Objectives. We aimed to assess if Caesarean section is a risk factor for overnutrition in early- and late-childhood, and to assess the magnitude of the effect of child- versus family-related variables in these risk estimates. Methods. Longitudinal data from Peruvian children from the Young Lives Study was used. Outcomes assessed were overweight, obesity, overnutrition (overweight plus obesity), and central obesity (waist circumference) at the age 5 (first follow-up) and 7 (second follow-up) years. The exposure of interests was delivery by Caesarean section. Relative risks (RR) and 95% confidence intervals (95% CI) were calculated using multivariable models adjusted for child-related (e.g., birth weight) and familyrelated (e.g., maternal nutritional status) variables. Results. At baseline, mean age was 11.7 (± 3.5) months and 50.1% were boys. Children born by Caesarean section were 15.6%. The 10.5% of the children were overweight and 2.4% were obese. For the obesity outcome, data from 6,038 and 9,625 children-years was included from baseline to the first and second follow-up, respectively. Compared to those who did not experience Caesarean delivery, the risk of having obesity was higher in the group born by Caesarean: RRs were higher at early-childhood (first follow-up: 2.25; 95% CI [1.36–3.74]) than later in life (second follow-up: 1.57; 95% CI [1.02–2.41]). Family-related variables had a greater effect in attenuating the risk estimates for obesity at the first, than at the second follow-up. Conclusion. Our results suggest a higher probability of developing obesity, but not overweight, among children born by Caesarean section delivery. The magnitude of risk estimates decreased over time, and family-related variables had a stronger effect on the risk estimates at early-childhood. / RMC-L, JJM, AB-O, and the CRONICAS Center of Excellence in Chronic Diseases were supported by the National Heart, Lung, and Blood Institute Global Health Initiative under the contract Global Health Activities in Developing Countries to Combat Non-Communicable Chronic Diseases (Project Number 268200900033C-1-0-1). AB-O is currently supported by a Wellcome Trust Research Training Fellowship in Public Health and Tropical Medicine (Grant 103994/Z/14/Z). The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript. / Revisión por pares

The promotion and development of resilience in children and young people has become increasingly the focus of many preventative and treatment interventions. This is informed by evidence that suggest that a high proportion of mental health difficulties start by adolescence and can have enduring consequences later in life. One of the psychological presentations that cause significant difficulties is personality disorder. Attachment theory has been connected to both resilience and personality disorders, however their interaction has not yet been studied. This thesis aims to bring together these concepts in an attempt to contribute to the evidence of developmental pathways to personality disorders and to resilience. Chapter one presents a systematic review of the association between attachment and personality disorders in children and adolescents. The findings of the review support the literature that has previously documented this association and confirms that attachment theory is a meaningful framework for the understanding of personality disorders in children and young people. Furthermore, it includes additional factors that may interact within this relationship. This has clinical and research implications that are discussed along with the limitations of the review. Chapter two contains an empirical paper that focuses on the interaction of resilience with attachment and personality disorder. Findings from this study support existing evidence that additional factors help explain the relationship between attachment and the development of personality disorders. Thus the empirical paper enhances the findings from the literature review. Chapter three offers an account of the author’s experiences of research, including reflections on personality constructs. It encompasses these reflections within the wider experiences of clinical training to finally consider these topics in the wider context of mental health services.

