improve clinical outcomes. Upon intake, patients are assessed as to whether they meet SE-AN criteria (e.g., duration of illness over seven years and multiple failed empirically supported treatment attempts) and their personal treatment goals are identified. Patients who meet these SE-AN criteria and express goals in line with improved quality of life and medical stability are informed of the SE-AN program. All new SE-AN patients are informed that their initial stay will be considered a brief evaluation stay of 2–4 weeks to achieve medical stability and assess readiness for the SE-AN program. During the first few days of the admission, patients meet with the provider to start an ongoing conversation about their therapeutic goals and receive psychoeducational materials about the SE-AN program. Patients are informed about the program’s guidelines, including working towards specific goals, SE-AN-specific interventions, length of stay, and discharge planning, all of which are presented below. If, at the end of the evaluation stay, the patient and team decide that the SE-AN program is suitable for the patient, the “ongoing admission” process is discussed. The details of the ongoing admission process will be described below. In short, this process ultimately allows the patient to return to the hospital on the SE-AN track for brief goal-oriented stabilization stays if they have adhered to their treatment plan for at least three months.

Treatment contract and goal setting

As noted by Woodside [ 34 ] collaborative goal setting that is realistic and tailored to each individual patient is crucial for treating individuals with SE-AN. While Woodside suggests that no goal is too small, we believe that at higher levels of care, goals must actively move the patient toward improved quality of life. Therefore, all patients with SE-AN in our program must set goals in three domains: quality of life improvement, ongoing medical stability, and maintaining a meal plan tailored to work with the patient’s goals (e.g., weight maintenance or varying degrees of weight restoration). Patients are asked to work with their treatment team in each domain to establish 2–3 measurable objectives that will help them move their lives forward. For example, a quality of life goal might be “going to get coffee once a week with a friend,” while an example of a goal to help a patient meet their meal plan requirements might be “establish appointments with an outpatient dietitian twice a month.” The treatment team retains measurable objectives created collaboratively to measure future progress and decide the suitability of continuing specific SE-AN programming for future admissions.

Furthermore, individuals with SE-AN often carry comorbidities that may be treatment-interfering (e.g., substance use, obsessive-compulsive disorder, post-traumatic stress disorder). If the treatment team, or patient, determine a patient’s comorbidities interfere with the SE-AN approach during the initial evaluation stay, additional goals must be set to address these ongoing issues either at the outpatient level of care or in a different treatment facility. For example, if a patient with SE-AN also experiences obsessive-compulsive behaviors, the patient and team must think through achievable goals (e.g., exposure and response prevention therapy or medication management) to reduce the impact on SE-AN treatment. These goals should be established with the treatment team and may range from traditional therapeutic interventions (e.g., exposure therapy or substance use treatment) to potentially more experimental approaches (e.g., repetitive transcranial magnetic stimulation [rTMS] or psychedelic-assisted psychotherapy) when indicated. The primary objectives regarding setting goals around comorbidities is to reduce treatment-interfering symptoms not directly related to the eating disorder outside the hospital and increase the likelihood an individual will be able to adhere to the treatment plan.

Another goal-related issue often pertains to step down and discharge planning. Following an inpatient admission on the SE-AN track, individuals may have the desire to step-down their level of care to a partial hospitalization program (PHP) or intensive outpatient program (IOP) to ensure a higher degree of aftercare compared to stepping down to outpatient therapy. As our primary goal is to improve quality of life outside of the hospital, our program has taken the stance that this is acceptable as long as there are specific, and clear goals that have been identified to work on while in the PHP or IOP. Additionally, we have occasionally utilized both PHP and IOP as the primary level of care for our SE-AN protocol; however, only for individuals who come to the hospital medically stable.

Specific interventions for SE-AN

Medical stability.

One of the immediate priorities of a SE-AN approach at a higher level of care is addressing the patients’ physical health and stabilizing any medical complications resulting from SE-AN. This includes addressing the various physical consequences of prolonged inadequate nutrition. Most crucially, medical experts should address issues such as cardiovascular complications, hypoglycemia, organ damage, electrolyte imbalances, and gastrointestinal distress that interferes with the ability to eat. While medication management of psychiatric comorbidities may also be necessary, the initial goal is to stabilize physical health so that there is a life remaining to improve.

