Issues in the prescribing of psychotropic and psychoactive medication for persons with learning disability: quantitative and qualitative perspectives

The administration of psychotropic and psychoactive medication for persons with learning disability and accompanying mental illness and/or challenging behaviour has undergone much critical review over the past two decades. Assessment and diagnosis of mental illness in this population continues to be psychopharmacological treatment include polypharmacy, irrational prescription procedures and frequent over-prescription. It is clear that all forms of treatment including non-pharmacological interventions need to be driven by accurate and appropriate diagnoses. Where a psychiatric diagnosis has been identified, it greatly aides the selection of appropriate medication, although a specific medication for each diagnosis, as was once hoped, is simply no longer a reality in practice. Part one of the present thesis seeks to address many of the current issues in mental health problems and pharmacological treatment to date. The author undertook a drug prevalence study within both residential and community facilities for persons with learning disability within the Mid-West region of Ireland in order to ascertain the current level of prescribing of psychotropic and psychoactive medications for this population. While many attempts have been made to account for the variation in prescribing, little systematic and empirical research has been undertaken to investigate the factors thought to influence such prescribing. While studies investigating the prescribing behaviours of General Practitioners (GP's) have illustrated the complex nature of the decision making process in the context of general practice, no similar efforts have yet been directed at examining the prescribing behaviours of Consultant Psychiatrists. Using The Critical Incident Technique, the author interviewed Consultant Psychiatrists in the Republic of Ireland to gather information relating not only to their patterns of prescribing for learning disabled populations, but also to examine reasons influencing their prescribing in addition to several related factors. Part two of this thesis presents the findings from this study and a number of issues are raised, not only in relation to attempting to account for the findings from part one of the thesis, but also with respect to implications for improved management and clinical practice.

Deer forests, game shooting and landed estates in the South West of Ireland, 1840 - 1970

This thesis is concentrated on the historical aspects of the elitist field sports of deer stalking and game shooting, as practiced by four Irish landed ascendancy families in the south west of Ireland. Four great estates were selected for study. Two of these were, by Irish standards, very large: the Kenmare estate of over 136,000 acres in the ownership of the Roman Catholic Earls of Kenmare, and the Herbert estate of over 44,000 acres in the ownership of the Protestant Herbert family. The other two were, in relative terms, small: the Grehan estate of c.7,500 acres in the ownership of the Roman Catholic Grehan family, and the Godfrey estate of c.5,000 acres, in the ownership of the Protestant Barons Godfrey. This mixture of contrasting estate size, owner's religions, nobleman, minor aristocrat and untitled gentry should, it is argued, yield a diversity of the field sports and lifestyles of their owners, and go some way to assess the contributions, good or bad, they have bequeathed to modern Ireland. Equally, it should help in assessing what importance, if any, applied to hunting. In this context, hunting is here used in its broadest meaning, and includes deer stalking and game shooting, as well as hunting with dogs and hounds on foot and horseback. Where a specific type of hunting is involved, it is so described; for example, fox hunting, stag hunting, hare hunting. Similarly, the term game is sometimes used in sporting literature to encompass all species of quarry killed, and can include deer, ground game (hares and rabbits), waterfowl, and various species of game birds. Where it refers to specific species, these are so described; for example grouse, pheasants, woodcork, wild duck, etc. Since two of these estates - the Kenmare and Herbert - each created a deer forest, unique in mid-19th century Ireland, they form the core study estates; the two smaller estates serve as comparative studies. And, equally unique, as these two larger estates held the only remnant population of native Irish red deer, the survival of that herd itself forms a concomitant core area of analysis. The numerary descriptions applied to these animals in popular literature are critically reassessed against prime source historical evidence, as are the so-called deer forest 'clearances'. The core period, 1840 to 1970, is selected as the seminal period, spanning 130 years, from the creation of the deer forests to when a fundamental change in policy and administration was introduced by the state. Comparison is made with similar estates elsewhere, in Britain and especially in Scotland. Their influence on the Irish methods and style of hunting is historically examined.

