One in four IVF pregnancies is a twin birth. This research explored the impact of a multiple IVF birth on maternal mental health and examined whether twin status conferred additional risk for poor mother-infant interaction and parenting stress following a premature birth. It further surveyed factors which had influenced couples' decisions regarding embryo transfer. A prospective study of 175 mothers conceiving after IVF found mothers of multiples (n=56) had a three-fold risk of scoring above the threshold for depression in the postpartum period. Unsettled and irregular infant behaviour was another independent risk factor. Theme analysis revealed mothers of multiples were more likely to express negative themes such as 'tiredness'. More mothers of singletons described 'feeling wonderful'. Mothers of premature twins (n=17) were closely matched with mothers of premature singletons and compared using the Nursing Child Assessment Teaching Scale (NCATS), Home Observation for Measurement of the Environment (HOME) Responsivity subscale and the Parenting Stress Index. There were no differences in maternal NCATS scores but twin infants were less responsive and provided less clear cues. Mothers of twins were less responsive in an everyday setting and 25% (versus 0%) reported extreme levels of parenting stress. Singleton mothers had significantly lower scores for the parent child dysfunctional interaction subscale. None of the couples surveyed (n=68) had chosen to transfer a single embryo (eSET). Only 19.1% rated desire for twins as an important factor in their decision. Most important was desire to increase the chance of pregnancy (92.6%). Couples perceived eSET as reducing the chance of pregnancy. Most couples found the decision about number of embryos to transfer easy and rated medical advice as very important suggesting a need for more support for this complex decision. This thesis established that a single birth offers important psychosocial advantages for both mother and baby, findings which could promote informed decisions regarding embryo transfer.

Technological advances in neonatal care have meant that the survival rates of preterm infants have dramatically increased. Improvements in mortality have not been reflected in improvements in morbidity, however, and the chances of extremely preterm infants surviving free from serious morbidity remain low. Concerns regarding mortality and morbidity rates have resulted in a plethora of ethical debates surrounding extremely preterm infants. The application and cost of advancing technology has been questioned. The impact that the risk of severe disability should have on decision making, along with who should make these decisions, the parents or the health care professionals, remains under debate. The influence that advancing fertility treatment has on decision making has yet to be explored, despite causing controversy in the media. Improving mortality rates have also prompted a proposal to reduce the current abortion limits in the United Kingdom. Despite a wealth of research into these ethical dilemmas, the voices of neonatal nurses towards these debates surrounding the infants which they care for have remained silent. The aim of this study is to therefore explore the perceptions of neonatal nurses towards extremely preterm infants. Q methodology was used to explore the attitudes of 36 nurses working in a perinatal network in the United Kingdom. Nurses 'sorted' a set of 53 statements developed from literature and previous research which represented the debates surrounding extremely preterm infants. Nurses then participated in a 'post Q sort' interview to explore the rationale behind their placement of the statements. The findings indicated that there were three types of nursing perceptions towards extremely preterm infants, centred on the involvement of parents in making difficult decisions. Some nurses reported their belief in accounting for parental choice is making difficult decisions. For others, they discussed their beliefs that the health care professional should undertake difficult decisions. The remaining nurses reported a belief in technology over and above decision making, suggesting that technology would prevail and allow more preterm infants to survive. The findings reflected the complex neonatal environment where core 'learnt' nursing values were often difficult to implement. Highlighting the perceptions of neonatal nurses' towards extremely preterm infants allowed for an in-depth exploration of the rationale behind these patterns of perceptions. Conclusions were drawn from this regarding how to improve the engagement of not only neonatal nurses, but the parents also, in the infant's care. A palliative care policy is suggested from these findings in order to help nurses make the transition from curative to palliative care. The conceptual framework developed for the study was adjusted accordingly, and future clinical and research recommendations made.

