Our current understanding of the use of online support and information among parents of people with rare syndromes is fragmented, both theoretically and methodologically. This thesis aimed to provide a more coherent picture by using Bourdieu’s concepts of capitals, habitus and fields to explore the interplay between the social differentiation of online support use and its role within the wider caring practices of parents of people with Rett syndrome. A mixed mode, mixed method approach was used. Parents were recruited through a charity’s mailing list and communication channels and through relevant online support sites. 190 parents completed a survey about Internet and online support use. Twenty of these parents took part in detailed interviews about their use of online peer support sites. Age most strongly differentiated the use of the Internet for caring-related information and support. Time-related variables (age of parent, age of child and years since diagnosis) strongly differentiated the use of online peer support and fewer years since diagnosis was associated with gaining greater benefits from online peer support. Use of online peer support in everyday caring practices was dynamic and changed in relation to alternative sources of social capital, current need and level of relevant expertise. Interviewees with adult children had lower information and support needs overall and online support sites, used predominantly by younger carers, offered them few useful ‘goods’, except keeping abreast of developments in research and treatment. Wealthier parents tended to use blogs to read and trade information. There was a suggestion that more educated interviewees accessed a range of primary sources of information while less educated parents relied upon online peer support as a primary source of information. These findings demonstrate the importance of exploring online caring and health practices within a wider social, historical and personal context.

Background: Irish-descended people in Britain experience elevated mortality and morbidity, compared with white British people, persisting across generations. Reasons are unknown. Objectives: 1. To determine the prevalence of: childhood and adulthood psychological morbidity, poorer self-rated health, alcohol misuse and tobacco use, in second generation Irish people relative to the rest of the sample, in a nationally representative cohort. 2. Assess life-course experiences of adversity in second generation Irish people relative to the rest of the samples. 3. Assess how far life-course adversity mediates the association between second generation Irish ethnicity and health outcomes. Methods: Data from the National Child Development Survey (NCDS) and The 1970 British Birth Cohort (BCS70), in which 17,000 babies born in 1958 and 1970, respectively, followed up until adulthood, was used. 6% were of second generation Irish descent. Results: Second generation Irish people grew up in marked material disadvantage. By mid-life, Irish people had reached parity with the rest of the cohort on most adversity indicators. Irish children were more likely than the rest of the cohort to experience psychological morbidity at 7, 11 and 16 (NCDS) OR 16 (BCS70). This diminished after adjustment for parental health and material hardship. By mid-life, second generation Irish cohort members were more likely to screen positive for common mental disorders (OR: 1.27 (95% CI: 0.96-1.69)), poorer self-rated health (OR: 1.25 (95% CI: 0.98-1.60)), binge alcohol use (OR 1.26 (95% CI: 1.00-1.58)) and tobacco use (OR: 1.29 (95% CI: 1.05-1.58)). Associations between Irish ethnicity and all health outcomes were either fully or partially attenuated after adjustment for childhood adversity. Conclusions: Second generation Irish people in Britain experience adverse mental and physical health over their life-course. This may be due to growing up in circumstances of marked childhood adversity.

