Practical joint dietetic/medical guidelines are required for children with differing levels of severity of chronic renal insufficiency (CRI). This thesis describes the current dietetic/medical package of care provided within a specialised paediatric renal unit, and provides an insight into considerations for future clinical guidelines. Children were grouped at baseline following [51Cr]-labelled EDTA glomerular filtration rate (GFR, m1/min/1.73m2) estimations, into 'normal' kidney function [GFR > 75, mean 106 (SD 19.5), n=58], providing baseline data only, mild (GFR 51-75, n=27), moderate (GFR 25-50, n=21) and severe (GFR < 25, n=19) CRI. Those with CRI were followed for two years and 51 children completed the study (19 mild, 19 moderate, 13 severe CRI). Baseline and 6 monthly measurements of anthropometry, blood pressure, laboratory investigations and yearly dietary intakes (3-day semi-quantitative diaries) were obtained. EDTA GFR's were compared to estimations of GFR using serum cystatin C and plasma creatinine/height concentrations. Amongst the findings, mean standard deviation scores (SDS) for all anthropometric markers deteriorated with worsening renal function at baseline, from mean SDS for weight, height, body mass index and mid upper arm circumference in 'normal' children of O.28 (SD 1.0), 0.19 (SD 1.0),0.21 (SD 1.1) and 0.39 (SD 1.0) respectively, to values of -1.32 (SD 1.0), -1.55 (SD 1.1), -0.44 (SD 1.1) and -0.58 (SD 0.9) in severe CRI. Over two years, mean height SDS significantly increased in children with severe CRI (p=0.003) and was maintained in mild and moderate CRI, despite deterioration in renal function. Correlation between changes in energy intake and height SDS was observed in severe CRI (r2=0.5, p=0.001). From individual observations and correlation, higher phosphate and sodium intakes appeared to be associated with greater deterioration in estimated GFR in children with mild CRI. An inverse correlation between calcium intake and plasma parathyroid hormone was observed in severe CRI (r2=0.27, p=0.065). Disturbances in nutritional intakes, bone biochemistry and growth occurred early in the course of CRI and deterioration in renal function, as determined by estimated GPR, was greatest in those with mild CRI. Regular joint dietetic/medical intervention is likely to be beneficial in children with mild and moderate CRI, in addition to those with more severe CRI, to both correct initial disturbances and reduce the chances of progression.

Unintentional injuries in childhood are a major cause of mortality and morbidity. Numerous risk factors for unintentional injury have been identified over recent years, and there have been several suggestions that injury prevention programmes should be targeted at children identified as high risk, based on these risk factors. There has also been increasing interest in, and emphasis on, the role of members of the primary health care team in preventing unintentional injuries to children, including within recent government policy. There is some evidence, so far, that primary care interventions can be effective in reducing hazards, increasing knowledge and changing behaviour. There is however, less evidence that they can be effective in reducing injury frequency or severity, with very few studies of high quality addressing this issue. The objectives of the research presented in this thesis are: 1.) to examine the relationship between accident and emergency department attendance and future hospital admission following unintentional injury, and to consider the transmission of injury data between secondary and primary care and the uses of such data within primary care; 2.) to examine the associations between risk factors for childhood injury and a variety of injury outcomes and to calculate the sensitivity, specificity and positive predictive value for risk factors in identifying children who will subsequently suffer an unintentional injury, and to consider high risk group and whole population strategies for injury prevention in the light of the findings; 3.) to assess knowledge, attitudes and current practices in childhood injury prevention amongst members of the primary health care team and to consider the implications of the findings for injury prevention in primary care. The first objective has been achieved by a matched case-control study. The main findings were that children who had been admitted to hospital following an unintentional injury were twice as likely to have previously attended the accident and emergency (A&E) department than community controls. However, only one third of hospital admissions had a history of previous A&E department attendance, hence most of the children admitted to hospital would not have been identified using A&E attendance. Current practice in many A&E departments is that a paediatric liaison health visitor notifies the community health visitor of children attending A&E following injury. Most authors in the field discuss post injury follow up visits as an appropriate response to receipt of such notifications, but there is little evidence for their effectiveness, and several studies show such visits are perceived to be difficult for both parents and health visitors. There is little evidence that, at present, injury data transmitted from secondary care is collated in a systematic way, to be used in primary care for needs assessment or injury surveillance. It is therefore recommended that the role of the paediatric liaison