Background: Breastfeeding is a key public health issue, conferring benefits associated with both infant and maternal health. Despite an increasing research base about what helps or hinders breastfeeding, there is a dramatic drop in breastfeeding prevalence within the first six weeks following birth. The reasons that mothers give for stopping breastfeeding suggest that few mothers gave up because they planned to. This would appear to suggest that there is a gap between women's experiences of breastfeeding and professional practice to promote, support and increase duration. Methodology: Using an interpretive phenomenological methodology this study was designed to capture mothers' own interpretations of their experiences of breastfeeding. In-depth interviews with 22 women from the city and surrounding areas of Lincoln were conducted and analysed. Findings: Analysis of the data from interviews with 22 primiparous and multiparous mothers resulted in the emergence of three main overarching themes: reality shock, illusions of compliance and tensions. Sub-themes Included idealised expectations, incessant demands, onus of responsibility, playing the game, breaking the rules, surveillance and scrutiny, conflicts and contradictions, and cultural constructs. Conclusions: The findings from this study revealed that women were ill-prepared for the realities of breastfeeding and for most women the shock of this experience was overwhelming. Those women who struggled to establish breastfeeding did so in silence. They tried to hide their vulnerabilities rather than admit that they were not coping. A lack of peer and family support, combined with the rigid and inflexible approach espoused by health care professionals, led to the perception that exclusive breastfeeding was an unrealistic and unattainable ideal. This has clear implications for practice and policy.

BACKGROUND The United Kingdom has the highest rate of teenage pregnancy in Western Europe, and also ranks highly on an international level. Previous research has shown that factors such as socio-economic status are strongly associated with variations in pregnancy rates and outcomes of pregnancy. However, the impact of service provision, specifically primary care based services, is less clear. AIMS AND OBJECTIVES The primary aim of this thesis is to describe the incidence of teenage pregnancy in the former Trent health region, and to identify any factors associated with variations in rates and outcomes. The specific objectives are as follows: To describe the incidence of teenage pregnancy in Trent, and identify any factors associated with outcome of pregnancy, and with risk of intervention at delivery. To describe general practice and family planning services in Trent, with an emphasis on services specifically provided for teenagers. To identify any potentially modifiable general practice characteristics associated with variations in teenage pregnancy rates. To explore the opinions and attitudes of GPs towards key issues such as prescribing contraception to under 16s, and relate these to both GP characteristics and pregnancy rates. METHODS Data for all pregnancies in women aged under 20 years at the time of hospital admission during the period 1994-1997, were collected from the Trent hospitals admissions database. General practice characteristics data for all 826 practices in existence in Trent in 1997 were collected from all health authorities that were part of the Trent region at the start of the study period (1994). These data were collected for inclusion in a cross sectional survey of potentially modifiable practice characteristics associated with variations in teenage pregnancy rates. Hours of service and location of family planning clinics within Trent were identified through a survey of all clinics in existence in 1997. A cross sectional survey of all GPs and practice managers from four health authority areas, was carried out to identify both the number and nature of teenage specific initiatives running during the study period, and also to explore GPs attitudes and opinions towards key issues relating to the care of young teenagers. RESULTS A total of 18692 pregnancies were identified, and 5.1 % of these were to women aged under 16 years. Outcome of pregnancy was significantly associated with deprivation status, with women from poorer areas being more likely to continue with their pregnancy (OR 4.04 95%CI 2.40-6.78, P<0.001). Of the 10554 women who continued with their pregnancy, 22% experienced intervention at delivery, and this was associated with place of treatment (hospital), with women who delivered at one hospital for example, having 1.5 times the risk of experiencing either a vaginally assisted birth or a caesarean section (OR 1.53 95%CI 1.30-1.81, P< 0.001). Risk of intervention at delivery was not associated with age or deprivation status. In terms of service provision, of the 826 general practices identified, 58% had at least one female GP and 39% had at least one GP aged under 36 years. Twenty one percent of practices from the four health authority areas studied in detail, offered teen specific services, and 11 % had a specific confidentiality policy for under 16s. In terms of family planning services, 108 clinics were identified, which provided 498 hours of service and 261 of these were accessible to younger teenagers. General Practices with younger GPs (OR 0.67 95%CI 0.49-0.93, P=0.02) and practices that were running teenage specific initiatives (OR 0.61 95%CI 0.41-0.91, P=0.02) had significantly lower teenage pregnancy rates in women aged under 16 years. In terms of attitudes towards key issues related to the care of younger teenagers, age of GP was significantly associated with most issues, with older GPs being less likely to prescribe contraception to under 16s without parental consent (OR 0.55 95%CI 0.33-0.93, P<0.001) and also being more likely to believe it was illegal to do so (OR 4.27 95%CI 1.50-12.22, P<0.001). CONCLUSION Deprivation status was associated with incidence and outcome of teenage pregnancy. General Practices with younger GPs (aged under 36 years) were found to have independently lower teenage pregnancy rates in women aged under 16, as were practices that were running a teenage specific initiative. Younger GPs were found to be more likely than older GPs to prescribe contraception to young women aged under 16 without parental consent, and to believe that it was legal to prescribe contraception to this age group. These issues of age of GP, and the impact of teen specific services,should be further researched in order to fully understand their relationship with variations in teenage pregnancy rates.