The transformation of Ireland 1958 - 93: the role of ideas in punctuating institutional path dependency at critical junctures

Ireland experienced two critical junctures when its economic survival was threatened: 1958/9 and 1986/7. Common to both crises was the supplanting of long established practices, that had become an integral part of the political culture of the state, by new ideas that ensured eventual economic recovery. In their adoption and implementation these ideas also fundamentally changed the institutions of state – how politics was done, how it was organised and regulated. The end result was the transformation of the Irish state. The main hypothesis of this thesis is that at those critical junctures the political and administrative elites who enabled economic recovery were not just making pragmatic decisions, their actions were influenced by ideas. Systematic content analysis of the published works of the main ideational actors, together with primary interviews with those actors still alive, reveals how their ideas were formed, what influenced them, and how they set about implementing their ideas. As the hypothesis assumes institutional change over time historical institutionalism serves as the theoretical framework. Central to this theory is the idea that choices made when a policy is being initiated or an institution formed will have a continuing influence long into the future. Institutions of state become ‘path dependent’ and impervious to change – the forces of inertia take over. That path dependency is broken at critical junctures. At those moments ideas play a major role as they offer a set of ready-made solutions. Historical institutionalism serves as a robust framework for proving that in the transformation of Ireland the role of ideas in punctuating institutional path dependency at critical junctures was central.

The Viking age glass beads of Ireland and their North Atlantic context

Hitherto, the majority of studies which have included the discussion of Viking glass beads have mainly focused on the assemblages from individual sites, with limited use of known parallels. Exceptions to this include recent publications regarding the Icelandic material and Callmer’s 1977 catalogue of the finds from mainland Scandinavia, now over thirty years old. Analysis of these finds from Ireland was, for the most part, non-existent. The aim of this research is to address this lack of analysis within Ireland, while incorporating the wider context of the beads within the Viking North Atlantic. The research thus examines the use of glass beads of diagnostically Scandinavian manufacture and import found in Ireland, particularly in relation to their context and distribution. The history of research from Ireland as well as from across the Viking world is considered and explored throughout the thesis, with critique of methods and discussions used. Focussed analysis of both published and unpublished material detailing artefacts from Scandinavia (especially Vestfold), Britain, Iceland, the Faroe Islands and L’Anse aux Meadows is presented within the thesis in order to provide the greater picture for the core section of the thesis, the glass beads found in Ireland. Three appendices are included within Volume 2, databases of the glass beads under discussion from Ireland, the Vestfold region graves in Norway and the topsoil finds from the Kaupang trading place, also located within Vestfold. These appendices therefore represent the first-hand analysis of glass beads by the author. In total, this research represents the most up-to-date analysis of Viking glass beads from Ireland and presents a new look at the patterns of use, trade and interpersonal contact that affected the everyday lives of individuals living within Viking Age Ireland.

Impact of the smoke-free workplace legislation on smoking behaviour, risk perception & stigmatisation

The Republic of Ireland became the first European country to implement nationwide smoke-free workplace legislation. Aims: To determine prevalence of smoking among bar workers and estimate the impact of the smoke-free workplace legislation on their smoking behaviour to that of a comparable general population sample. To approximate the influence of tobacco control measures on risk perception of second-hand smoke (SHS) among the general population. To explore the de-normalisation of smoking behaviour and the potential increased stigmatisation of smokers and their smoking. Methods: Prevalence estimates and behavioural changes were examined among a random sample of bar workers before and 1 year after the smoke-free legislation; comparisons made with a general population sub-sample. Changes in risk knowledge related to SHS exposure were based on general population data. Qualitative interviews were conducted among a purposive sample of smokers and non-smokers four years after the implementation of the legislation. Results: Smoking prevalence was extremely high among bar workers. Smoking prevalence dropped in bar workers and significantly among the general population 1 year post ban while cigarette consumption dropped significantly among bar workers. Disparity in knowledge between smokers and non-smoker of risk associated with SHS exposure reduced. Lack of understanding of the risk of ear infections in children posed by SHS exposure was notable. Evidence for advanced de-normalisation of smoking behaviour and intensification of stigma because of the introduction of the legislation was dependent on many factors, quality of smoking facilities played a key role. Conclusions: Ireland’s smoke-free legislation was associated with a drop in prevalence and cigarette consumption. Disparity in knowledge between smokers and non-smokers of the risk posed by SHS exposure reduced however the risk of ear infections in children needs to be effectively disseminated. The proliferation of ‘good’ smoking areas may diminish the potential to reduce smoking behaviour and de-normalise smoking.