Debate surrounding the issue of pain management in neonates has mushroomed over the last ten years. Previously held beliefs that neonates do not feel pain because their anatomical make up is different from that of an adult, and that they do not remember pain therefore there is no need to relieve it have been demonstrated as erroneous. Studies such as Volpe (1981), Gilles, Shankle and Dooling (1983) and Beyer and Wells (1989) refuted previously held physiological misconceptions. Anand and Hickeys' 1987 study did much to raise our awareness of the deleterious effects of unrelieved pain in neonates. The impetus for the present study was the wish to improve analgesic techniques in one such group of infants - postoperative neonates. Valid assessment is foundational to improving analgesia and measuring the efficacy of interventions thus broadening our knowledge of safe, effective methods of preventing undue pain in newborns. The research presented here follows four distinct phases. The primary aim of the research was to develop a pain assessment tool. This was initially developed by use of an observational research technique, watching and cataloguing the behaviour of newborns (n=25) over a number of hours in their home environment. Video recordings of normal neonatal behaviour and development were also viewed and empirical evidence from neonatal behaviour experts such as Wolff (1966), Brazelton (1977) and Trevarthan (1977) was drawn upon to provide a detailed overview of neonatal behaviour. Observations were then made on a surgical group of babies (n=34) around normal caregiving episodes. Each observation lasted a number of hours. Some of these episodes were videod for later viewing by 3 clinical psychologists. The qualitative data collected from the observations of these babies (n = 59) was transcribed. The unstructured observations of both real life and video recordings collected by pen and paper provided rich, descriptive information to be analysed qualitatively. Glaser & Strauss (1967) term these "field notes". The field notes were then reduced in order to summarise the information by teasing out themes around which behaviours were clustered (Miles and Huberman 1984). These categories were organised into a detailed scoring system. This was called the Liverpool Infant Distress Score (LIDS). Following initial development the scale was subjected to rigorous reliability and validity tests. After piloting the scale on a further 10 babies undergoing surgery, adjustments were made to the initial scale. The scale was then applied to 31 babies in the peri operative period and a control group of 10 non surgical babies. Validity of LIDS was demonstrated. The value of an assessment tool such as LIDS also lies in its ability to be reproduced consistently and accurately by differing carers. (Melzack 1984). The next part of the study addressed this issue. By teaching the scale to a group of 4 nurses and testing their scores over a number of assessments, inter rater reliability was demonstrated. The final phase of the study compared the subjective scores of two groups of nurses – one experienced neonatal nurses, one paediatric nurses- to the more objective LIDS scores. The results from this final phase of the study suggest that despite an increase generally in nurse awareness regarding pain cues in neonates, pain assessment is still open to subjectivity.

Background Hyperbilirubinemia is a condition that affects most infants, but typically self-resolves and is not harmful. However, if bilirubin levels exceed neuroprotective defenses, the compound can cross the blood-brain barrier and have neurotoxic and potentially fatal effects. Treatment of neonatal hyperbilirubinemia with phototherapy is necessary for the prevention of kernicterus. Guidelines for the use of phototherapy in infants born at ≥ 35 weeks’ gestation were published by Bhutani et al. and endorsed by the American Academy of Pediatrics. Consensus-based recommendations for phototherapy treatment and exchange transfusion of premature infants were published in 2012 by Maisels, et al. However, there are no published recommendations for the timing of screening for hyperbilirubinemia in NICU patients. In 2012, the Kapʻiolani Medical Center for Women & Children Neonatology Division implemented internal guidelines for phototherapy with recommendations for the timing of screening serum bilirubin levels, based on the group’s opinion. Five years later, the current study queried whether these guidelines for screening were appropriate. Objective The present study sought to describe current practices of obtaining serum bilirubin levels and the use of phototherapy in the NICU during the first five days of life. It was hypothesized that many bilirubin levels obtained at ≤ 48 hours of life are below published recommended treatment thresholds and are potentially unnecessary. Methods Retrospective chart review was performed on all infants admitted to the NICU at < 24 hours of life, from July 2016-June 2017. Eligible infants were divided into three gestation age groups: ≤ 28, 29-35, and ≥ 36 weeks at birth. Patient demographics, bilirubin levels, and phototherapy treatment were noted. The primary outcome of interest was the percent of serum bilirubin levels obtained during the first 48 hours of life that did not meet phototherapy treatment criteria. Results 931 charts were reviewed. Infants born at ≤ 28, 29-35 and ≥ 36 weeks’ gestation made up 10%, 51% and 39% of the cohort. Overall mortality was 3%, and no exchange transfusions were performed during the study period. At least one serum bilirubin level was obtained for 96% of the patients, but only 55% were treated with phototherapy within the first five days of life. Phototherapy was rarely prescribed on day of life (DOL) 1 (0.7%). By DOL 2, a total of 563 bilirubin levels were obtained, but only 108 infants (19%) were treated with phototherapy. However, one-third of these patients’ bilirubin levels did not meet published criteria for treatment. The timing of phototherapy treatment varied by gestational age. Ninety percent of infants born ≤ 28 weeks’ gestation who received phototherapy were treated starting between DOL 2-3. In contrast, eighty-five percent of infants born ≥ 29 weeks’ gestation who received phototherapy, started on DOL 3-5. Discussion Far more bilirubin levels were obtained than courses of phototherapy prescribed. Given the distinct patterns of phototherapy for infants of varying gestational age, there is ample opportunity to improve resource utilization with targeted recommendations for obtaining screening bilirubin levels in the neonate without early jaundice.