Nutritional rehabilitation

An essential consideration for nutritional rehabilitation for individuals with SE-AN is the role of dietitians in the care team and developing simple, and achievable menu plans. While traditional goals, like improved diet variety, have been linked to sustained recovery following weight restoration treatments [ 37 ], the SE-AN program shifts away from what or how these patients eat, prioritizing only that they eat a sufficient amount. Thus, in collaboration with a dietitian, the SE-AN patient creates a meal plan based on foods they are already eating, described as “simple and doable.” While the dietitian works to ensure the patient meets their macronutrient targets (within what is possible given what the patient is willing and able to eat),, there is initially less concern about various food or meal challenges. Over time, if patients successfully adhere to their meal plan, they may choose to increase variety or do meal exposures during future SE-AN admissions. As has been discussed among our team while developing this program, some of these recommendations may challenge the traditional treatment targets utilized by dietitians in treating eating disorders. However, the concept of helping a patient find a meal plan to stabilize their weight and stop weight loss is a skill dietitians most likely already possess. Thus, this does not require extensive additional training. However, we encourage collaborative, and ongoing, discussions among the medical providers and the dietitians in determining various nutritional rehabilitation interventions, such as determining rate of increase in calories to stop weight loss while not destabilize the patient and potentially changes to the macronutrient breakdown of the diet to address medicals needs like treatment of edema. While many of the skills needed to treat SE-AN are already possessed by dietitians, specialized training for working with severely low-weighted, chronically-ill patients may want to be pursued by dietitians, or any of the team members, when it comes to how to best treat SE-AN patients nutritionally.

Another important consideration is how individuals with SE-AN utilize the dining room. Among providers, it has often been argued that the dining room is the most therapeutic intervention for individuals with eating disorders at a higher level of care. While this remains true for individuals with SE-AN, the dining room often serves a very different purpose. The primary function of the dining room is to support SE-AN patients who are trying a different eating model than what they have tried in previous treatments. For the treatment team, this might require changing the expectations in the dining room. For example, in our program, it is understood that patients with SE-AN may engage in some behaviors in the dining room that are often considered disordered. Rather than providing redirection for any eating disorder behavior (e.g., cutting food into small pieces, overuse of condiments), only behaviors that interfere with the patient’s ability to consume their expected nutritional goals (e.g., delaying the start of their meal until the last 5 min so that they are not able to finish their meal) receive redirection. Discussions between SE-AN patients and staff should be supportive, calming, and reassuring. Calm, kind, and reassuring non-verbal messages are also encouraged. Ideally, SE-AN patients should be able to complete their meal in food, given that the patient and dietitian agreed the meal was simple and doable, and that these patients are given only the amount of nutrition needed for medical stabilization and to support their own weight goals, which often means halting weight loss and stabilizing and maintaining current weight. However if a patient does not finish their meal in food, they are expected to consume the missed nutrition immediately following the meal via a liquid supplement. Repeated refusal of planned foods or supplements suggests that the patient is not able to utilize and benefit from the SE-AN program at this time, and calls into question the utility of future admissions under the SE-AN track. The team and the patient would collaboratively discuss expectations for treatment adherence and how nonadherence may decrease the likelihood of the patient being allowed to continue treatment in the SE-AN track.

As previously noted, one of the challenges of creating a hospital-based treatment for SE-AN is the potential interaction of these patients with other patients pursuing different treatment goals. While this might not be an issue in some settings, the dining room can often create a space of conflict between individuals on a traditional restoration plan and those on the SE-AN program. To reduce interference with patients on weight restoration programs, patients on the SE-AN program eat at a designated table within the dining room. These simple modifications are essential in dealing with the heterogeneity of the eating disorder patient population.

