A cohort of boys with developmental language disorders (DLD) have been followed up from childhood into adult life. At this most recent follow up, the DLD cohort was in their mid thirties (n = 17). The cohort was assessed on their cognitive, social and psychiatric functioning compared to their non language disordered siblings (n = 16), an intelligence quotient (IQ) match comparison group (n = 17) and a general population comparison group (n = 1155). The DLD, siblings and IQ match groups were assessed on intelligence, language, literacy, social cognition, visual and verbal memory, phonological processing, psychopathology and adult social adaptation. Relative to the comparison groups, the DLD cohort showed a significantly impaired performance on all of the cognitive measures except performance intelligence and visual and verbal memory. Even in their mid thirties, the social adaptation of the DLD cohort continued to be poor compared to the siblings and a general population cohort, particularly in the areas of employment, independent living and relationships. In adult life, three members of the DLD cohort had developed psychoses and one DLD adult had been diagnosed with major depression. No major psychopathology was found in the sibling group. The fourth phase of this study has shown that as adults the DLD cohort continued to have persisting impaired cognitive abilities including language, literacy and specific deficits within phonological processing and social cognition. Furthermore, the DLD cohort experienced significant difficulties in adult social adaptation and are at an increased risk of severe psychiatric disorder. It is proposed that phonological processing and social cognition are two independent causal cognitive deficits in developmental language disorders. The phonological processing deficit causes the persisting language and literacy impairments and the social cognition deficit underpins the social adaptation difficulties which develop later in life. Explanatory theories are put forward to delineate the changing symptomatology within the cognitive, social and psychiatric functioning of developmental language disorders from childhood into adult life.