Objective: The purpose of this study was to develop and test psychometric properties of a Mealtime Interaction Clinical Observation Tool (MICOT) that could be used to facilitate assessment and behavioural intervention in childhood feeding difficulties. Methods: Thematic analysis of four focus groups with feeding and behaviour experts identified the content and structure of the MICOT. Following refinement, inter-rater reliability was tested between three healthcare professionals. Results: Six themes were identified for the MICOT, which utilises a traffic-light system to identify areas of strength and areas for intervention. Despite poor inter-rater reliability, for which a number of reasons are postulated, some correlation between psychologists’ ratings was evident. Healthcare professionals liked the tool and reported that it could have good clinical utility. Conclusion: The study provides a promising first version of a clinical observation tool that facilitates assessment and behavioural intervention in childhood feeding difficulties.

In recent decades the number of children with overweight has increased worldwide. To understand the mechanisms behind this development, knowledge regarding metabolism and physiology in relation to the nutritional situation in early life is of importance. In particular, information about body composition development during early childhood is relevant. This thesis presents three studies in this area. In the pregnancy study serum samples, collected from 23 women before, during and after pregnancy, were analysed for serum levels of leptin, adiponectin and resistin and used to assess insulin resistance (HOMA-IR) in relation to the total body fat (TBF) content of the women. TBF (%) and leptin were significantly correlated with HOMA-IR before and during pregnancy. When HOMA-IR was regressed on TBF (%) the slope of the regression line was 0.111 in gestational week 32 and significantly (p&lt;0.05) higher than the value before pregnancy, 0.046, indicating that healthy pregnancy enhances the relationship between body fatness and insulin resistance. In the HF-study hydration of fat-free mass (hydration factor, HF) was assessed in 12 newborns using the doubly labelled water (DLW) method and air displacement plethysmography (PeaPod). HF was 80.9% with a low biological variability (0.81% of average HF). In the longitudinal study the body density of 108 healthy fullterm infants (53 girls, 55 boys) was measured at one and 12 weeks of age using PeaPod. Body composition was calculated using two models (Fomon’s and Butte’s). BMI values for the mothers of the infants were assessed before pregnancy. Body composition and total energy expenditure using the DLW-method were assessed in 20 of these children at the age of 1.5 years, when their sleeping metabolic rate was measured using indirect calorimetry and their resting energy metabolism was calculated using prediction equations. Butte´s model gave significantly (p&lt;0.05) lower values for TBF than Fomon´s model, and invalid results for five newborns. Using Fomon´s model, at one week of age girls contained 13.4 ± 3.7 % and boys contained 12.5 ± 4.0 % TBF. The corresponding figures at 12 weeks were 26.3 ± 4.2 % and 26.4 ± 5.1 %. The mothers’ BMI values before pregnancy were correlated with the body weight but not with the TBF (g,%) or fat-free mass (g) of their infants at one week of age. At 1.5 years of age girls (n=9) contained 28.0±2.8 % and boys (n=11) 28.3±3.7 % TBF. Between one and 12 weeks of age all infants increased their TBF content, while 13 children increased and seven children decreased their TBF content between the ages of 12 weeks and 1.5 years. The results demonstrated that predicting rather than measuring resting energy metabolism involves a risk for spurious correlations between TBF and physical activity level. The level of physical activity (x), was negatively correlated with [TBF (%) at 1.5 years minus TBF (%) at 12 weeks] (y), r=-0.52, p=0.02. In conclusion, the results