Apraxia, a high-level movement disorder, is associated with performance errors during gesture imitation, demonstrating the use of familiar objects that are present (actual object-use) or absent (pantomime), or all three scenarios. Focusing on objects, apraxia has an isolated effect on manipulation judgements regarding skilled object-use. These manipulation deficits are potentially attributed to damage to a purported ventro-dorsal stream resulting in impaired internal representations of movement (i.e. motor imagery). Instead, patients over-rely on visual affordances during object-directed motor behaviour. The cortical regions associated with the ventro-dorsal stream correspond to those damaged in apraxia, in particular the left inferior parietal lobe (IPL), adding weight to this proposal. Using a perceptual matching task with familiar objects and an action execution grasping task with novel objects, behavioural work with left hemisphere stroke patients assessed whether apraxic deficits are specific to object manipulation and whether these patients over-rely on object affordances during skilled object-manipulation. In parallel, the effect of neuromodulation technique transcranial direct current stimulation (tDCS) on motor imagery was explored with healthy populations. Performance changes during left IPL stimulation was assessed during classic motor mental rotation and the same perceptual matching task used with patients. Apraxic patients showed a selective impairment during object manipulation judgements of the perceptual matching task, which increased with apraxia severity. Despite tDCS over the left or right IPL equally affecting motor mental rotation performance in healthy populations, during the perceptual matching task only modulation of the left IPL slowed reaction times when making manipulation judgements but not functional semantic judgements regarding object-use. These results suggest that disruption of ventro-dorsal processing specifically disturbs motor representations of object-use. When repeatedly grasping novel objects of differing weight distribution, most apraxic patients consistently selected a structurally afforded grasp-point, indicating that apraxic patients over-rely on visual affordances after ventro-dorsal disruption. These results confirm that the ventro-dorsal stream, in particular the left IPL, is critical in integrating perceptual internal representations of skilled movement into context-dependent action plans based on visual information. Over-reliance on visual affordances caused by disruption to this pathway not only affects perceptual manipulation judgements of familiar objects but also experience-based learning when grasping novel objects.

Background: Adults with intellectual disabilities who display aggression appear to be vulnerable to aversive social interactions. This may lead some to develop a negative self view which, in turn, can reduce their ability to take benefit from praise. Exposure to aversive social experiences may also lead some adults to become sensitive to forms of criticism. An underlying sensitivity to criticism and a reduced ability to take benefit from positive interaction have both been associated with psychological distress. The clinical field is unclear how adults with intellectual disabilities who display aggression perceive and experience criticism and praise. Method: Adults with intellectual disabilities were recruited into two study groups; one that displayed aggression, one that did not. A Praise and Criticism Task was developed for the study. Participants were presented with 10 hypothetical scenarios and were asked to imagine someone saying something negative (criticism) or positive (praise). After the presentation of each scenario, participants were asked about their thoughts, emotions and beliefs. Results: In contrast to their peers, participants who displayed aggression were not more likely to accept, believe or be distressed by criticism. They tended to believe and experience positive affect in response to praise. Conclusion: Adults with intellectual disabilities may not always have an underlying tendency to misinterpret or misunderstand forms of social interaction. Those who display aggression can benefit from praise and do not appear to be sensitive to criticism. Caution is perhaps warranted before generically applying cognitive theories of aggression in this population.

Background: Previous research has identified that the occurrence of a Global Tonic Clonic Seizure (GTCS) is a high risk factor for serious injury or death within the epilepsy population. Fast intervention during a GTCS accompanied by EEG suppression is needed to reduce the risk of serious injury or death. Research has suggested that intervention should optimally occur within 50 seconds of EEG suppression commencing. Identifying patients who are at greatest risk of GTCS could enable targeted monitoring of patients and facilitate quicker intervention. However, at this time there are no specific guidelines for risk assessment in regards to risk of GTCS. The William Quarrier’s Scottish Epilepsy Centre (SEC) developed a Seizure Assessment Risk Score (SARS) tool for use in Video Telemetry (VT) epilepsy units based on risk factors highlighted by previous research. The SARS was implemented with all new admissions to the SEC and data was collected on seizure activity through routine clinical practice. Aim: The aim of this study was to investigate the efficacy of the SARS tool at predicting the occurrence of GTCS activity in patients admitted to the SEC. Methods: Seizure activity data and daily SARS scores were collected from 37 patients admitted to the SEC over an 8 month period. The data were then explored to determine if there was a predictive relationship between higher SARS scores and GTCS occurrence. Results: Data from 37 patients indicated that there was no significant relationship between higher scores on the SARS and the incidence of GTCS. The current SARS tool does not appear to adequately differentiate between those patients who do experience a GTCS during their admission to the VT unit and those who do not. Conclusion: The study highlights that the SARS tool requires further development to ensure that patients are adequately assessed for risk of experiencing a GTCS. While the majority of the sample was rated ‘high risk’ according to the SARS tool, the incidence of GTCS was in fact relatively low. The study also discusses the difficulties surrounding risk assessing an already specialised and clinically risky population.