The development of a model of continuing professional development for teachers of primary science

A new science curriculum was introduced to primary schools in the Republic of Ireland in 2003. This curriculum, broader in scope than its 1971 predecessor (Curaclam na Bunscoile, 1971), requires teachers at all levels of primary school to teach science. A review carried out in 2008 of children’s experiences of this curriculum found that its implementation throughout the country was uneven. This finding, together with the increasing numbers of teachers who were requesting support to implement this curriculum, suggested the need for a review of Irish primary teachers’ needs in the area of science. The research study described in this thesis was undertaken to establish the extent of Irish primary teachers’ needs in the area of science by conducting a national survey. The data from this survey, together with data from international studies, were used to develop a theoretical framework for a model of Continuing Professional Development (CPD). This theoretical framework was used to design the Whole- School, In-School (WSIS) CPD model which was trialled in two case-study schools. The participants in these ‘action-research’ case-studies acted as co-researchers, who contributed to the development and evolution of the CPD model in each school. Analysis of the data gathered as part of the evaluation of the Whole-School, In- School (WSIS) model of CPD found an improved experience of science for children and improved confidence for teachers teaching at all levels of the primary school. In addition, a template for the establishment of a culture of collaborative CPD in schools has been developed from an analysis of the data

Assessment of dietary background exposure of the Irish adult population to dioxins and PCBs particularly taking into account additional exposure due to the 2008 Irish dioxin food contamination incident

Irish monitoring data on PCDD/Fs, DL-PCBs and Marker PCBs were collated and combined with Irish Adult Food Consumption Data, to estimate dietary background exposure of Irish adults to dioxins and PCBs. Furthermore, all available information on the 2008 Irish pork dioxin food contamination incident was collated and analysed with a view to evaluate any potential impact the incident may have had on general dioxin and PCB background exposure levels estimated for the adult population in Ireland. The average upperbound daily intake of Irish adults to dioxins Total WHO TEQ (2005) (PCDD/Fs & DLPCBs) from environmental background contamination, was estimated at 0.3 pg/kg bw/d and at the 95th percentile at 1 pg/kg bw/d. The average upperbound daily intake of Irish adults to the sum of 6 Marker PCBs from environmental background contamination ubiquitous in the environment was estimated at 1.6 ng/kg bw/d and at the 95th percentile at 6.8 ng/kg bw/d. Dietary background exposure estimates for both dioxins and PCBs indicate that the Irish adult population has exposures below the European average, a finding which is also supported by the levels detected in breast milk of Irish mothers. Exposure levels are below health based guidance values and/or Body Burdens associated with the TWI (for dioxins) or associated with a NOAEL (for PCBs). Given the current toxicological knowledge, based on biomarker data and estimated dietary exposure, general background exposure of the Irish adult population to dioxins and PCBs is of no human health concern. In 2008, a porcine fat sample taken as part of the national residues monitoring programme led to the detection of a major feed contamination incidence in the Republic of Ireland. The source of the contamination was traced back to the use of contaminated oil in a direct-drying feed operation system. Congener profiles in animal fat and feed samples showed a high level of consistency and pinpointed the likely source of fuel contamination to be a highly chlorinated commercial PCB mixture. To estimate additional exposure to dioxins and PCBs due to the contamination of pig and cattle herds, collection and a systematic review of all data associated with the contamination incident was conducted. A model was devised that took into account the proportion of contaminated product reaching the final consumer during the 90 day contamination incident window. For a 90 day period, the total additional exposure to Total TEQ (PCDD/F &DL-PCB) WHO (2005) amounted to 407 pg/kg bw/90d at the 95th percentile and 1911 pg/kg bw/90d at the 99th percentile. Exposure estimates derived for both dioxins and PCBs showed that the Body Burden of the general population remained largely unaffected by the contamination incident and approximately 10 % of the adult population in Ireland was exposed to elevated levels of dioxins and PCBs. Whilst people in this 10 % cohort experienced quite a significant additional load to the existing body burden, the estimated exposure values do not indicate approximation of body burdens associated with adverse health effects, based on current knowledge. The exposure period was also limited in time to approximately 3 months, following the FSAI recall of contaminated meat immediately on detection of the contamination. A follow up breast milk study on Irish first time mothers conducted in 2009/2010 did not show any increase in concentrations compared to the study conducted in 2002. The latter supports the conclusion that the majority of the Irish adult population was not affected by the contamination incident.

