The assessment and prediction of aggression has been the subject of considerable research attention among mainstream adult populations. With the inherent limitations and biases of unstructured clinical judgement, most attempts to assess risk are aided by use of structured measures. Clinicians and researchers working with mainstream populations have over 120 different structured risk assessments available to inform clinical assessment of violent and sexual offending (Singh & Fazel, 2010). Furthermore, numerous meta-analysis have been conducted comparing risk instruments with one another (see the meta-analytic review by Hanson & Morton-Bourgon, 2009) with the aim of guiding clinician's choice of which measure to use in practice. Knowledge and research regarding risk assessment procedures in the field of intellectual disability (ID) has been considerably slower to develop (Lindsay & Beail, 2004). One implication of the limited research is that professionals are unsure which assessments to use in clinical practice and research. For this reason, clinicians are likely to use measures developed for mainstream populations with unknown reliability and validity. Alternatively, clinicians may be inclined to develop their own idiosyncratic measures or modify established measures to be more in line with the characteristics of adults with ID. As a result, assessing the risk of adults with ID who engage in aggressive behaviour is likely to be inaccurate. The implications of such inaccuracies are costly for adults with ID, those involved in their care and the public. Without the ability to reliably predict who will engage in aggressive behaviour, clinicians may unnecessarily restrict the freedom of adults with ID out of concern for the safety of the individual and the public. Conversely, clinicians may unintentionally underestimate the adult's potential to harm others. A balance between the human rights and ethical implications of restricting liberty and the need to protect the human rights and safety of the public is paramount, particularly in community settings. Risk assessment measures offer increased transparency and reliability in estimating risk. This thesis describes two studies that aim to advance the literature in the ID field in order to assist clinicians and researchers in selecting, assessing and managing the risk assessment process. In Chapter 1, a meta-analysis reports on the predictive accuracy of risk assessment measures commonly used with adults with ID. Unlike previous reviews in this area, the present study is the first in the field to offer a meta-analysis in this area. Therefore, the research is more robust and offers greater validity for the performance of risk assessments in this population. The sub-group analysis offers insight into the accuracy of risk assessment measures with different orientations (i.e., static, dynamic and structured professional judgment). The empirical paper in chapter two assesses the predictive accuracy of two risk assessment measures: the Current Risk of Violence (CuRV; Lofthouse, Lindsay, Totsika, Hastings, & Roberts, 2014) and the Short Dynamic Risk Scale (SDRS; Quinsey, 2004) developed specifically for adults with ID. The study is novel in that it is one of the few in the field to include a community sample. UK policy (Department of Health, 2009) stipulates that adults with ID should receive services in the least restrictive environments, ideally in the community. Therefore, it is important for professionals in community services to be aware of which measures are suitable to use as part of the risk assessment process.

The transition to adulthood is known to be a challenging period, particularly for care leavers who have been known to achieve poor outcomes. This study aimed to examine the Throughcare experience and outcomes achieved by young people who are simultaneously leaving care and experiencing depression. This study also adopted a multi-theoretical approach which accommodates both inner and external factors as potential elements which influence care leavers’ transitions. This theoretical position offered a useful approach for studying the multi-dimensional and complex reality of care leavers who suffer from depression. A qualitative methodological approach based on the constructivist paradigm was adopted for this study. Twenty seven young people who suffer from depression were interviewed and their data was complemented by information collected from seventeen key informants and a small group of young people leaving care who were not suffering from depression. The data was inductively analysed. The study found that some young people develop a material meaning of independence which leads them to disregard their mental health. This contributes to their inability to deal with problems and the difficult transitions they experience, where self-harm and suicide are often perceived as viable solutions for their problems. Poor mental health was also found to negatively impact on educational and work performance, school attendance, finding work, ability to maintain a job and perceptions of education and work. Other factors which impacted on education and work were attachment problems, inability to deal with simultaneous challenging problems, peer pressure, and the lack of appropriate formal and informal support. These young people also experienced poor housing outcomes, including the inability to sustain a tenancy, poor gate keeping, problems with neighbours and eviction leading to homelessness. Overall, the study concluded that care leavers with depression have specific vulnerabilities that contribute to difficult transitions to independent living. More attention needs to be paid to supporting these young people through strategic planning and policy, and investment in adequate resources to enable them to make successful transitions.

