Many authors have commented on the perceived gap between psychotherapy research and clinical practice, but with the rise of 'evidence-based practice' over the past decade, this gap has become more problematic. Whilst funders of services increasingly emphasise the importance of practice being informed by the best available research evidence, clinicians have become concerned with the way in which clinical and service-level decisions are based on an overly narrow definition of 'evidence'. Psychodynamic therapists have been especially cautious about 'evidence-based practice', arguing that the methodologies used are not appropriate for this type of therapy. Clinicians working with children have also been concerned that there is limited funding available to evaluate therapy with young people, and that the approaches used are often transposed from studies with adults, without attention to whether they are developmentally appropriate. This PhD by Published Works brings together a series of papers published between 2003 and 2014, which engage with these topics. They address issues of methodology and policy, as well as providing examples of attempts to 'bridge the gap' using both primary research and secondary reviews of the existing literature. The papers are mostly presented in chronological order, and have been organised into three sections. Part one, 'Incorporating qualitative research methods into child psychotherapy', includes three papers that deal conceptually and practically with the issue of identifying appropriate research methods for investigating child psychotherapy. The papers in part two, 'The case study as a method of research in child psychotherapy', examine the traditional method of investigating child psychotherapy, and explore the pros and cons of this approach. The final section, 'Engaging with the evidence-base for psychoanalytic child psychotherapy’, offers an approach to evaluation that draws on a range of methodologies, and thereby engages with evidence-based practice whilst also offering a critique of current approaches.

At a time when health literacy is emerging as a central concern in the health field, this thesis examines whether and how practitioners involved in the promotion of breastfeeding incorporate dimensions of health literacy as described in the current literature. Although there is little evidence that practitioners are familiar with specific definitions of health literacy, their description of practices reflected various facets of health literacy including functional health literacy, interactive and critical health literacy, and health literacy as composed of multiple literacies. This qualitative case study was set in a rural health district in the Canadian province of Nova Scotia where breastfeeding initiation and duration rates are lower than national averages and where health literacy was identified as a community health issue. In-depth face-to-face interviews were conducted with 30 professional and lay practitioners. Practices in one hospital-based and two community-based settings were observed. Data were analyzed for themes using an iterative process of constant comparison. Interview informants and mothers provided feedback on preliminary findings in focus group interviews. Findings reflect an emphasis on the transmission of information to persuade mothers to breastfeed, in contrast to strengthening their capacity to use information in making or acting on choices about how to feed their babies. Practitioners’ discomfort in identifying clients with low literacy skills raises fundamental concerns about the stigma associated with low literacy. A focus on the functional health literacy deficiencies of clients, not on their capacities, appears limiting in addressing the complexities of breastfeeding promotion. There is little evidence of practices which reflect critical health literacy or efforts to reduce structural barriers to breastfeeding. In conclusion, the study suggests that practitioners’ engagement in critical reflection of their breastfeeding promotion practices through the multidimensional frame of health literacy could help to further their practice and the conceptual development of health literacy.

Introduction: The segregation of patients with Cystic Fibrosis, purposefully keeping them apart from one another, has become common practice in order to reduce infections being passed from one CF patient to another. There is sufficient medical evidence to support these measures as an effective method of preventing early deterioration of the lungs, yet, there has been virtually no research exploring the psycho-social impact of such a policy. This study aimed to fill this void and become the first study to explore segregation from the perspectives of young people with cystic fibrosis. Method: A qualitative design was used and eight young people with Cystic Fibrosis, (aged 13-15) were interviewed at The Royal Hospital for Sick Children, NHS Greater Glasgow & Clyde. Following transcription, in-depth analysis using Interpretative Phenomenological Analysis was carried out. Results: Analysis of transcripts led to the identification of three super-ordinate themes; ‘Acceptance of Source’ which refers to participants overall acceptance of being in source isolation, after weighing up the pros and cons, ‘Personal Models of CF’ which refers to both medical and psycho-social perceptions of having CF, and ‘Normalisation’ emerged through descriptions of methods used to help to them feel normal and cope with CF. It is proposed that loss of any one of these factors may have a negative impact on adjustment. Conclusions: Support was found for the practice of segregation however this is not without a psycho-social cost (i.e. loss of opportunity to openly discuss their health with others and have their experiences validated). These young people also appeared to have heightened awareness of the wider impact of the policy upon their parents. Contact with CF others was recognised by these young people as valuable. Innovative solutions are urgently required to address these potential costs. In light of this, a number of clinical recommendations have been made and areas for future research have been outlined.