Background: Smoking in pregnancy is the most significant preventable cause of poor health outcomes for women and their babies and, therefore, is a major public health concern. In the UK there is a wide range of interventions and support for pregnant women who want to quit. One of these is nicotine replacement therapy (NRT) which has been widely available for retail purchase and prescribing to pregnant women since 2005. However, measures of NRT prescribing in pregnant women are scarce. These measures are vital to assess its usefulness in smoking cessation during pregnancy at a population level. Furthermore, evidence of NRT safety in pregnancy for the mother and child’s health so far is nebulous, with existing studies being small or using retrospectively reported exposures. Aims and Objectives: The main aim of this work was to assess population-level estimates of maternal smoking and NRT prescribing in pregnancy and the safety of NRT for both the mother and the child in the UK. Currently, the only population-level data on UK maternal smoking are from repeated cross-sectional surveys or routinely collected maternity data during pregnancy or at delivery. These obtain information at one point in time, and there are no population-level data on NRT use available. As a novel approach, therefore, this thesis used the routinely collected primary care data that are currently available for approximately 6% of the UK population and provide longitudinal/prospectively recorded information throughout pregnancy. The specific objectives for this thesis were: • To assess the quality of smoking data recorded during pregnancy in primary care • To quantify annual NRT prescribing trends in and around pregnancy and describe the characteristics of mothers prescribed NRT • To assess the association between NRT and smoking exposure during pregnancy and major congenital anomalies (MCAs), stillbirth, low birth weight and mode of delivery Methods: All women aged 15-49 years, with pregnancies ending in live or stillbirth, were identified from The Health Improvement Network (THIN) primary care database (2000-2009). Medical Read codes related to smoking status and Multilex smoking cessation drug prescription codes were used to extract data on women’s smoking status and NRT prescriptions. The proportion of pregnancies with a smoking status record was calculated and logistic regression was used to assess how this varied by women’s characteristics. Women were categorised as being smokers or non-smokers during pregnancy based on the recorded Read codes. Where smoking data were missing during pregnancy, smoking status recorded before pregnancy (up to 27 months before pregnancy, ever before pregnancy) was used as a proxy for smoking status during pregnancy. Annual smoking measures from THIN were then compared to other national datasets. Pregnancies ending in early fetal losses were not included for calculating smoking prevalence, as these outcomes can go unrecognised or can be the first recognised sign of pregnancy, making early ascertainment of all pregnancies uncomprehensive; this was also broadly in line with pregnancy ascertainment in the other national datasets. Prescribing prevalence of NRT and patterns of prescribing in terms of frequency, timing and different form of NRT were assessed. Logistic regression was used to assess women’s likelihood of receiving NRT prescriptions by maternal characteristics. Absolute and relative risks (99% Confidence Interval (CI)) for four birth outcomes (MCAs, stillbirth, low birth weight and mode of delivery) were calculated for women prescribed NRT (defined as the NRT group) and women who continued to smoke during pregnancy (defined as smokers) compared to women who did not smoke during pregnancy (defined as non-smokers) with appropriate adjustments for potential confounders. To assess MCAs and birth weight in relation to NRT and smoking a restricted cohort of children was used who had maternal-child linked records in THIN. Results: There were 277,552 pregnancies in 215,703 women, of which 28% had a gestational smoking status record. In 2000, smoking status was recorded in 9% of pregnancies; 43% in 2009. Smoking estimates from THIN data did not completely agree with estimates from other sources. For example, in 2009 smoking prevalence was 12.9% in THIN, compared to 19.5% in Child Health Systems Programme (CHSP) data. However, the use of smoking data recorded up to 27 months before conception increased the THIN prevalence to 22.9%, which was slightly higher, but compared better with the CHSP estimates. NRT was prescribed in 4,826 pregnancies for an average duration of 2 weeks (Interquartile range 1-2 weeks), which represented 2% of all pregnancies (11% in smokers). NRT prescribing prevalence before and after pregnancy was half the prevalence during pregnancy. NRT prescribing increased with socioeconomic deprivation (Odds Ratio (OR) =1.33, 95% CI 1.14-1.52) for the most compared to the least deprived group). Prescribing was higher in pregnant smokers with asthma (OR=1.34, 95% CI 1.21-1.50) and mental illness (OR=1.29, 95% CI 1.18-1.43) compared to smokers without these diagnoses. The absolute risk of MCA was 279/10,000 live births. Compared with non-smokers the adjusted OR for MCA in the NRT group was 1.34 (99% CI 0.94-1.91). No statistically significant increase in the risk of MCA for the NRT group was found when the reference group was changed to smokers (OR=1.35, 99% CI 0.94-1.93).The absolute risk of stillbirth was 4/1000 live and stillbirths. Compared with non-smokers the adjusted OR for stillbirth in the NRT group was 1.19 (99% CI 0.47-3.01). In smokers, the risk of stillbirth increased by 27% compared to non-smokers (OR 1.27, 99% CI 1.01-1.60). The mean birth weight was 3.41kg (standard deviation 0.59) and the absolute risk of low birth weight was 6.4%. Compared to non-smokers, the risk of women having low birth weight babies was 93% higher in the NRT group (OR 1.93, 99% CI 1.48-2.53). However, there was no statistically significant increase in the risk of low birth weight in the NRT group compared with smokers. There was no increased risk of assisted delivery or caesarean section in the NRT group compared to smokers. However the risk of assisted delivery decreased by 25% in the NRT group (Relative Risk Ratio 0.75, 99% CI 0.60-0.93) compared to non-smokers. Conclusion: The completeness of smoking status recording during pregnancy in primary care data is improving; however, under-recording of smoking status during pregnancy still results in unreliable estimates of the prevalence of smoking in pregnancy and needs improvement. Pre-conception smoking records are reasonably complete and it is possible that low recording in pregnancy is because a woman’s smoking status has not changed or that increased interaction with other health services, such as midwifery, during pregnancy means women are less likely to be asked about their smoking by their primary physician and information on their smoking does not get relayed back to their primary care record. Nevertheless records should be updated in pregnancy to ensure comprehensive health care. NRT was most commonly prescribed in pregnancy for about two weeks, which may not be adequate time for effective smoking cessation. Nevertheless, prescribing was higher during pregnancy compared to the nine months before and after pregnancy, which makes establishing its safety during pregnancy even more crucial. The safety studies in this thesis did not find NRT to be any more harmful than smoking during pregnancy if not beneficial. Considering that smoking in pregnancy remains one of the largest public health problems in the UK, improvements of antenatal and postnatal smoking in primary care may not only help identify women for preventive measures earlier but would be invaluable for safety studies considering the outcomes are rare yet severe.

