Thesis (M.P.H.)--University of Michigan, 1947.

Autism is considered to be a chronic developmental disability that affects communication, relationships, emotional development and imagination (NAS, 2010). Prevalence rates for autism spectrum disorder (ASD) suggest that the rates have increased over time and recent research shows that 1 in 68 children are diagnosed with the disorder (Baio, 2014). These children’s difficulties in the areas of communication, social skills and restricted/repetitive behaviours and interests lead to the need of therapeutic support (APA, 2013) and often it falls to parents to find an appropriate treatment for their child (Marcus et al, 2005). Among recommended services to these children are speech and language therapy, occupational therapy (Johnson and Myer, 2007) and psychotherapy (Alvarez et al, 1999). There are a number of intervention approaches for children with autism that have been developed, however none have been universally accepted as being the most effective (Farrell et al, 2005). As a result, parents often find it difficult to know which is the most appropriate approach for their child. This study aims to explore the development of children with autism over time in the areas of social skill and communication, regardless of the kind of treatment (speech and language therapy, psychoanalytic/psychodynamic psychotherapy and occupational therapy) they are receiving and to investigate the association between therapy context and the patterns of developmental change. This thesis is designed as a cross-national study in order to examine the aspects of the disorder that differ in the UK and Greece along with the differences (if any) in the developmental patterns across countries. The significance of doing a cross-national study is to explore autism from a wider international perspective and to identify any differences and similarities across the two countries. Twenty children with autism who had completed one of two differing types of treatment in the UK (psychotherapy, n=10 and speech and language therapy, n=10) were recruited to be monitored post-therapy twice over a two-year period. Twenty children with autism who had received one of two types of treatment in Greece (occupational therapy, n=10 and speech and language therapy, n=10) were also recruited to be monitored post-therapy twice over a two-year period. The research found that all children changed significantly over time on all aspects of measurement. Furthermore, no significant differences were found in the children from the two different countries at the start of the study and they developed in a very similar way as well. The results suggested though that based on the ADOS-Social (p=0.008) and ADOS-Imagination (p=0.008) children in the UK improve faster in the areas of social skill, imagination and the CDI-no of words understood and produced (p=0.015) showed an increase in their ability to understand and say words compared to the children in Greece. However, the CDI-no of words understood (p=0.027) showed that the children in Greece improved faster in the area of comprehension. The children who received SLT are also mainly developing in a very similar way across the two countries. Most measures showed change over time, except for the SCQ (p=0.081), ADOS-Ster (p=0.050) and CDI-U (p=0.141|). Also, only the ADOS-Social (p=0.021) and the Social Communication Questionnaire (p=0.021) showed a significant interaction effect. Thus, the SLT group from the UK seems to improve faster in the area of social skills compared to the SLT group from Greece. Additionally, in regards to the effect of the therapy context on the developmental pattern of children with autism, there were no differences across intervention contexts at the beginning and there were mainly non-significant interactions in the rate of change across the differing types of intervention. The findings suggested that all measures showed change over time. Only the SCQ (p=0.041) and the ADOS-imagination (p=0.033) showed a significant interaction effect before adjusting for age. Therefore, the SLT group in the UK seems to improve faster in the social communication area and the Psychotherapy group in the UK improved faster in the area of imagination. Conclusively, the SLT groups showed more change on language and communication measures, whilst the psychotherapy and occupational therapy groups saw changes in other areas of autistic symptomatology not achieved in the SLT groups, such as imagination and stereotypical behaviour. In summary, the current study helps parents gain better insight in different therapy choices and raises awareness of other types of therapy that are available in terms of intervention. The findings of this study can help professionals who work with children with autism further their understanding of the disorder and how it manifests through time in order to provide appropriate services based on each child’s needs. Additionally, the cross-national approach was intended to give some suggestions about the manifestation of autism across countries and about the way childhood autism is treated in each country. In regards to the more specific changes that the analysis revealed, they seem to fit well with the intervention targets of each type of therapy. Thus, the analysis suggested that certain characteristics tend to be associated with specific treatment types, which leads us to believe that sometimes the most effective course of treatment is a combination of therapies depending on the individual needs of each family. Finally, the results of this study offer original findings with respect to the outcomes of psychodynamic/psychoanalytic psychotherapy for children with autism since there is a lack of rigorous research in this field.