suggest that the body fat content of a woman has a stimulating effect on the growth, rather than on the fat retention, of her foetus. They also show that the Fomon model is the best available model when calculating the body composition of infants from body density. Finally, the results indicate that physical activity at the age of 1.5 years is important regarding the rate at which the high level of body fat, typical of infancy, decreases in early childhood. / Övervikt och fetma bland barn har under senare år blivit allt vanligare i många delar av världen. Studier av nutrition, metabolism och fysiologi under graviditet och de tidiga barnaåren är av vikt för att förstå vilka faktorer som ligger bakom denna utveckling. Speciellt viktigt är att studera hur kroppssammansättningen förändras tidigt i livet. Den här avhandlingen innehåller tre studier som berör detta ämnesområde. I en studie på gravida analyserades serumprover, insamlade från 23 kvinnor innan, under och efter deras graviditet, med avseende på halter av leptin, adiponektin och resistin. Via serumproverna fastställdes också kvinnornas insulinresistens (HOMA-IR). Dessa resultat relaterades sedan till mängden kroppsfett hos dessa kvinnor. Mängden kroppsfett (%) och leptin visade, före och under graviditet, en signifikant korrelation med HOMA-IR. En regressionsanalys av HOMA-IR (y) och % kroppsfett (x) i graviditetsvecka 32 gav ett k-värde (lutning) på 0,111, vilket i jämförelse med motsvarande k-värde före graviditet 0,046 var signifikant högre (p&lt;0.05). Detta resultat visar att hos friska kvinnor potentierar graviditeten sambandet mellan kroppsfett och insulinresistens. I en studie av hydreringsgrad i fettfri kroppsvikt (HF) fastställdes HF i 12 nyfödda med hjälp av dubbelmärkt vatten och helkroppsplethysmografi (PeaPod). HF uppmättes till 80,9% med en låg biologisk variation (0,81 % av genomsnittlig HF). I en longitudinell studie mättes kroppsdensiteten med PeaPod hos 108 friska fullgångna spädbarn (53 flickor, 55 pojkar) när de var en respektive tolv veckor gamla. Deras kroppssammansättning beräknades med två olika modeller (Fomons och Buttes). Uppgift om mödrarnas pregravida BMI samlades in. Vid 1,5 års ålder mättes kroppssammansättning och total energiomsättning hos 20 av de 108 barnen. Vid detta tillfälle mättes även viloomsättningen med indirekt kalorimetri under sömn. Viloomsättningen predikterades även med en formel. Buttes modell gav signifikant (p&lt;0.05) lägre nivå av kroppsfett (%) jämfört med Fomons modell och i fem fall erhölls inga resultat alls. Beräkningar med Fomons modell visade att vid en veckas ålder innehöll flickorna 13.4 ± 3.7 % och pojkarna 12.5 ± 4.0 % kroppsfett. Motsvarande värden vid 12 veckors ålder var 26.3 ± 4.2 % och 26.4 ± 5.1 %. Mödrarnas BMI innan graviditet korrelerade med kroppsvikt men inte med kroppsfett (g,%) eller fettfri vikt (g) hos deras barn vid en veckas ålder. Vid 1,5 års ålder innehöll flickorna (n=9) 28.0±2.8 % och pojkarna (n=11) 28.3±3.7 % kroppsfett. Mellan en och 12 veckors ålder ökade alla barnen sin kroppsfetthalt. Mellan 12 veckor och 1,5 år ökade kroppsfetthalten hos 13 barn medan den minskade hos 7. Resultat visar att predikterad viloomsättning ökar risken för att få en falsk korrelation mellan kroppsfetthalt och fysisk aktivitetsnivå jämfört med om man använder uppmätt viloomsättning. Den fysiska aktivitetsnivån vid 1,5 års ålder (x), var negativt korrelerad till förändring i kroppsfetthalt [kroppsfett (%) vid 1.5 år minus kroppsfett (%) vid 12 veckor] (y), r=-0.52, p=0.02. Sammanfattningsvis tyder resultaten på att kvinnors kroppsfetthalt har en stimulerande effekt på fostrets på totala tillväxt men inte på dess retention av kroppsfett. Dessutom visar resultaten att Fomons modell är den bästa tillgängliga när det gäller att beräkna kroppssammansättningen hos spädbarn från kroppsdensitet. Slutligen tyder resultaten på att den fysiska aktivitetsnivån vid 1,5 års ålder har betydelse för hur fort den höga kroppsfetthalten, som är typisk för spädbarnsperioden, sjunker under tidig barndom.