This thesis aims to provide a broad overview of topics relating to desistance factors and strength-based approaches to working with male sex offenders. It incorporates diverse methods, including a systematic review, an empirical study, an individual case study, and a critique of an actuarial risk assessment. Following an introductory chapter, Chapter 2 presents a systematic evaluation of 15 studies reporting on the relationship between denial or minimisation of offending and recidivism by adult male sex offenders. The highest quality studies (n = 5) do not find a consistent relationship between these variables. Some support for the view of denial as a protective mechanism against recidivism is found. Four studies exploring categorical denial find no relationship between denial and recidivism, lower recidivism rates by categorical deniers. Higher recidivism rates are found for low static risk and intra-familial offenders in categorical denial. In Chapter 3, predictors of belief in sex offender redeemability are explored in participants working or volunteering with sex offenders, and participants not working or volunteering with offenders. For those working or volunteering with sex offenders, stronger redeemability beliefs were predicted by being less punitive, younger and having a professional role which involved delivering treatment or working with sex offenders in a therapeutic capacity. For participants who did not work or volunteer with offenders, belief in sex offender redeemability was predicted by being less punitive, male, younger and endorsing more situational (rather than dispositional) explanations for sex offending. For female participants, those working or volunteering with sex offenders were less punitive and held stronger redeemability beliefs than females who did not work or volunteer with offenders. This difference was not found for male participants. Chapter 4 describes a strength-based approach to the assessment, formulation and treatment of an adult male sex offender with an intellectual disability in a prison-setting. The client was deemed to have responded positively to the strength-based treatment approach and progress was made in addressing his treatment need relating to offence-supportive attitudes, antisocial peer network and coping skills. Treatment need remained in relation to sexual interests and intimacy deficits. Positives in the strength-based approach included the use of the ‘success wheel’ to encourage focus on pro-social goals, encouragement to develop an adaptive, pro-social identity and the positive impact on the client’s motivation for change. However, restrictions resulting from the prison setting and standardised framework were highlighted in terms of their impact on strength-based practice. Chapter 5 critiques the Risk Matrix 2000 actuarial assessment tool for use with intellectually disabled sex offenders. It finds limited empirical support for using the Risk Matrix 2000 with this population and raises concern that high stake decisions are made based on information from this assessment. Further research to explore its reliability and validity for use with this client group is recommended. The Assessment of Risk Manageability for Intellectually Disabled Individuals who Offend Sexually is highlighted as an assessment tool with stronger empirical support in terms of predictive validity. It is found to be a more ethically defensible tool than the Risk Matrix 2000, given its holistic consideration of strengths in addition to deficits. Chapter 6 concludes that the thesis achieves its overall aims of developing understanding of desistance factors and strength-based approaches to working with sex offenders. A model is developed which proposes several mechanisms through which the desistance process is enabled or impeded for sex offenders. This model incorporates consideration of denial, staff and public attitudes about sex offenders, community reintegration, social capital, self-identity, static risk, supervision, strength-based practice and treatment effectiveness. Future research is recommended to empirically test this model, through further exploration of the potential protective function of denial for sex offenders, exploration of additional variables explaining variation in redeemability beliefs and exploration of the effectiveness of strength-based approaches to assessment and intervention for sex offenders.

Mental health literacy encompasses an individual’s knowledge and attitudes which influence recognition, treatment and management of a mental health problem. Depression is a common mental health problem experienced by university students, but they often do not seek professional help for their mental health, and prefer more informal sources of help. Online interventions to improve students’ mental health literacy could be a useful and engaging mental health promotion strategy in this population, in order to help improve their recognition and appraisal of depression, their ability to respond to it appropriately (either through seeking professional help or applying self-help), and improve their ability to support others experiencing depression. This thesis describes four studies conducted to inform the development of an online mental health literacy intervention tailored for Nottingham-based university students. These studies describe: 1) a systematic review and meta-analysis of website-based interventions for common mental health problems in university students; 2) a survey-based study investigating the profile of depressive, anxiety and hypomanic/manic symptomology in local students; 3) an interview-based study with students about their mental health and well-being since entering university, and their perspectives about help-seeking and self-management; and 4) an exploratory study investigating students’ mental health first aid skills for a hypothetical friend experiencing depression. This, coupled with literature review of student mental health, mental health help-seeking, and mental health literacy, resulted in the development of the pilot online intervention (“Managing Your Mood Online”), which underwent usability testing with a sample of representative end users. This study found the pilot intervention to be acceptable and usable, but with many potential areas for improvement. This thesis concludes with several considerations for future development of the online intervention.