This thesis explores the experience of caring for people with the new diseases of variant Creutzfeldt-Jakob disease (CJD) by hospice services. The experiences of the hospice staff and carers of five people, who had died, or were dying, as a result of variant CJD, at three different hospice sites in the South of England were explored. Data from four focus groups and 11 interviews, with hospice staff (included health care assistants, nurses, doctors and social workers) and family members, plus hospice patient records were analysed. Media material was also examined and used to inform the study. The thesis offers a theoretical explanation of these experiences developed through grounded theory methodology using an emergent fit design. It describes the event of the admission into the hospice service of a person with a new disease, that of variant CJD, and how the dying experience of these people was managed by both in-house and community hospice teams, 'Open systems' theory is used to assist in analysis and interpretation of the participant experiences, and as a means of 'contextualising' the hospice service. The hospice is presented as a metaphorical container within which dying is processed, and where the primary task of the organisation had a different emphasis and focus, depending on individual perspectives of participants. A theory of 'dealing with the unknown' was developed to explain the impact of this new disease on system equilibrium. The disease was a novelty and influenced admissions into the service and responses to the disease by others. It engendered the need for staff to use controlling practices to maintain the system balance. There were paradoxes between the practices of in-house and community teams, and between in- house and family member 'understanding' of how care was managed. The experience of caring for people with variant CJD was also profoundly humbling for participants. Humility was identified as a response to the realisation of limitations in relieving the suffering of people with variant CJD and their families. The study demonstrated change over time, where hospice staff moved from not knowing to becoming knowledgeable about managing the care of the person with variant CJD. The theory is complimented by and builds on existing theories of hospice practice.

The widespread introduction of enhanced recovery (ER) programmes for surgical patients is driven by the need to improve their outcomes. One of the principles of ER is to use specific perioperative measures that modify the surgical stress response. However, the impact of a complete enhanced recovery programme (ERP) on the stress response has never been examined in a randomised controlled trial (RCT). The primary hypothesis of this study was that, after open liver resection, an ERP alters the stress response compared with standard perioperative care. Ninety-­one patients (45 control; 46 ERP) were enrolled in an RCT. The concentration of stress response markers were analysed in perioperative blood samples, i.e.: IL-­6, IL-­1β, IL-­4, IL-­8, IL-­10, GM-­CSF, IFN-­γ, TNF-α, VEGF, CRP, cortisol, insulin and glucose. Samples were also analysed in 24 patients per group for immunological response markers; i.e. white cell, lymphocyte, CD3, CD4, CD8, CD16, CD19, CD56, HLA-­DR cell counts. Patients randomised to the treatment group received a comprehensive ERP: pre-­admission counselling, preoperative nutritional supplements, preoperative oral carbohydrate loading, goal-­directed fluid therapy, early postoperative feeding and mobilisation. The control group received standard perioperative care. Postoperative morbidity data were collected for all patients and complications graded for severity. ERP and control data sets were compared by ANOVA and appropriate parametric or non-­parametric tests, categorical values were tested with chi-­squared tests In the treatment group, there were more patients with colorectal metastases, who had received preoperative chemotherapy and a higher P-­POSSUM operative severity score, otherwise groups were well-­matched. There was no significant difference in IL-­6, IL-­1β, IL-­4, IL-­8, IL-­10, GM-­CSF, IFN-­γ, TNF-­α, VEGF or CRP responses between groups. Peak serum cortisol was significantly reduced and serum insulin was significantly higher in the treatment group. The incidence and severity of medical complications were significantly less in the treatment group. CD3 counts were significantly lower, but CD19 counts were significantly higher in the treatment group. The study aimed to measure the stress response following liver resection using an ERP compared with standard care and to demonstrate a physiological basis for any clinical outcomes. The significant reduction of postoperative morbidity with an ERP correlated with, and may result from, significant alterations of cortisol and insulin responses, but not cytokine levels, including IL-­6.