Aggression Replacement Training (ART) is a 10-week, multi-component intervention based in cognitive behaviour therapy (CBT), which aims to improve social competence. It has been applied internationally as part of offender rehabilitation (NOMS, 2010). However, more recent research has focused upon its application in school-based settings. The aim of the current research is to investigate the efficacy of ART when implemented in the UK with an adolescent sample in mainstream school settings. These sessions were facilitated by newly-trained staff from the Educational Psychology Service (EPS). A quasi-experimental design was employed to evaluate this initial pilot of the programme in one Local Authority. 41 participants across six settings were allocated to intervention (N=23) and wait-list control (N=18) conditions. The Social Skills Improvement System-Rating Scales (SSIS-RS), a multi-source measure, was used to assess the group member’s problem behaviours and social skills, with data gathered from teachers, parents and pupils themselves. The Sociomoral Reflection Measure-Short Form (SRM-SF) was also completed by the participants to ascertain their moral reasoning maturity. Non-parametric statistical tests demonstrated no significant improvements in the intervention participant’s social skills or problem behaviours. However, their moral reasoning ability did increase significantly from pre to post-test, achieving a large effect size (r=-0.64), which was not reflected in the data from the control group. In contrast to the quantitative findings, supplementary qualitative data gathered from the facilitators and group members involved in the ART programme demonstrated that all felt the intervention had resulted in positive outcomes for the young people. Factors which may have contributed to the success of the programme were also provided, including organisational support and group composition. Possible explanations for these findings, including methodological considerations and comparison with previous research are discussed and the implications of these findings in future practice and in guiding further research suggested.

CHAPTER ONE: The literature review critically evaluates research that has explored the psychological impact of parental acquired brain injury (ABI) on children. The review identifies a number of factors that affect the psychological well-being of children, including both adverse and protective factors. Evidence from the studies reviewed indicates that children are vulnerable to experiencing a range of emotional and behavioural difficulties following parental ABI. Clinical implications of the review findings are discussed, and directions for future research considered. CHAPTER TWO: The empirical paper aimed to explore the role of mutual support in Traumatic Brain Injury (TBI) survivors’ reformation of their identity among individuals attending a mutual support group. Using a Grounded Theory approach, a model of the participants experience was developed. The core category reflected how participants regained a sense of self through getting to know the “new” me. Five conceptual categories were identified in relation to identity formation: pre-injury self, comparison with others; accessing the social world of brain injury; purpose and self-efficacy; and acceptance of the post-injury self. The findings highlight a potentially important role for mutual support in identity reformation following TBI and implications for brain injury rehabilitation programmes are discussed. CHAPTER THREE: The third paper presents my personal and professional reflections of the research process and how my views have changed over the course of training. To illustrate these changes, elements of the grounded theory model proposed in the empirical paper (Chapter 2) have been applied to my own experiences. It is hoped that this approach will evidence my experience and exploration of getting to know the scientist-practitioner.