health visitor in the collection and transmission of injury data is in need of further consideration, and that post injury follow up visits require further study to demonstrate their effectiveness. The second objective has been achieved by a cross sectional survey followed by a cohort study. The main findings from this study are that only previous injury and male sex were associated with A&E department attendance and only previous injury with primary health care team attendance, despite sufficient power to demonstrate associations for several other risk factors. Consequently the sensitivity and positive predictive value of the risk factors in identifying children who will suffer previous injury was found to be low. The specificity was high for most risk factors, suggesting they will miss most children who will have injuries but will correctly identify most children who will not suffer future injury. The number of children needing to be targeted with an intervention to prevent one injury was similar for most risk factors, and similar to that if the whole population received an intervention. The results could not be adequately explained by bias, confounding or insufficient power Further work examining associations between risk fectors and unintentional injury in childhood is needed with larger sample sizes and in a population with a wide cross section of socioeconomic status to confirm these findings. At present, it is recommended that injury prevention programmes in primary care use a population approach. The third objective was achieved by a cross sectional survey of general practitioners, practice nurses and health visitors in Nottinghamshire. The main findings from this survey were that health visitors had a significantly higher score for knowledge of childhood unintentional injury epidemiology than general practitioners or practice nurses. They held significantly more positive attitudes to, and were undertaking significantly more injury prevention than, both general practitioners and practice nurses. Despite this both general practitioners and practice nurses held positive attitudes to at least some injury prevention activities. The activities most commonly undertaken were those using a preventive model of health education, for all professional groups. Activities involving empowerment or radical or political models of health education were used less often. There was little evidence of a systematic approach to injury prevention, with prevention occurring most often opportunistically. For all activities, and across all professional groups, a greater proportion of respondents agreed that an activity should be undertaken than actually undertook that activity, suggesting there may be barriers to undertaking injury prevention in primary care. The difference between the proportion agreeing an activity should be undertaken and doing so, was greatest for lobbying or campaigning and for collecting injury data. The conclusions from this study are that current injury prevention practice, which often uses a preventive model of health education, often as an isolated approach, and most often opportunistically, may not be the most effective strategy for reducing unintentional injuries in primary care. Further studies are needed to assess the effectiveness of primary health care team interventions offered systematically, using a combination of health education models and approaches. Such studies must address the barriers to injury prevention in primary care. The findings from this study suggest there is already some knowledge, and positive attitudes towards injury prevention, amongst at least some primary health care team members, on which to build interest in such future research. NB. This ethesis has been created by scanning the typescript original and contains some inaccuracies. In case of difficulty, please refer to the original text.

This project set out to develop a cognitive training intervention for individuals with attention deficit hyperactivity disorder (ADHD). The thesis builds on research suggesting that reinforcement deficits in the ADHD population give rise to the underdevelopment of a number of cognitive abilities, in particular inhibitory control skills. Arguing that this skill is explicitly trainable and that training inhibitory gaze control is a means of training inhibitory control, this thesis set out to utilise eye-tracking technology to assess inhibitory gaze control performance in ADHD and to develop an engaging intervention in the form of a computer game capable of training the inhibitory gaze control system. Drawing on literature on inhibitory control in ADHD, the saccadic system, game development, and cognitive load theory a training intervention and battery of assessment tasks were developed iteratively across a number of pilot studies. The development process and resultant cognitive training interventions are described. The final proof-of-concept study was trialled for eight one-hour training sessions with an ADHD population (N = 8). Comparisons of pre- and post-training assessments produced strong effects for measures of gaze control, inhibitory control, timing, and attention. The results are interpreted and a number of limitations noted. The potential benefits of such interventions to aid clinicians to diagnose, to monitor, and to treat ADHD are considered. The relevance of cognitive interventions in contributing to research attempting to identify endophenotypes of ADHD is also discussed.

