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Abstract

The empty nest syndrome (ENS) has been a term used in psychology to denote the psychological symptoms that arise when the youngest child leaves the family for work or further studies causing a void in the family leaving the aged parents behind termed as the empty nest. There have been many theories posited to explain the empty nest and multiple viewpoints exist regarding the phenomenon. This phenomenon was described in the 1940s and 1950s and the present review evaluates the existing literature on the ENS in the light of modern era conceptions of human development. The advent of neurobiology and better understanding of menopause and the hormonal changes that ensue have resulted in us having a greater insight into this phenomenon. There are many changes that a couple undergoes in mid life and these all contribute to the ENS in some way or another. Marital and family factors as well as the parent child relationship play a vital role in adjustment to the empty nest situation. This review also tries to explain the validity of a concept like ENS in the modern digital era and in the light of modern relationships and their effect on the mind of the people involved. Key words: empty nest syndrome, empty nest, marital, family, human development, mid life.
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Review Article
The Empty Nest Syndrome : critical clinical considerations
Feryl Badiani1, Avinash De Sousa2
12nd year graduate student, Sophia College for Women, Mumbai.
2Consultant Psychiatrist and Founder Trustee, Desousa Foundation, Mumbai.
E-mail avinashdes888@gmail.com
ABSTRACT
The empty nest syndrome (ENS) has been a term used in psychology to denote the psychological
symptoms that arise when the youngest child leaves the family for work or further studies causing a void in
the family leaving the aged parents behind termed as the empty nest. There have been many theories
posited to explain the empty nest and multiple viewpoints exist regarding the phenomenon. This
phenomenon was described in the 1940s and 1950s and the present review evaluates the existing literature
on the ENS in the light of modern era conceptions of human development. The advent of neurobiology
and better understanding of menopause and the hormonal changes that ensue have resulted in us having a
greater insight into this phenomenon. There are many changes that a couple undergoes in mid life and
these all contribute to the ENS in some way or another. Marital and family factors as well as the parent
child relationship play a vital role in adjustment to the empty nest situation. This review also tries to
explain the validity of a concept like ENS in the modern digital era and in the light of modern
relationships and their effect on the mind of the people involved.
Key words: empty nest syndrome, empty nest, marital, family, human development, mid life.
(Paper received 28th April 2016, Peer review completed 29th May 2016, Accepted 6th June 2016)
INTRODUCTION
The „Empty Nest Syndrome‟ (ENS) has been a term that used in psychology for the past five decades. It is
a term used to describe the long-lasting maladaptive responses exhibited by parents once their last child
moves out of their household and thereby leaves the two middle aged / aging parents alone at home [1].
These responses include depression, sadness, anxiety, guilt, somatic symptoms, anger, resentment,
irritability, frustration and loneliness. Sometimes these maladaptive responses may be the start of a major
psychopathology like major depressive disorder, anxiety disorders and rarely a psychotic reaction [2]. This
syndrome has often been compared to post-partum depression as parents face loss of their children as well
as loss of reproductive roles of mothering or fathering a child [3]. The „Empty Nest‟ refers to the household
once all of the children have moved out for various reasons such as studying or employment or settlement
in a different city, to explore their lives or simply even to begin adulthood independent of one‟s parents [4].
The „Empty Nest‟ may not always evoke negative emotions, but a series of mixed emotions with a relief
towards the end of parental responsibilities and excitement towards much awaited freedom coupled with
guilt in response to these feelings of relief, concern of the children‟s well-being as well as worry and anxiety
over rejection by the children in the future [5]. Summarizing the ENS denotes a series of prolonged
negative / mixed emotions triggered by parting with one‟s child that poorly affects an individual or a
marital relationship [6].
