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Health-related fear is a normal and common response in the face of the global pandemic of COVID-19. Children and young people are frequently being exposed to messages about the threat to health, including from the media and authorities. Whilst for most, their anxiety will be proportionate to the threat, for some, existing pre-occupation with physical symptoms and illness will become more problematic. There is a growing body of evidence that health anxiety may occur in childhood, however much of the literature is taken from research using adult samples. This practitioner review aims to give an overview of the assessment and treatment of health-related worries in children and young people in the context of the COVID-19 pandemic. This review is based on the limited existing evidence in this population and the more substantial evidence base for treating health anxiety in adults. We consider the adaptations needed to ensure such interventions are developmentally appropriate.

This study aimed to identify the attributes that autistic people perceive as positively and negatively impacting on their identity and wellbeing. In Study 1, we recruited 140 autistic participants for an online survey. Participants completed autism social identification and collective self-esteem measures and listed attributes they associated with autism. In Study 2, we conducted focus groups with 15 autistic people to explore how positively they perceived the attributes of autism. Participants then discussed the autism attributes in relation to their own experiences and identity. We found a positive relationship between the number of positive attributes participants associated with autism, and their collective self-esteem, to the extent that they identified with other autistic people.

Repetitive and restricted behaviours are a core feature of autism, and cognition in autistic individuals may also be repetitive and restricted. We aimed to investigate the relationship between repetitive behaviours and repetitive thinking. We predicted that autistic people would experience more repetitive, perseverative, visual and negative cognition than controls. We predicted that repetitive thinking would be associated with repetitive behaviours in the autistic participants. We recruited autistic ( n = 54) and control ( n = 66) participants who completed measures of insistence on sameness and obsessive-compulsive behaviours. Participants then took part in 5 days of descriptive experiencing sampling, recording their thoughts when a random alarm sounded. Consistent with our hypothesis, autistic participants reported more repetitive thinking. Contrary with our other hypotheses, autistic participants reported equivalent frequency of perseveration, visual thoughts and negative thoughts to non-autistic participants. Moreover, participants who reported more obsessive thinking reported more repetitive behaviour (insistence on sameness), but there was no such relationship between repetitive thinking and behaviour. Autistic participants who reported more repeated thoughts in the descriptive experience sampling had significantly lower obsessive thinking scores. We conclude that anxiety focused cognitions may drive insistence on sameness behaviours, and that the relationship between repetitive cognition and behaviour is complex and warrants further investigation. Lay abstract A core feature of autism is the tendency to do the same activity or behaviour repetitively. We wanted to find out if autistic people also experience repetitive thinking, for example, having the same thoughts repeatedly. We thought that there would be a link between repetitive behaviour and repetitive thinking. We asked 54 autistic people and 66 non-autistic people to complete questionnaires measuring repetitive behaviours and obsessive thinking. Next, participants were trained by a researcher to record their thoughts using a structured paper form. They then completed 5 days of thought recording, which they did each time a random alarm sounded on their mobile phone. We found that autistic people had more repetitive thoughts than non-autistic people, but they did not report having more negative or visual thoughts compared with non-autistic people. Autistic people who had more repetitive thoughts during the 5 days of thought recording did not report more repetitive behaviour. However, autistic people who reported more obsessive thinking, for example, more negative and unwanted thoughts, also reported higher levels of repetitive behaviour. We conclude that some repetitive behaviours may be linked to anxiety and that more research is needed to better understand repetitive behaviours in autism.

Loneliness is a common experience in adolescence and is related to a range of mental health problems. Such feelings may have been increased by social distancing measures introduced during the COVID-19 pandemic. We aimed to investigate the effect of loneliness, social contact, and parent relationships on adolescent mental health during lockdown in the UK. Young people aged 11–16 years (n = 894) completed measures of loneliness, social contact, parent-adolescent relationships, and mental health difficulties during the first 11 weeks of lockdown and one-month later (n = 443). We examined cross-sectional associations and longitudinal relationships between loneliness, social contact, and parent relationships and subsequent mental health. Adolescents who reported higher loneliness had significantly higher symptoms of mental health difficulties during lockdown. We found that adolescents who had closer relationships with their parents reported significantly less severe symptoms of mental health difficulties and lower levels of loneliness. We also found that adolescents who spent more time texting others reported higher symptoms of mental health difficulties. Our hypothesis that loneliness would predict poorer mental health one month later was not supported. Time spent texting others at baseline was significantly associated with higher hyperactivity at follow-up, and closeness to parents was significantly associated with lower psychological distress at follow-up. We conclude that while loneliness was associated with greater mental health difficulties at baseline, it did not predict increased mental health difficulties one month later. Moreover, existing mental health problems significantly predicted later increase, thereby highlighting the importance of continuing support for vulnerable people.

