Pregnancy is a time of physiological and psychosocial change for women, and can be a stressful life event (Hodgkinson, Smith & Wittkowski, 2014). Therefore, for some women, pregnancy can exacerbate existing psychological distress (e.g. depression, anxiety and/or stress), or contribute to its development (Biaggi, Conroy, Pawlby & Pariante, 2016). Although there are many reasons why some women experience psychological distress during pregnancy (e.g. lack of social support; Biaggi et al., 2016), this thesis is concerned with the impact of foetal congenital anomaly diagnosis on maternal mental health. Specifically, congenital heart disease (CHD) and cleft lip and/or palate (CL/P). The original focus of the thesis was planned to be exclusively on prenatal CL/P diagnosis, however it was deemed unfeasible to conduct a systematic review in this area due to a lack of relevant quantitative research. CHD was therefore chosen as it is a commonly diagnosed congenital anomaly with sufficient literature available to conduct a systematic review. Chapter one of this thesis therefore aims to critically review, and synthesise the available literature to gain an understanding of whether prenatal CHD diagnosis is associated with maternal mental health difficulties. Clinical implications and directions for future research are considered. The empirical paper presented in chapter two of this thesis focusses on the impact of prenatal CL/P diagnosis on maternal mental health and its associations with antenatal attachment (AA), mindfulness and self-compassion (SC). AA was selected as a variable of interest due to associations between psychological distress in pregnancy and reduced maternal-foetal attachment (Alhusen, 2008; Rubertsson, Pallant, Sydsjo, Haines & Hildingsson, 2015). Furthermore, identifying factors that might contribute to the promotion of increased AA and optimal mental health in pregnancy is therefore important. Mindfulness and SC are two such factors which are increasingly demonstrating their efficacy as concepts related to reducing psychological distress and enhancing AA in pregnant women (Dunn, Hanich, Roberts & Powrie, 2012; Matvienko-Silkar, Lee, Murphy & Murphy, 2016; Mohamadirizi & Kordi, 2016). The empirical paper provides an overview of relevant research, a description of the methods used to address the research question, followed by a discussion of the results. Implications for antenatal services and directions for future research are provided.

Chapter One is a systematic review which aims to investigate existing research into the relationships between socio-economic status (SES), psychological distress and maladaptive eating behaviours. To date, no systematic review has been published which examines the available literature on the inter-relationships between these variables. This area was chosen for review due to a recent theoretic model by Hemmingsson (2014), which proposes a socio-emotional model of obesity encompassing these variables. Eleven papers were found to meet criteria for the review. Chapter Two is an empirical paper which aimed to explore the role of psychological and emotional factors in the relationship between SES and BMI. Lower SES has been shown to be significantly associated with higher body weight (Parsons, Power, Logan, & Summerbelt,1999). There is currently little understanding as to the psychological mechanisms which underpin this relationship (Stamatakis, Primatesta, Chinn, Rona, & Falascheti, 2005). The majority of available research has considered non-psychological factors such as availability of low-cost food, however, findings of such research have not been able to fully account for the relationship between SES and obesity (Cobb et al., 2015). The aim of the empirical paper was to investigate predictions based on the theoretical socio-emotional model of obesity proposed by Hemmingsson (2014). Primarily, the study considers whether socio-economic disadvantage increases psychological distress which, in turn, promotes maladaptive coping behaviours, such as emotional eating, and ultimately obesity. Furthermore, the study assesses if resilience moderates the association between socio-economic disadvantage and distress, thus providing a protective role. The empirical paper will be submitted to the British Journal of Health Psychology for publication. This journal was chosen by the author due to its interest in publishing original research into psychological aspects of health and health-related behaviours. As a result, it was felt that the empirical paper was appropriate for the journal in question and satisfied its remit and objectives.

Previous research has identified a relationship between early maladaptive schemas (EMS) and substance dependence, but there is a dearth of research investigating EMS and alcohol use in non-clinical populations, despite alcohol being the most commonly misused substance in the UK population. The aim of this study was to explore if EMS mediate the relationship between adult insecure romantic attachment (attachment anxiety and attachment avoidance) and alcohol use in a student population. A cross-sectional study of 128 student participants were recruited through the University of Liverpool intranet and by poster advertisement. Participants completed self-report measures comprising of: Alcohol Use Disorders Identification Test (AUDIT), Leeds Dependence Questionnaire (LDQ), Drinking Motive Questionnaire-Revised Short Form (DMQ-R SF), Experiences in Close Relationships –Revised (ECR-R) and Young Schema Questionnaire Short Form, Third Version (YSQ-S3). Bias-corrected bootstrapping indicated that the EMS domain ‘impaired limits’ mediated the relationship between adult insecure romantic attachment (both attachment anxiety and attachment avoidance) and alcohol use. Furthermore ‘impaired limits’ and drinking to cope with depression and anxiety were serial mediators in the relationship between attachment avoidance and alcohol use, but not for attachment anxiety and alcohol use. This research highlights the relationship between EMS and avoidant coping strategies (attachment avoidance and drinking to cope) on drinking behaviour.

