Background: Puberty is considered to be delayed if sexual maturation occurs beyond 13 years in girls and 14 years in boys. Physical consequences of delayed puberty include short stature and immature appearance, relative to their chronological age. Psychosocial consequences include social withdrawal and isolation, teasing and bullying, parental over protection, poor body image, low self-esteem and declining academic performance. Research findings in this area can be conflicting with most of the focus being upon delayed growth. Consequently, the psychosocial impact of delayed puberty remains unclear. This study aimed to explore adolescents’ experiences of delayed puberty from a psychosocial perspective. Method: Five adolescents with delayed puberty attending the Royal Hospital for Sick Children were recruited to the study. Semi-structured interviews were conducted, recorded and transcribed. The data were analysed using Interpretative Phenomenological Analysis. Results: Analysis identified five super-ordinate themes: Confusion Surrounding Diagnosis, Adolescents’ Internal Experience, Adolescents’ External Experience, Coping and Future Prognosis. They reported a range of emotional, behavioural, social and psychological affects. Adolescents utilised various maladaptive and adaptive coping strategies to help them manage the consequences they experience. They reported feelings of confusion and uncertainty surrounding their diagnosis and treatment which may be contributing to the emotional and psychological symptoms. Conclusion: Adolescents reported that delayed puberty only affects certain areas of their life and that they are generally happy with who they are. This study emphasises the importance of adolescents receiving clear information about delayed puberty and its treatment as soon as possible when they first attend the endocrine clinic to help manage the psychological and emotional consequences reported.

BACKROUND: The population of the Arab World is about 300 million and the Arabic language is one of the six official languages of the United Nations. As with the rest of the world, degenerative neurological conditions represent a major health problem in regions such as the Middle-East where Arab people are in the majority. However, clinical neuropsychology is still in its infancy in this region. Very few tools for the assessment of cognition have been developed for use with Arabic speakers in the Middle-East region. The Addenbrooke's Cognitive Examination – Revised is a brief cognitive assessment tool that has been well validated in its original English version as well as a number of other languages, but never been adapted for use with Arabic speakers. An important issue for the assessment of cognition in this region is the high level of illiteracy, particularly in older adults, making the development of tools that can be used with both literate and illiterate participants a priority. OBJECTIVES: The studies presented in this thesis involved the translation, adaptation and validation of an Arabic Addenbrookes Cognitive Examination- Revised (ACE-R) and involved data collection from both literate and iliterate participants. METHODS: The ACE-R was translated into Arabic and the process is described in Chapter 2. Critical to the process was the cultural adaption of the test items. Three parallel versions were developed. Data was collected from four participant samples, recruited in Riyadh, Saudi Arabia: (1) Healthy literate (N= 147); (2) Healthy illiterate (N= 283); (3) Literate with a diagnosis of Alzheimer’s disease (AD) or Mild Cognitive Impairment (MCI) (N= 54); (4) Illiterate with a diagnosis of AD or MCI (N= 169). Chapter 3 presents a study of the validity of the Arabic ACE-R in literate participants. Receiver operating curve (ROC) analyses were undertaken to determine the sensitivity and specificity of the Arabic ACE-R to MCI/dementia, as well as positive and negative predictive values. Optimal cut-off scores were determined. Chapter 4 presents a study of the reliability of the Arabic ACE-R with literate participants. Parallel forms of the Arabic ACE-R were administered on two occasions separated by approximately one week. Test-retest and internal reliability (Cronbach’s alpha) were examined. A version of the test was developed for use with non-literate participants and Chapter 5 presents a study of its validity with this population. Chapter 6 reports a study of the reliability of the tool with non-literate participants. Chapter 7 reports normative data for the Arabic ACE-R, identifying fifth percentile cut-off points. RESULTS: Literate participants: Amongst healthy controls Arabic ACE-R data were not normally distributed, hence non-parametric statistics used in analyses. Amongst healthy controls age was correlated with Arabic ACE-R performance (rho = -0.568, p<0.0001) and level of education was also correlated with Arabic ACE-R performance (rho = 0.559, p<0.0001). As there was a significant difference in age between healthy controls and patient groups, groups were matched for age by removal of young controls and participants also examined in three age bands. Groups were matched for level of education. There were significant differences between each of the three groups examined – Mild Cognitive Impairment, Dementia of the Alzheimer’s type and healthy controls. As the MCI group was small, Receiver Operating Curve (ROC) analyses were conducted on the combined MCI/DAT group compared with the healthy control group. Levels of sensitivity/specificity were high. For a cut-off point of 70, sensitivity was 1.000 and specificity was 0.946. The positive and negative predictive values (PPV and NPV) were also high, particular for base rates that are likely to be closer to those found in clinical practice. For literate participants, internal reliability was high (Cronbach’s alpha, 0.932) as was total score test-retest reliability (rho=0.944). Individual subscale reliability ranged from rho=0.685 (Fluency) to rho=0.865 (Memory). Illiterate participants: Amongst healthy controls Arabic ACE-R data was not normally distributed, hence non-parametric statistics were used again. Amongst healthy controls age was correlated with Arabic ACE-R performance (rho = -286, p<0.001). As there was a significant difference in age between healthy controls and patient groups, groups were matched for age by removal of young controls and participants were also examined in three age bands. At a group level the data showed that there was a significant difference going from healthy to MCI and from MCI to DAT groups. ROC analyses showed that the Arabic ACE-R distinguished well between the healthy controls and patients with a diagnosis of either MCI or DAT. The optimum cut-off point on the Arabic ACE-R (65) had good sensitivity and specificity. Internal reliability was also high (Cronbach’s alpha, 0.987) as was total score test-retest reliability (rho=0.916), with individual sub-scale scores ranging from rho=0.647 (Language) to 0.861 (visuo-spatial). Analysis of normative data indicated the cut-off scores based on fifth percentile point results in somewhat higher cut-off points that those derived from ROC analyses, particularly for the younger literate participants. Potential reasons for these differences are discussed. CONCLUSION: The Arabic ACE-R shows good sensitivity and specificity in the detection of patients with a clinical diagnosis of either AD or MCI. This appears to be the case for both literate and illiterate participants. The Arabic ACE-R (Illiterate version) was straightforward to administer with just four tasks being omitted. This study only compared healthy controls and patients with clear evidence of dementia/MCI (and only small numbers of MCI). Because of the strong tradition of caring for older adults within families, and stigma associated with mental health problems, people with dementia are typically not referred to a doctor until the condition appears very clearly. Further research is needed to examine participants in earlier stages of disease and also participants with psychological/mood disorder. The Arabic ACE-R appears to be a reliable instrument for the assessment of cognitive impairment that may be arising from a degenerative neurological condition for both literate and illiterate participants.