Anticipatory vigilance: A classic grounded theory of risk reduction and management in the perioperative setting

This research aimed to investigate the main concern facing nurses in minimising risk within the perioperative setting and to generate an explanatory substantive theory of how they resolve this through anticipatory vigilance. In the context of the perioperative setting, nurses encounter challenges in minimising risks for their patients on a continuous basis. Current explanations of minimising risk in the perioperative setting offers insights into how perioperative nurses undertake their work. Currently research in minimising risk is broadly related to dealing with errors as opposed to preventing them. To date, little is known about how perioperative nurses practice and maintain safety. This study was guided by the principles of classic grounded theory as described by Glaser (1978, 1998, 2001). Data was collected through individual unstructured interviews with thirty seven perioperative nurses (with varying lengths of experiences of working in the area) and thirty three hours of non-participant observation within eight different perioperative settings in the Republic of Ireland. Data was simultaneously collected and analysed. The theory of anticipatory vigilance emerged as the pattern of behaviour through which nurse’s deal with their main concern of minimising risk in a high risk setting. Anticipatory vigilance is enacted through orchestrating, routinising and momentary adapting within a spirit of trusting relations within the substantive area of the perioperative setting. This theory of offers an explanation on how nurses resolve their main concern of minimising risk within the perioperative setting. The theory of anticipatory vigilance will be useful to nurses in providing a comprehensive framework of explanation and understanding on how nurses deal with minimising risk in the perioperative setting. The theory links perioperative nursing, risk and vigilance together. Clinical improvements through understanding and awareness of the theory of anticipatory vigilance will result in an improved quality environment, leading to safe patient outcomes.

The treatment of landfill leachate using natural systems

Leachate may be defined as any liquid percolating through deposited waste and emitted from or contained within a landfill. If leachate migrates from a site it may pose a severe threat to the surrounding environment. Increasingly stringent environmental legislation both at European level and national level (Republic of Ireland) regarding the operation of landfill sites, control of associated emissions, as well as requirements for restoration and aftercare management (up to 30 years) has prompted research for this project into the design and development of a low cost, low maintenance, low technology trial system to treat landfill leachate at Kinsale Road Landfill Site, located on the outskirts of Cork city. A trial leachate treatment plant was constructed consisting of 14 separate treatment units (10 open top cylindrical cells [Ø 1.8 m x 2.0 high] and four reed beds [5.0m x 5.0m x 1.0m]) incorporating various alternative natural treatment processes including reed beds (vertical flow [VF] and horizontal flow [HF]), grass treatment planes, compost units, timber chip units, compost-timber chip units, stratified sand filters and willow treatment plots. High treatment efficiencies were achieved in units operating in sequence containing compost and timber chip media, vertical flow reed beds and grass treatment planes. Pollutant load removal rates of 99% for NH4, 84% for BOD5, 46% for COD, 63% for suspended solids, 94% for iron and 98% for manganese were recorded in the final effluent of successfully operated sequences at irrigation rates of 945 l/m2/day in the cylindrical cells and 96 l/m2/day in the VF reed beds and grass treatment planes. Almost total pathogen removal (E. coli) occurred in the final effluent of the same sequence. Denitrification rates of 37% were achieved for a limited period. A draft, up-scaled leachate treatment plant is presented, based on treatment performance of the trial plant.

Environmental and biological characteristics of lagoons on the southwest coast of Ireland