For most, becoming a parent is referred to as an overwhelming experience that requires the person to change their identity and lifestyle (Palkovitz, 2007). Although fathers' experiences are often overlooked, strong paternal relationships can not only benefit fathers, but also enhance children's development (Brown, Mangelsdorf & Neff, 2012). The past few decades have seen an increase in the active involvement of fathers in their children's care, attributed to changes in social circumstances and cultural values (Machin, 2015). However, there still remains a paucity of research focusing solely on paternal experiences. A further neglected group are those who parent a child with an intellectual disability (ID). Historically, research has focused exclusively on maternal experiences, describing fathers as 'hard to reach' (Hastings, 2003). Although research highlights mothers of children with an ID experience distress), it is suggested that fathers' experiences differ (Bailey, Blasco & Simeonsson, 1992; Lanfranchi & Vianello, 2012). The first paper presented within this thesis, a systematic review of paternal parenting experiences of a child with an ID, synthesises the results of the limited published literature. Eight papers are included in the review, with the majority being quantitative in nature and drawing conclusions from questionnaires completed by fathers. Moreover, several papers group fathers of children with ID together under one umbrella, where individual characteristics of different diagnostic groups might be lost (Cuskelly, 1999). For example, parents of children with Down's syndrome (DS) are believed to have different experiences to those parents of children with an ID of a different aetiology. It is suggested that parents experience a 'DS advantage', which is associated with lower stress levels and more positive views to parents of children with other IDs (Hartley, Seltzer & Abbeduto, 2012). Down's syndrome (DS) is a genetic condition, resulting from an extra chromosome 21 in each of the body's cells, which leads to most children with DS having mild to moderate levels of ID (Dykens, Hodapp & Finucane, 2000). Most studies which focus on fathers of children with DS highlight that, despite challenges particularly at the time of birth, fathers adapt positively (Bentley, Zvonkovic, McCarty & Springer, 2015; Henn & Piccinini, 2010; Herbert & Carpenter, 1994; Hornby, 1995). As noted earlier, most of these studies use quantitative methodology which fail to provide an in-depth understanding of experiences to the same extent as qualitative methods (Cuskelly, Hauser-Cram & Van Riper, 2008). Moreover, they specifically focus on different aspects of fathers' experiences (e.g. psychological well-being/stress), rather than fathers' adjustment overall and involvement in their child's provision. The second paper within this thesis does just that, through exploring fathers' lived experiences of parenting a child with DS. Through the use of the analytic methodology of Grounded Theory (GT) (Strauss & Corbin, 1998), fathers' accounts have contributed to a model of paternal adjustment to parenting a child with DS. Parenting a child with DS appears to be on a fluid trajectory, highlighting that the course of adjustment varies over time for each father. Three categories were identified which feed into this trajectory: 'Accommodating the child'; 'Adapting the parental/spousal role'; and 'Adapting society'. Each of these categories captured the challenges fathers' encounter that can hinder the adjustment process. Additionally, fathers discussed the deliberate strategies they use to overcome these challenges and shape their adjustment, which ultimately led to all 15 participants considering themselves to have achieved positive adjustment. The two papers together highlight the need for society, most importantly services, to support both parents as equal, without disregarding the involvement and needs of fathers. Fathers' roles and experiences need to be openly explored and recognised, enabling support to be offered if and when fathers would most benefit. Future studies exploring paternal experiences following the birth of their child with DS would further add to the richness of the model presented here. The empirical paper will be submitted to the Journal of Applied Research in Intellectual Disabilities. This journal brings together research in the area of ID and the author felt that the study's aims and findings were appropriate to fulfil the journal's scope and objectives.