There is a well-established association between thinking and doing and so it is no surprise that thinking about violence can be associated with risk of violent behaviour. Violent thoughts are recognised as a treatment target in many offender treatment programmes, yet given the multi-faceted nature of violent cognition and absence of integrating theory of violent offenders’ cognition it can sometimes be difficult to assess and treat the cognition that is associated with violent behaviour. This research project aims to explore Violent Thoughts and Fantasies (VTF) in a clinical and forensic client group. The thesis begins with a review of violent cognition and related constructs. A systematic review then highlights the role of violent cognition at various stages in the offending process. The main empirical study uses qualitative methodology to explore VTF amongst a sample of mentally disordered offenders detained within a high secure hospital. The thematic analysis yielded four super-ordinate themes which included ‘part of who I am’, ‘emotional regulation’, ‘aware of the need to be careful’ and ‘thinking to doing, to thinking, to doing’. Violent thoughts and fantasies appeared to be integral to one’s self concept and functioned to sustain the individual in some way, depending on individual need. A range of functions of VTF were identified using functional analysis and these included: emotional regulation, dealing with provocation and using VTF to plan or guide violent offending. Consequently, there continues to be a need to carefully assess and manage these experiences as the link between thinking about violence and acting in a violent way continues to be a likely possibility. Clinical implications are directed towards a thorough assessment of VTF, with particular emphasis on assessing the underlying function of VTF and supporting offenders to find alternative ways of addressing the need that the fantasy currently fulfils.

This thesis provides an investigation into the presentation and treatment of childhood maltreatment in adolescents, with a key focus on adolescents with developmental disabilities (DD). A range of methods, including an empirical study, a systematic review, a single case study and a critical evaluation of a psychometric assessment were used to explore this field. The empirical study explores the presentation of childhood maltreatment in a cohort of adolescents with and without DD, within a specialist inpatient setting. The systematic review investigates the effectiveness of psychological treatments for adolescents with a history of childhood maltreatment. The case study explores the effectiveness of an Adapted Sex Offender Treatment Programme (ASOTP) at reducing the risk of sexual re-offending, for a male adolescent with DD and a history of childhood maltreatment. The critical evaluation of the Trauma Symptom Checklist for Children (TSCC) (Briere, 1996) focuses on evaluating the reliability, validity and applicability of the measure for use with adolescents in secure psychiatric settings. The preliminary results of the empirical study found no significant differences between both groups for the dependent measures, however data trends suggested that adolescents with DD display a higher frequency of problematic behaviours. They also displayed some trauma symptoms and emotions more frequently compared with adolescents without DD. The findings of the systematic review were unclear due to methodological issues and bias, however the review showed that Cognitive Behavioural Therapy was not effective at reducing depression but Attachment Based Family Therapy may be an effective intervention for reducing depression and suicidal ideation in adolescents. The case study found that the ASOTP was not effective at reducing the Client’s risk of re-offending. The Client did not engage well with the work and the reasons for this are discussed in relation to the Client’s history of maltreatment and development of personality disorder traits. In the critical evaluation of the TSCC, it is recognised that the TSCC is a strong measure of trauma, however it has not been validated or standardised for use with children/adolescents with DD. The thesis concludes that there are many avenues of research about maltreated adolescents with DD which need to be explored. This research field needs to be substantially developed before clinicians can reap the beneficial clinical implications of the research.

No description available.

A thesis to be submitted in fulfilment of the requirements for the degree of Doctor of Medicine in the Department of Psychiatry and Mental Hygiene, University of the Witwatersrand. / The introduction to the problem covers mainly three sections, namely. Biblical, Historical and Psychological. Various tests are then named and described. This is followed by the section dealing with the Test Results, statistical methods used and finally a summary and conclusion. The summary and conclusion are of necessity brief, and cannot be expected to cover the whole field. Special mention must here be made of & B. Cutten whose book Speaking with Tongues is considered by the present writer to be the most scholarly and extensive account of the historical aspect of GLOSSOLALIA yet systematised. Portions relevant to the present investigation were either quoted in toto or epitomised because the writer felt they could not be improved upon. An intimate knowledge of the historical instances quoted by Cutten is essential to a complete understanding of the scope of the present work. The only originality claimed lies in the selection and presentation of the material to be found in Cutten's invaluable work. Extensive references and/or quotations have also been taken from the works of A. Schweitzer - Mysticism of St. Paul the Apostle and E.B. Tylor - Primitive Culturo, both of whom are regarded as being leaders of thought in their respective fields. / WHSLYP2017