The portfolio thesis consists of three parts: a systematic meta-synthesis, an empirical study, and appendices. Part one is a meta-synthesis of hospital staffs’ relationships with people who self-harm. The review aimed to gain an insight in to staffs’ experiences of their interactions with people who self-harm, and how that may influence the delivery of care. Three main themes emerged from nine papers detailing experiences, and the influence of contextual factors on their interaction with people who self-harm. The themes were discussed in relation to theory, and the implications for clinical practice are described. Part two is an empirical study exploring experiences of people who re-attend Accident and Emergency with self-harm. Six people were interviewed and the data was analysed through Interpretive Phenomenological Analysis. Three superordinate themes encompassed the experiences of peoples’ relationships with A&E, but also of additional support networks in times of crisis. Implications on the delivery of care for people in crisis are discussed. Part three is an appendix that provides additional information for the meta-synthesis and the empirical study, as well an epistemological, reflexive and reflective statement.

The personality disorder (PD) concept has attracted widespread criticism (see Cromby, Harper & Reavey, 2012). Research suggests those who receive this diagnosis are often stigmatised by mental health professionals. Psychological approaches to understanding staff views about PD have been dominated by realist methodologies which are limited in their capacity to attend to the complexity, contradictions and context of health professionals’ views. Recently, studies have explored the ways that mental health staff talk about their work and account for their treatment decisions; these studies show how dominant categories and practices are produced and maintained through staff talk (see Harper, 1995; Parker, Georgaca, Harper, McLaughlin, & Stowell-Smith, 1995). A central aim of this thesis is to contribute to the body of research which has explored staff discursive practices, their function and their relationship with wider discourses. This study set out to explore the PD construct and how staff make sense of distress within this diagnostic framework. This research is informed by a social constructionist perspective. Semi-structured interviews were used to elicit talk regarding PD, diagnosis and what staff constitute as key elements of their work. Staff were recruited from across a multidisciplinary (MDT) team; all participants (n = 11) worked in a secure, inpatient PD ward in an independent hospital. The analysis was informed by discursive psychology (Potter & Wetherell, 1987) and Foucauldian discourse analysis (Foucault, 1979). Staff both drew on and resisted the practice of diagnosis. Staff foregrounded a biopsychosocial framework for understanding PD and variably questioned the status of PD as a mental illness. Staff talk about the challenges and goals of their work centred on constructions of emotion and emotional control. Implications are discussed in terms of staff decisions about care, the role of clinical psychologists within MDT’s and the wider socio-political context around PD. The current findings draw attention to the construction of psychological concepts in understanding PD, and the essentialist treatment of diagnosis, as well as the complexity and flexibility of implementation of these strategies to justify decisions. There is a need to foster space to explore staff values, mainstream categories and to reflect on dominant ideologies which will influence staff work with people with a PD diagnosis.