This thesis focuses on the relationship between young people who affiliate with alternative subcultures and self-harm and/or suicide. Alternative subcultures can be described as groups that are distinct from 'mainstream' cultures. Affiliation with such groups can be broadly defined as having a strong collective identity to a group with specific values and tastes, typically centred around music preference, clothing, hairstyles, make-up, tattoos and piercings (Greater Manchester Police; GMP, 2013; Moore, 2005). Some alternative subcultures have also been associated with 'dark, sinister and morbid' themes, such as Goths, Emos, and Metallers (Young, Sproeber, Groschwitz, Preiss, & Plener, 2014). Self-harm can be defined as the deliberate act of harming oneself, with or without suicidal intent. This commonly involves cutting and self-poisoning (NICE, 2013). Other behaviours that can be described using this term include non-suicidal self-injury (NSSI; the intentional destruction of body tissue without suicidal intent) and suicidal behaviours such as suicidal ideation and attempts (self-harm with some intent to die; Klonsky & Muehlenkamp, 2007; Nock, Borges, Bromet, Cha, Kessler, & Lee, 2008). Some would argue that NSSI is distinct from self-harm, and as such it features as a disorder in the DSM-V as Non-Suicidal Self-Injury Disorder (NSSID; APA, 2013), however there remains some controversy over the latter (Kapur, Cooper, O'Connor, & Hawton, 2013). The associations between alternative subgroup affiliation and self-harm and/or suicide were explored through a systematic review and empirical research study using quantitative methodology. It is well documented in the literature that the prevalence of self-harm and suicide is particularly high in adolescents and young adults, with suicide being one of the leading causes of death in this population (Hawton, Saunders, & O'Connor, 2012; WHO, 2014). Self-harm has become a clinical and public health concern with up to 30,000 adolescents receiving hospital treatment each year (Hawton, Rodham, & Evans, 2006) and prevalence rates rising to between 7-14% for young people in the UK (Hawton & James, 2005; Skegg, 2005; Swannell, Martin, Page, Hasking, & St John, 2014). Minority groups are another population who appear to have elevated rates of self-harm, including Lesbian Gay Bisexual and Transgender (LGBT; Jackman, Honig, & Bockting, 2016), ethnic minorities (Bhui, McKnezie, & Rasul, 2007) and alternative subcultures (Young et al., 2014). However, there is a paucity of research into the latter population. This presented a gap to conduct a systematic review of the available literature in an attempt to understand the association between alternative subculture affiliation and self-harm and suicide. Chapter 1 describes the systematic process taken in an attempt to understand the links between alternative subculture affiliation and both self-harm and suicide. Ten studies were included which focused on self-harm and/or suicide and alternative identity through subculture affiliation (e.g. Goth) or music preference (e.g. Heavy Metal). The results indicated that there is an association between alternative subculture affiliation and self-harm and suicide, though the lack of research in the area and methodological limitations impact on the extent to which the underlying mechanisms can be understood. Leading on from the systematic review, Chapter 2 presents the empirical study which investigated the factors that might contribute to the increased risk of NSSI in alternative subcultures, specifically focusing on variables that have been found to be linked to NSSI in young people; emotion dysregulation, depression, identity confusion and exposure to self-harm. The aim of this study was to increase our understanding of the mechanisms involved that might explain this increased risk of NSSI. Alternative subcultures were found to be at a greater risk of NSSI in comparison to affiliations with other subcultures, though this association lessened when the other variables were accounted for. A key predictor of NSSI in this population was emotion dysregulation. The findings highlight the importance of raising awareness of the potential risk of self-harm/suicide in alternative subcultures in order to create a greater understanding and direct resources appropriately.

Attention Deficit Hyperactivity Disorder (ADHD) is the most common childhood mental health diagnosis, with estimates of prevalence continually increasing. However very little research has explored young people's experiences of their diagnosis and treatment, despite adolescence being a critical period for development. This thesis synthesises and extends the existing qualitative research undertaken with adolescents diagnosed with ADHD regarding their life experiences following diagnosis. It particularly focuses upon the impact of 'being diagnosed with' and 'medicated for' ADHD. Two papers comprise this thesis: a systematic literature review and an original research paper, which are briefly described below. The systematic literature review was prepared for submission to Emotional and Behavioural Difficulties. It utilised systematic search strategies and conducted a thematic synthesis to identify and synthesise the existing qualitative literature on the experiences of adolescents diagnosed with ADHD. Eleven papers were eligible for inclusion in the review and each was appraised for methodological quality. Five analytical themes were identified: Differing perspectives of the problem; Societal pressures; Sense of self; Feelings about medication; and Maturational shift from passive to active. The findings are discussed in terms of culture and identity, and the need to highlight strengths and autonomy is emphasised. The empirical paper was prepared for submission to Clinical Child Psychology and Psychiatry. It used a grounded theory approach with eleven adolescent participants (aged 16-18 years old) who had been diagnosed when they were aged between 8 and 13 years old. This paper focused on young people's identity development and how this was impacted by their diagnosis and treatment. A comprehensive theoretical model of the findings was constructed, which visually depicted participants' transitions through seven distinct stages, which each had profound implications for their identity. These findings were discussed in relation to the factors involved in the development of a healthy identity, and the value of diagnosis and treatment was critically considered.