This thesis explores what ‘woman centred care’ means to both women and midwives and how this care is offered by midwives and perceived by women. It is set within the context of current health care policy and the way in which this impacts on both the organisation and implementation of maternity care. A flexible qualitative design was used to explore both women’s and midwives’ experiences of current maternity care over the full trajectory of maternity provision. A modified grounded theory approach was used framed within a feminist perspective. The fieldwork was undertaken in two phases. In phase one and interviews were undertaken with twelve women in early pregnancy, later pregnancy and after the birth; a total of twenty-five interviews with women were completed. Nine midwives were also interviewed in phase one. Preliminary and tentative categories were identified from both sets of interviews and were used to inform phase two of the study. Five women participated in the second phase of data collection. This included both informal, telephone contact and in-depth interviews spanning from early pregnancy until after the birth and included observation of their care in labour. The community midwives and delivery suite midwives specifically involved in their care were also interviewed. The data demonstrated a continued mismatch between the women’s and the midwives’ perspectives and it was evident that despite the policy drivers and consumerist rhetoric of ‘woman centred care’ and its original underpinning principles of continuity, choice and control, that this was not the overriding experience for the women who participated in the study. Data analysis highlighted some opportunities for negotiation but these were not explicitly recognised or realised by the women or midwives and there was little time or flexibility in the system to accommodate such opportunities. The increasing bureaucracy of the maternity care system also constrains continuity of carer over the full spectrum of the childbearing trajectory and reduces the potential for women to know the midwife who provided care. Thus for many midwives being ‘with the institution’ was more likely than ‘being ‘with woman’.

Since the late 1990s there has been an increasing focus on parenting ability, support and education which is reflected in policy, practice and research in the UK. This research analyses how nurses might intervene to provide this support, specifically in relation to crying baby and the role of nurses at NHS direct. It involves collection and analysis of data from NHS Direct call data in 2002, and solo focus group data in 2006. Within the wider tradition of grounded theory, the methodology includes use of discourse and thematic analytical approaches. The research analyses the means by which NHS Direct nurses make different use of the algorithms and organisational protocols to make decisions and give advice to parents with crying babies, how their clinical knowledge and experience influences these decisions, and how nurses explore parents’ ability to cope. This is seen within the organisational context of NHS Direct, a 24 hour government funded telephone service described as both a triage service and an advice/helpline service. Findings from the study indicate a degree of tension between the essentially humanistic nursing culture and the highly scripted, protocol driven rules based system that underpins NHS Direct. Despite this tension, nurses will sometimes combine their knowledge with that of the algorithm where the call is involved with eliminating emergencies. The same synthesis of knowledge is not apparent with the knowledge contained in the algorithm regarding non-medical, nonemergency, value-sensitive issues relating to parental coping with excessive infant crying. Findings suggest that NHS Direct nurses use the ‘crying baby’ algorithm differently and this variance is influenced by experience and familiarity with the algorithm. Adherence to the algorithm is perceived by nurses as safe in relation to the medical questions which exclude emergencies. The non-medical elements of the algorithm, which include prompting the nurse to ask about parent coping ability and the possibility of shaking their child, are treated differently and it is considered safe to not ask, or ask around the question and to not offer the advice prompted by the decision aid software. The algorithm prompt to assess parental coping ability is rarely successful in encouraging the nurse to do so overtly. From these findings, consideration might be given to enhancing nurses’ knowledge, skills and confidence, supported with appropriate supervision, to provide effective intervention in relation to value sensitive, non-medical issues such as parental coping ability and in handling the uncertainty such issues may yield. Allied to this would be establishing clarity and recognition of the inherently different, but not opposing functions of providing a triage service and an advice/ helpline service.