Psychotherapeutic interventions

Psychotherapeutic strategies for patients with eating disorders at higher levels of care, in general, are extremely varied, making decisions about psychotherapy interventions for individuals with SE-AN difficult [ 38 , 39 ]. Given that the goal of our SE-AN program is to promote quality of life and increase time outside of hospital units, we have shifted the programming towards values-oriented therapies [ 40 ] and skills-based distress tolerance interventions [ 41 ]. Acceptance and Commitment Therapy (ACT) techniques, like cognitive defusion and committed action, help patients deal with ruminative thinking, a hallmark of SE-AN, while pursuing valued goals following discharge from the hospital. Meanwhile, Dialectical Behavior Therapy (DBT) distress tolerance skills help SE-AN patients more effectively cope with the distress involved in changing eating disorder behaviors and resisting eating disorder urges, in order to approach valued personal goals, even when distressed. With these simple interventions, we hope to help patients increase their treatment motivation and adherence to the treatment plan. The hope is that this approach reduces the pressure on the patient and leads to greater hope and self-efficacy, as they take steps toward recovery in achievable ways, rather than having patients see recovery as an externally imposed goal that is also an insurmountable obstacle.

Additionally, conventional relapse prevention planning, consistent with Cognitive Behavioral Therapy (CBT), is also promoted to assist patients in adhering to clinical goals regarding relapse in the SE-AN program. An essential structural treatment issue is the need to strongly promote continued collaboration with the patient’s outpatient providers following discharge from the hospital program. Such ongoing collaboration is necessary for protecting gains made during the hospitalization.

Criteria for return visits and staying in the SE-AN program

Following discharge from a SE-AN hospital stay, patients are encouraged to immediately begin working towards the goals they set at intake to improve the quality of their life, adhere to their meal plan, and stay medically stable. If, after three months, the patient has been able to meet all of their goals, the patient should still be medically stable and have maintained their weight. Thus, SE-AN patients can return to treatment for 2–3 weeks to work on potential increases in their meal plan, maintaining their progress, or identify opportunities to enhance medical stability. However, patients who are meeting their goals and feel confident in their ability to continue doing so may choose to wait longer than three months before returning. If medically stable patients wait longer than three months, the expectation is still that they can return to treatment for short term stays if they have remained medically stable and have adhered to their individualized meal plan.

While the program aims to provide a more “doable” treatment option, it is necessary to recognize that there is less of a safety net with a maintenance intervention than a full-weight restoration treatment. The likelihood that there are slips, lapses, or relapses for individuals with SE-AN is still high. However, given the slower pace of treatment, getting back on track requires less effort than when relapse happens on traditional treatment approaches. Thus, the first step for any patient who slips on the SE-AN program is simply returning to their meal plan outlined at discharge. The patient-centered meal plan was created to be doable by the patient using foods they were already eating. Returning to the meal plan, the patient can maintain their current weight and potentially drift back to their discharge weight.

If a patient lapses and cannot maintain their weight, we may request that the patient delay return admission beyond three months and begin working to get back on track with their previous discharge plan to demonstrate that they can maintain their weight and stick to their meal plan outside the hospital. For patients unable to get back on track, we advise they seek treatment for medical stabilization. Once medically stable, if they can get back on track, the patient and treatment team must discuss whether it would be appropriate to return for continuation of the SE-AN program. Just as the creation of this program arose from the ethical considerations regarding continually trying unsuccessful full-weight restoration approaches with individuals with chronic anorexia nervosa, the SE-AN program must fall under the same scrutiny. For patients for whom the SE-AN program did not work, the treatment team and patient must carefully weigh the minimal potential for benefit of continuing in a treatment that has not proven to be effective, relative to the costs of continuing a treatment that is not working, as well as the missed opportunity of pursuing other potential treatments options. The treatment team needs to be willing to discuss all alternative options, including returning to weight restoration approaches or the initiation of palliative, or even hospice, care.

Staff and patient feedback

As reviewed above, there is a dearth of research on effective treatments at higher levels of care for patients with SE-AN. Furthermore, the heterogeneity of the limited existing research impedes the ability to meaningfully synthesize this work and translate it to clinical practice. Meanwhile, patients with SE-AN frequently request admissions for hospital care, and programs must decide, with little evidence to consult, how to best serve these patients. Absent empirical guidance or professional consensus on the best way to serve these patients, we believe that exposing higher levels of care treatment programs to professional scrutiny in order to prompt more in-depth discussion of treatment issues for this population would be beneficial. Additionally, without a generalizable understanding of hospital treatment for patients with SE-AN, program evaluations should be conducted within individual treatment programs to inform strengths and shortcomings of each specific program, from the perspective of the patients and staff. We recently began a quality assessment effort to elicit feedback on our program, in order to further refine and enhance the SE-AN treatment protocol. Below, we provide an overview of staff and patient feedback. Of note, this feedback was given as part of evaluation efforts for our particular program, rather than as part of a methodologically rigorous research protocol, and as such is not intended to create generalized knowledge about hospital treatment of SE-AN.