As Crohn’s disease (CD) is a disease of the gastrointestinal tract, nutrition is very important and is implicated in several aspects of the disease, from aetiology, management, and the long-term health of the patient. Nutritional therapy with EEN is the mainstream approach in the management of active paediatric CD and has a dual effect, inducing clinical remission and providing nutritional support and rehabilitation. Although its efficacy is well established by human trials and clinical experience, the mode of action remains unknown. Initial speculations for a mechanism of action mediated through gut rest, and protein/energy reconstitution have not been established. On the other hand the strong evidence for the role of the indigenous microbiota and micronutrients in disease aetiology and mucosal injury, challenged the researcher to explore whether the action of EEN is mediated through changes in these parameters. This study aimed to assess aspects of the nutritional status of paediatric patients with inflammatory bowel disease (IBD), to appraise the use of nutritional remedies in the same population, and to explore putative mechanisms of action of EEN, the nutritional therapy, with the most robust evidence of clinically efficacy. The first of these studies was a questionnaire survey which assessed the use of special diets, nutritional supplements, herbals, and alternative medicine in a representative sample of paediatric patients with IBD. Use of these treatments was declared by two thirds of the patients with probiotic use and dairy free diet being the commonest forms used. Prevalence of anaemia and predictors of its progress at six and 12 months were assessed in a large retrospective case review study. Anaemia was as high as 73% of patients at diagnosis and haemoglobin concentration improvement at six and 12 post diagnosis was associated with the use of oral iron supplementation, improvement of nutritional status markers, growth, and systemic markers of disease activity. In a mechanistic study the validity of a bedside method, used to assess the body composition of children with CD, was compared against a reference method. The agreement of the two methods was low and the inter-individual bias between them was substantial. The aim of this thesis was to study the effect of EEN on gut microbiota diversity, bacterial metabolic activity, inflammatory response and nutritional status in paediatric patients with active CD. Newly diagnosed children with active CD, and patients with longstanding disease, on clinical relapse, who started treatment with EEN as part of their standard clinical management, were recruited. Four stool samples were collected while on treatment with EEN and one when the patient returned to their normal diet. Bacterial diversity was assessed with molecular microbiology techniques, and bacterial metabolites were measured in serial stool samples and correlated with faecal calprotectin levels, systemic inflammatory markers and clinical activity. A single stool sample was collected from their first-degree relatives and two serial samples from healthy children with no family history of IBD. Significant changes were observed for the metabolic activity of the commensal microbiota during the course of treatment. In particular, faecal butyrate significantly decreased by more than 100%, faecal pH moved into the alkaline range, and a five-fold increase was observed in total sulphide but only in those patients who achieved clinical remission, or in whom faecal calprotectin levels decreased at the end of treatment. No such changes were observed in children who did not achieve complete clinical remission or when the treatment failed. Gut bacterial diversity did not change significantly during treatment, but was significantly lower than in healthy children, who also presented a higher degree of similarity between the two serial samples. Interestingly the gut microbiota of the healthy first degree relatives of CD children had significantly lower bacterial diversity compared with the healthy children but no such difference was observed compared with their CD relatives. The majority of the healthy relatives had also significantly high levels of calprotectin suggesting intestinal inflammation but no clinical presentation of gastrointestinal disease. A secondary outcome of this study was to measure changes in the systemic and gut specific markers of disease activity during treatment. Although systemic markers of disease activity improved to normal levels in the majority of the patients, intestinal inflammation was still ongoing and only one of the 16 children had normal calprotectin levels at the end of EEN. Moreover, only in those patients who achieved clinically complete remission, did calprotectin levels decrease significantly at the end of treatment. From the same cohort of patients three blood samples were also collected before, at the end of treatment and on normal diet. Changes in the concentration of 19 different micronutrients were measured in the serum and some in erythrocytes and correlated with systemic markers of disease activity. Serial changes in anthropometry and body composition were assessed during EEN and correlated with disease activity markers. Body weight increased in all patients at the end of treatment but fat free mass significantly increased only in those patients who entered in clinical remission. Several micronutrients and mainly antioxidants were below the reference range for the majority of patients at the time of treatment initiation. Most of them improved by the end of treatment but the serum concentration of carotenoids further deteriorated with more than 90% of the patients presenting concentration lower than the lower sensitivity level of the assay. A strong association was found between systemic markers of disease activity and antioxidant vitamins, but not with intestinal inflammation. In conclusion, paediatric patients with IBD, and mainly those with CD present with suboptimal protein/energy status, anaemia, and low circulating levels for many antioxidants. Treatment with EEN corrected the majority of these markers of nutritional status but the carotenoid levels deteriorated. Although the improvement in the serum levels of some micronutrients can be an epiphenomenon of the acute phase response, it does not explain the depleted levels of carotenoids at the end of EEN. This may be attributed to the lack of carotenoids in the feeds used in conjunction with excessive utilisation during the active course of the disease. On the other hand, the unhealthy intestinal microenvironment observed, in only those patients who clinically improved at the end of treatment; do not support a prebiotic mode of EEN action, as was proposed by a recent Italian study. These changes may be a secondary phenomenon, associated with changes in gut motility, better absorption of butyrate with disease improvement, or changes in the availability of colonic bacterial substrates. Alternatively these changes may be associated with changes in the microbiota composition and production of so far unknown bacterial bioproducts which may have a causative association with the onset and propagation of intestinal inflammation in CD. These results may have significant implications in manufacturers of clinical nutrition products. Addition of carotenoids may improve the provision of antioxidant micronutrients and a dual nutritional therapy combining EEN with prebiotics, butyrate supplementation, or probiotics may increase the efficacy of the existing formulae. This should be addressed in future studies.