BACKGROUND: Tackling severe acute malnutrition (SAM) is a global public health priority. This thesis explores two major influences on treatment outcomes: -Treatment efficacy -Patient-related risk factors OBJECTIVES: 1. To explore whether a pre/probiotic mixture (Synbiotic2000 Forte™) improves treatment outcomes (nutritional and clinical) in children affected by SAM. 2. To describe long term outcomes from SAM and identify key mortality risk factors. METHODS: All 1024 malnourished children admitted to a therapeutic feeding centre in Malawi from July 2006 to March 2007 were eligible for: The PRONUT study (Pre and PRObiotics in the treatment of severe acute malNUTrition): 795 were recruited into a randomised, double-blind, placebo-controlled trial. They received Readyto- Use Therapeutic Food either with or without Synbiotic2000 Forte™. Primary outcome was nutritional cure (weight-for-height >80% of NCHS median). The FUSAM study (Long term Follow-Up after Severe Acute Malnutrition): all children known to be still alive were followed up ≥1 year post discharge. RESULTS: In PRONUT, nutritional cure was similar in both groups: 54%(215/399) for Synbiotic-enhanced RUTF and 51%(203/396) for controls (p=0.40). Main secondary outcomes were also similar (p>0.05). Overall mortality from SAM was 41%(427/1024). Mortality was highest during initial inpatient treatment: 23%(238/1024). In FUSAM, 8%(84/1024) more died within 90 days of admission and 10%(105/1024) during long term follow-up. Cox regression identified HIV, low weight-forheight, low mid-upper arm circumference and low weight-for-age as major risk factors for death (p<0.001). CONCLUSIONS: In this high-mortality setting, Synbiotic2000 ForteTM, did not improve clinical or nutritional outcomes from SAM. A more promising strategy to improve outcomes might be to tackle the major risk factors for SAM mortality: HIV and severity of malnutrition disease. It is likely that earlier treatment would be beneficial. This is a focus of current strategies for both HIV and malnutrition. Rollout of such programmes should be supported and their impact on SAM evaluated.

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This thesis is primarily concerned with the experience of parenting a child with a visible difference. The focus of the papers were chosen due to their under-representation in the literature and relevance to clinical psychology provision. The thesis commences with a review of the qualitative literature that explored the experience of being a parent of a child with a cleft lip and/or palate. Using Noblit and Hare’s (1988) meta-ethnographic approach, 18 papers were reviewed to produce five over-arching themes. The findings illuminated the central experiences associated with the parenting role. Clinical implications concern the enhancement of emotional support for parents within healthcare settings. A pertinent finding emerged relating to the role of parent identity in navigating treatment pathways and its potential influence on treatment decisions. The research paper explored the experiences of parenting a child with limb difference who has been provided with an artificial limb. Seven parents were interviewed and data analysed using interpretative phenomenological analysis (IPA). Four themes were identified: (1) managing the initial emotional experience through the development of coping resources; (2) opportunities through prosthesis use and its relationship with ‘normality’; (3) managing and making sense of social reactions toward their child; (4) the intrinsic role of support: developing a collective connection and enabling shared knowledge. Clinical implications once more concern the provision of emotional support. In addition, the management of social responses and the co-ordination of healthcare services with support networks are discussed. Of relevance to prosthetic rehabilitation services was an interesting divergence related to the experience and meaning of their child’s use of a prosthesis concerning functionality. Finally, the critical appraisal documents the process of reflexivity within the research paper, including the navigation of methodological issues to ensure fidelity with IPA, before discussing the pertinent clinical implications as I move toward qualified life.

This thesis aimed to examine how children's and adolescents' eating behaviour is socially influenced by their parents and their peers. Chapter 2 aimed to examine whether there was evidence that adolescents may mimic their parent when eating a lunchtime meal together. Chapter 2 showed that adolescents may mimic their parent when eating together, looking to their parents to determine what to eat and when. Chapters 3-5 aimed to examine whether perceived eating norms influenced children's eating behaviour, the mechanisms underlying this influence, and whether perceived eating norms in the form of messages may be used as an intervention tool. Across chapters 3 and 4 perceived eating norms influenced children's vegetable consumption. In addition, in Chapter 4 the perceived eating norm continued to influence children's eating behaviour in an eating session twenty-four hours later. Furthermore, Chapter 4 found that perceived eating norms may act as a form of informational social influence, through removing uncertainty about how much to eat. Finally, Chapter 5 showed that perceived eating norm messages may be a potential way of increasing children's fruit and vegetable intake. We argued that children's and adolescents' eating behaviour is socially influenced by their parents and their peers, and that interventions could make use of perceived eating norms to increase children's fruit and vegetable intake.