Background: Childhood critical illness is characterised by a rapid and potentially catastrophic loss of physiological reserve caused by a wide variety of illnesses and injuries. In the Western world, death from childhood critical illness is rare due to advances in paediatric intensive care (PIC) provision, medicine, technology and public health. However, surviving PIC can expose children and their families to a complex array of physical, psychological and social problems. Physical disability, chronic illness, delirium, and stress symptoms have been reported to manifest in the immediate to short-term (<six months post-PIC). Existing research has focused on quantifying the outcomes and impact of surviving childhood critical illness. Furthermore, decontextualised, pathologised, and uni-dimensional platforms to inquiry are the dominant approaches used. Collectively, this has impeded understanding of how childhood survivors construct and experience long-term (≥ six months post-PIC) psychosocial well-being. Aim: This study aimed to explore how long-term psychosocial well-being is described, experienced and constructed by PIC survivors within the context of their lives. Methods: A longitudinal, qualitative, multiple case study approach was used. Nine case studies were formed around a heterogeneous group of nine child and adolescent PIC survivors of an acute life-threatening critical illness (aged six-16 years), admitted to a single UK Paediatric Intensive Care Unit (PICU) at least six months previously. A further 23 significant others, including family members, health professionals and teachers, were identified by the PIC survivors to participate. Each case, bar one, was explored longitudinally over a six-month period collectively providing a follow-up period of six to 20 months post-PICU discharge. Data were collected from October 2012 until July 2013 and included 42 data collection visits. A flexible toolbox of qualitative methods (interviews and art-based approaches) was used to capture stories and accounts. Collectively, 33 hours of audio data and 427 images were collected. Data were analysed sequentially that provided insights into psychosocial well-being from the individual, within the case, and across cases. Both abductive and inductive analytical approaches were used that included narrative psychological analysis, correspondence and pattern matching, and aggregating of case findings. Findings: Findings from survivor accounts illuminate multifaceted and complex storied experiences. Stories were distinctive, varying in how they were constructed as well as in content, with differing biographical, experiential and aspirational accounts. These remained grounded in survivors’ day-to-day lives involving vibrant imagery of life events, contextual factors and prosperities. However, adversities also featured through reports of amnesia, uncertainties, traumas, contemplation of death and dying, and stigma, which appeared to collectively direct constructions of psychosocial well-being. From exploring within each case study, the context of PIC survivors’ lives appeared complex, featuring ongoing adversities, chaos and change. Stories diverged between survivors and significant others as untold and hidden narratives emerged. However, shared stories also appeared, with a distinct focus on future aspirations and recovery. Shared residual traumas and adversities also featured, with narratives of sacrifice and protection being told, that in turn exposed significant others to additional adversity. Findings from across contexts identified multifarious imagery with interwoven and intricate stories that illuminated the complexity of survivor experiences and lives. However, amongst this chaos, common themes from across PIC survivor stories were evident. Themes included: disrupted lives; exposure to death and dying; mediation between different social worlds and identities; and the focus on getting on with life. Through aggregating instances across whole-cases, the inter-relational nature of long-term psychosocial well-being was highlighted. Collectively, findings identify that PIC survivors construct long-term psychosocial well-being within the context of their lives as a paradox; a state of disruption and flux, and an inter-relational and dynamic entity. Conclusion: Childhood PIC survivors’ stories are complex and identify numerous challenges and adversities that are faced when attempting to readjust to life in the long-term post-PICU. Mediation between psychological and social worlds can expose survivors to both negative and positive well-being. However, biographical, individual, familial, social, and wider societal influences also appear significant in how PIC survivors construct and experience psychosocial well-being in the longer term. These novel insights into this unexplored phenomenon challenge existing theoretical propositions from the literature and provide a platform for further inquiry.

Over the last two decades, obesity has become a major public health concern. Evidence suggests that obesity can be programmed by nutrition in early life. A way to treat/prevent obesity would be a major breakthrough for public health and brown adipose tissue (BAT) has been identified as a potential target for this, due to its propensity to utilise stored energy to produce heat, a process mediated by the uncoupling protein (UCP) 1 gene. In humans and sheep, UCP1 decreases with age. Diet during lactation and subsequent alterations in milk fatty acid profile have not been studied in relation to effects on offspring BAT function. There is evidence from in vitro and rodent studies to suggest the potential for some fatty acids, such as conjugated linoleic acid (CLA), to increase UCP1 expression. The aim of this thesis is to use sheep as a model to investigate the potential to alter the milk fatty acid profile by supplementing ewes’ diet with canola or sunflower oil, as previous research has found these to be effective in increasing milk CLA. I then investigated the effects on offspring in early life, with a particular focus on their BAT and its UCP1 abundance. The perirenal adipose depot was studied due to it being the largest depot in young sheep, which is known to transition from brown to white adipose tissue in the first month of life. In addition to this, I set out to investigate the CLA concentrations of infant formula milk and how they compare to those reported for human breast milk. From the day of delivery, ewes raising two lambs each were supplemented with 3% canola or sunflower oil or fed a control diet. Milk samples and ewe and lamb weights were taken at 7 and 28 days and offspring were tissue and blood sampled at either 7 or 28 days. The mRNA expression several of genes associated with thermogenesis was measured. Results showed that supplementation of ewe’s diet with canola, and to a lesser extent, sunflower oil, resulted in decreases in milk medium-chain saturated fatty acids (SFAs). Both supplements increased milk monounsaturated fatty acids (MUFAs) by ~50%, and total and cis-9, trans-11 CLA by ~80%. In addition, sunflower supplementation increased omega-6 PUFAs by 25% and the trans-10, cis-12 CLA isomer by 177% at 28 days of lactation compared to controls. Female lambs fed by sunflower oil supplemented ewes showed a 50% increase in adipose tissue weights compared with controls. Male and, to a lesser extent, female lambs fed by canola oil supplemented ewes showed increased UCP1 abundance at 28 days of age compared with controls. There was an increase in mRNA expression of other thermogenic genes in the canola females at 7 but not 28 days, however, not in males, so this unlikely to be the main cause of the increases seen in UCP1. Results from my investigation into infant formula showed that CLA was present in 67% of the infant formula milks tested but at lower concentrations to those reported in human breast milk. In conclusion, it is possible to induce changes in ewes’ milk fatty acid profile with dietary supplementation and I have shown that the fatty acid profile of milk received in early life has the potential to affect adipose tissue development and UCP1 gene expression. If in the prevention of the normal decline in UCP1 were to be maintained into adulthood it could improve long-term health by helping to maintain body weight. Further research is now necessary to establish whether this increase in UCP1 is maintained beyond the sampling time points of my investigation.

The overarching aim of this thesis is to further understanding and knowledge of risk factors relevant to children who runaway. More specifically to; identify risk factors most relevant to children running away; establish whether risk factors can be used to distinguish between those children reported missing once versus those reported on multiple occasions; and evaluate assessment methods currently being used with this group. The systematic review explores risk factors associated with children who runaway. Successful identification of risk factors can be used to inform risk assessment which in turn inform intervention strategies. Through an electronic search 573 references were identified since 2002. However, only 15 references were included in the final review once inclusion and exclusion criteria were applied. Through this review it was identified that runaways are a heterogeneous group. Risk factors most consistently identified to be associated with running away spanned multiple levels including; gender, socioeconomic status, family structure, history of abuse/neglect, substance use and school attachment/engagement. Implications for intervention are discussed. The empirical study utilised data collected by the Gwent Missing Children’s Team collected over a one year period (N= 523) to explore risk factors associated with repeat missing reports. The aim of this study was to develop a model that could be utilised in practice to identify those most at risk of repeat missing incidences in order to direct resources effectively. Through logistic regression analyses it was found that five risk factors can be used to distinguish between those children reported missing once (low risk, N= 275) versus those reported missing on multiple occasions (high risk, N= 248). This provided a simple summation checklist that can correctly classify 70.4% of missing cases. This checklist can be used to inform resource allocation with those children identified as high risk warranting more comprehensive intervention and support. The case study presented the assessment and intervention of an adolescent reported missing to Gwent Police. The aim of this study was to provide an in-depth analysis of a missing child case making links to relevant psychological theory and highlighting implications on practice. This case study demonstrated the cross over between running away and sexual exploitation and highlighted the importance in providing specialist intervention services in order to reduce risk of harm through repeat running away. Finally, a critique of a risk assessment tool widely used in Wales with runaways who are suspected to be at risk of sexual exploitation is presented. Within this critique it was found that the Sexual Exploitation Risk Assessment Framework (SERAF) combines consistency in approach with ease and efficiency of identification and intervention for children at risk of, or abused through, sexual exploitation. However, the tool requires empirical validation and reliability analyses before it can be considered a scientific assessment of risk. Overall, this thesis provides evidence for the use of risk factors in identifying children who are likely to be reported missing or runaway. It suggests that this group is heterogeneous and that risk factors relevant to predicting running away span multiple levels. This suggests that intervention should be holistic and target identified risk factors. Risk assessments currently utilised in respect of this group require validation. Further research to inform such risk assessments is also recommended.

The aim of the systematic literature review was to gain an in-depth understanding of how parents of children with an autism spectrum diagnosis experience stigma and in what ways they might manage this. Electronic databases and reference lists of published articles were systematically searched and six qualitative articles were selected for inclusion in the review. Findings from the studies formed the data for a thematic synthesis. Four interconnected themes were identified which capture parents experience of stigma: parent blame/responsibility; hidden disability; diagnosis/label and social isolation/avoidance. A further four themes were identified to highlight ways in which parents may manage this: diagnosis as a weapon; celebrating; increased resilience over time and planning and avoidance. The review suggests that negotiating public spaces may continue to be a challenge for some parents who experience both felt and enacted stigma. The aim of the study was to explore how parents share an autism spectrum diagnosis with their child and the processes which may be involved in this. Literature regarding parental experiences of autism assessment and diagnosis indicate that this is a highly emotive time for both parent and child and highlights multiple factors which may impact on the sharing process. There is also an indication in the literature that there is often a delay between the autism diagnosis being confirmed and this being shared with the child. In the absence of autism specific research, literature pertaining to diagnosis disclosure in developmental disabilities and in paediatric chronic illness is examined, outlining a range of emotional and social factors which may shape parental decisions of whether to share their child’s diagnosis with them. The researcher adopted a critical realist position and employed a qualitative approach to explore this under-researched area. A total of 10 parents were recruited to the study and participated in a semi-structured interview. Transcribed interviews were analysed using thematic analysis. A secondary thematic analysis was undertaken to produce a leaflet reflecting the accounts shared by the group of parents in the study. It is hoped that this may be useful to other parents who are contemplating sharing an autism spectrum diagnosis with their child and the professionals who support them. Three inter-connected themes were identified, each with further sub-themes: (1) Sharing is a process: naming autism, exploring and meaning-making and acceptance and integration; (2) Parental motivation to share: providing an explanation and protection and (3) Parental management of sharing: parental preparedness, perceived child preparedness and approach and strategies. Sharing is a process and its related sub-themes are discussed in the journal paper, whilst the remaining themes and sub-themes are presented in the extended paper. The findings illustrate that sharing an autism diagnosis with one’s child is a complex and dynamic process involving the balancing of many parent, child and social factors. Commonalities with previous literature are discussed alongside some alternative insights gained. The thesis concludes with personal reflections of aspects of the research process including the nature of autism as a diagnosis and the potential ethical issues raised when considering whether this is shared with children or not.

