The study is a retrospective review of pre-schoolers 6 years old and younger who were referred to the Charlotte Maxeke Johannesburg Academic Hospital Child, Family and Adolescent Unit, Johannesburg for psychiatric intervention between 1 January 2006 and 31 December 2010. The study described and analysed demographics and the various characteristics of children 6 years old and under who were referred to the unit for psychiatric intervention. The several psychiatric conditions and interventions were also evaluated. One hundred and forty nine (149) pre-schoolers who were 6 years old and under presented to the Unit and the majority were male (77.2%;N=115). The mean age of presentation was 54 months (SD=12.59) and the majority of the pre-schoolers were referred to the Unit by medical professionals. Attention-Deficit/ Hyperactivity Disorder (ADHD) was the most common presenting condition. Girls were more likely to present with Anxiety disorders (44.1%;15/34) and Reactive Attachment Disorder (35.3%;12/34) and boys were more likely to present with Autism Spectrum Disorders (26%;30/115). There were no statistical differences in the rates of Attention-Deficit/ Hyperactivity Disorder between girls (38.2%;13/34) and boys (43.6%;65/115) with ADHD (x2=2.705; df=1; p=0.1001). A psychological assessment was conducted in 68.5 % (102/149) of referrals. Almost half the children (46.3%; N=69) received pharmacological intervention. The defaulting rate after the initial assessment was high. The study highlights the frequency of psychiatric illness in pre-schoolers and necessitates the need to conduct further research in this vulnerable age group at other clinical sites.

This thesis contributes to the executive dysfunction account of autism by demonstrating that impairments in inhibitory control, an aspect of executive functioning, are partially responsible for deficits in the cooperative play of highfunctioning children with autism (HFA). As past research on whether inhibitory control is impaired in autism has been inconclusive, a meta-analysis of 42 empirical studies (57 effect sizes, total n = 2,256) was conducted, which provided clear evidence for impaired inhibition in HFA children. It was also found that the degree of impairment shown does not vary across measures of inhibition, which has important methodological implications for future research. Two experimental studies were carried out to directly test the link between inhibition and three components of cooperation: reciprocity, accepting the play partner's input, and fairness. In study one, HFA children in primary school and agematched typically-developing (TD) peers were tested on engaging in joint attention, theory of mind (ToM), measures of inhibition, and a cooperative drawing task. The groups did not differ on first-order ToM and joint attention, but HFA participants demonstrated poorer inhibitory control and less cooperative behaviour. Importantly, the degree of impairment in inhibitory control predicted reciprocity and accepting the play partner's input in HFA children. The second experimental study investigated whether poor inhibitory control can explain the well-established discrepancy between moral reasoning and actual sharing behaviour. A sample of HFA and TD children of primary school age completed a moral reasoning interview, inhibitory control tasks, and a Dictator Game. The results showed that while HFA children demonstrated age-typical levels of moral reasoning and sharing, inhibitory control emerged as the most important predictor of sharing behaviour, lending support to the hypothesis that the ability to suppress one's own desires is a prerequisite of acting considerately. The last study comprises a qualitative investigation of TD children's experience of engaging in cooperative play with their sibling who has a diagnosis of HFA. Six children between the ages of 5 and 11 were interviewed, and their reports analysed using interpretative phenomenological analysis (IPA). Five themes emerged: poor emotion regulation, restricted interests, and no acceptance of the playmate's contributions reduced the hedonistic value of joint play for the participants, but these were mitigated by appreciation for the HFA sibling's creativity and adjustment to the HFA sibling's behavioural atypicalities. These results can inform the development of support programmes for TD siblings and social skills training for HFA children. Overall, the results of the studies included in this thesis provide evidence that deficits in inhibitory control moderate the relationship between relatively intact social knowledge and impaired social competence in HFA children. This refinement of the executive dysfunction account is a useful building block for an improved multiple-deficit model of the autism phenotype.

Diss. (sammanfattning) Umeå : Umeå universitet, 2008. / Härtill 4 uppsatser.