Aims: The current research explores the impact psychological training has on attributions held by health and social care staff regarding the causes of distressed behaviour exhibited by individuals with dementia. Method: Participants attended a two-day formal training workshop aimed at developing knowledge and skills regarding assessment, formulation, and interventions for distressed behaviours within a psychological model (James, 2011). Attributions made by participants were measured before and after training using the Challenging Behaviour Attribution Scale – Dementia (CHABA-D), adapted from the CHABA (Hastings, 1997) and findings examined in the context of attributional shift post-training. Additionally the internal reliability of the CHABA-D was measured using Cronbach’s alpha. Results: The scale was found to have good internal reliability and analysis indicated that participants made more psychological attributions regarding the cause of distressed behaviour both before training and on course completion, although there was no increase in the number of psychological attributions made following training. Additionally, participants demonstrated increased awareness of learned behaviour, physical environment, and activity and stimulation as causal factors in the development of distressed behaviour in individuals with dementia following training. Future directions: Further research is on-going to evaluate the effects of training on clinical practice, focusing on evaluating the impact on prescribing of anti-psychotic medication for distressed behaviour exhibited by individuals with dementia.

Background: The theories used to explain autobiographical memory and mentalization cite complementary mechanisms, and positive associations have been demonstrated between these functions. These cognitive operations may vary in different social contexts, dependent upon the prevailing social mentality (Gilbert, 1989, 2005). Aim: This study evaluated a new method for assessing autobiographical memory retrieval, and reflective-functioning, in response to cues consistent with different social mentalities. Methods: A sample consisting of participants with either schizophrenia-spectrum disorders or complex trauma was recruited. These populations were selected as both exhibit impairments in autobiographical memory and mentalization, and because trauma and psychosis are reciprocally and causally linked. The participants were asked to recall specific memories in response to cues reflecting compassion, threat and drive-focused social contexts, and to reflect upon the retrieval process. The specificity and latency of retrieval were measured, and the narrative coded for level of reflective functioning. Results: Retrieval was less specific in response to drive cues compared to threat cues. Drive cues were associated with longer retrieval latencies compared to threat and compassion cues. Reflective functioning was consistently poor, and did not differ following the different cues. However, consistent with previous research, reflective functioning was positively associated with retrieval specificity. Conclusions: This new method detected differential retrieval patterns in response to the three cue types. Poor retrieval of drive-cued events may reflect a paucity of competitive and motivation-based experiences to draw from, or the abstract nature of the cues. Spontaneous self-reflectivity appears to be poor in these patients, who may require greater support with this process. Specific task developments are recommended to disentangle these hypotheses, including controlling cue familiarity and imageability, and providing more instruction and encouragement for the elaboration of metacognitive responses.

