Adolescents with T1D are more vulnerable to developing depressive symptoms than their peers and the presence of depressive symptoms can have a negative influence on the self-management of T1D. It is therefore important to gain an understanding of the processes that underlie depressive symptoms in adolescents with T1D and also to examine the relationship between depressive symptoms and metabolic control. A systematic literature review is presented that synthesized and evaluated evidence on the longitudinal relationship between depressive symptoms and metabolic control in adolescents with Type 1 diabetes. The main focus was on issues of directionality within this relationship over time and identifying factors that may influence identified longitudinal associations. An empirical paper that investigated the role of cognitions proposed by Beck’s cognitive theory of depression (1967) and Bandura’s social cognitive theory (1997) in depressive symptoms in adolescents with T1D is also presented. Further research exploring depressive symptoms in adolescents with T1D is required.

This thesis explored the processes underlying interprofessional working relationships between midwives and health visitors in UK maternity services; using a multi method approach consisting of a systematic review, interviews, and focus groups. The systematic review synthesised the literature on midwife-health visitor collaboration, identifying barriers and enablers that are influential to successful interprofessional collaboration. Thus, the subsequent empirical studies attempted to explore these barriers and enablers in greater depth, from the perspectives of midwives and health visitors. Two studies utilised the Theoretical Domains Framework to explore the barriers and enablers to midwife-health visitor collaboration (Chapters 3 6). These are the first studies to examine midwives’ and health visitors’ perceived barriers and enablers to interprofessional collaboration using a psychologically grounded theoretical framework. Midwives and health visitors identified barriers and enablers to interprofessional collaboration across each of the 12 theoretical domains, such as ‘Knowledge’ (e.g. awareness of processes involved in contacting midwives) and ‘Memory, attention, and decision processes’ (e.g. contacting health visitors when there is a concern). Chapter 6 compared midwives’ and health visitors’ perceived barriers and enablers to interprofessional collaboration, and discussed its research and practice implications, including approaches to intervention development for improving interprofessional collaboration. For example, various behaviour change techniques can be integrated as part of interventions aiming to enhance interprofessional collaboration. The final empirical study attempted to address the gap in the interprofessional literature by involving service users’ views. Focus groups with recent mothers were conducted to gain explore their perspectives of interprofessional collaboration in maternity services. Findings suggest that women observe fragmentation between midwifery and health visiting. Participants recommended service changes including group based antenatal classes jointly provided by midwives and health visitors. In summary, the findings indicate that midwife-health visitor interprofessional collaboration is important to professionals and women, but will require health professional behaviour change along with service changes.

Although the survival rates for children with cancer have improved significantly due to biomedicine advancements, the illness nonetheless is devastating and presents significant challenges for parents. Given that parents have an important role in their child’s well-being, it is necessary that we develop an understanding of their experiences to better support them. For this purpose, the aim of the current study was to explicate the parents’ lived experiences of their child being diagnosed with cancer. Semi-structured interviews were conducted with eight parents attending a UK oncology unit within the National Health Service. The empirical data was analysed using Interpretative Phenomenological Analysis. Four superordinate themes emerged from the data: “Sense-making”, “Powerless”, “Relationship with Others”, and “A Process of Transformation”. The findings revealed how parents strove to find purpose and made sense of their shock of the diagnosis. It also appeared that parents felt a loss of control over their child’s condition that impacted their lifestyle. Despite their struggles, participants reported on their need to appear strong and resilient to facilitate their child’s coping. Parents conveyed the ways in which their relationships with others, both with the healthcare professional and their social network, affected their experiences of having a child with cancer. The findings indicate how parents seek to re-evaluate their values in life, reconsider future relationships and observe the significant changes to their child during their treatment. The findings are considered in relation to existing literature and discuss implication for clinical practice, as well as the limitations and recommendations for future research.