BackgroundPsychological interventions informed by cognitive behavioural theory have proven efficacy in treating mild-moderate anxiety and depression. They have been successfully adapted for autistic children and adults who experience disproportionately high rates of co-occurring emotional problems. There has been little research into the perspectives and experience of psychological therapists adapting cognitive behavioural therapy (CBT) as part of routine clinical practice. We surveyed therapist skills, experience and confidence in working psychologically with autistic people, in order to highlight gaps and needs, as well as strengths in terms of therapist skills when working with this group.MethodFifty therapists attending a training event completed a survey about their experience of adapting CBT for autistic clients, alongside a measure of therapist confidence.ResultsAlmost all therapists reported making adaptations to CBT practice when working with autistic clients. Key challenges identified were rigidity in thinking and pacing sessions appropriately. Therapists were relatively confident about core engagement and assessment skills but reported less confidence in using their knowledge to help this group. Therapist confidence was not associated with years of practice or number of adaptations made, but was positively associated with level of therapy training received.ConclusionsThis study highlights a need for training and ongoing supervision to increase therapist confidence in and ability to make appropriate adaptations to CBT treatment protocols for autistic people.

Background Co-occurring depression frequently occurs in autism. Evidence-based psychological interventions have been successfully adapted to treat co-occurring anxiety, but there is little evidence about the usefulness of adapted cognitive–behavioural therapy for depression. To the authors’ knowledge, to date there have been no randomised trials investigating the usefulness of low-intensity cognitive–behavioural therapy for depression in autism. Objectives The objectives of the study were to (1) develop a low-intensity psychological intervention for depression adapted for autism, (2) assess the feasibility and patient and therapist acceptability of the intervention, (3) estimate the rates of recruitment and retention for a full-scale randomised controlled trial and (4) identify an appropriate measure of depression to be used in a full-scale randomised controlled trial. Design The study comprised a randomised controlled trial (n = 70) with a nested qualitative evaluation (n = 21). Seventy eligible and consenting participants were randomly allocated to guided self-help or to treatment as usual. Setting Adult autism services in two NHS regions. Participants Adults with a diagnosis of autism spectrum disorder with depression, that is, a Patient Health Questionnaire-9 items score of ≥ 10. People who had attended more than six sessions of cognitive–behavioural therapy in the previous 6 months were excluded. Interventions The low-intensity intervention (guided self-help) comprised materials for nine individual sessions, based on behavioural activation adapted for autism, facilitated by therapist guides (coaches) who were graduate-level psychologists who attended training and regular supervision. Treatment as usual was standard NHS care for depression. Main outcome measures Outcomes were measured 10, 16 and 24 weeks post randomisation using self-report and interview measures of depression, anxiety, obsessive–compulsive symptoms, social function and quality of life, and a health-care and service use questionnaire. As this was a feasibility study also designed to identify the most appropriate measure of depression, it was not possible to specify the primary outcome measure or outcome point a priori. Results The aims of the study were met in full. The guided self-help intervention was feasible and well received by participants and coaches. The majority of allocated participants attended the intervention in full. The most practical outcome point was determined to be 16 weeks. There were differential rates of attrition across the treatment groups: 86% of the guided self-help group remained in the study at 24 weeks, compared with 54% of treatment as usual group. The qualitative study suggested that guided self-help had enhanced credibility with participants at the point of randomisation. Inter-rater reliability of the interview measure of depression was less than adequate, limiting the conclusions that can be drawn from the prespecified sensitivity to change analyses. Conclusions The intervention was feasible and well received. Although this feasibility study was not a fully powered trial, it provided some evidence that the guided self-help intervention was effective in reducing depressive symptoms. A full-scale clinical effectiveness and cost-effectiveness trial of the intervention is warranted. Future work Improvements to the intervention materials as a result of qualitative interviews. Stakeholder consultation to consider future trial design, consider strategies to improve retention in a treatment as usual arm and select a self-report measure of depression to serve as the primary outcome measure. Trial registration Current Controlled Trials ISRCTN54650760. Funding This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 23, No. 68. See the NIHR Journals Library website for further project information. This study was also supported by the NIHR Biomedical Research Centre at the University Hospitals Bristol NHS Foundation Trust and the University of Bristol.

Low-intensity cognitive behaviour therapy including behavioural activation is an evidence-based treatment for depression, a condition frequently co-occurring with autism. The feasibility of adapting low-intensity cognitive behaviour therapy for depression to meet the needs of autistic adults via a randomised controlled trial was investigated. The adapted intervention (guided self-help) comprised materials for nine individual sessions with a low-intensity psychological therapist. Autistic adults (n = 70) with depression (Patient Health Questionnaire-9 score ⩾10) recruited from National Health Service adult autism services and research cohorts were randomly allocated to guided self-help or treatment as usual. Outcomes at 10-, 16- and 24-weeks post-randomisation were blind to treatment group. Rates of retention in the study differed by treatment group with more participants attending follow-up in the guided self-help group than treatment as usual. The adapted intervention was well-received, 86% (n = 30/35) of participants attended the pre-defined ‘dose’ of five sessions of treatment and 71% (25/35) attended all treatment sessions. The findings of this pilot randomised controlled trial indicate that low-intensity cognitive behaviour therapy informed by behavioural activation can be successfully adapted to meet the needs of autistic people. