Over the last several decades there has been a growing recognition that children with serious emotional disturbances are considerably underserved. The Comprehensive Community Mental Health Services for Children and Their Family Program is the largest federal grant program to help communities to implement, advance, and evaluate the system of care approach to service delivery. One of the goals of the evaluation has been to determine if children who participate in system of care services demonstrate improved clinical and functional outcomes over time. Prior research has revealed that children do display significant improvements over time. While this research is promising, it is also important to explore the variability in the rates of improvement to determine who benefits the most from system of care services. This dissertation explores the predictive role of a selected group of variables (behavioral and emotional strengths, caregiver strain, and demographic variables) on differential rates of improvements in clinical and functional outcomes over time for children who participate in systems of care. These variables were also examined in relation to differences in levels of clinical and functional impairments at intake into system of care services. The results from the latent variable quadratic growth models indicated that children who are served by systems of care displayed significant improvements in clinical and functional outcomes over time, with the greatest improvement occurring in the first six months. Children's behavioral and emotional strengths, caregiver strain, sex, age, and race significantly predicted differences in instantaneous growth, as well as rates of deceleration, for clinical and functional outcomes. Clinical implications, limitations of the study, and directions for future research are discussed. / text

Background: Research exploring the developmental of adolescent antisocial behaviour suggests that a secure attachment style is a protective factor against problem behaviour (Bowlby, 1969). It is theorised that disruptions in the attachment relationship can increase the likelihood of adjustment difficulties in adolescence, including antisocial behaviour (MacDonald, 1985). Such relationships have been inferred by cross-sectional research studies, but have yet to be tested in a longitudinal sample. Aims: This research is a secondary data analysis, using data from the Avon Longitudinal Study of Parents and Children cohort study, to explore the relationship between attachment and adolescent antisocial behaviour at age 15.5 years. Attachment was measured using three component measures; maternal sensitivity in infancy (sample 1), separations from main caregiver in early childhood, age 3-5 years (sample 2) and the presence of separation anxiety in middle childhood, age 81 months, 6.75 years (sample 3). Results: Logistic regression analyses were used to explore the relationships. Using available data, in sample 1 (n=456 complete cases) no evidence was found to support an association between non-positive maternal sensitivity in infancy and an increased incidence of adolescent antisocial behaviour (OR=0.79 [CI=0.42-1.48], p=0.46). In sample two (n=3,961), the number of separations in infancy were not found to significantly increase the risk of adolescent antisocial behaviour (OR=1.26 [CI=0.94-1.71], p=0.17). Separation anxiety in middle childhood was not found to have an effect on adolescent antisocial behaviour (OR=1.01 [CI=0.80-1.26], p=0.96). Conclusions: The findings suggest that although components of attachment, as measured in this study, were hypothesised to be associated with an increased risk of adolescent antisocial behaviour, this was not statistically supported in this study. In this study effects may be limited due to attrition, leading to the loss of antisocial adolescents from the study, creating a bias in the sample studied.