Background: Caring for a child with a chronic health condition is often associated with high levels of anxiety, depression and stress (Burton et al., 2003). Demanding caring duties, a lack of time and social isolation create barriers for carers accessing mental health support. The internet may be useful way for carers to access psychological supports but to date no research has explored this. Aims: To identify common difficulties which carers face and adapt a pre-existing computerised CBT (cCBT) based course to reduce carer stress. To determine the feasibility of providing mental health support to carers through an online course and assess its potential effectiveness and accessibility. Methods: Focus groups and questionnaires completed by hospice staff provided information regarding common stressors encountered by carers. Thematic analysis (Braun and Clarke, 2006) was used to identify topics which were then used to adapt a pre-existing cCBT course which consisted of 6 primary modules and additional online materials/modules plus the offer of weekly email support for 6 weeks from a support worker to encourage use. A single arm feasibility trial of the tailored cCBT was conducted using carers of children with chronic conditions recruited through advertisements and local hospice staff. Participants were provided with access to the cCBT course for 6 weeks and received weekly personalised support emails. Self-report measures of anxiety, depression and daily functioning were measures at baseline and at post-treatment. Questionnaires administered online explored participant satisfaction and course use which were then analysed. Results: 19 hospice workers were recruited to complete questionnaires regarding common difficulties faced by carers. Several themes emerged from thematic analysis of the data including: physical and interpersonal difficulties, external pressures, time constraints, limited support, responding to the child’s illness and difficulties accessing appropriate care for their child. 29 carers were recruited to trial the online course, with 55.6% recruited through social media. 12 (30.8%) carers logged onto the course and 6 (15.4%) completed follow-up measures at 8 weeks post intervention. Of the participants that started the course only 2 (18.2%) completed all 6 course modules. Exploratory analyses showed no statistically significant differences in depression, anxiety or functional impairment. However, results indicated a general reduction in clinically significant anxiety symptoms and functional impairment. Satisfaction questionnaires completed by carers post-intervention indicated a high level of satisfaction with the course. Qualitative results showed that participants valued the email support they received and the flexibility that an online approach provided. Some carers still struggled to find time to complete the course and suggestions were made to amend the course to enable it to be accessed offline and on portable devices. Conclusion: Computerised courses may be an acceptable way of offering mental health support to some carers. Difficulties in retention and recruiting suggest that further adaptations to the course are needed to improve engagement (i.e. delivering the course via apps, or moving to stand alone course topics rather than a recommended course). Alternative methods of delivering psychological support should be explored to avoid excluding those who do not have internet access.

This thesis presents the work completed over the course of the author’s doctorate of clinical psychology, and consists of two volumes. The first volume includes three chapters, the first of which is a systematic literature review and meta-analysis of the prevalence of insomnia in clinical and non-clinical populations of children and adolescents. The second chapter is an empirical paper exploring the relationship between sleep problems and daytime challenging behaviour in children with Autism Spectrum Disorders. The final chapter is a document summarising chapters one and two for the purpose of public dissemination. The second volume constitutes each of the five clinical practice reports completed over the course of the doctoral training and will be available online in December 2026.

The literature review explores the relationship between parenting and the development of narcissism with a specific focus on the role of overindulgence. 13 empirical studies were identified for the review, 2 of which were unpublished. A quality assessment was completed for each study. The papers are examined for the strength of their findings and the constructs they purport to measure are considered in relation to each other and overindulgence. A distinction is drawn between ‘healthy’ and ‘unhealthy’ narcissism. Overall, both types of narcissism were found to be associated with low levels of parental monitoring and higher levels of overvaluation. Healthy narcissism was also associated with higher levels of warmth and empathy whereas unhealthy narcissism was associated with parental coldness, less empathy and harsher treatment. However, all individual effects were rather weak. Overindulgence remains rather unexamined in a reliable way in relation to narcissism, despite claims to the contrary. Clinical and research implications are discussed. The empirical paper comprises a cross-sectional questionnaire-based study investigating associations between parental illness perceptions of their child’s ADHD, with coping styles, wellbeing and stress levels of those parents. Forty parents of children with ADHD participated. Higher parental stress levels and reduced wellbeing were associated with greater perceived consequences for parent and child, higher emotional responses for parent and child, a longer expected duration for ADHD and more perceived symptoms of ADHD. Coping was also related to several illness perception domains and levels of general wellbeing and stress. Problem-focused coping was associated with positive effects and dysfunctional coping was associated with negative effects upon wellbeing and stress. The combination of several domains of perceptions with coping strategies explained moderate to large amounts of variance in stress and wellbeing.