Children who have language disorder frequently have difficulties with vocabulary acquisition, and these difficulties often persist into adolescence. Language disorder is known to be associated with long-term influences on a range of academic, social, emotional, health, and employment outcomes. Phonological-semantic intervention has been shown to be effective in enhancing the vocabulary skills of children with language disorder in small-group or individual settings, but less is known about vocabulary interventions for adolescents with language disorder or interventions in whole-class models of delivery. This thesis undertook three strands of enquiry: a systematic review; a survey of teaching and speech and language therapy practice; and an experimental effectiveness study. The systematic review of the evidence regarding vocabulary intervention with adolescents confirmed that the use of a phonological-semantic approach in a universal model of delivery is under-researched in this age group. The survey of mainstream secondary school teachers and speech and language therapists showed that a phonological-semantic approach is frequently used by speech and language therapists but less often by teachers. The experimental study investigated the effectiveness of phonological-semantic vocabulary intervention, delivered by teachers and embedded into the secondary school curriculum in a whole-class model of delivery, for adolescents with language disorder. In the intervention study, 78 adolescents with language disorder aged 11 – 13 years were taught science curriculum words by teachers in class, under two conditions: 1) 10 words taught through usual teaching practice; and 2) 10 matched words taught using an experimental intervention incorporating phonological-semantic activities, embedded into the teaching of the syllabus. Ten matched control words received no intervention. Word knowledge was assessed at pre-intervention, post-intervention, and follow-up timepoints. The main findings of the study were that: the experimental classroom vocabulary intervention was more effective than usual teaching practice in increasing the word knowledge of participating students; there was a high degree of acceptability for the intervention activities amongst both students and teachers; and there were mixed preferences amongst students for whole-class, small-group, and individual models of intervention delivery. Clinical and teaching implications include the importance of intervening during the adolescent years, with classroom vocabulary intervention being a viable option for collaborative teacher and speech and language therapy practice.

This study was carried out following observation from health professionals in the paediatric intensive care community that the incidence of chylothorax development in infants and children in the United Kingdom was unknown. Furthermore, treatment strategies were based on limited international evidence from single centre, small scale, retrospective cohort studies or case series. The aim of this study was therefore to determine the size and extent of the problem by establishing the current incidence, patient profile, management strategies and discharge destination or outcome of infants and children who developed a chylothorax in the UK. Infants and children ≥ 24 weeks gestation to ≤ 16 years, who developed a chylothorax in the UK were prospectively reported through the British Paediatric Surveillance Unit (BPSU). Clinicians completed a questionnaire on the presentation, diagnosis, management and discharge destination or outcome of these children. Three further additional data sources were accessed to confirm this data. A total of 219 questionnaires were returned with 173 cases meeting the eligibility criteria for inclusion. The incidence in children in the UK was 1.4 in 100,000 (0.0014%), in infants ≤ 12 months 16 in 100,000 (0.016%) and for those developing a chylothorax following cardiac surgery it was 3.1% (3,100 in 100,000). The majority of chylothoraces were reported following cardiac surgery (65.3%). Chylothorax was most frequently confirmed by laboratory verification of triglyceride content of the pleural fluid ≥ 1.1 mmol/litre (66%). Although a variety of management strategies were employed, treatment with an intercostal pleural catheter (86.5%) and a Medium Chain Triglyceride (MCT) diet (89%) were most commonly reported. The majority of the children had a prolonged hospital stay (median 29.5 days), with a reported mortality of 12.5%. The results of this study indicate that the development of a chylothorax in infants and children in the UK is not common; although incidence is higher in children having cardiac surgery. The duration of hospital stay is lengthy and therefore the impact on the child, family and hospital resources are significant. Common management strategies exist, but the variation in these and the lack of an outcome based rationale suggest national guidance is required.