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METHOD OF CONDUCTING THE PRESENT REVIEW
For identifying articles that focused on ENS, the terms „empty nest‟, „empty nest syndrome‟, mid life
crisis‟, role adjustments in middle age and „psychological aspects of menopause‟ were used. For
identifying articles that focused on specific terms, like „anxiety‟, „anxiety disorder‟, „depression‟, gender
differences‟, „couples‟, marital satisfaction‟, intimacy‟, „social issues‟ and other terms were used. These
two search strategy results were combined with an “and” statement in the following data bases with the
time frame being specified from 1950 through 2016. The databases used were Medline, Pubmed and the
Google Scholar. In total, 103 articles were identified which included reviews, mini reviews and clinical
studies in populations with or at risk for the ENS. The clinical studies reviewed were centered on those
addressing psychological issues and adjustment in ENS.
We included studies with sample sizes of more than 30 participants and few qualitative studies with fewer
participants were also reviewed. Both the authors reviewed all of the articles and the most relevant ones
were chosen for incorporation in this review. The papers reviewed in this article include review articles,
clinical studies, research papers and books on and around the theme of ENS. This is supplemented with
the personal clinical experience of the authors who work regularly with this middle age patients and have
further insight into the problems faced by them. Wherever fit, hypotheses related to ENS based on the
author‟s clinical acumen have been posited.
GENDER DIFFERENCES IN THE EMPTY NEST SYNDROME
It is believed that women are more likely to suffer from the ENS [7], however this is because most of the
literature available was collected with women as their subjects of study. This also explains the stereotypical
name for this syndrome. Oliver points out that our society has a preoccupation with using language of the
barnyard when referring to women; with words such as birds, chicks, old hens etc. Thus the term ENS
triggers a sexist notion that hinders identification of those who suffer from this syndrome [8]. Conversely,
recent studies suggest that even men could suffer from the ENS. A recent study of 147 mothers and 114
fathers with a child graduating from high school found that the women with their primary role as care
taker of children as say-at-home-mothers were looking forward to the departure of their child and were
also preparing for the next stage in life such as seeking additional hobbies, etc. On the other hand, the men
in her sample did not talk about their child‟s departure and were also less likely to see their departure as a
major life transaction. Hence, the men were less prepared for the separation and later exhibited regrets
over lost opportunities to play a greater role in their child‟s life before they left home [9].
These findings are supported by other researchers [10], who reported that men were more likely to report
neutral or ambivalent responses to the „emptying nest‟ than women. This difference has been explained in
self-expression as a predisposition of women who can express complex attitudes and feelings freely in the
society. Moreover, men do experience “self-evaluation” and “disequilibrium” during the „Empty Nest‟
transition, but may be unwilling and/or unable to express their response in any other terms that are not
neutral or ambivalent [11]. This goes on to show that the „Empty Nest Syndrome‟ is not exclusive to
women but is also experienced by men, albeit differently in terms of expression [11].
THE VALIDITY OF THE EMPTY NEST SYNDROME PHENOMENON
However, the validity of the ENS phenomenon is highly questioned. This is pre-dominantly as it is not
recognized as a psychiatric disorder in any classification system followed worldwide but is rather viewed
as a transition life epoch that many people undergo [12]. The argument to be considered is whether the
ENS is a myth or a reality. It is believed that there are various biological, social and cognitive changes that
can explain the symptoms seen during the ENS transition and whether the psychological theory of ENS
needs to be posited. One the leading causes for the ENS to be considered a myth is that the period of the
„emptying nest‟ transition usually coincides with the biological process of ageing and more specifically
during phases of menopause or peri-menopause for women. It is believed that depression caused by the
hormonal changes at these times may be misattributed to the ENS [13].
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PERI-MENOPAUSE NEUROBIOLOGY AND ENS
The term peri-menopause refers to the period before and after the final menstrual period marked by
fluctuating ovarian function which is a period of about 3-4 years on average in most women while the
range for this period is 2-10 years [14]. During this time multiple changes occur in hormonal levels viz.
estrogen and progesterone [15]. A primary function of estrogen to block serotonin from being cleared the
synaptic cleft; hence it enhances serotonergic neurotransmission. Serotonin is a neurotransmitter
associated to mood. When the oestrogen levels drop, the serotonin levels too are affected in a negative
manner inducing low mood [16]. Research shows that 61% women suffer from anxiety during the peri-
menopause period and 71% of the women between 41-45 years age experience low moods, which could be
attributed to peri-menopause [17]. Thus the symptoms experienced in ENS could be the symptoms for
peri-menopause hormonal changes and may provide an inference to explain why ENS may be considered
a myth.