The core process is responsible for internal business development and is the process that runs through the organization and the results which creates a value for the customer. Some research suggests that identification of the client's conscious or unconscious needs clarifying the so-called core process in the organization and operations can thus be more effective. The study aims to identify and analyze the experience of the core process within child health care. The method has been interviews with nine managers and 10 clinic nurses in a county. The results show a lack of knowledge regarding core process and process work. However, the respondents have a sense of what the core process is, although the experience of the core process differs between managers and child health nurses in the study. The discussion describes the obstacles and supporting factors for a common core process.   Keywords: core process, child health care, core process management, process in health care, process management / Kärnprocessen står för verksamhetens inre utveckling och är den process som löper tvärs igenom organisationen och vars resultat skapar ett värde för kunden. Det finns forskning som tyder på att identifikation av kundens medvetna eller omedvetna behov tydliggör den så kallade kärnprocessen i organisationen. Genom processledning får medarbetarna en helhetssyn och kunskap om både interna och externa kunders behov. Det har en positiv inverkan på medarbetarnas arbetstrivsel och verksamhetens utveckling. Syftet med studien är att identifiera och analysera upplevelsen av kärnprocessen inom barnhälsovården. Metoden har varit kvalitativa intervjuer med nio verksamhetschefer och 10 BVC-sköterskor i ett av landets län. Resultatet visar på en kunskapsbrist beträffande kärnprocess och processarbete. Däremot har respondenterna en upplevelse av vad kärnprocessen är, även om upplevelsen av kärnprocessen skiljer sig mellan verksamhetscheferna och BVC-sköterskorna i studien. I diskussionen beskrivs hindrande och stödjande faktorer för en gemensam kärnprocess.

It is well known that, in Western countries, people of all ages and both sexes are becoming ‘fatter’ in general. In a ‘healthy’ population, we arbitrarily consider cut-offs to be that 10% of people should be ‘overweight’ and 5% ‘obese’, as there is limited evidence that these cut-off points are related to ill-health. However, we are seeing a dramatic rise in the numbers of people in each of these categories. The mechanism behind weight gain is energy-imbalance. At energy-balance for adults - i.e. where weight is expected to remain stable over time, we know that: energy intake (EI) = energy expenditure (EE) This equation is far less straightforward than it first appears. The first important issue is that EE has several different components (e.g. resting EE). The second issue is to do with measurement - how do we measure energy intake and energy expenditure? Another is down to physiological differences between people - how do things vary between individuals and do they differ systematically between males and females, adults and children? The above equation applies to adults, but we know that children and adolescents actually require a positive imbalance for healthy growth - what is not known is what degree of positive imbalance is healthy. This thesis is particularly concerned with energy-balance and imbalance during puberty, at which time the human body goes through extreme changes. We investigate how these changes are measured, and how energy-imbalance and the modelling thereof must change across this time. We will show that the proportions of children who are overweight and obese are higher than we would expect; commonly used models for body composition are not in agreement; commonly used models for resting energy expenditure are not in agreement; children do not need a high energy-imbalance for normal growth; and those girls with early menarche are more likely to become overweight than their counterparts.