Bakgrund: Palliativ vård i hemmet är en ökande företeelse. Närstående vill ofta delta i vården som informella vårdgivare trots att det innebär stor påverkan på deras livssituation. Den palliativa vårdens uppgift är att i livets slutskede lindra och möjliggöra ett så bra liv som möjligt inte bara för patienten utan också för dennes närstående. Syfte: Syftet med studien var att belysa hur närstående upplever sin situation i den palliativa hemsjukvården. Metod: En litteraturstudie har genomförts med sökning i databaserna Cinahl, Pubmed och Medline. Tolv artiklar valdes ut för resultatet. I sju av de utvalda artiklarna användes kvalitativ metod, i två artiklar kvantitativ metod och i tre både kvalitativ och kvantitativ metod. Sju studier var svenska och övriga från Canada, Italien, Japan och Australien. Resultat: Resultatet visade att närståendevårdare hade både positiva och negativa upplevelser av att delta i vården av patienten och att de ofta kände otillräcklighet, osäkerhet och trötthet, vilket sedan gav upphov till många andra symtom såväl fysiska som psykiska och existentiella. Resultatet visade också att  närståendevårdarna hade ett stort behov av att få stöd, information och utbildning av sjuksköterskan i det professionella vårdteamet såväl under pågående vård som efter att patienten avlidit. Diskussion: Det blir ofta en svår balansgång för närståendevårdare mellan att ta hand om patienten och de egna behoven av vila och egen tid. De närstående behöver därför mycket stöd från det professionella vårdteamet för att kunna hantera sin roll som informell vårdare. Sjuksköterskan måste kunna uppmärksamma den enskilde individens unika behov genom att vara behjälplig i att finna omvårdnadsåtgärder som kan hjälpa de närstående att få så bra balans som möjligt i sitt dagliga liv trots vårdbördan. Jag anser att Carnevalis omvårdnadsmodell kan vara ett stöd i detta arbete. / Background: Palliative homecare is a growing phenomenon. Next of kins often participate in the care as informal caregivers, although it means a major impact on their lives. The goal of palliative care is to relieve and allow as good a life as possible, not only for the patients but also for their next of kins. Aim: The aim of the study was to shed light on how next of kins perceive their situation in palliative homecare. Methods: A literature study has been accomplished through searches in the databases Cinahl, Pubmed and Medline. Twelve articles were selected for the result. In seven of the articles qualitative method was used, in two articles quantitative method and and three articles both qualitative and quantitative method were used. Seven studies were Swedish and the others were from Canada, Italy, Japan and Australia. Results: The result showed that informal caregivers had both positive and negative experiences of taking part in the care of the patient and they often felt insufficiency, uncertainty and fatigue, which caused other symptoms, both physical and psychological and spiritual. The result also showed that the informal caregivers had a great need to get support, information and training from the nurse in the professional care team both during treatment and after the patient had died. Discussion: There is often a difficult balance for the next of kins between taking care of the patient and their own personal needs of rest and personal time. Next of kins therefore need support from the professional care team to manage their role as informal caregivers. The nurse must be able to pay attention to the individuals unique needs and to assist in finding nursing interventions that can help next of kins to get the best possible balance in their daily lives despite the care burden. I consider that Carnevalis nursing model can be supportive in this work.

Caring for an elder with dementia at home is considered a challenging and complex process. The purpose of this study was to describe the impact of family caregiving upon caregivers of elders with dementia on caregiver's health in the context of Chinese family caregiving. The investigation also describes the roles of caregiving appraisal, coping, familism, and perceived social support on the relationship between caregving stressors and caregiver outcomes.A cross-sectional correlational design was used to examine relationships among the variables. Ninety-six family caregivers of elders with dementia in China were recruited. Self-reported questionnaires were utilized to measure the variables.Results from bivariate correlational analysis found that ADL impairments had no any significant relationship with other variables and was not used in model testing.. Path analysis indicated that the proposed Dementia Caregiving Model did not fit the data well. Model modifications were performed based on AMOS 5.0 output and the theoretical rationale for the potential modifications. The modified final model fit the data perfectly. It explained 21.1% and 39.7% of the variance in caregiver physical health and psychological health respectively. In the final models, behavioral problems of care-recipients and perceived social support of caregivers had direct and indirect effects on caregiver physical health and psychological health. Familism and caregiving satisfaction only had indirect effects on caregiver psychological health and no effects on caregiver physical health. Conversely, caregiving subjective burden and coping had direct effects on caregiver health; burden had direct effects on both physical and psychological health of caregivers, whereas coping had a direct effect on caregiver psychological health.The findings enrich knowledge of dementia family caregiving in the context of China and Chinese culture and add the important variables of caregiver appraisal of caregiving satisfaction and familism to existing theories and models of stress and coping on family caregiving cross culturally. This study not only contributes to Chinese nursing research by introducing a conceptual model for family caregiving of elders with dementia, but also can be a basis for formulating interventions to help family caregivers of elders with dementia cope with their caregiving situations.