Staff feedback

Overall, staff feedback about the SE-AN treatment model has been quite positive. Staff responses consistently indicated that the SE-AN model seemed to give a sense of hopefulness for many patients, and provided a good opportunity for us to “meet patients where they’re at.” Staff acknowledged that this can be a last resort for patients without other options, who are deemed “too sick” or noncompliant and are thus turned away from many other programs. Staff also noted that the greater autonomy given to patients in SE-AN protocol is helpful for their treatment process and progress, and appears to contribute to an increase in effective collaboration between the patient and providers. Staff believe that patients find this approach to be more tolerable, which decreases patient resistance and defensiveness. Finally, staff appreciated being able to individualize treatment around identifying realistic goals for patients to achieve incremental change outside of the hospital, and felt that in this way they were helping to set the patients up for success rather than contributing to a treatment/relapse cycle.

Staff also noted challenging aspects of the SE-AN treatment model, and areas for improvement. Specifically, several staff noted that explaining this model can be difficult as some patients initially worry that providers are “giving up on them.” And although individualization of treatment is generally seen as a strength of the model (by staff and patients alike), staff note that this can also cause issues with consistency and clarity, and for some patients not in the SE-AN program, it can cause an increase in comparisons with others (e.g., patients questioning why other patients are allowed certain accommodations, but they are not). A third challenge noted was that some patients do not use the treatment model effectively. For example, doing it to placate family or outside providers by “doing treatment,” but without genuine collaborative intent, is inconsistent with the model. Finally, this model can lead to significant challenges when patients (and/or their families and outside providers) do not have a realistic understanding of the severity of and impairment from their disorder, which can cause disagreement between the patient and their team regarding what goals are realistic. For example, a patient who states they want to gain significant weight but is unable to adhere to even a maintenance meal plan while in the hospital, would be required to set a more realistic goal. Treatment staff indicated that patients can at times get fixated on the parameters of the SE-AN model, and consistently challenge the SE-AN model limits (e.g., on length of stay, being asked to set more realistic goals); working through this reactivity and conflict detracts from providers being able to more meaningfully work on the eating disorder itself and provide patients with the full benefit of this model.

Patient feedback

Overall, patient feedback has been positive, though somewhat more mixed than staff feedback. Generally, patient and staff feedback show good correspondence, with both groups noting similar strengths and weaknesses of the treatment model. On the positive side, patients voiced appreciation for the autonomy and individuality that this approach provided with regards to being able to tailor their goals to what is specific for them. Patients stated that they “felt heard” and that their team collaborated well with them. As one patient stated “I don’t need to have a 4-hour panic attack over…lasagna which I’m never going to eat outside treatment. It just made sense to me working on what I wanted to work on.” Patients described the program as “realistic” and “autonomy supporting” and “humane” because it is “not forcing something that’s not worked in the past. And it’s not forcing, like, the cookie cutter model on a person, because every person is unique.” One patient with a trauma history stated that being given autonomy over her own choices while being kept safe from her ED was like “nothing I’ve experienced before and I think so incredibly healing.” Another patient highlighted that “people with AN often desire a high need for control. This program helps give us some level of control while working on difficult recovery goals…. This is the first time where I feel like I am in control of my recovery. I’m no longer scared I am going to die. I am no longer going to the ER 1–2 times a week…. It really seems to be working.”

Some patients were conflicted on the theoretical approach to treatment. For example, one patient expressed appreciation that “skills are repeatedly used to help facilitate success on the outside” [outside the hospital], while another patient stated that “more of the process work could be utilized rather than skills over and over” because “if you’re on the SE-AN track you probably have learned that before and probably done those groups a million times.”