ENS AS A REALITY BASED PHENOMENON
According to Parse‟s theory of human becoming, a person is an open being who is more than and
different from the sum of the parts [18]. This theory assumes that there a constant interaction between the
environment and a person and thus the person and his experiences are inseparable [19]. Moreover this
theory suggests that a person has the freedom to choose between alternative ways of becoming and hence
their health is not pre-determined by biological processes [20]. In relation to ENS, based on this theory, it
can be assumed that biological changes are not solely responsible for the symptoms associated with ENS
and that changes in the environment could also trigger the symptoms [21]. One of those changes could be
parting with one‟s child, making the „Empty Nest‟ a reality.
Nevertheless, there are other factors separate to biological ones that effect one‟s becoming to a positive or a
negative state after their nest empties. It is believed that that one‟s ability to adapt and adjust to other roles
plays a critical role in one developing the ENS [22]. Women who are socialized to fulfil the quintessential
role of a women and hence to primarily cater to her reproductive roles of nurturing a child, tend to be over
involved in the lives of her children, to a point where their needs have been subjugated for the needs of her
children. This makes them particularly susceptible to the syndrome [23]. Hence, when the children leave,
these mothers face an identity crisis, wherein they have to identify new roles to fulfil, and the inability to
adjust to the new roles, in turn causes the anxiety and depression [24]. Such an identity crisis is believed to
be labelled as the ENS.
CHILDBEARING, EMPLOYMENT AND THE ENS
There is a recent social phenomenon in which child bearing is delayed for the later part of life.
Childbearing may be delayed for various reasons with the most common one being developing a career
prior to a child. In such cases, the women have developed alternative roles in the workplace that coincided
with the decline in their reproductive roles as mothers and hence they find it easier to detach themselves
from the identity of being a mother that resulted in them feeling less distressed [25]. Such a finding is
supported by Borland [26] who provides a historical perspective to the ENS as well. She attempted to
examine how women adjusted to their changing roles. In order to do so she subdivided her participants
into 3 age cohorts of 21-year intervals and life cycle into four 20-year spans. The post paternal period when
the women had an Empty Nest‟ most likely occurred during the third 20-year spans (ages 41-60) [25].
Borland noticed that in the first cohort of women, between the ages of 41-60, from 1940 to 1959, few of the
women had maladaptive responses to the „Empty Nest. This is particularly because these were the first
generation of women who were provided with alternative roles, by having the opportunity to join the work
force as the men were out fighting in World War 2 [26].
Conversely, women in the second cohort from 1960 to 1979, between, the ages of 41-60 were young
mothers during World War 2, who never left their maternal role or had to return to it once the war ended.
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Their identity was solely limited to their reproductive responsibilities and hence were the most likely to fall
prey to the ENS [26].
Lastly, the third cohort of women between the age of 41-60 years from 1980 to 1999 were active
participants in the workforce and also have struggled for equality in the field. Their identity is not limited
to their maternal role, but their work also contributed to their self-esteem. Thus, Borland concluded that
many of the women in this cohort may not experience the ENS [26].
Upon critically reviewing the existing studies on middle-aged women allegedly suffering from the ENS,
researchers found that reproductive roles were the focal point of the identities of the women that were
under study [27].
