Assessing the impulse control of violent offenders using computer-based cognitive performance tasks

The topic of this thesis is impulsivity. The meaning and measurement of impulse control is explored, with a particular focus on forensic settings. Impulsivity is central to many areas of psychology; it is one of the most common diagnostic criteria of mental disorders and is fundamental to the understanding of forensic personalities. Despite this widespread importance there is little agreement as to the definition or structure of impulsivity, and its measurement is fraught with difficulty owing to a reliance on self-report methods. This research aims to address this problem by investigating the viability of using simple computerised cognitive performance tasks as complementary components of a multi-method assessment strategy for impulse control. Ultimately, the usefulness of this measurement strategy for a forensic sample is assessed. Impulsivity is found to be a multifaceted construct comprised of a constellation of distinct sub-dimensions. Computerised cognitive performance tasks are valid and reliable measures that can assess impulsivity at a neuronal level. Self-report and performance task methods assess distinct components of impulse control and, for the optimal assessment of impulse control, a multi-method battery of self-report and performance task measures is advocated. Such a battery is shown to have demonstrated utility in a forensic sample, and recommendations for forensic assessment in the Irish context are discussed.

At what price? A cost-effectiveness analysis comparing trial of labour after previous caesarean versus elective repeat caesarean delivery

Background: Elective repeat caesarean delivery (ERCD) rates have been increasing worldwide, thus prompting obstetric discourse on the risks and benefits for the mother and infant. Yet, these increasing rates also have major economic implications for the health care system. Given the dearth of information on the cost-effectiveness related to mode of delivery, the aim of this paper was to perform an economic evaluation on the costs and short-term maternal health consequences associated with a trial of labour after one previous caesarean delivery compared with ERCD for low risk women in Ireland.Methods: Using a decision analytic model, a cost-effectiveness analysis (CEA) was performed where the measure of health gain was quality-adjusted life years (QALYs) over a six-week time horizon. A review of international literature was conducted to derive representative estimates of adverse maternal health outcomes following a trial of labour after caesarean (TOLAC) and ERCD. Delivery/procedure costs derived from primary data collection and combined both "bottom-up" and "top-down" costing estimations.Results: Maternal morbidities emerged in twice as many cases in the TOLAC group than the ERCD group. However, a TOLAC was found to be the most-effective method of delivery because it was substantially less expensive than ERCD ((sic)1,835.06 versus (sic)4,039.87 per women, respectively), and QALYs were modestly higher (0.84 versus 0.70). Our findings were supported by probabilistic sensitivity analysis.Conclusions: Clinicians need to be well informed of the benefits and risks of TOLAC among low risk women. Ideally, clinician-patient discourse would address differences in length of hospital stay and postpartum recovery time. While it is premature advocate a policy of TOLAC across maternity units, the results of the study prompt further analysis and repeat iterations, encouraging future studies to synthesis previous research and new and relevant evidence under a single comprehensive decision model.