The overall aim of this thesis was to improve the knowledge of the public health burden of personality disorders in South East London, specifically as this relates to the health and mortality of individuals with personality disorders. An additional aim was to enhance the knowledge of the psychiatric service use of people with personality disorders in South East London. This thesis addresses the above aims by focusing on four specific objectives. Each objective formed the basis of a discrete study. 1. To establish the life expectancy and all-cause mortality among secondary care patients with personality disorder 2. To establish the clinical predictors of all-cause and cause-specific mortality among secondary care patients with personality disorder 3. To establish the impact of co-morbid personality disorder on the service use of people with severe mental illness within secondary mental healthcare. 4. To use the SAPAS in order to examine the association between personality disorder screen status and general health in a local community sample The thesis opens with an introduction chapter, Chapter 1, covering the relevant background literature – definition, classification and assessment of personality disorder. The current literature on epidemiology of personality disorder, in particular on health, mortality, costs and service use of people with personality disorder, is further expounded. Next, the chapter outlines the aims and objectives of the thesis, the sources of data used and my contribution to the work. In Chapters 2, 3, 4 and 5, the four studies, corresponding to the four defined objectives, are presented in the form of published manuscripts. Chapter 6, the final chapter, presents a discussion of the findings, methodological considerations, implications for clinical practice and future research, and conclusions. The References section at the end of the thesis includes all bibliographic references from the Introduction (Chapter 1) and the Discussion (Chapter 6).

In this thesis, multivariate statistical modelling approaches are applied to longitudinal data to examine how social and non-social abilities in infancy relate to later developmental and clinical outcomes in infants at high- and low-risk for autism spectrum disorder (ASD). ASD is a heritable developmental disorder, rarely diagnosed before 2 years, and characterised by impairments in social interaction, communication and restricted and repetitive behaviours (DSM-IV-TR, American Psychiatric Association, 2000). The application of multivariate techniques to experimental, clinical and questionnaire data from 54 high-risk infants (who have an older sibling with ASD) and 50 low-risk controls, seen at 7, 13, 24 and 36 months, enables the simultaneous modelling of multiple factors in relation to ASD outcome. In Chapter 3, eye-tracking of gaze following behaviour demonstrated that infants who later develop ASD symptoms can correctly follow another person's eye-gaze, but by 13 months they show reduced looking to the gazed-at object compared to typically developing infants. Looking time is an index ofreferential understanding and was also related to children's subsequent receptive vocabulary. Chapter 4 reported that both high- and low-risk 24-montholds can apply mutual exclusivity (the principle that each object has one name) to make a word-object mapping. However, high-risk toddlers did not use social feedback to learn the word, and this difficulty was related to their lower receptive vocabularies. Further, 13 month looking time (from the gaze following task) predicted later learning from reinforcing feedback, suggesting a degree of continuity in children's social understanding across development. Finally, Chapter 5 found that social (gaze following) and non-social (disengagement) attention independently predict ASD, and while disengagement predicts looking time early in development, the measures become de-correlated over time. The findings suggest that in order to understand the variable developmental trajectories leading to ASD, multiple risk markers over time should be analysed.

This document is separated into three parts. Part A provides a detailed literature review that examines the current understanding of Autism Spectrum Conditions (ASC). Attention is drawn to the social difficulties that this population shares and how these might impact upon general life outcomes. It considers the psychological theories that aim to explain the population’s difficulties in generalising knowledge and skills to novel settings. The body of research on the approach of social skills training (SST) for developing the social and communication difficulties of those with ASC is then discussed, followed by a critique of these approaches. Virtual environments are then introduced and their potential usefulness in social skills training is argued. Current exploratory research in the area of virtual environments and SST is briefly critiqued and subsequent research questions are proposed. Part B is an account of the empirical study, which aimed to evaluate the outcomes of a video virtual environment for teaching social skills to 18 adolescents with ASC. The approach to creating a virtual environment was novel and the unique materials and arrangement were described in detail. Specific teaching strategies to promote generalization were included in the design. Participants were observed pre- and post-intervention in a targeted social scenario. Pre- and post-test questionnaires were administered with parents and teachers. The results are discussed and implications for future practice are provided.