MARITAL PROBLEMS AND THE ENS
Literature also suggests that the tension caused by a failed marriage that is enhanced once the children
leave also may be misattributed to the ENS [28]. Authors explain this issue by stating that couples stay
together while children are the focus of the relationship; when the children leave home, the reasons for
staying in the relationship dwindle [29]. Moreover they further say that the issues that create tension in the
marriage remain the same throughout the marriage, but are heightened in the absence of children [29]. In a
survey conducted by the same authors, they found that there were strong gender differences in issues the
couple faced during the Empty Nest years. Females reported the lack of communication whilst males
reported a lack of sex as a major issue [30]. These sources of conflicts cause the symptoms associated with
ENS and thus the subsequently affect the marriage. These are conflicts that were not deemed enough to
separate in the past, while now couples do not want to stay together in the presence of these conflicts and
hence decide to split, very often blaming the ENS for their symptoms [31].
There is however contradictory evidence that showcases positive emotions upon the nest emptying such as
increased marital satisfaction, greater intimacy, more freedom and improved financial conditions once the
couple has rediscovered one another after the children have departed [32].
DEPRESSION AND THE ENS
The effects of environmental factors causing depression, one of the symptoms of the ENS can be further
explained by a socio-cultural model of depression [33]. In a study aimed to investigate the extent to which
social and cultural factors could contribute to the development of depression in women, researchers
interviewed 458 middle-class women about their daily lives and depressive attitudes. They found three
major factors present in one‟s socio-cultural environment that affected the development of depression.
First, the presence of protective factors that prevent the development of depression despite the stressors,
these include intimacy with one‟s husband as well as factors that lead to higher self-esteem and the
possibility of finding other sources of meaning in life [33]. Second the presence of vulnerability factors or
those stressful life events that pre-dispose one to depression. One of the major vulnerability factors
included that lack of a confiding relationship [33]. Last the presence of provoking agents or factors that
add to one‟s ongoing stress and leave the women feeling hopeless and grief [33].
Another study reported a common theme of seeking support amongst women. Some women may seek
information in a journal or magazine articles to support themselves. While, on the other hand some
women seek support in their husband [34]. According to Hinson Langford [35], there are four
distinguished types of support: emotional, instrumental, informative and appraisal. Based on his research
one can conclude that the presence of emotional support, which involves the provision of caring, love and
trust [35] as well as informational support helped the women develop not a negative but a positive outlook
to the empty nest. This magnifies the importance of a confiding or an intimate relationship in order to
prevent the development of depression and other symptoms that are associated with the ENS [35].
After the child leaves, the lack of an intimate marriage becomes obvious, which makes it harder to deal
with the loss, enhancing the negative responses to the empty nest experience [36]. It is also important to
note that depression is a common psychological problem encountered in middle age [37]. In most cases,
these individuals are not going through an empty nest experience and likely have other triggers. Moreover,
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as depression is so common, it is highly possible that the depression an individual goes through is termed
as the ENS and this depression could possibly be a relapse of a prior depressive episode [38].
THE REFILLING OF THE NEST
A similar distress associated with the ENS may also be seen if adult children come back to live with their
parents, thereby refilling the nest. These set of adult children, known as the boomerang generation, are
those who return home after previously living on their own [39]. The return could be for many reasons
however, a 2008 census showed that around 20 million 18-34 year olds after having been through the grind
during the rough economy of recent years return home as they‟re unable to find employment [40]. Such
financial and emotional dependence of adult children can strain the parents, and more importantly can
hinder the positive aspects associated to the emptied nest [39].
GEOGRAPHY, CULTURE AND THE ENS
Amongst the innumerable environmental factors that lead to the ENS, one‟s geographical background and
cultural orientation is believed to play a major role in whether one experiences the syndrome or not [41].
Authors have reported a cultural difference in the meaning attached to the emptying of the nest. In western
cultures, which are pre-dominantly individualistic cultures, nest leaving is typically reflects the success of
parents to raise their children into well-adjusted, independent adults [42]. On the other hand, in non-
western cultures that are usually collective in nature, the „emptying nest‟ reflects the failures of the parents
of being unable to instil the family values in a child that keep the family bound together. Moreover, leaving
the nest in non-western cultures is also seen as breaking the family. Such negative implications of the
„Empty Nest‟ are likely to have negative impact on the parents [43].