This thesis in part addressed a call by Hodapp, Glidden & Kaiser (2005) to focus on identifying potential mediators and moderators of the relationship between growing up with a sibling with an autism spectrum condition (ASC) and adverse outcomes such as poorer sibling relationship quality (SRQ) and adjustment problems. It attempted to clarify previous inconsistent findings in the literature by considering autism as a dimensional disorder (with traits present on a continuum between the general population and those on the higher end reaching a clinical cut-off for diagnosis of ASC) and focusing on the autistic traits of (mainly) older siblings in a dyad. Specifically, these related to attention to detail, impaired mind reading ability, impaired social skills and impaired imagination. In addition, when looking at families with an ASC child, using a relatively homogenous sample group of typically developing younger siblings (YS) in middle childhood controlled for factors that potentially influenced past mixed findings. Hypotheses were extended to an analogous sample of young adults by asking dyads for both retrospective and current (adult) SRQ and self reported autistic traits. Themes emerging from the actual lived experiences of typically developing younger siblings of children with autism were also considered, and highlighted a number of difficulties faced by these siblings. The quantitative findings indicate that different elements of the social and communication domains relate to negativity compared to positivity in SRQ, and that there is a significant relationship between attention to detail (i.e. the non-social domain) and typical YS adjustment but not between YS adjustment and the social and communication domains. For young adults, reports of higher impairments in imagination were associated with retrospective reports of lower positivity in SRQ, and level of attention to detail was significantly associated with rivalry in adult SRQ. Overall these findings indicate that different autistic traits should be considered as separate influences on SRQ and adjustment.

The study aimed to investigate childhood adversity in a sample of clients with first-episode psychosis. The mediating impact of dissociation and early maladaptive schemas and moderating effect of social support were investigated. The study (N = 42) assessed childhood adversity using the Parental Bonding Instrument and the Childhood Trauma Questionnaire. Early Maladaptive Schema were measured using the Young Schema Questionnaire (Short form), the Dissociative Experiences Scale (2nd Edition) measured Dissociation and the Social Support Questionnaire assessed the quality and size of each participant’s social network. Correlational, mediation and moderation analyses were used. There were high levels of childhood adversity within this sample. Dissociation did not mediate the relationship between childhood adversity and psychosis. Some early maladaptive schemas concerned with unrelenting standards and insufficient self-control mediated the relationship between adversity and psychosis, in particular hallucinations. Social support, in terms of both quality and quantity was an important moderator between childhood adversity and psychosis. The study supports the notion that childhood adversity is a risk factor for psychosis and highlights some evidence about specific mediating and moderating mechanisms.

The present study investigated parental attachment insecurity, specifically Insecure-Anxious and Avoidant attachment styles, and their relationship to children’s ADHD symptoms of hyperactivity, inattention and aggression. The study used a between­ subjects, correlational (cross­sectional) design and quantitative data was collected using reliable and valid self-report questionnaires. Data was analysed using SPSS 19.0. There were no significant differences in attachment insecurity or attachment styles between parents of ADHD and non-ADHD children. However a highly significant association was found between parental attachment insecurity and child aggression, and a moderate association with hyperactivity. There was no significant effect of attachment style, but the study was underpowered and a larger sample size may have differentiated specific effects of parental attachment style. The study used a largely non-clinical sample, with children who were low risk and significantly less impaired than the ADHD participants. A higher risk population would have potentially brought some of the trends of association between parental attachment and child symptoms to significant levels. The study concluded that parental insecure attachment, specifically Dual/Disorganised attachment style, contributes to the emotional environment that increases risk of child aggression and hyperactivity, however methodological limitations were acknowledged. Clinical implications were drawn and recommendations made for future research.

Section A is a literature review evaluating the role of Therapetuic Care Workers (TCWs) and Therapeutic Foster Carers (TFCs) working relationally with a sub-group of Looked After Children (LAC) who are highlighted as having intense emotional and behavioural needs. These LAC are thought to benefit from living in specialist, therapeutic placements where carers work relationally. However, to date, there is no known review evaluating relational residential interventions or the role of TCWs and TFCs. Therefore, literature exploring the theoretical underpinnings of the work, and the emotional impact and protective factors involved in the carer role is considered. Implications for future research and clinical practice are suggested. Section B describes a qualitative study which explores how TCWs experience their role and their perceptions of the potential benefits for LAC. A qualitative design using Interpretative Phenomenological Analysis (IPA; Smith, Flowers & Larkin, 2009) was applied. Methods. Nine TCWs currently working in one of two therapeutic communities were interviewed. Results. Five master themes were identified: ‘Therapeutic group living’; ‘Importance of carer-child relationships’; ‘Working with the unconscious’; ‘Personal meaning of professional role’, and ‘Children’s progress’. Participants considered that forums for reflection were crucial to their ability to think clearly and analytically about the children, and utilised psychodynamic concepts to gain insight into the children’s inner worlds. TCWs’ increased self-awareness was central to this process. Participants also reported experiencing their role as emotionally challenging. One focus of reflection was on the small steps of progress the children were perceived to achieve. Conclusions. Overall, the findings suggested a synergy between relevant theory, descriptive accounts of therapeutic childcare, and TCWs’ perceptions of their role. New information regarding the personal investment of TCWs and internalisation of the framework of practice was identified. Further research is needed to extend the evidence-base. The clinical implications of the findings are discussed.