Background: Aphasia is a language impairment affecting approximately one third of people after stroke. It can disrupt speaking, comprehension, reading and writing. This thesis concerned people with aphasia (PWA) with spelling and writing impairments (some also had reading difficulties) but relatively preserved speech and comprehension. Aims: 1. Consider the evidence for writing treatment interventions with a systematic review of the literature; 2. Conduct a pilot study testing the acceptability of a compensatory narrative writing treatment intervention using assistive technology (AT) software; 3. Report an empirical study which designed, delivered and evaluated a program to train ten PWA to operate two mainstream AT packages (Dragon NaturallySpeaking™, a voice recognition software (VRS) to support writing via dictation, and ClaroRead™, supporting reading via auditory processing). The study tested whether: a) AT could be used to produce functional narrative writing, b) reading support promoted writing success c) the intervention could be customised to suit individual goals. Methods: 1. Systematic literature review Electronic databases were searched; 53 papers meeting inclusion criteria were identified. Data were extracted, papers were critically appraised and their findings described. 2. Pilot Ten week AT training with two PWA to test acceptability of the intervention, design training schedule and materials, and test quantitative assessments and qualitative data collection methods for the main study 3. Main study Design and setting: Small group study with mixed methods, repeated measures design. Assessments and AT training in participants’ homes or at City, University of London. Participants: Ten participants meeting eligibility criteria (over 18 years old, medically stable, no significant cognitive impairment, aphasia due to stroke, presenting with acquired dysgraphia) were recruited via convenience sampling. They were not receiving speech and language therapy, had no marked evidence of neuromuscular, structural or motor-speech impairments, nor self-reported history of developmental dyslexia. Measures and procedure. Participants received 7-10 one-hour individual training sessions. Screening (language, cognition) and diagnostic (single word writing, single word reading) assessments took place at T1 (first baseline). Outcome measures (narrative writing, reading comprehension, quality of life, mood) were taken at T1 and repeated at T2 (second baseline), T3 (end of intervention) and T4 (three month follow up). Participant observation occurred throughout training; qualitative semi-structured interviews, a social participation assessment and cognitive monitoring took place at T2, T3 and T4. Results: 1. Systematic literature review Writing treatments were effective but often focused on single word production and seldom tested functional generalisation. Most were single case or small case series studies with remediatory goals; few used qualitative methodologies or investigated the impact of reading deficits. All narrative writing therapies were delivered via technology. 2. Pilot The intervention was acceptable to participants. Training schedule and materials were created and refined; quantitative outcome measures were finalised; emphasis on participant observation was increased. 3. Main study: Keyboard narrative writing was significantly improved by AT (Friedman’s χ² (3) = 8.27, p = .041), as was keyboard reading comprehension (Friedman’s χ² (3) = 21.07, p < .001), indicating compensatory effects of both AT. There was no change over time in pen and paper assessments of writing or reading, indicating no remediatory effect. A wide range of written genres were produced. Social network size significantly increased. There were no significant changes in mood or quality of life. Individual success rates varied; diagnostic and observation data suggested contributing factors were attitude, creativity, preserved speech production skills, spectrum of other aphasic traits, therapeutic goals, and cognition. Conclusion: The compensatory customisable AT training was acceptable to eight of ten participants, and resulted in significantly improved narrative writing performance. Implications: Compensatory AT interventions serve as a useful adjunct to remediatory spelling interventions, and are particularly useful for supporting functional narrative writing.

Aphasia intervention has made increasing use of technology in recent years. The evidence base, which is largely limited to the investigation of spoken language outcomes, indicates positive treatment effects for people with mild to moderate levels of aphasia. Outcomes for those with severe aphasia however, are less well documented and - where reported - present less consistent gains for measures of spoken output. In light of this issue for existing approaches, and due to the fact that non-speech focused interventions might therefore be more suitable, the current thesis explores the use of computer gesture therapy for people with severe aphasia. An initial review of gesture therapy is presented, followed by a systematic review of current computer therapy literature. A pseudo-randomised, wait-list control study of twenty participants with severe aphasia forms the experimental body of the thesis. The study investigates the effects of two purpose-built gesture therapy technologies: GeST and PowerGeST. The latter of these was developed for the purposes of the thesis. Following completion of a range of candidacy measures examining gesture comprehension, language, cognition and praxis, participants undertook a five-week intervention period comprising practice with GeST and PowerGeST. Primary outcomes were assessed using a measure of gesture production in isolation. Secondary outcome measures included an assessment of naming production, a novel assessment of interactive gesture abilities and an accessible computer use and confidence measure. These two latter measures were developed for the purposes of the thesis. Study outcomes show significant improvement in gesture production abilities for adults with severe aphasia following computer intervention. They indicate no transfer of effects into naming gains or interactive gesture. Findings reveal comparatively low levels of access to everyday technologies for this group. Outcomes therefore, indicate the positive effects of a purpose built computer-delivered therapy for a population who commonly experience challenges with access to everyday technology. Insights gained within this thesis offer encouraging results for computer therapy methods within this hitherto under-researched population and propose a case for further development of the evidence base in this field.