Coastal lagoons are defined as shallow coastal water bodies partially separated from the adjacent sea by a restrictive barrier. Coastal lagoons are protected under Annex I of the European Habitats Directive (92/43/EEC). Lagoons are also considered to be “transitional water bodies” and are therefore included in the “register of protected areas” under the Water Framework Directive (2000/60/EC). Consequently, EU member states are required to establish monitoring plans and to regularly report on lagoon condition and conservation status. Irish lagoons are considered relatively rare and unusual because of their North Atlantic, macrotidal location on high energy coastlines and have received little attention. This work aimed to assess the physicochemical and ecological status of three lagoons, Cuskinny, Farranamanagh and Toormore, on the southwest coast of Ireland. Baseline salinity, nutrient and biological conditions were determined in order to provide reference conditions to detect perturbations, and to inform future maintenance of ecosystem health. Accumulation of organic matter is an increasing pressure in coastal lagoon habitats worldwide, often compounding existing eutrophication problems. This research also aimed to investigate the in situ decomposition process in a lagoon habitat together with exploring the associated invertebrate assemblages. Re-classification of the lagoons, under the guidelines of the Venice system for the classifications of marine waters according to salinity, was completed by taking spatial and temporal changes in salinity regimes into consideration. Based on the results of this study, Cuskinny, Farranamanagh and Toormore lagoons are now classified as mesohaline (5 ppt – 18 ppt), oligohaline (0.5 ppt – 5 ppt) and polyhaline (18 ppt – 30 ppt), respectively. Varying vertical, longitudinal and transverse salinity patterns were observed in the three lagoons. Strong correlations between salinity and cumulative rainfall highlighted the important role of precipitation in controlling the lagoon environment. Maximum effect of precipitation on the salinity of the lagoon was observed between four and fourteen days later depending on catchment area geology, indicating the uniqueness of each lagoon system. Seasonal nutrient patterns were evident in the lagoons. Nutrient concentrations were found to be reflective of the catchment area and the magnitude of the freshwater inflow. Assessment based on the Redfield molar ratio indicated a trend towards phosphorus, rather than nitrogen, limitation in Irish lagoons. Investigation of the decomposition process in Cuskinny Lagoon revealed that greatest biomass loss occurred in the winter season. Lowest biomass loss occurred in spring, possibly due to the high density of invertebrates feeding on the thick microbial layer rather than the decomposing litter. It has been reported that the decomposition of plant biomass is highest in the preferential distribution area of the plant species; however, no similar trend was observed in this study with the most active zones of decomposition varying spatially throughout the seasons. Macroinvertebrate analysis revealed low species diversity but high abundance, indicating the dominance of a small number of species. Invertebrate assemblages within the lagoon varied significantly from communities in the adjacent freshwater or marine environments. Although carried out in coastal lagoons on the southwest coast of Ireland, it is envisaged that the overall findings of this study have relevance throughout the entire island of Ireland and possibly to many North Atlantic coastal lagoon ecosystems elsewhere.

Health in the medieval world: Regionality and the bioarchaeology of Ireland and Britain

This study assesses regional health patterns in early medieval Ireland and Britain by analysing and interpreting palaeopathological indicators of stress. This was achieved by incorporating the results of demographic and palaeopathological study into the specific historical contexts. Although relatively small islands, both are home to unique and diverse cultural, physical, and political landscapes, which could potentially affect the general health of the population in different ways. To accurately answer the research question, a bioarchaeological survey of six regions within both islands was carried out, specifically analysing and comparing the demographic profile and general health trends within each region with one another. Results from the analysis have demonstrated statistically significant differences within and between the islands. Inferring that even the more subtle differences observed within the cultural, physical, and political landscapes, such as in the case of Ireland and Britain, can and do affect general health trends. The health of early medieval Ireland and Britain appears to be significantly affected by the physical landscape, specifically a north/south divide. The most northerly regions, Scotland South and Ireland North, manifested higher levels of stress indicators when compared to the more southerly positioned regions. Although it can only be hypothesised what factors within these regions are causing, enhancing or buffering stress, the study has established the potential and necessity for regional work to be continued when interpreting the historical past of these two islands.

Research into the potential of short interventions in promoting well-being among adolescents

The present research examines the issue of universal interventions designed to enhance wellbeing among a community-based adolescent population. The first phase saw a cross-sectional survey conducted among Transition Year students in 13 secondary schools in Cork city and county, Republic of Ireland, with a view towards identifying dimensions linked with wellbeing (operationalised as subjective happiness, life satisfaction, and depressive symptoms) and which might prove effective in informing intervention approaches. Arising from this, mindfulness, gratitude, and cognitive-behavioural dimensions emerged as predictors of wellbeing, and short interventions (four sessions/four weeks) informed by each were conducted with participant groups in three secondary schools, one intervention in each school. Results from statistical analysis showed that the mindfulness and cognitive-behavioural interventions facilitated significant reductions in depressive symptoms among active condition participants at post-test, but that these benefits were not sustained over time, while no statistically significant changes were detected on subjective happiness and life satisfaction. The gratitude intervention was found to have had no effect on the three outcome variables. The findings are discussed in the context of theory and past research, while limitations, implications, and possible future directions are also addressed.