Background: This thesis sits within the arena of weight status during and after childhood acute lymphoblastic leukaemia (ALL), with a particular focus on the prevalence of unhealthy weight status amongst (ALL), Saudi and UK populations. Each chapter in the thesis explores different aspects of unhealthy weight status in ALL which had been highlighted as gaps in the literature at a conference in Puebla, Mexico, at the end of 2006. A summary of each study is given below. Study 1: Background: This study estimated prevalence of unhealthy weight status and metabolic syndrome (MS) amongst Saudi survivors of standard risk ALL. Methods: We recruited 56 survivors, mean age 13.4 years (SD 4.1), a mean of 9.1 years (SD 4.1) post-diagnosis. The BMI for age was used to define weight status relative to national (Saudi) and international (Cole et al., International Obesity Task Force (IOTF), World Health Organisation (WHO), and Centre for Disease Control and Prevention (CDC)) reference data. We measured body composition by dual energy X-ray absorptiometry (DXA), waist circumference, blood pressure, lipid profile (HDL-C, Triglycerides), fasting glucose and insulin. Results: According to international definitions based on BMI for age, around half of the sample had unhealthy weight status. All of the approaches based on BMI for age underestimated over-fatness, present in 27/51 (53%) of the sample according to DXA. Prevalence of MS was 7.1% (3/42 of those over 9-years old) and 5.4% (3/56) by applying the International Diabetes Federation (IDF) definition and National Cholesterol Education Program Third Adult Treatment panel Guidelines (NCEP III), respectively. However, MS by the NCEP III definition was present in 19% of the overweight and obese survivors and 7.1% of the sample had at least two of the components of MS. Conclusions: Unhealthy body weight and over-fatness may be common amongst adolescent Saudi survivors of standard risk ALL, though overweight and obesity may be no more common than in the general Saudi adolescent population. Defining weight status using BMI underestimates over-fatness in this population, as in other populations. Study 2: Background: Underweight, overweight, and obesity at diagnosis may all worsen prognosis in childhood ALL, but no studies have estimated prevalence of unhealthy weight status at diagnosis in large representative samples using contemporary definitions of weight status based on BMI for age. Methods: Retrospective study which aimed to estimate prevalence of underweight, overweight, and obesity at diagnosis for patients with childhood ALL on three successive UK treatment trials: UKALL X (1985-1990, n 1033), UKALL XI (1990- 1997, n 2031), UKALL 97/97-99 (1997-2002, n 898) .The BMI for age was used to define weight status with both UK 1990 BMI for age reference data and the IOTF definitions. Results: Prevalence of underweight was 6% in the most recent trial for which data were available. Prevalence of overweight and obesity was 35% in the most recent trial when expressed using IOTF definitions; 41% when expressed relative to UK 1990 reference data. Conclusions: Even with highly conservative estimates >40% of all UK patients with ALL were underweight, overweight, or obese at diagnosis in the most recent trial for which UK data are available (UKALL 97/99, 1997-2002). Study 3: Background: This study tested the hypothesis that overweight/obesity at diagnosis of childhood ALL was related to risk of relapse. Methods and results: In a national cohort of 1033 patients from the UK there was no evidence that weight status at diagnosis was related significantly to risk of relapse: log ranks test (p value= 0.90) with overweight and obesity as the exposure (n 917); individual (p value= 0.42) and stepwise (p value= 0.96) proportional hazards models, with BMI z score as the exposure (n 1033). Conclusion: The study does not support the hypothesis that overweight/obesity at diagnosis impairs prognosis in childhood ALL in the UK. Study 4: Background: In the sample of Saudi patients recruited to study 1 we compared DXA whole body and lumbar spine bone mineral density (BMD) using manufacturers software with a body size correction which derived bone mineral content (BMC) for bone area and Apparent bone mineral density of lumbar spine (BMADLS). Methods and results: The survivors of ALL were from Saudi Arabia (n 51, mean age 13.5 years). With no corrections, 29 patients (57%) had lumbar spine BMD z score < -1.0 and 21 (41%) had whole body BMD z score < -2. After correction, by using BMC for bone area method only 6 (12%) had lumbar spine BMC z score <-1.0 and 4 (8%) had whole body BMC z score <-2. By using BMADLS method, 18 (35%) had BMC <-1.0 and 6 (11%) had BMC Z score <-2. Conclusions: Correction for body size seems essential to accurate interpretation of DXA bone health data in adolescent survivors of ALL. The three correction methods provided different conclusions, but bone health remains a concern after treatment for ALL.

Study 1: Aims: Compare the uniaxial MTI/CSA accelerometer and the biaxial Actiwatch accelerometer against direct observation of total physical activity and minute-by-minute physical activity in 3-4 year olds. Methods: MTI/CSA-7164 and Actiwatch accelerometers simultaneously measured activity during 35-45 minute sessions of structured play in 78, 3-4 year olds. Rank order correlations between accelerometry and direct observation were used to assess the ability of the accelerometers to assess total activity. Within-child minute-by-minute correlations were calculated between accelerometry output and direct observation. Results: For assessment of total activity MTI/CSA output was significantly positively correlated with direct observation (r 0.72, p<0.001), Actiwatch was not (r 0.16, p>0.05). Conclusion: The present study suggests that for epidemiological assessment of total physical activity in young children the MTI/CSA-7164 provides greater accuracy than the Actiwatch. Study 2: Aim: To cross-validate the 1100 counts/ minute cut-off for the assessment of sedentary behaviour in an independent sample of young children using the MTI/CSA accelerometer. Methods: A previously developed cut-off for MTI-CSA accelerometry output (validation study) in 30 healthy Scottish 3-4 year olds, was cross-validated against direct observation in an independent sample of (n = 52) healthy Scottish 3-4 year olds. Results: In the cross-validation study sensitivity was 83%: 438/528 inactive minutes were correctly classified. Specificity was 82%: 1251/1526 non-inactive minutes were correctly classified using this cut-off. Conclusion: Sedentary behaviour can be quantified objectively in young children using accelerometry.