Persons with aphasia (PWA) have language difficulties and their Quality of Life (QoL) has most likely been affected. Because of their loss of language abilities, it is difficult to use PWA in QoL studies. This can lead to the use of proxy responses (a person who answers for the PWA). The aim of this study was to compare the rankings from QoL questionnaires for PWA with the rankings from their spouses/caregivers (i.e., proxyresponse). We also wanted to find out which of the 11 aspects of life PWA andspouses/caregivers ranked as the most respectively the least impacted ones. A totalnumber of 57 persons participated in the study. The participants consisted of two groups, one group with PWA and one group of their spouses/caregivers. A questionnaire-based cross-sectional survey completed via a face-to-face interview was used to collect data from both groups. The results showed that there was poor internal consistency and a weak correlation between the two groups. The two groups ranked different aspects of life as “most impacted” and “least impacted”. The PWA ranked Vocation/Occupation as the “most impacted” and Family life as the “least impacted”aspects of life. The spouses/caregivers ranked Overall ability to communicate as the“most impacted” and Ability to self-care as the “least impacted” aspects of life. The results indicate that proxy responses may not be appropriate and should be interpreted with caution in QoL studies with PWA.

This thesis explores the role of media in the lives of live-in caregivers in Montréal by looking at two Filipino newspapers and mainstream news coverage on Filipinas and the Philippines. While Filipino newspapers elaborate Filipino identity and speak back to stereotypes in mainstream news, their impact is curtailed by limited distribution and content range. Live-in caregivers in Montréal were selected as a special audience group through which to examine media representations of Filipinos because they are ‘othered’ through interlocking processes of gender and race. The live-in caregiver program (LCP), through which they migrate to Canada, lays bare the price that third world women immigrants are asked to pay for citizenship rights in Canada. LCP work is often underpaid, demeaning, and exploitative. Examining the lives and media habits of LCP workers ethnographically breaks new ground in studies of both domestic work and minorities and media in Canada.

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Around 14,000 men in New Zealand are the primary caregiver for their children, yet little recent research has focused on this phenomenon. Seventy fathers were recruited from the community, consisting of 35 primary-caregiving fathers, and 35 secondary-caregiving fathers. Participants completed a variety of measures which gathered data about their developmental history, personal characteristics, marital relationship, work and economic factors, social network factors, and child characteristics. Results indicated that primary-caregiving fathers earned significantly less income than secondary-caregiving fathers; were significantly more likely to identify with non-Pakeha ethnicity, and were significantly more likely to have no educational qualifications than secondary-caregiving fathers. Primary-caregiving fathers also rated their relationship with their mother as having significantly more care. Primary-caregiving status was predicted by older age of fathers, and increased parenting self-efficacy. Implications of the results are discussed, as are strengths and limitations of the study, as well as future directions for research.