Six electronic databases were searched and 153 studies which identified the number or the rate of paediatric medication errors were identified; mainly from the US. These studies were compared to identify factors responsible for the great variations seen in reported error rates (Chapter 2). The most important factors were the use of different denominators, different definitions of medication errors, and the use of different methods of data collection. To explore further the reasons for the wide ranges of error rate identified in Chapter 2, the studies that used the same denominators, methods, and error types were compared, yet showed a difference between the highest and lowest error rate of more than 50% (Chapter 3). Factors identified for the variation in error rates included differences in setting, drugs studied, participants, study design details and countries involved. To try to clarify the relationship between the method of data collection and results obtained (Chapter 3), the rates of specific types of medication errors reported by studies using different methods but the same denominator were compared. Conclusions were difficult to draw due to the heterogeneity of the current literature. Prescription errors are probably best studied using chart review and administration errors by direct observation. The relationship between the clarity of definitions and results was investigated in Chapter 3, in terms of how clearly the studies had defined errors and the degree to which the definition(s) used matched each study’s aim. Studies were too heterogeneous and unfortunately could not adequately be compared. Chapter 3 also explores the interventional tools reported. Of all studies, 59 used interventional tools and assessed their benefit. These included dosing supporting tools, electronic prescribing, education, health and safety strategies, clinical pharmacist services and pre-printed forms among others. Most studies reported that their interventions effectively reduced or prevented medication errors, despite in some cases not measuring errors before and after interventions and even in some studies where error rates increased. Chapter 3 also explores the UK studies. Very few studies occurred in the same setting and used both the same methodology and denominators to identify the rate of the same types of medication errors. It was difficult to draw firm conclusions but prescribing and administration errors seem to happen more often in paediatric units in general hospitals than in specialist children’s hospitals. Most studies were of prescribing errors with other types of error rarely studied in the UK. Four studies identified the time of day most associated with errors; three the time of day and days of the week most associated with errors; and one the days of the week most associated with errors (Chapter 3). However, given the diversity of definitions of times of day, shifts, and weekdays, it was impossible to draw conclusions regarding the temporal aspect of medication errors from these studies. A second systematic review was conducted to explore the current literature that examines the role of paediatric clinical pharmacists in reducing the rate of medication errors (Chapter 4). Twenty-five studies published until the end of July 2013 were identified that reported pharmacists’ activities in reducing or preventing medication errors. The most commonly intercepted types of errors were wrong dose, wrong drug and wrong route of administration. The most common types of pharmacists’ contributions were reactive information giving in response to other healthcare professionals’ queries, education of healthcare professionals and cost saving. Based on knowledge gained from the second systematic review, an observational study of the role of paediatric clinical pharmacists was conducted in two NHS Trusts in the UK (Chapter 5). By shadowing pharmacists, they were observed during their day-to-day work and their contributions to health care were documented, as well as the errors that they identified and addressed. Having ultimately shadowed 14 pharmacists over the course of 197 ward visits, clinical pharmacists were found to play an important role in improving the health care services provided to paediatric patients and are effective in averting different types of medication errors. Pharmacists intercepted errors in 8.4% of all prescriptions and the overall contribution rate of all prescriptions was 54.8%. The most common types of errors intercepted by pharmacists were omission errors (27.9%), wrong dose (24%) and illegible prescribing (19.2%). The most common types of contributions were annotating prescriptions with information (e.g. administration instructions) (19.2% of all prescriptions), drug history check (97% of all new patients) and allergy status checked (100% of all new patients). The acceptance rate of pharmacists’ recommendations by doctors was very high (99.5%).