In India, a country with a pre-dominantly non-western culture, it is traditional for the eldest son to
continue staying at home through adulthood, and continue to support his parents accompanied with his
wife [44]. However, in India, the number of nuclear families has been increasing. According to the census
report of Delhi 2011, the largest number of households (69.5%) has only one married couple [45] and less
than 6% of the households have more than 9 people living in them. This could happen for a variety of
reasons; majorly because the many children are leaving their house in the rural parts of India to look for
job opportunities in the city, or to pursue higher education available only in colleges found within the
cities. To adjust to such rapidly increasing individualism in the pre-dominantly collectivist culture of India,
ambiguity and distress created may be incorrectly interpreted as the ENS [46].
THE SANDWICH GENERATION AND ENS
Growing individualism is not the only reason for the increasing trend of nuclear families in India. Middle
life couples stuck in an intergenerational squeeze are termed as the Sandwich generation. These set of
people living are caught in a household with adult children who delay their move and with a set of
grandparents, who are now living longer. It is common to see the sandwich generation in India as the
concept of living together in non-nuclear families is the norm [47]. The sandwich generation wishes to
achieve financial and relationship growth for themselves and in order to achieve such development they
may move out of their pre-existing household to cultivate a nuclear family. This illustrates that separation
from one‟s family forming an empty nest may not always have a negative impact, however it illustrates
how the acceptable time for separation may be different, culturally [48]. According to authors, parents
hold certain expectations on how their child‟s path to adulthood should be carved out. These expectations
are based on social timelines, regarding when a child should leave, reasons for leaving, etc. all of which
should align with their social, cultural and personal beliefs and norms [49]. Based on this and the
collectivist nature of India, authors have reported that children from certain ethnic background such as
South Asia were more likely to delay home leaving [50].
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THE ENS CRITICAL POINTS AND CONCLUSIONS
While one may go on speculating and hypothesizing the various factors revolving round the genesis and
the maintenance of the ENS, there are many points of relevance that remain to be investigated and proven
via stringent research. These are also some personal viewpoints of the authors and may be the source for
future debate and discussion on the ENS. These include
The first key question that remains to be answered is whether ENS exists in today‟s modern era or
is it just an exaggeration of the symptoms of middle age and transition life epochs that have been
given this fancy name. Also whether the ENS sounded good at a time when psychodynamic
explanations were relevant and today with the advent of neurobiology and the effects of hormones
on behaviour known, the phenomenon has become redundant.
Late marriages in metro cities are common. Most couples get married when past their 30s and
children enter the job sphere and university study when the couple is usually post 55. Children still
have to leave their homes for greener pastures and it is noteworthy to look at whether the ENS of
middle age in the last 4 decades has now progressed to become a geriatric or early geriatric
problem. Most couples shall be in their geriatric age when the youngest child leaves home and this
may make the ENS a geriatric problem for the future.
It is also prudent that the ENS be viewed in the light of emergent parent child relationships. In the
past few years, parent child relationship paradigms have changed and duty towards parents is not
looked at as a moral compulsion while parenting is often viewed as something everyone has to do
and after a certain stage children need to be set free. Children and parents have always had their
generation gaps and with a further widening of these gaps in the modern era, the emotional
bonding between parent and child has reduced leading to probably a lower occurrence of the ENS
phenomenon.
In today‟s modern era with digitalization the world has come closer and we can now speak live on
the internet to people from any corner of the world. Digitalization though having its ramifications
on the emotional life of people, has brought many families closer. Thus with digital media and the
internet children can always stay in touch with parents who use digital media to communicate at
least once a day with children abroad. It would be an interesting research enterprise to look at
whether digital contact has reduced the pangs of the ENS.