Access to the world of men can be closely guarded by non-disabled people and so disabled men can be persuaded to either conform, subvert or attempt to create an alternative masculine hegemony. For boys and men with Intellectual Disability (ID) little is known about their attempts to develop their gendered identities. This study aimed to explore whether boys with ID have ideas of what it means to be a boy, what influenced this and what ideas the boys had about their futures as men. Using an approach based on grounded theory, group and individual interviews were conducted with 21 boys in 7 groups from a special school engaged in plans about transition from school to the adult world. Using innovative methods including a sorting exercise and the boys own artwork, interviews were recorded and then transcribed. Analysis of the data revealed a developing construct of masculine identity established both outside and inside the interview room that could be identified as the way we do boy. The way we do boy is described in four themes: changes; ideals; experiences; vicariousness. Findings demonstrate that the four themes were instrumental in assisting the boys to think about their identities. However, the opportunities to practice their developing masculinity was limited and the boys talked about their struggles when their attempt to do this resulted in the uncovering of their difference and vulnerability. The analysis and discussion of this study develops into an explanatory theoretical framework for working with boys and men with ID about their masculinity. With the addition of Thomas’s (1999) work expressed as lenses, it is hoped this will provide a practical framework for use in services for both boys and men with ID.

Background Important developments in the research literature exploring extrafamilial victimisation have been made in the USA. However, the comparable literature from the UK is underdeveloped, limiting our understanding of the prevalence and characteristics of extrafamilial victimisation in UK settings. In addition, greater understanding of the risk and protective factors for extrafamilial victimisation is needed to develop the most effective preventative interventions. Objectives/ research questions To address these gaps within the literature, two studies are presented within this thesis; one cross-sectional survey and one systematic literature review. The aims of study one were to provide a comprehensive assessment of all forms of extrafamilial victimisation with an English sample of young people, exploring; the prevalence, characteristics and location of extrafamilial victimisation, associated factors relating to routine activities, and the impact of extrafamilial victimisation on psychological well-being. Study two was designed to synthesise the research findings from longitudinal cohort studies regarding the predictive factors for all forms of extrafamilial victimisation, and to explore the quality of research in this area. This research was carried out within the theoretical context of the routine activities theory (RAT) and ecological systems theory. This provided a coherent structure to aid understanding of the processes involved in extrafamilial victimisation, as well as a way in which the different elements of the young person’s ecology could be brought together to encourage exploration and to interpret the research findings. Study design, participants and setting Study one explores the extrafamilial victim experiences of 730 young people from eight mainstream secondary schools within one county in England. This incorporated one smaller case study of young people (N = 214) attending three secondary schools in one English town. Two pilot studies were carried out with two separate samples of young people (N= 27 & N= 30) in order to test, develop and refine the methods and procedures used in this study. The second study provided a narrative synthesis of the findings of 37 longitudinal (>1 year follow-up) cohort studies which investigated the risk factors for, and protective factors against, extrafamilial victimisation during childhood. Main findings The findings from study one revealed how widespread extrafamilial victimisation was amongst the young people taking part. Many of the characteristics of the young persons’ activities within the community were found to increase their risk of extrafamilial victimisation, providing support for the RAT of extrafamilial victimisation. However, the characteristics of the young persons’ journey home from school were not found to influence the prevalence of victimisation on this journey and some research findings based on the RAT of extrafamilial victimisation were not found to be significant predictors of community-based victimisation. Geographical victimisation ‘hotspots’ were identified in the case study, which revealed how the geographical distribution of community-based victimisation was located within close proximity to the young person’s school. Finally, different categories of extrafamilial victimisation were significant negative predictors of psychological well-being, as was past-year poly-victimisation and victimisation in more than one location. Finally, social support was identified as a potential moderator of the relationship between victimisation and psychological well-being. Findings from the systematic review (study two) highlighted a number of areas of bias within the cohort studies carried out in this area, particularly population bias and outcome (i.e., extrafamilial victimisation) measurement bias. A large number of risk factors (N= 56) were investigated in the included studies, the significance of which differed according to the extent of the extrafamilial victimisation explored and the definition of extrafamilial victimisation used. Less attention was given to protective factors (N= 18) within the included studies, yet a small number of individual characteristics were identified as potentially important predictors of peer victimisation. Crucially, interaction effects were identified between predictors (mediating and moderating variables) and between risk and protective factors. These findings highlight the complexity of the network of risk and protective factors for extrafamilial victimisation. They also reveal interaction effects between predictors operating across a number of different levels of the young person’s ecology (e.g., individual predictors, environmental predictors, etc.). Conclusion The two studies presented within this thesis highlight the complex, multidimensional nature of extrafamilial victimisation. The thesis concludes by drawing upon the research findings and theories outlined within the literature to propose a new model of extrafamilial victimisation. This takes account of the different vulnerabilities and processes involved in victimisation, as well as recognising the reciprocal relationship between predictors and outcome. As such, recommendations for the development of prevention and intervention are outlined, as is the need for future research in this area.