Background and aims: Parenteral nutrition is a complex, risky procedure administered by parents to children with intestinal failure. Previous research has demonstrated that, while psychological and social challenges are associated with the procedure, families can adapt to their circumstances. The mechanisms through which coping occurs have not been explored. Age-specific exploration, such as feeding and attachment in the early developing child, is also required. This study aims to examine the experience of living and coping with intestinal failure and parenteral nutrition during early childhood (age 0 – 5) from mothers’ perspectives. Methods: Seven mothers with children aged between 0 – 5 years were interviewed using a semi-structured interview schedule. Transcripts were analysed using Interpretative Phenomenological Analysis. Results: A four stage model of experience emerged from the data with specific tasks to negotiate in each stage: experiencing trauma, preparing to launch, transitioning home, and reflection and re-organising. Adjustment and coping in each stage was mediated by individual, interpersonal and environmental/systemic factors. Conclusions: The model of parenteral nutrition has implications for enhancing clinicians’, policy makers’ and health care providers’ understanding of the experience and impact of this procedure on families with young children. Suggestions are made for improvements in the delivery of care and treatment for these children, such as supporting mothers to meet and help each other and providing support around living without food.

Objective: It has been found that 50% of older adults who fall will develop fear of falling. Group delivered Cognitive Behaviour Therapy (CBT) has been found to be effective in reducing fear of falling however, research has found that individually delivered CBT may be more effective and acceptable than group delivered CBT. This research is a preliminary study evaluating the effectiveness of an individually delivered CBT intervention for fear of falling in older adults compared to a control group receiving physiotherapy. The study also reports data on indicators of the acceptability and feasibility of CBT in this sample. Method: Eighteen participants were recruited from the NHS Greater Glasgow and Clyde Falls Prevention Service and were allocated to either the CBT or control group according to the treatment site that they attended for the Falls Prevention Service. Measures of fear of falling, anxiety, and quality of life were compared within subjects and between groups at pre and post treatment. Results: On the measure of fear of falling, significant within subject differences for those who received the CBT and between subject differences compared to a group receiving standard physiotherapy were found. No differences were found within subjects or between groups on measures of anxiety or quality or life. The intervention was found to be acceptable to older adults and practical in terms of delivery. Discussion: Individually delivered CBT is an effective and feasible intervention for older adults who are fearful of falling and is more effective than standard physiotherapy. Future studies should aim to investigate if this beneficial effect is replicable.

Background: Cognitive defusion is a core therapeutic process in Acceptance and Commitment Therapy (ACT). ACT helps clients distance themselves from cognitive content that functions as a barrier to pursuing valued behavioural directions. This systematic review focuses on cognitive defusion techniques that use deliteralisation to try to reduce the literal quality of thoughts and help individuals see them as just thoughts rather than absolute truths. Aims: To synthesise experimental findings regarding the effects of cognitive defusion on distress and believability in experimental laboratory-based component studies. Method: A systematic literature search was conducted in June 2013 using CINAHL, EMBASE, MEDLINE, PsychINFO, Web of Science, and the Cochrane Library databases to identify relevant studies. Results: Nine studies met inclusion criteria for review. The majority of studies (i.e. 7) were rated “moderate” in quality, the remaining two were rated “good” and “low”. Cognitive defusion was generally shown to produce superior results to distraction, imaginal exposure, and control conditions, and similar results to cognitive restructuring and thought suppression. The studies reviewed also reported findings about potential moderator variables, namely the use of experiential exercises and the duration of cognitive defusion techniques. Conclusions: Given the promising findings in relation to cognitive defusion and the dearth of research in this area, it would seem that further research into this therapeutic technique is warranted.

Background: Sleep loss can impair cognition in healthy adults (Waters & Bucks, 2011). Poor sleepers post head injury (HI) have significantly worse sustained attention than good sleepers post HI (Bloomfield et al., 2010, Sinclair et al., 2013). Aims: The present study explores the relationships between objective and subjective sleep measures and overall cognitive functioning, sustained attention, memory and executive functioning in people with an Acquired Brain Injury (ABI) who are currently participating in inpatient neurorehabilitation. Methods: This study has a correlational design with exploratory between groups analyses. Twenty participants were recruited and their sleep was assessed using a subjective (Pittsburgh Sleep Quality Index; PSQI) and an objective (Actigraphy) measure of sleep. Cognitive tests were completed to determine current cognitive functioning on specific cognitive domains. Results: Self-reported sleep difficulties were associated with better overall cognitive functioning (r=0.46, N=20, p=0.04) and memory domain scores (r=0.50, N=20, p=0.01). No associations were found between Actigraphy and cognitive performance. There were discrepancies between subjective and objective sleep measures in 45% of participants. 67% of participants with discrepancies between sleep measures under reported poor sleep and 33% over reported poor sleep when compared to an objective measure. Exploratory analysis of clearly good and poor sleepers, defined by congruent objective and subjective sleep measures, revealed poor sleepers have significantly better memory cognitive domain scores than good sleepers (t(9)=2.27, p=0.049;d=1.37). Conclusions/Recommendations: The phenomenon of poor sleep and better memory performance may be explained by poor sleepers having better memory for their difficulties post injury than good sleepers or increased awareness of their current sleep patterns because their memory is better preserved. Clinicians should adopt an objective measure of sleep in addition to subjective measures of sleep when assessing sleep difficulties in an inpatient neurorehabilitation population. Patients who do not report sleep difficulties may in fact be experiencing sleep problems that that could impact on their neurorehabilitation schedule.