ENS may sometimes also be a manifestation of subclinical psychopathology. There are many
patients that have had depression and anxiety all their lives and fail to have it in a severity that
warrants a psychiatric diagnosis. Thus the ENS may serve as a cling wrap that covers sub-
threshold psychiatric disorders and may also serves as an armour that protects that these disorders
and those afflicted by it from seeking probable treatment.
Another consideration on similar lines is whether we must treat patients who present with ENS
symptoms of depression and anxiety medically even in the absence of them meeting clinical
criteria for various psychiatric disorders. Would psychotherapy and counselling be enough as
treatment in these cases or whether they need medical treatment is a question that is debatable and
would raise many ethical issues clinically.
We also have never had research that has elucidated various subtypes of ENS based on the
symptoms and underlying psychopathology manifested and it is worthwhile exploring this
clinically to uncover some subtypes of the syndrome. We may well find a depressive, an anxious
and various other subtypes that may help plan treatment in these cases.
Lastly is the quandary as to whether the ENS is real or fake. Is the ENS a myth of psychological
folklore or is it a concrete phenomenon strewed with emotional underpinnings. We believe that
ENS must be viewed from a biopsychosocial perspective rather than a purely psychological
standpoint. Thus various genetic, biological, social and psychological factors play a role in the
development of the ENS and this is further brewed by the presence of marital and environmental
determinants. It is vital that clinicians view the ENS phenomenon as real and focus towards
treatment as they would for any other psychological problems. It is also important considering
psychological preparation for the ENS and having a preventive module in place for the same.
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Couples must be spoken to about the ENS in advance long before it may manifest and they must
be informed about methods to cope with the same.
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... ENS is not a clinical entity under the Diagnostic and Statistical Manual -V (DSM-V), however, it is listed in the International Classi cation of Diseases (ICD)-11 under "Other Associated Problems with Social or Cultural Environment" (Code: QE0Y) [1]. However, it is a well-observed psychological phenomenon among the parents in the society for ve decades, mostly in the developing nations [2], when their children leave home for a job or higher educational purposes or marriage [3]. In recent days, o ces and institutions are opening in India and overseas, causing children to move out to chase their dreams. ...
... The grief is mostly distributed around the loneliness due to the disassociation with the children. Middle-aged parents in our society also face a similar grief state, which usually lasts for 2 weeks [5] following the departure of the children, especially when the youngest one departs [2]. Indians prefer joint families, where middle-aged parents cohabitate with their grown-up adult children. ...
... Indians prefer joint families, where middle-aged parents cohabitate with their grown-up adult children. These parents are stuck within the intergenerational gap and their generations are called the sandwich generation [2]. Given a situation, when these children leave, the jolt is even higher on them. ...
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Background Empty Nest Syndrome (ENS) is not a listed clinical entity in DSM-5, although ICD-11 has listed it under “Other Associated Problems with Social or Cultural Environment”. However, a complex grief state is observed in the parents when their children leave home for study and work or marriage. Literature shows ENS may progress to clinical-grade depression and anxiety, if left uncared. Methods The study presents a solution (LENS) to assess such risks in ENS using Cardiovascular Optical Biomarkers (COB) from the capillary blood flow signal of the index finger using the technique of arterial photoplethysmography when the finger is gently pressed on the phone camera with the torchlight ‘on’. The scores of COB provide the psychological and metabolic snapshots of the mind-body homeostasis. Results The study observes that (a) COB (e.g., SD1/SD2, LF/HF, HRVScore, and ENERGY), obtained through Lyfas tests, and (b) physical e.g., Diastolic Blood Pressure, BMI, Heart rate, HbA1c, TSH, and Estradiol have significant roles in the backdrop of ENS. Bland Altman's reliability measure shows that LENS (novel instrument under trial) has a high agreement of 92.85% and 93.86%, respectively with ENS scoring done by senior psychologists (champion instrument – 1) and HAM-D grading performed by psychiatrists (champion instrument – 2). Conclusions LENS can be used as an assistive tool to screen and monitor ENS cases in a health set up.
Article
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