Objectives - To develop and pilot a community-based family programme, ‘Families for Health’, for intervention with overweight and obese children aged 7-11 years. Intervention – ‘Families for Health’ is a 12-week programme, with parallel groups for parents and children, combining support for parenting, lifestyle change, as well as social & emotional development. Design of the Evaluation – Pilot study using mixed-methods comprising: process evaluation; outcome evaluation involving a ‘before and after’ evaluation and triangulation with interview data; economic evaluation (cost-outcome description); users and providers perspectives. Setting – Leisure Centre, Coventry, England Participants – 27 overweight or obese children aged 7-13 years (18 girls, 9 boys) and their parents, from 21 families. Process Evaluation – Two groups were run, and were delivered as planned. Recruitment was difficult, although most effective via the media. Attendance rate was 62%, with 18(67%) children completing the programme. Outcome Evaluation – Primary outcome was change in the BMI z-score from baseline. For 22 children with follow-up data, BMI z-score was significantly reduced by -0.18 (95% CI -0.30 to -0.05, p=0.008) at the end of the programme, and was sustained to 9-months (-0.21) and 2-years (-0.23). There were also significant improvements in the children’s quality-of-life, eating and activity environment, child-parent relationships and parent’s mental health. Fruit and vegetable consumption, participation in moderate/vigorous exercise, and children’s self-esteem did not change significantly. Interview data illustrated the changes made by the families, particularly to their eating environment. User and Provider Perspectives – The group-based parenting approach was received well, providing the ‘tools’ for parents to become ‘agents of change’ in the family. Suggested changes to the programme include providing follow-up sessions and a greater focus on physical activity. Economic Evaluation - Costs to run ‘Families for Health’ were £517 per family or £402 per child, in-line with other group-based obesity management or parenting interventions. Conclusion - ‘Families for Health’ is a promising new intervention for the management of childhood obesity.

Attention Deficit Hyperactivity Disorder (ADHD) is the most commonly diagnosed mental disorder of childhood. Most of the deficits it describes are situated examples of classroom misdemeanour, and yet the school’s complicity in rising diagnostic trends has not been extensively questioned. This study aims to provide this through an ethnographic account of ADHD in the infant classroom. Underscored by Foucault’s analysis of power and discourse, this study aims to describe some of the conditions of school and home which make the application of a diagnosis possible. The project firstly presents textual critique of the dichotomous and categorical channels through which ADHD is currently known. Following this the ethnographic account is presented, the data for which derives mainly from observational work in two schools and interviews with two families. The data explores four problematics in early education and social care; routinisation, gendering, responsibilisation and emotional governance. Together these relations produce binds in the conceptualisation of childhood, schooling and family, through which therapeutic discourse is able to form objects, producing the classroom subject ‘ADHD’. Through this argument I offer the means to re-insert the social and cultural into naturalised and individualised therapeutic narratives. In conclusion I argue for a re-imagination of the manner in which we interrogate choice, and state the case for a more reflexive pedagogical encounter with the construction of others.

This thesis describes the evaluation of a targeted group intervention that is broadly based on cognitive-behavioural approaches. The intervention incorporates aspects of social skills training and anger management training, and utilises the concepts of cognitive behavioural therapy. The intervention aims to promote emotional literacy and behavioural change and to impact upon school exclusions in secondary school pupils. The theoretical and historical underpinnings relating to cognitive-behavioural approaches, the methods of cognitive-behavioural approaches, and emotional literacy are described and explored. The literature considering these areas within the educational context is highlighted. Further exploration of the literature presents a systematic literature review of secondary school-based studies using cognitive behavioural approaches in targeted group interventions; these studies aim to promote behavioural change and prevent school exclusion. The evaluation of the targeted group intervention employs a pre/post-test randomised controlled trial. The methodological implications of such a study are described and discussed. The study involves a mixed group of N=43 (20=experimental; 23=control) Year 8 pupils who were identified as having some behavioural needs. The study did not demonstrate any statistically significant impact on the participants’ behaviour or emotional literacy, and exclusion rates between the groups were equal. The findings of this study are discussed considering the methodology, measures used, and data analysis employed. How this study contributes to knowledge and research is explained and the implications the study may have for policy makers and educational psychologists are described.

Introduction: Malaysia is experiencing an increase in the prevalence of childhood obesity/overweight. This current study included the investigation of the psychosocial behavioural determinants and school environmental factors that could potentially mediate healthier eating in the school setting. Methods: In stage 1 of the work presented here, a survey was conducted in 8 randomly selected schools (4 urban/ 4 rural) in Terengganu. It involved 1000 children aged 10-12 yr. Weight and height were measured. Questionnaire to investigate psychosocial factors based on the Theory of Planned Behaviour (TPB) (attitude, subjective norm, perceived behaviour control, i.e. self-efficacy/ barriers) combined with knowledge were developed and validated (Cronbach's alpha ranged from 0.61-0.83). Chi-square tests and multinomial regression analyses were used to determine the association between psychosocial constructs and knowledge with weight status and sociodemographic factors. In stage 2 of the work, whole school mapping assessed the school environment on 4 levels (physical, economic, political and sociocultural) in these 8 schools, plus a further 4 randomly selected schools from the same area (6 rural; 6 urban in total). Results: The findings showed that nearly one-quarter (21.4%) of the sample was overweight/obese (WHO cut-offs), which was most prevalent in boys, urban children, older children and those in the higher socio-economic group (p<0.001). Findings for psychosocial constructs highlight that those who were in this overweight/obese category were significantly (p<0.0001) more likely to have negative attitudes (OR 31.52), more barriers (OR 24.12) less self efficacy (OR 19.00) and less subjective norm (OR 17.46) as well as low intention to eat healthily (OR 1.50) and less healthy eating behaviour (OR 23.56) compared with underweight and normal weight children. Interestingly, there was greater knowledge among obese children, but no significant difference in healthy eating behaviour, suggesting that knowledge alone does not help to improve behaviour to prevent obesity. No significant difference (p>0.05) between knowledge of obesity and psychosocial factors (with all the TPB constructs) also further supported the conclusion that increasing knowledge needs to be supported by enhancing other factors influencing behaviour in order to strengthen children's intention to eat healthily. Findings indicate there is much room for improvement in the physical, economic, policy and socio-cultural environments to improve healthy eating and physically active in the schools surveyed. Conclusion: The findings suggest that psychosocial factors among obese /overweight children need to be modified holistically. Enhancing knowledge and improving the school environment to help increase children's intention to eat healthily and be more physically active are required in order to prevent overweight/obesity among children.

This study presents an evaluation of the Lego® Therapy intervention (LeGoff, 2004) for six children, aged six to ten, with varying social communication difficulties. Lego® Therapy is a small-group, child-led and peer-based social development programme. Relevant theory and existing literature is explored firstly, before a systematic review of social communication intervention evaluations is presented. This is followed by a review of current Lego® Therapy studies, highlighting the limited evidence base that has been developed thus far. The present study’s aims of extending and applying more reliable and valid research designs to evaluate the intervention are then presented. An ABA single case experimental design (SCED) was used to evaluate the effectiveness of the intervention in increasing, maintaining and generalising the social confidence and independence, as well as the sense of school belonging, of the participants. Weekly classroom based video observations, which were coded, using an adapted version of Thunberg, Ahlsen and Sandberg’s (2007) Communication Coding Scheme, explored the participant’s social confidence and independence development and maintenance. Pre, post and delayed measures using The Social Competence Inventory (Rydell, Hagekull & Bohlin, 1997) and The Belonging Scale (Goodenow, 1993) assessed the participant’s parent and teachers perceptions of skill generalisation and the participant’s self-reported sense of school belonging. Outcomes from the SCED showed that the majority of the participants (five out of six) improved in at least one of the social communication skills measured and this maintained post intervention for three of the participants. An increase in perceptions of the participant’s social communication skills was reported within the school (five out of six) and home environment (three out of six). All participants rated a high level of sense of school belonging prior to the intervention, and change was variable per participant following the intervention. Study limitations require acknowledgement when considering the outcomes, particularly the generalisability of the findings due to the design of the study and stability of some of the participant’s Baseline phases that reduce the reliability of the measures. The study concludes with some support for the positive impact Lego® Therapy can have on social confidence and independence. Recommendations are made for future research to enhance the growing evidence base for this intervention.

Vaccination is regarded by the medical profession as one of the greatest public health success stories, and recent opposition, for example over the MMR (measles, mumps and rubella) vaccine, as a failure of understanding. Relatively little social scientific analysis exists on vaccination opposition. However, risk, trust and science are dominant themes within literature on public resistance to technology, and in contemporary theories such as risk society. This thesis therefore evaluates the relevance of these themes for an understanding of vaccination resistance in the UK. The empirical research primarily involves a discourse analysis of interview, document and website data generated from ten parental organisations, established to campaign against aspects of vaccination policy. The study defines these organisations as 'Vaccine Critical groups' and further classifies them into Radical and Reformist categories. In contrast to smallpox vaccination in nineteenth century England, vaccination is no longer compulsory in the UK. Nevertheless, from a governmentality perspective, the individual is still subjected to, what can be termed, the 'imperative of vaccination'. This thesis argues that the Vaccine Critical groups resist this imperative: first, by reframing risk as unknown, non-objective and individual specific; second, by demonstrating an ambivalent relationship with science; and third, by challenging faith in professional expertise and constructing the parent as the potential vaccine expert. These discourses create another type of moral imperative, which actually conforms to developments in the new public health that are encouraged by the state and the medical profession. The findings demonstrate the limits of a realist approach to risk, challenge existing theories of risk society and complicate assumptions about a public crisis of trust in expertise or science. Policy implications include the need to engage with vaccine resisters and their critical discourses, and to reassess the value of risk communication strategies.