Background: Cognitive impairment is a risk factor for falls in older adults. There is some evidence that the ability to dual-task contributes to maintaining postural stability and that cognitive impairment may impair this ability, thereby increasing falls risk. This research aims to explore physical risk factors associated with cognitive impairment and falls in older adults with mild dementia. Potential interventions for these participants will be searched for, described and theoretically modelled to develop an intervention programme to reduce their falls risk. Methods: A cross-sectional survey described gait, dual-task cost, balance and falls risk characteristics of participants with mild dementia. Potential interventions were identified using two systematic literature reviews. A realist review explored theoretical mechanisms underpinning exercise-based interventions in older adults with dementia. An intervention programme was developed and preliminarily tested during a 6-week, small sample, non-randomised feasibility study. Results: Older adult participants (n 69; mean age 81 years) with mild dementia (mean MoCA 21) had an increased risk of falls (1.5 median falls in previous six months; 2.48 mean physiological profile assessment [PPA] falls risk score), poor gait pattern and reduced balance. Cognition was negatively associated with gait pattern in both in simple walking and dual-task conditions. Exercise was a frequently reported intervention, with combined physical and cognitive exercise-components showing efficacy at improving gait speed (weighted mean difference [WMD] 0.08 [0.03-0.12] Z=3.65 [p≤0.001]) and balance (WMD 1.23 [0.69-1.77] Z=4.48 [p < 0.001]) at a mild stage of cognitive impairment. Physiological-responses and encouragement were identifiable important mechanisms in these interventions. Findings were synthesised into a study protocol. Ten older adults (median age 84, range 69 to 89; 50% women) with mild dementia (median MoCA 21, range 16 to 26) were recruited and completed the developed intervention of combined physical and cognitive exercises. Mean differences between pre- and post-intervention assessment demonstrated improvement in falls risk, balance, and gait. Conclusion: Mixed methods contributed to each component of development for this complex intervention. A combined physical and cognitive exercise-based programme was deliverable, feasible, and acceptable to older adults with mild dementia. A list of clinically-relevant recommendations for the content, delivery, and supervision of this intervention for an adequately powered, and randomised study, was produced.

24 million people worldwide are affected by schizophrenia. Its complex psychopathology, including changes in perception, can incur substantial personal distress and economic burden. Finding appropriate treatment that attracts voluntary adherence is an ongoing challenge for clinicians to prevent relapse and poor prognosis. This thesis conceives the psychiatrist-patient alliance - mediated through talk - as an intervention point that demands analytic attention. Conceptualising ‘good’ communication is however hindered by a lack of a) conceptual clarity on its constituents b) knowledge of what actually happens in psychiatric encounters. Abstract ideals of ‘Patient Centredness’ and ‘Shared Decision Making’ are widely endorsed as beneficial to adherence, but do not pragmatically translate into specific practices, conducive to training. Following a preparatory systematic review, this thesis addresses a gap in literature by observing psychiatric communication in 3 mixed method studies. Synthesising coding methodologies and statistical analyses with principles of conversation analysis, two studies explore the association - and explanatory mechanism - between adherence and specific communication practices: patient other-initiated repair and psychiatrist questions. Treatment decisions, the precursor to adherent behaviour, are also examined: alternative resources that psychiatrists employ and their interactional consequences are mapped, with a focus on patients’ overt resistance. The findings collectively extend knowledge on medical interaction and demonstrate the utility of a novel approach to outcome research in field dominated by cross sectional studies. Clinical, methodological and theoretical contributions are yielded relating to six themes 1) the consequentiality of psychiatrists’ communicative choices 2) the manifestation of alliance and adherence in clinical talk 3) orientations to experiential expertise and the contingencies of antipsychotic medication adherence 4) reconceptualising ‘good’ communication: misalignment as key to clinical success 5) evidence of the interaction order in schizophrenia 6) reconciling the nuances of naturalistic interaction with global clinical outcomes.