Background: Integrated child health events (ICHEs) are an established and popular mechanism for delivering essential health interventions in low- and middle-income countries (LMICs) suffering resource constraints and health system deficiencies. There is scarce empirical research on whether their expansion and addition of multiple components affect coverage, on the institutional capacities and processes required to support these, and on their implications for routine delivery of immunization. Aim: To examine whether delivering multiple interventions through campaign-style events is an effective strategy in LMICs, given the drive towards expansion of this delivery strategy, and the need to sustain and strengthen routine immunization systems in the long-term. Methods: Guided by an implementation research framework, the study involved a quantitative analysis of a global ICHE dataset, and a qualitative case study of CHWk in Zambia (1999-2014) including semi-structured interviews and document reviews. Zambia represented a unique case as it has consistently relied on campaigns with larger numbers of interventions per event than elsewhere. Findings: ICHEs represented an effective platform with a potential to incorporate multiple key interventions globally without necessarily compromising their coverage. Political stability, government stewardship, high levels of collaborative action and coordination, and the institutionalization of CHWk in Zambia provided a solid base for expansion. Lack of financial and human resources to strengthen district health management fostered a reliance on CHWk to deliver routine immunization. An abrupt top-down policy shift to de-emphasize CHWk, and insufficient local buy-in, in effect obstructed the move towards re-building routine systems. Conclusions: ICHEs continue to play a major role in delivering multiple essential child health interventions in many LMICs. Given their potential to undermine routine immunization systems, a synchronised approach of continued delivery of key services through campaigns in targeted areas, in parallel with strengthening routine delivery, is a viable strategy in pursuing child mortality reductions in the long term.

Main Research Project 1: Existing research indicates that caring for a child with additional difficulties can be challenging and stressful for caregivers (Mendenhall and Mount, 2011). Mental health problems and deafness can both be considered additional difficulties. However less is known about the impact of this co-morbid presentation in children on their caregivers. The present study explored how caregivers of children with co-morbid deafness and mental health difficulties experienced and coped with their child's conditions. The project took place in two stages. The first stage was designed to measure stress, coping and adjustment in caregivers of deaf and non-deaf children with mental health difficulties. The second stage provided some contextual background to caregiver's experiences of rearing a child with co-morbid deafness and mental health difficulties. Main Research Project 2: Background. Despite the potentially severe psychosocial impact of OCD and the its treatability, evidence suggests that people wait many years to seek treatment (Stobie, Taylor, Quigley, Ewing, and Salkovskis, 2007). The psychological processes involved in the decision to seek treatment for OCD have received surprisingly little research attention. It has been documented that a lack of information can act as a barrier to seeking treatment for OCD (Robinson, Rose and Salkovskis, in press). Research in other areas has indicated that decision making outcomes correspond with areas in which people are encouraged to focus on at the time of decision making (Wroe and Salkovskis, 2000; Wroe, Salkovskis and Rimes, 2000; Salkovskis, Rimes, Bolton and Wroe, 2010). Objectives. The present study aimed to explore whether the type of information presented and focussed on by community controls (without OCD) influenced the likelihood that they would seek treatment if they developed OCD. Design. An analogue study was conducted using people who were not suffering from OCD that were recruited in the community. Methods. The seventy-five included participants were recruited through community settings to complete a focussing intervention. Participants were asked to rate how likely they would be to seek help for OCD before and after reading and rating for self-applicability, specific information designed to focus their attention either on previously identified 'enabler' factors or on general information about OCD. Results. Results indicated a significant shift in the likelihood of seeking treatment for OCD when participants were asked to focus on enabling information as opposed to more general information on OCD. Conclusions. Providing people with any type of information about OCD is helpful in increasing the likelihood of hypothetically seeking help, however focussing on enabling factors is more facilitative in terms of adjusting people's attitudes towards treatment seeking.