Parents of children with autism spectrum disorder (ASD) experience numerous challenges caring for their children. Research shows that those parents, and specifically mothers, suffer from high levels of stress and poorer well-being compared to parents of children with other disabilities. Developing and evaluating interventions to help enhance their well-being and their interaction with their children is recommended (NICE, 2013). Parenting interventions have been shown to be efficacious for parents of children with ASD , yet practical barriers may have an impact on their widespread uptake (McConachie & Diggle, 2007). Self-help parenting interventions with minimal therapists’ support, which have the potential to overcome barriers to adherence, have been used with parents of children with other neurodevelopmental disorders. However, there is limited evidence evaluating these interventions and their effectiveness for parents of children with ASD. Moreover, most parenting interventions for parents of children with ASD focus on developing the parents’ abilities to enhance specific skills in their children, while only few include psychoeducation components addressing knowledge about ASD and parental well-being. The main aims of this thesis were to understand the impact of having a child with ASD on parental functioning both internationally and for Saudi Arabian mothers and to then develop and evaluate both quantitatively and qualitatively the effectiveness of a brief psychoeducation intervention for mothers of children with ASD in the Kingdom of Saudi Arabia (KSA). Chapter One provides an introduction to ASD including its current definition, diagnosis, co-morbidities, risk factors, and treatment options. In addition, it discusses the theoretical models related to parenting children with ASD, and autism within the context of KSA including gaps in current research there. Chapter Two (study one), presents a systematic review investigating the impact of having children with ASD on parental life. Autism was found to impact areas including response to ASD, parental well-being, relationships, positive perception, financial problems, and future worries. Differences in findings between mothers and fathers were identified. Chapter Three (study two) explores the unmet needs of Saudi mothers of children with ASD in KSA through a pilot qualitative study that used semi-structured interviews. Mothers expressed a range of issues and needs including feelings of lack of sufficient information about ASD, the need for parental training, shortage of quality ASD services, lack of fathers’ assistance, and stigma associated with having children with ASD. Moreover, mothers insisted that barriers such as lack of transportation add to their burden. Chapter Four (study three) presents a meta-analysis evaluating the effectiveness of parenting interventions on parental functioning of parents of children with ASD. Analyses revealed that parenting interventions are effective in enhancing parental well-being (stress, depression, and anxiety), parenting practices, and in increasing parents’ sense of competence SOC. Chapter Six (study four) delivers the findings from a small-scale randomised controlled trial (RCT) investigating the effectiveness of a self-help psychoeducation intervention with minimal therapists’ support, delivered via WhatsApp for mothers of children with ASD in KSA. The intervention was successful in reducing maternal reports of stress, depression, ASD symptoms, and child behaviour problems. Change of clinical significance was minimal and limited to maternal depression. Chapter Seven (study five) describes a qualitative study that evaluates the acceptability and views of mothers who participated in the trial in Chapter Six. Mothers had positive views of the intervention and many of them were actively engaged in the intervention and discussed new parenting skills and behaviours that they had acquired. Finally, Chapter Eight provides a general and overall discussion of the thesis findings, including a summary of the findings of all the studies within the thesis. In addition, methodological strengths and considerations, clinical implications, and direction for future research are discussed. Collectively, the studies within this thesis provided evidence for the effectiveness of self-help psychoeducation parenting intervention with minimal therapist support and delivered via a virtual medium for mothers of children with ASD in KSA indicating that such interventions may have a place in future routine care.