Caregiver-child conversation is an important platform for children’s development of language and conversational skills and can form the basis for an approach to intervention for children with pragmatic difficulties. While most intervention studies have focused on reporting overall improvements in children’s language and conversational skills as a result of changes in caregiver behaviour, there is limited fine-grained understanding of children’s ability to achieve conversational topic contingency as a result of specific changes in their caregivers’ use of conversational topic turns and/or the facilitative techniques employed by therapists. The studies described in this thesis aim to address this limitation. The following questions are raised: (i) What is the impact of caregiver training intervention programmes on caregivers’ conversational topic turns and facilitative techniques? (ii) What is the impact of caregiver training intervention programmes on children’s conversational topic turns? and (iii) How do specific facilitative techniques impact children’s conversational skills? The first part of this thesis involves establishing the methodology for data transcription and data coding used in the four studies conducted for this thesis. Conversational recordings were transcribed using the CHAT format and conventions. Then a conversational coding system and a facilitative technique coding system were used to code the communicative acts transcribed. The conversational acts coded were topic change (TC), topic extension (TE), topic maintaining responses (TM), and non-relevant responses (NR). The facilitative techniques coded were imitation, expansion, follow-in questions, and follow-in cloze procedures. Inter-rater reliability levels of the transcription and coding of conversational acts and facilitative techniques were high. Study 1 (presented in Chapter 3) was designed to investigate changes following an ‘It Takes Two to Talk’ Hanen programme in the conversations of four caregiver-child dyads where the children had identified language delay. It employed a single subject design and the outcome measures were analysed in three phases: baseline, intervention and follow-up. The outcome measures were the rates of (i) caregivers’ conversational topic turns (i.e., TC, TE and TM), (ii) caregivers’ facilitative techniques (i.e., imitation, expansion, follow-in questions, and follow-in cloze procedures) and (iii) children’s conversational topic turns (i.e., TC, TE and TM). Results showed that all caregivers produced fewer TCs and higher rates of facilitative techniques, while all children produced significantly more TEs following intervention. Individual caregiver patterns of change appeared to be reflected in their children’s conversational skills. This study supports the effectiveness of caregiver group training programmes in improving the quality of caregiver-child conversations and highlighted the importance of investigating individual variations in intervention. Study 2 (presented in Chapter 4) was designed to investigate the changes in conversational skills of three children with features of autism spectrum disorders (ASD) following the dyads’ participation in caregiver-child individual training as part of a multidisciplinary programme for children with ASD. This study employed a case series design and the outcome measures were analysed in two phases (i.e., intervention and follow-up). Similar to Study 1, the outcome measures were rates of the (i) caregivers’ conversational topic turns (i.e., TC, TE and TM), (ii) caregivers’ facilitative techniques (i.e., imitation, expansion, follow-in questions, and follow-in cloze procedures) and (iii) children’s conversational topic turns (i.e., TC, TE and TM). Results of Study 2 showed that one of the three caregivers decreased the rates of TC, and one of them increased the rates of TM following intervention. The caregivers also increased their rates of facilitative techniques (i.e., imitation, expansion and follow-in questions). Concurrently, the children whose caregivers showed positive changes following intervention increased their rates of TCs and TMs. Consistent with the findings of Study 1, high individual variations were observed in the changes exhibited by the caregivers. Study 2 supports the effectiveness of individual training programmes in improving the quality of caregiver-child conversations and emphasizes the importance of investigating individual variations in intervention. Study 3 (presented in Chapter 5) was designed to investigate the qualitative changes made by a child from each of the first two studies. The two children presented with different language levels and aetiologies but both were receiving individualised programmes designed to enhance their conversational abilities. Taking a functional approach to communication development, Study 3 examined how each child (i) collaborated on an activity; (ii) expanded an activity; and (iii) returned to a previous activity or proposed a new activity, through conversational topic turns. Results suggest that the children learnt to collaborate on and expand activities through their caregivers’ repeated use of contingent topic turns (i.e., TM and TE) and facilitative techniques (i.e., expansion, follow-in questions and follow-in cloze procedures). However, they tended to return to a previous activity or propose a new activity when they did not attend to the preceding act or topic, seemed to not comprehend or were not interested in the preceding act or topic, or when their caregivers failed to attend to their preceding act or topic. These findings highlights that while caregivers’ topic turns that are contingent and facilitative help children to advance their activities, caregivers’ topic turns that are non-contingent have the potential to cause the children to end the preceding activity and switch to another activity. Study 4 was designed to compare the effectiveness of expansion, as a technique for facilitating children’s conversational topic turns, with expansion combined with other techniques when implemented by speech and language therapists (SLTs). Using a repeated measures design, this study aimed to compare the effects of expansion alone (EA); expansion combined with wh-questions (EQ); and expansion followed by a cloze procedure (EC) on the conversational skills of eight preschool children with conversational difficulties in conversation with their regular speech-language therapists (SLTs). Results showed that while there were no significant differences in child verbal topic maintaining responses across all techniques, EA elicited a significantly higher number of TEs, more non-verbal TMs and fewer NRs from the children, than either EQ or EC. The positive effects of each technique on the pragmatic appropriateness in conversations suggest that they could be used strategically in language intervention to enhance therapeutic effect. This thesis suggests that caregiver training programmes that focus on following the child’s lead and support caregivers and therapists to use contingent topic turns and facilitative techniques have positive outcomes for children’s conversational development. It also suggested that caregivers’ and therapists’ facilitative strategies that do not obligate responses from the child (i.e., expansion) have better potentials to help the child to expand the scope of conversations than strategies that obligate a response from the child (i.e., wh-questions and cloze procedures). Finally this thesis suggests that family-focussed intervention that follows the child’s lead appears likely to improve the conversational skills of children with a range of diagnoses by helping to address the common underlying features of conversational difficulties.