Background: Several quantitative studies have demonstrated that Mindfulness Based Stress Reduction (MBSR) may be able to reduce levels of stress in staff who work in a healthcare setting by increasing wellbeing and enhancing the ability to cope with stress. There is a dearth of qualitative research regarding the experiences of healthcare staff that undertake MBSR courses. Method: Eight participants were recruited and interviewed from a group of twenty healthcare staff who had completed an 8-week MBSR course. Interpretative Phenomenological Analysis was used to explore the participants’ experiences of the MBSR course. Results: Three superordinate themes emerged from the data. Quotations from the participants were used to label each theme. Superordinate theme 1 - “I would love to be like that” , relates to the participants’ aspiration to attain the qualities they observed in ‘mindful people’ and their hope that mindfulness could assist them to feel less stressed in their personal and work life. Superordinate theme 2 -“It was about going along ... for me. And that was something I hadn’t experienced before” captured the surprise that the participants felt regarding the fact that the course was focussed on their self- care as opposed to the care of patients and the safeness and security they experienced whilst in the group. Finally, superordinate theme 3 - “Whereas before I would probably just let it take over and consume me”, related to the participants’ experiences of adopting a less passive and self-critical response to stressful thoughts after they had completed the mindfulness course. Discussion: The MBSR course led to changes in most of the participants’ ways of being. Participants described mindfulness as an appealing personality characteristic to have and that the groups were a novel experience because of the focus on their own self-care as opposed to patient care. The facilitators and group members contributed to the group as being described as experienced like a ‘sanctuary’. The changes that came about as a result of increased mindfulness were particularly described as relating to an increase in awareness of low self-compassion and then a drive to increase compassion towards the self and others. This fits with recent research regarding how mindfulness achieves its treatment effects. These findings offer insight into potential areas for further exploration in future research such as the importance of the group effect, quantitatively examining the interpersonal and intrapersonal changes that mindfulness can lead to in terms of increased compassion as well as evaluating the importance of formal and informal practices of mindfulness.

The central topic of this thesis is the role of individual differences in the development of imitation. The main claim of the thesis is that individual differences reflect infants’ active involvement in their own developmental process. The thesis utilizes a combination of experimental and parent report data to demonstrate the manifold nature of the origins of imitation. Chapter one introduces the topic of individual differences in imitation by reviewing, in the first part of the chapter, the literature on imitation during the first 18 months of life, and the literature on the role of temperament in social-cognitive development, in the second part of the chapter. Furthermore, the open questions concerning the role of individual differences and the infants’ active involvement in the development of imitation are discussed. Chapter two studies the relation between attentional preferences and individual differences in imitation of facial and vocal models in the first few months of life. Thus far studies of early imitation have dismissed individual differences as noise, therefore not much is known about the role of individual differences in imitation. The findings demonstrate that attentional preferences as measured with the Infant Behaviour Questionnaire-Revised (Gartstein & Rothbart, 2003) are related to specific differences in imitation. Furthermore the findings demonstrate that the major theoretical accounts of imitation are not sufficient to explain these results and a new theoretical model is proposed. In chapter three the infant’s active involvement in its own developmental process is studied by assessing the role of spontaneous imitation in the development of imitation of actions on objects during the first year of life. I demonstrate that infants’ own initiative to imitate actions on objects is the most important predictor of the observed increase in imitation of actions on objects around 10- to12- months of age. V Chapter four assesses the role of infant sociability in imitation. In particular, it examines the hypothesis that sociability is related to faithful, but not selective, imitation. The findings demonstrate a positive link between sociability, as measured by the surgency scale of the Early Childhood Behaviour Questionnaire (Putnam, Gartstein & Rothbart, 2006), and faithful imitation. Finally, in the general conclusion I will argue that the two current dominant accounts of imitation, i.e. an innate account and a learning account, do not account for these results, and I will propose an alternative theoretical model that does account for these findings.