Background: Gestures are spontaneous hand and arm movements that frequently accompany speech and play an important role in everyday communication. When communication is impaired by aphasia, gestures are affected as well. It is important to find out how people with aphasia (PWA) use gesture as an accompaniment to speech, as a compensatory modality, and during lexical retrieval. This novel study examined the use and functions of gesture in conversation and investigated parameters (i.e., conversation partner, topic, and participant factors) that could have an influence on gesture production. Methodology: Language and conversation data of 20 PWA and 21 neurologically healthy participants (NHP) were collected. Participants took part in conversations with two conversation partners (familiar and unfamiliar) and two conversation topics (narrative and procedural). Video samples were analysed for gesture production, speech production, and word-finding difficulties (WFD). Results: The two groups of participants produced a similar number of gestures (t (37) = -1.060, p = .296). Gesture type was not examined statistically but showed some marginal differences between groups. Unfamiliar conversation partners elicited significantly more gestures than familiar conversation partners (F (1, 37) = 24.358, p < .001). Additionally, participants produced significantly more gestures in procedural than in narrative topics (F (1, 37) =44.807, p < .001). While all participants experienced a similar number of WFD, there was a difference between PWA and NHP regarding gesture production and resolution of WFD: NHP resolved the majority of all WFD, independent of a co-occurring gesture. Nevertheless, for PWA and NHP, there was a significant relationship between gesture production and the resolution of the WFD (X2 (1) = 12.356, p < .01 for PWA and X2 (1) = 40.657, p < .01 for NHP), indicating that WFD that occurred with gestures were more likely to be resolved than WFD that occurred without gesture production. Participants used gestures with different functions, such as facilitative gestures to resolve WFD or augmentative gestures to supplement speech. For PWA, different participant factures, such as fluency of speech (rs (17) = .487, p = .035), lexical production skills (rs (17) = .584, p = .009), and cognition (rs (17) = .582, p = .009) were linked to gesture production. Conclusions: These findings shed light on gesture processing and the different functions gestures can serve within conversation. Furthermore, they highlight the importance of pragmatic influence, such as conversation topic and conversation partner on the production of gestures. The significant relationships between participant factors and gesture production in aphasia extend the understanding of relevant skills needed to successfully employ gestures in conversation. Next to language skills, such as speech fluency and lexical retrieval, cognitive skills affected gesture production as well.

Previous research has shown that children with Autism Spectrum Conditions (ASC) frequently present with aberrant eating behaviour. Although typically developing children may also face eating difficulties, these difficulties seem to be more prevalent and more severe in children with ASC. The present thesis aimed to explore the prevalence of the following problematic behaviour: food neophobia, eating selectivity, rigid/perseverant eating behaviour and selectivity in terms of texture, in a sample of 254 children (103 children with ASC and 151 control children). This thesis also explored whether the existence of early feeding problems may link with a more problematic current eating behaviour, or higher sensory sensitivity. Associations between a more problematic social-communication and behavioural profile and problems in eating and sensory sensitivity were also investigated. Despite the health benefits, vegetables are commonly identified as one of the least preferred food categories. Therefore, the present thesis aimed to identify, in two observational studies, how factors such as food neophobia, sensory sensitivity and previous vegetable eating experiences can affect the willingness to try real food vegetable options, in a sample of 53 typically developing pre-schoolers and 77 adults with and without autistic traits. Overall, children with ASC presented a significantly more problematic profile in terms of eating, sensory, social-communication and behavioural performance than the control group. However, findings highlighted that generally there are more similarities than differences in the observed relationships between the factors affecting the eating behaviour of children with and without ASC.

The systematic review examines the association between gastrointestinal disease and behavioural change in individuals with intellectual disabilities and Autism Spectrum Disorder. A systematic search of literature databases identified fourteen relevant research articles. Several behaviour classes associated with gastrointestinal disorder were identified, including challenging behaviour, sleep problems, and anxiety and mood related behaviours. Multiple forms of gastrointestinal disorder were also identified as did the quality of its assessment. There was varying degrees of evidence for an association between certain behaviours and gastrointestinal disorders due to assessment methods and behavioural definitions. The empirical paper reports the development of a challenging behaviour report form. A functional assessment tool and protocol was developed to take into account various factors when assessing challenging behaviour such as pain related behaviours, affect, and precursor behaviours. The assessment was trialled on footage of experimental functional analysis of non-verbal children with Autism Spectrum Disorder. The development of the assessment and inter-observer agreement is reported as well as future directions in the development of the assessment. Volume I also contains a public domain briefing paper, which provides an overview of the systematic review and empirical study.