Children may use social support to manage symptoms of post-traumatic stress disorder (PTSD). Good perceived social support is associated with fewer PTSD symptoms. Limited research exists about actual support children receive post-trauma and whether this is associated with PTSD. This study explored actual and perceived support, factors that influence actual and perceived support and the relationship between social support and PTSD 4-weeks and 3-months post-trauma. Eighty-nine children and their parents completed measures of PTSD and social support 4-weeks after attending the emergency department following a single-incident trauma. Seventy children completed PTSD measures 3-months post-trauma. Children had good levels of perceived social support which was associated with lower perceived barriers to support, after controlling for gender. Perceived social support at 4-weeks predicted PTSD cross-sectionally, after controlling for age, but did not predict change in PTSD at 3-months. Eighty-percent of children felt they needed support post-trauma, seeking it from parents or friends. Actual support did not predict PTSD cross-sectionally or longitudinally. These findings support previous research that perceived social support is protective post-trauma. More information is needed about what support children want post-trauma and whether they receive this. These findings will help inform interventions to promote perceived social support post-trauma. Service Improvement Project Children in care are at increased risk of developing mental health problems potentially due to the increased experience and impact of social and environmental risk factors in their early life. However, there are difficulties accessing mental health services that understand their specific needs. Mental health consultations have been recommended to increase access to mental health services for those working with children in care. A child and adolescent mental health service has been providing a consultation service to social workers for over 4 years. Clare Dixon reports the results of an audit of 83 consultations and a survey completed by 34 social workers, to gather their views about the consultations. The results showed that consultations were utilised by several social work teams, were requested for a variety of reasons and resulted in a range of outcomes. The social workers were positive about their experiences of the consultations and reported that it gave them a better understanding of the difficulties they were experiencing and how to manage them. The results highlighted difficulties with the internal administration processes, practicalities 6 and social workers’ understanding of what the consultations provide. Recommendations were provided highlighting areas of good practice and ways to improve the consultations that are provided to the social workers for children in care. Critical Review of the Literature The prevalence of post-traumatic stress disorder (PTSD) in people with psychosis is high. Intervention guidelines for psychosis recommended that if PTSD is diagnosed then intervention guidelines for PTSD should be followed. However, studies evaluating PTSD interventions often exclude people with psychosis. Eighteen studies were included in this review which aimed to evaluate the evidence for the effectiveness of PTSD interventions for people with psychosis and see if there was any additional impact on symptoms of psychosis. Interventions included trauma-focused cognitive therapies, EMDR, prolonged exposure, video testimony and written emotional disclosure to treat single and multiple traumas. The findings suggest PTSD interventions have some positive effects for people with psychosis but there are considerable methodological limitations which bias the results and limit the conclusions that can be drawn. The findings also provide some tentative evidence that the interventions have a positive impact on comorbid symptoms of psychosis but there are several limitations to consider. More work is needed adopting stronger methodologies with better controls and looking at symptoms of psychosis as a specific outcome of the intervention. This review concludes that evidence in this area is still in its infancy thus limited conclusions can be drawn about the effectiveness of PTSD interventions for people with psychosis.

Post-trauma adjustment in children and adolescents has attracted increasing research and clinical interest in recent years and workers have been particularly interested in identifying the risk and protective factors influencing trauma outcome. These issues form the focus of this research thesis, which will be presented in three parts. (1) The literature review examines current evidence on children's psychosocial functioning following trauma, and the risk and protective factors influencing outcome, with particular emphasis on coping style and social support. The review highlights the complexity of this area, reflected in multifactorial models of children's post-trauma adjustment and suggests that coping and social support may be particularly important. However few childhood trauma studies have directly examined these factors and future directions are suggested for addressing these issues in childhood trauma research. (2) The empirical paper therefore examines the influence of coping style and social support on children's post-trauma adjustment. Fifty-six children aged 7-14 years, and their main caregiver, completed a battery of measures 3-4 weeks after a traumatic event and again 3 months later. Children frequently experienced post-traumatic stress, anxiety and depressive symptoms, and these symptoms were associated with reduced social support and increased use of coping strategies, the latter finding indicating a bi-directional relationship between distress and coping. The findings are discussed in relation to multifactorial models of children's posttrauma adjustment, and recommendations made for further research. (3) The critical appraisal discusses the methodological and theoretical issues, which emerged during the course of the study and considers implications for future research and clinical practice with children exposed to traumatic events.