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Developmental dyslexia is suggested to affect approximately 5-10% of the population (Habib, 2000). The most influential theory of dyslexia is the phonological-deficit theory of dyslexia (Liberman, 1973; Stanovich, 1988; Snowling, 2000). An alternative explanation is that visual deficits can lead to reading difficulties (e.g. Stein & Walsh, 1997). To date the findings are mixed regarding the extent of visual deficits within the dyslexic population. Whether these problems represent a cause, correlation or consequence of the reading difficulty also remains highly controversial. The data presented throughout this Thesis examined the possibility that reading difficulties, associated with dyslexia, are linked to poor binocular coordination. In three experiments binocular eye movements of adults, typically developing children and children with dyslexia were measured while they read sentences or scanned dot string targets. In these experiments findings of previous binocular studies were replicated. Specifically, fixation disparity was modulated by the amplitude of the preceding saccade and the fixation position on the screen regardless of whether fixations and saccades were targeted to dots or words. Additionally, during the dot scanning task adult’s binocular coordination was improved in relation to children’s, but no reliable differences were found between the three groups. Critically, a significantly greater magnitude of fixation disparity was found for dyslexic children compared to typically developing children and adults during the reading task alone. The existence of linguistically modulated differences in binocular coordination for dyslexic children is a novel finding. The patterns of results from the three experiments indicate that poor binocular coordination in dyslexic children is restricted to reading linguistic material. Clearly, this represents a stimulus specific deficit in regard to binocular coordination, for children with dyslexia.

The aim of this study is to develop a pain assessment scale for use during neonatal transport. Underpinned by the rights of the child to have appropriate assessment and management of pain and the important deleterious effects pain can have on the physiological stability of the neonate, this study utilises a qualitative consensus paradigm of enquiry to inform the content and structure a pain assessment scale specific to the transport setting. The study was conducted in three Phases, the first Phase consisted of a nominal group meeting with transport clinicians to ascertain their views on items to include in a pain assessment scale for transport. Phase Two utilised the Delphi technique to gain consensus from a large cohort of clinicians experienced in the field of neonatal transport on the content, structure and design of a transport pain assessment scale. Results of the first two Phases of the study were then applied to the adaptation of an existing pain assessment scale. Face validity of the newly developed Neonatal Transport Pain Assessment Scale (NTPAS) was then tested in Phase Three by semi-structured interviews with transport clinicians. Results of initial face validity testing suggested positive results in relation to feasibility and clinical utility of the scale, however further testing is strongly recommended. Currently there are no pain assessment scales developed for use in the transport setting, and little evidence on the effects of transport on pain and pain assessment. This study offers a unique approach in adding to the body of knowledge on neonatal pain assessment and facilitated the development of a scale adapted to transport. Further research is suggested to undertake psychometric testing of the scale and establish validity and reliability in the clinical setting.

Childhood aggression affects a significant number of children and represents the majority of referrals to child clinical services (Ford, Hamilton, Meltzer, & Goodman, 2007). There are substantial costs for the child, their family and society more generally if aggressive behaviour remains untreated (Shivram et al., 2009). Social-cognitive models of aggression have provided the theoretical framework for much of the research into childhood aggression over the past twenty years and formed the focus of clinical interventions (Crick & Dodge, 1994). A key finding from this research is that aggressive children have a tendency to attribute hostility to the intentions of others in ambiguous situations (Orobio de Castro, Veerman, Koops, Bosch and Monshouwer, 2002). The aim of literature review is to explore the factors that lead to the development of this bias. Limitations to extant literature and suggestions for future research are discussed. Although evidence from a number of studies demonstrates the effects of socialisation or peer contagion on children’s aggressive and anti-social behaviour (Prinstein & Dodge, 2008; Thornberry & Krohn, 1997), currently no studies have examined peer contagion effects on hostile attribution bias. The empirical paper describes a study investigating whether hostile attribution biases are contagious amongst adolescents in a community sample of boys and girls. Using a computerised ‘Chat-room’ experimental paradigm, contagion effects were demonstrated across two conditions (hostile and benign) with those exposed to hostile group norms showing greater contagion effects. Four possible moderators on the effects of peer contagion were explored; gender, dispositional levels of aggression, social anxiety and friendship style. The role of peers in the socialisation of hostile intent attribution styles and implications for preventative interventions are discussed.

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