This study aimed to develop and test the feasibility of a peer-led parenting intervention for parents living in London in temporary accommodation, seeking help with managing behavioural difficulties of a child (aged 2–11). A structured, group-based intervention (‘Empowering Parents, Empowering Communities- Temporary Accommodation’) was delivered by peer facilitators to N=15 parents across three group cohorts. Twelve parents (80%) completed the group programme at first attempt; one parent completed on their second attempt after re-joining in a different cohort. A mixed-method formative evaluation was used. The intervention’s feasibility was assessed in terms of attendance and completion rates (% parents completing ≥6 sessions); acceptability was assessed by satisfaction measure and qualitative participant interviews; and potential for impact was assessed by parent-reported standardised measures of child behaviour, parenting behaviour, parental wellbeing, parenting stress and social support. Reductions in child behavioural difficulties and improved parenting knowledge and practices were reported on standardised measures. Improved parental outcomes were described in qualitative interviews. Participants were highly satisfied with the intervention. The study concluded that peer-led parenting groups are feasible and potentially effective interventions for parents living in temporary accommodation. These findings warrant further testing under controlled conditions.

Tangible User Interfaces (TUIs) offer the potential for new modes of social interaction for children with Autism Spectrum Conditions (ASC). Familiar objects that are embedded with digital technology may help children with autism understand the actions of others by providing feedback that is logical and predictable. Objects that move, playback sound or create sound – thus repeating programmed effects – offer an exciting way for children to investigate objects and their effects. This thesis presents three studies of children with autism interacting with objects augmented with digital technology. Study one looked at Topobo, a construction toy augmented with kinetic memory. Children played with Topobo in groups of three of either Typically Developing (TD) or ASC children. The children were given a construction task, and were also allowed to play with the construction sets with no task. Topobo in the task condition showed an overall significant effect for more onlooker, cooperative, parallel, and less solitary behaviour. For ASC children significantly less solitary and more parallel behaviour was recorded than other play states. In study two, an Augmented Knights Castle (AKC) playset was presented to children with ASC. The task condition was extended to allow children to configure the playset with sound. A significant effect in a small sample was found for configuration of the AKC, leading to less solitary behaviour, and more cooperative behaviour. Compared to non-digital play, the AKC showed reduction of solitary behaviour because of augmentation. Qualitative analysis showed further differences in learning phase, user content, behaviour oriented to other children, and system responsiveness. Tangible musical blocks (‘d-touch') in study three focused on the task. TD and ASC children were presented with a guided/non-guided task in pairs, to isolate effects of augmentation. Significant effects were found for an increase in cooperative symbolic play in the guided condition, and more solitary functional play was found in the unguided condition. Qualitative analysis highlighted differences in understanding blocks and block representation, exploratory and expressive play, understanding of shared space and understanding of the system. These studies suggest that the structure of the task conducted with TUIs may be an important factor for children's use. When the task is undefined, play tends to lose structure and the benefits of TUIs decline. Tangible technology needs to be used in an appropriately structured manner with close coupling (the distance between digital housing and digital effect), and works best when objects are presented in familiar form.

Research shows that the integration of physical and mental healthcare in paediatric settings is beneficial in terms of clinical and cost effectiveness (Kahana, Drotar, & Frazier, 2008; Douglas & Benson 2008, Griffin & Christie, 2008). Due to the high rates of mental health problems within this population, several studies have shown that referral to paediatric psychology should be increased (e.g. Wagner & Smith, 2007). However, there are few studies investigating factors influencing healthcare professionals’ referral behaviour. The current study used theory of planned behaviour (Ajzen, 1988; 1991) to develop a questionnaire which explores factors influencing the referral of children and families to paediatric psychology. Psychometric properties of the questionnaire were examined. Findings indicate that the questionnaire holds good reliability and validity and that the main constructs of theory of planned behaviour are useful in predicting intention to refer to paediatric psychology. Specific beliefs about referral were also shown to influence intention to refer. Findings that individual referrer factors such as attitudes and beliefs can impact healthcare professionals’ referral behaviour indicates that multidisciplinary interventions and inter-professional education relating to the psychological aspects of illness are required. Recommendations for future research are discussed.