This thesis focuses on how it is possible to measure people’s knowledge on a topic where certain statements can effectively discriminate between knowledgeable and non knowledgeable people. It presents an application in measuring healthcare professionals’ knowledge about Sudden Infant Death Syndrome (SIDS) and its risk factors. Identifying the best and worst prepared healthcare professionals allows policymakers to reconsider the structure of their healthcare system and to implement targeted training initiatives about this topic. To do so, this research uses data belonging to the SIDS Project, a project meant to provide the first data about this topic in the United Kingdom and Spain. The mail survey referring to the United Kingdom was carried out in the South Central Strategic Health Authority in 2012, while the Spanish one was carried out in the provinces of Barcelona, Lérida and Tarragona in 2012 and 2013. The target population for the British survey consisted of general practitioners (GPs), while the target population for the Spanish survey consisted of paediatricians. Moreover, data about Italy were also available, which allowed cross country comparisons involving three different realities. This research shows that the Back-To-Sleep (BTS) message seems to have been effectively adopted by the British GPs, but, surprisingly, not as well received by the Spanish and Italian paediatricians. In the first case, in fact, more than 90% of the respondents recommended parents the supine position exclusively. In Spain and Italy, instead, this percentage was of 58% and 69% respectively. By contract, instead, the whole SIDS prevention message seems to have been better received in Spain and Italy than in the United Kingdom. British policymakers should reconsider the role of GPs in terms of delivering parents the BTS message, as they were found to be quite prepared. Spanish and Italian policymakers, instead, should try to increase the degree of adoption of the BTS message among their healthcare professionals. In particular, Spanish policymakers should urgently intervene in order to clarify that the supine position is the only one that can be deemed to be a protective factor against SIDS.

This study builds on existing research into the efficacy of universal Cognitive Behaviour Therapy (CBT) based programmes in schools in the promotion of Emotional Literacy and more broadly Mental Wellbeing. Previous research in this area has focused on CBT interventions delivered to targeted groups. In this instance, the focus was on CBT based universal, whole class intervention. The specific CBT intervention utilised the ‘Think Good Feel Good: A Cognitive Behaviour Therapy Workbook for Children and Young People’ (TGFG) resource (Stallard, 2002). The researcher was also able to take the opportunity to evaluate the possible additional impact of conducting CBT based interventions in parallel with the Social and Emotional Aspects of Learning (SEAL) programme. Initially, a pilot study was conducted with a single Year 5 child. The purpose of the pilot was to provide a guide as to the effectiveness of the resources to be used, to familiarise the researcher with those tools and principles of the study, and to provide meaningful feedback to aid in the fine tuning of the full research. The main research study was conducted in two schools within the local authority in which the researcher was a practising Trainee Educational Psychologist. Participants consisted of 85 Year 5 pupils (aged between 9 and 10). Measures were recorded before and following intervention using the Southampton Emotional Literacy Resource (SELR) and the Strength and Difficulties Questionnaire (SDQ). Data were collected from teachers, parents and the children. A fixed design was employed, with participants placed in one of three groups:  Experimental group 1 - One class (n=25) received CBT intervention alongside the SEAL programme over a 6 week period. The CBT intervention consisted of two one hour long sessions per week and was delivered by the researcher, with support from the relevant class teachers  Experimental group 2 - A second class (n=31) received only the CBT based intervention, for the same period and delivered in the same manner as with experimental group 1  Control group 3 - A group of 29 Year 5 pupils were also part of the study but received no intervention. Statistical analysis on the non-normally distributed dataset indicated that significant differences were found in some domains for experimental group 2 (CBT) compared to the control group (3). Further analysis indicated that these significant differences were as a result of positive change. Additionally, significant differences were found in some domains for experimental group 1 (SEAL + CBT) when compared with experimental group 2 (CBT alone). Further analysis indicated that these significant differences were as a result of negative change. The researcher suggests that the present study tentatively contributes to the growing evidence base for the potential effectiveness of CBT based interventions delivered within a universal framework regarding the promotion of emotional literacy and mental wellbeing. Findings lend some support for the use of CBT based interventions (i.e. the Think Good Feel Good resource) as part of the standard curriculum for Year 5 pupils, suggesting a possible positive impact on some areas of emotional literacy and more broadly mental wellbeing. Additionally, the study offers potential suggestions for future study along with implications and considerations for educational psychologists when undertaking therapeutic type work with children.

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.

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.

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.

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