Childhood obesity in Ireland: recent trends and modifiable determinants

Background: Childhood obesity is a global epidemic posing a significant threat to the health and wellbeing of children. To reverse this epidemic, it is essential that we gain a deeper understanding of the complex array of driving factors at an individual, family and wider ecological level. Using a social-ecological framework, this thesis investigates the direction, magnitude and contribution of risk factors for childhood overweight and obesity at multiple levels of influence, with a particular focus on diet and physical activity. Methods: A systematic review was conducted to describe recent trends (from 2002-2012) in childhood overweight and obesity prevalence in Irish school children from the Republic of Ireland. Two datasets (Cork Children’s Lifestyle [CCLaS] Study and the Growing Up in Ireland [GUI] Study) were used to explore determinants of childhood overweight and obesity. Individual lifestyle factors examined were diet, physical activity and sedentary behaviour. The determinants of physical activity were also explored. Family factors examined were parental weight status and household socio-economic status. The impact of food access in the local area on diet quality and body mass index (BMI) was investigated as an environmental level risk factor. Results: Between 2002 and 2012, the prevalence of childhood overweight and obesity in Ireland remained stable. There was some evidence to suggest that childhood obesity rates may have decreased slightly though one in four Irish children remained either overweight or obese. In the CCLaS study, overweight and obese children consumed more unhealthy foods than normal weight children. A diet quality score was constructed based on a previously validated adult diet score. Each one unit increase in diet quality was significantly associated with a decreased risk of childhood overweight and obesity. Individual level factors (including gender, being a member of a sports team, weight status) were more strongly associated with physical activity levels than family or environmental factors. Overweight and obese children were more sedentary and less active than normal weight children. There was a dose response relationship between time spent at moderate to vigorous physical activity (MVPA) and the risk of childhood obesity independent of sedentary time. In contrast, total sedentary time was not associated with the risk of childhood obesity independent of MVPA though screen time was associated with childhood overweight and obesity. In the GUI Study, only one in five children had 2 normal weight parents (or one normal weight parent in the case of single parent families). Having overweight and obese parents was a significant risk factor for overweight and obesity regardless of socio-economic characteristics of the household. Family income was not associated with the odds of childhood obesity but social class and parental education were important risk factors for childhood obesity. Access to food stores in the local environment did not impact dietary quality or the BMI of Irish children. However, there was some evidence to suggest that the economic resources of the family influenced diet and BMI. Discussion: Though childhood overweight and obesity rates appear to have stabilised over the previous decade, prevalence rates are unacceptably high. As expected, overweight and obesity were associated with a high energy intake and poor dietary quality. The findings also highlight strong associations between physical inactivity and the risk of overweight and obesity, with effect sizes greater than what have been typically found in adults. Important family level determinants of childhood overweight and obesity were also identified. The findings highlight the need for a multifaceted approach, targeting a range of modifiable determinants to tackle the problem. In particular, policies and interventions at the shared family environment or community level may be an effective mean of tackling this current epidemic.

A nation preferring visions: moving statues, apparitions and vernacular religion in contemporary Ireland

This thesis examines important issues of Irish vernacular Catholicism, Irish religious and cultural identities, the impacts of modernity plus socio-religious and economic change on traditional religiosity, sacred landscape and topophilia, religious material culture, folk and individual creativity, gender roles and expectations, and devotional subcultures through the vehicle of Marian apparitions and their aftermath in the Republic of Ireland in the late 20th and early 21st centuries. This thesis examines in detail five Irish Marian shrines as case studies; Knock shrine (Co. Mayo), Ballinspittle and Mitchelstown grottoes (Co. Cork), Mount Melleray grotto (Co. Waterford) and the Marian shrines of Inchigeela in West Cork and the attached houses of prayer. Key themes include; vernacular religious theory; the nature of Irish indigenous Catholicism; local, global and transnational trends in contemporary Irish devotional life; areas of individual creativity, fluidity and agency in Marian devotion; and the vital role and influence of material culture in and on local and individual religiosity.