Both posttraumatic growth (PTG) and posttraumatic stress disorder (PTSD) are associated with spirituality and different kinds of repetitive thinking, such as deliberate rumination (DR) and intrusive rumination (IR) respectively. This study aimed to examine if spirituality modifies the relationship between types of rumination and trauma outcomes. Method: Ninety-six students from the University of Liverpool completed an online survey of four questionnaires: The Posttraumatic stress Diagnostic Scale, the Event Related Rumination Inventory, the Posttraumatic Growth Inventory-Short form and the Expressions of Spirituality Inventory- Revised. Results: Correlations revealed that spirituality was related to DR and PTG, but not to IR or PTSD symptoms. Moderation analysis showed that spirituality significantly moderated the relationship between PTG and DR, but not the relationship between PTSD and IR. Conclusions: The findings suggest that although spirituality has no relationship with negative outcomes of trauma, it may help individuals to ruminate in a constructive manner in order to develop positive outcomes. Keywords: trauma, posttraumatic growth, posttraumatic stress disorder, rumination, cognitive processes, spirituality.

The study of Executive function (EF) in early child development is not fully established, with much still to be confirmed regarding its latent structure and early precursors. Proposed mechanisms underlying reported inverse associations between prenatal stress (PNS) and general cognitive development suggest that brain regions associated with early EF may be specifically vulnerable, yet this is a largely unstudied area. Postnatal caregiving may modify PNS effects on EF providing a possible early intervention target to improve developmental outcomes. This thesis comprises three linked studies. Study 1 examined latent EF structure in toddlers. Study 2 investigated associations between different forms of PNS in each trimester of pregnancy and toddler EF, and tested whether they were sex-dependent. Study 3 tested the moderating influence of early maternal caregiving on associations observed in study 2. Methods: This research was embedded within the prospective longitudinal Wirral Child Health and Development Study. Study 1: 254 toddlers (mean age 31.4m) completed a battery of EF tasks. Study 2: Mothers reported anxiety symptoms (STAI) at 20 weeks’ and 32 weeks’ gestation, and number of stressful life events (SLEs) via an investigator-led interview for each pregnancy trimester and at multiple postnatal timepoints. Toddler latent EF abilities derived in study 1 were the cognitive outcome. Study 3: Mothers reported frequency of stroking their baby at 4 and 9-12 weeks old, yielding a tactile stimulation index of early caregiving. At 6 months, maternal sensitivity was observed and rated during free play. Results: Study 1: CFA applied to EF data yielded 2 distinguishable yet moderately correlated (r = .43) factors:- working memory (WM) and inhibitory control (IC). Study 2: Multiple linear regression models revealed that 32-week STAI scores in interaction with sex predicted toddler WM (β =0 .55; p < .05), accounting for 2% of the variance in scores after accounting for pre and postnatal confounders; and 1st trimester SLEs in interaction with sex predicted IC (β = 0.45; p = .05), accounting for 2% in outcome. Both interactions arose from a similar pattern of opposite associations between PNS and EF in males and females. Study 3: PNS effects were not moderated by maternal tactile stimulation. The prediction of toddler IC by the 1st trimester SLE by sex interaction was moderated by maternal sensitivity. This 3-way interaction accounted for 3% of variance after accounting for confounders. Conclusions: EF exhibits an integrative latent structure in toddlerhood; PNS was associated with poorer EF in males and relatively enhanced EF in females; exposure to higher maternal sensitivity in the first months of life eliminated the observed sex-dependent PNS effects on toddler IC but not WM. Findings are discussed in the context of Developmental Origins of Health and Disease model and evolutionary perspectives on sex-dependent development.