Patients struggled with the structure of the treatment model. Some stated that they “wish it was faster” though they know “this is the speed it has to be for me.” Patients also expressed a desire for even more individualization, though also acknowledged that it can be difficult to balance individualization and consistency. One patient stated that she has seen other patients “just messing around” and “not actually working…just doing your disorder in treatment.” So, while patients understand the need for structure and limitations, they tend to think those limits make sense in general and for other patients on the SE-AN model, but should be less rigid for themselves. Patients discussed feeling worried that they may not be allowed to return if they struggle and are unable to meet their goals in between hospital stays, which highlights the difficult balance between requiring patients to demonstrate that they are being helped by the treatment model (to ensure we are not enabling stagnation and continued disorder) while also making allowances for nonlinear recovery processes. Patients also expressed that the SE-AN model can feel limiting. One patient stated that as a result of the SE-AN treatment model she had “lower expectations for myself” and felt the “agenda for this stay was tainted by previous stays” and that “once labeled, no matter your willingness to move forward, regardless of want to go further, it’s shut down.” Several patients similarly commented that being “labeled” as SE-AN and being recommended to the SE-AN treatment model was originally hard as it made them feel hopeless and given up on, but that once the goals of this approach were more clearly communicated, they understood its value better. Finally, patients noted some concern about lack of community resources and understanding of this approach, with one patient stating “I am scared that other treatment programs won’t take an approach like this. It can also be hard to get my outpatient providers to understand the program.”

Staff and patient feedback takeaways

Overall, staff and patient feedback suggest that the SE-AN treatment protocol is beneficial in many ways, especially in providing a treatment option—one that has the potential to extend life and willingness to engage with treatment—for those who are “too sick” for other treatment or who feel they cannot tolerate or do not want full/traditional recovery. Areas for potential improvement have been highlighted. Specifically, further consideration should be given to balancing individualization with consistency and having clearer guidelines for when, and with whom, to hold rigid expectations and under what circumstances greater flexibility can be extended. It will be important to continue to develop better strategies to communicate clearly and collaboratively with patients around what being classified as SE-AN means and the potential benefits of the SE-AN model in a way that can instill hope rather than hopelessness. Also, greater attention should be paid to addressing patient dissatisfaction when they feel limited by the SE-AN model but may not be able or willing to do traditional treatment with full weight restoration. Finally, thorough integration of the SE-AN program with outpatient providers is critical, but it can be challenging to find outpatient providers who will accept patients with SE-AN and who will agree to work on the patient’s SE-AN goals rather than traditional recovery goals and weight restoration.

In summary, we have provided a brief overview of SE-AN both scientifically and clinically. We have also attempted to highlight the limited empirically supported treatment options for SE-AN, but wish to underscore that this dearth of treatment options is significantly pronounced at higher levels of care. Given the severity of SE-AN, it is a simple fact that these patients will often use hospital-based services, and thus, greater attention to this deficit is encouraged.

Our program developed a structured treatment program for SE-AN which highlights flexible goalsetting, high levels of collaboration between patient and clinical staff, and an emphasis on enhancing quality of life, medical stability, and adequate nutritional rehabilitation. Furthermore, the approach highlights the importance of tailoring treatment planning to a given patient and their collaboratively established goals. Explicit treatment contracts are developed with patients and include a shared understanding of targeted objectives. Additionally, there is a significant effort to develop a detailed plan for maintaining health and returning to treatment after discharge from the hospital. This may include future “booster” admissions for limited periods of time to assist patients in continuing to maintain, or incrementally advance, health related goal achievement. Presently, our survey of patients, and staff suggest that the program offers significant advantages for both the treatment team and the patient, but also the continued challenges that a program for SE-AN in a hospital environment must face. We would strongly recommend that clinicians and scientists work to establish empirically supported approaches to treating patients with SE-AN in a hospital environment. Given this is a necessary type of care for such patients and the very serious nature of this illness, it is worthy of such an investment.

Data availability

No datasets were generated or analysed during the current study.

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Wonderlich, J.A., Dodd, D.R., Sondag, C. et al. Clinical and scientific review of severe and enduring anorexia nervosa in intensive care settings: introducing an innovative treatment paradigm. J Eat Disord 12 , 131 (2024). https://doi.org/10.1186/s40337-024-01079-9

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Received : 31 May 2024

Accepted : 06 August 2024

Published : 03 September 2024

DOI : https://doi.org/10.1186/s40337-024-01079-9

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