Adult Placement offers people with a learning disability a highly flexible form of accommodation and person-centred support provided by individuals and families in the local community and enables an individual to share in the life of the Adult Placement carer. A limited amount of research has focused on the characteristics of carers, and the reasons why people become providers of such placements. There has been little focus in research on service users’ experiences of Adult Placements. The aim of the present study was to explore the experiences of adults with learning disabilities living in long-term Adult Placements, drawing upon the perspectives of service users and carers. Twelve participants (six service users and six carers) were recruited from two Adult Placement Schemes and took part in a semi-structured interview. Interpretative Phenomenological Analysis produced four superordinate themes from the participants’ experiences: The Function of Adult Placements - as a different model of care offering an opportunity for an ‘ordinary’ life for service users; Characteristics of the Service User/ Carer Relationship – one that is differentiated from others and provides a ‘secure base’ and ‘safe haven’ for service users; “Family” – integration into the family, experiences of family dynamics, family changes and coping; and Personal and Professional Issues for Carers – their relationships with the teams, important factors for the carer role, rewards and benefits, and challenges and dilemmas. The results highlight the meaning associated with Adult Placement for service users and relationships developed with carers were found to closely resemble attachments as they are conceptualised in adulthood. This study provides evidence from the service user perspective to support the view that Adult Placement carers fulfil the role of attachment figures for adults with learning disabilities. Findings are considered in relation to existing literature. Clinical and service implications are discussed and recommendations for future research are made.

Social cognition is an area of growing interest in mental health research. Impairments in social cognition have been found in a variety of conditions. Impairments in these processes can lead to relationship difficulties; relationships are instrumental in the management and recovery from difficulties. Few studies have focused on emotional recognition in a PTSD population, this study aimed to expand on the current literature by looking at the associations between emotional recognition and interpersonal relationships. Twenty-seven individuals were recruited to participate, along with age and gender matched healthy controls. They completed two emotional recognition tasks (auditory and facial) and self-report questionnaires measuring views on interpersonal relationships and social support. Those with PTSD were found to have generalised impairments in facial recognition when compared to controls and specific impairments in auditory recognition. The emotions of fear, sadness and disgust were consistently recognised with less accuracy across tasks. No gender differences in accuracy on tasks were found in the PTSD group performance. Comparisons between trauma groups (childhood or adulthood traumas) found no differences in accuracy rates. Significant differences were found between the clinical and control groups on the interpersonal relationship questionnaires, with the PTSD group reporting greater difficulties. Partial associations were found between lower accuracy scores on recognition tasks and reported difficulties in interpersonal relationships. The emotion of sadness on the auditory recognition task mediated the relationship between trauma and interpersonal difficulties. These findings support the view that interventions should also target interpersonal difficulties in PTSD.

Autism Spectrum Disorders (ASDs) are characterised by impairments in social interaction and communication, and restricted interests or repetitive behaviours. Autism traits are theorised to lie on a continuum throughout the general population, with individuals with a clinical diagnosis at one extreme. Those with high levels of autism traits in the general population have been found to display similar characteristics to those with ASD, but to a lesser extent. Differences in visual attention to social and non-social information are thought to contribute to the characteristic behaviours in autism. Whilst social attention may be diminished in ASD, ASD may also be associated with an increase in attention towards objects that are of circumscribed interest. The present thesis investigated visual attention to social and non-social objects in participants with ASD and those from the general population with high and low autism traits, to investigate whether differences in social and non-social visual attention relate to the autism spectrum. Dot probe, peripheral cueing, and eye tracking tasks were used to explore different elements of visual attention, including orienting and disengaging. Overall, social objects captured attention more than non-social objects, revealing the high salience of social information. Participants with high levels of autism traits and a diagnosis of ASD showed reduced social attention in the dot probe and eye tracking tasks, but not the peripheral cueing experiment. Across all experiments, there was no evidence to suggest that the autism spectrum was related to attentional biases towards objects related to circumscribed interests. However, other non-social stimuli appeared to capture attention to a greater extent across the spectrum. The differences in social attention in those with higher autism traits and ASD appeared greater when more stimuli were competing for attention, suggesting reduced social attention may involve interference from non-social stimuli in the visual field. This may indicate that attention is guided more by visual properties of the stimuli than their semantic meaning in the autism spectrum.