Callous-unemotional (CU) traits have proved to be a robust and informative construct; identifying a subgroup of children with conduct problems who show more severe and persistent antisocial behaviour. The majority of this work has focused on mid to late childhood and adolescent samples, yet the study of CU traits in early childhood allows identification of developmental pathways to CU traits and may inform the development of preventative interventions. The three empirical studies included in this doctoral thesis use a longitudinal epidemiological sample (Wirral Child Health and Development Study; WCHADS) followed from pregnancy up to age 7 years to examine important questions regarding: 1) the measurement of CU traits in early childhood 2) the contribution of the early parenting relationship to child CU traits; specifically maternal sensitivity to infant distress, with possible mediation by child attachment status, and 3) a candidate sex dependant mechanism for the translation of CU traits into physical aggressive from early to mid-childhood. The first study uses the extensive sample of consecutively recruited first time mothers and the second two studies focus on a subsample stratified by psychosocial risk. The aim of the first study (Chapter 2; n = 775) was to adapt a CU traits measure for use with preschool children. The CU measure derived showed acceptable psychometric properties, factorial invariance by sex and good stability to 5 years. Validity was supported by cross-sectional associations with physical aggression for both boys and girls and incremental prediction to aggression at age 5 in girls only. The second study (Chapter 3; n = 272) examined the longitudinal contribution of maternal parenting behaviours (sensitivity to distress and to non-distress, positive regard, intrusiveness) at 7 months and attachment status at 14 months to child CU traits assessed from age 2.5 to 5 years. Latent variable modelling yielded a single parenting factor which, in line with predictions, significantly predicted reduced CU traits. The effect was mainly explained by sensitivity to infant distress and positive regard towards the infant. These two indicators evidenced a significant interaction, such that the combination of low positive regard and low sensitivity to distress predicted increased child CU traits. Neither attachment security nor disorganization predicted CU traits, so there was no evidence for mediation by attachment status. The final study (Chapter 4; n = 276) examined a hypothesised sex-specific mechanism for the translation of CU traits to aggression via HPA –axis reactivity to stress. Age 5 cortisol reactivity was found to significantly moderate the association between age 5 CU traits and age 7 teacher and mother reported aggression, evidenced by a significant 3-way interaction with sex. There was a significant two-way interaction in boys, such that higher CU traits and lower cortisol reactivity predicted increased physical aggression. Overall, this thesis provides support for the valid measurement of CU traits over the early preschool period. Sensitivity to infant distress, alongside positive regard/warmth, predicted reduced CU traits suggesting that early interventions might also focus on enhancing maternal responsiveness to distress. Findings supported the role of cortisol reactivity to social stress in the translation of CU traits to aggression and critically this was sex specific.

A review of academic literature revealed a dearth of published research concerning whether dramatherapy might help UK combat veterans recover from Post Traumatic Stress Disorder (PTSD). Furthermore no published research sought to capture veterans’ perspectives during dramatherapy in the UK. My research questions addressed the gap in the research literature: What is the participant’s perspective on the use of dramatherapy in helping British combat veterans a) to recover from PTSD? and b) to adjust to civilian life? The research design was a phenomenological mixed methods case study. The qualitative measures were arts-based. Interpretative Phenomenological Analysis (IPA) was used to examine the transcripts of the dramatherapy sessions. The quantitative measures were the Clinical Outcomes Routine Evaluation (CORE) -34 and CORE-10; Short Warwick Edinburgh Mental Well-being Scale (SWEMWBS) and the PTSD Checklist – Military (PCL-M). The multiple methods synthesis raised questions and gave new insights rather than confirming results. The participants were 3 male veterans from the same region of the UK. I was the researcher/dramatherapist. The aim of the research was to achieve an in-depth study underpinned by a participant-centred approach. The research theme was journeying towards recovery. The choice of play-text, an excerpt from The Odyssey, reflected this. The initial 5 dramatherapy sessions were individual and the remaining 3 were group sessions. The IPA indicated that the participants’ perspectives were that dramatherapy might help other veterans towards recovery from PTS. Furthermore dramatherapy might help in their adjustment to civilian life. The use of , imagination and role rehearsal and assisted in reframing of their personal stories. The participants found the use of a novel method developed by myself, from Turner’s Model of Crisis (TMOC) (Turner, 1967) particularly helpful in moving through traumatic memories, utilising metaphor and a problem-solving approach. This led to embodiment of reprised positive military roles in overcoming obstacles on their journeys. They used this method in other situations arising outside of the research and recommended it as potentially having a positive impact on other veterans, seeking recovery. They remained in the clinically significant scoring for PTSD. However, they identified the framework of dramatherapy methods resulted in an increase in confidence, creativity and ability to manage conflict. This was supported by the IPA results.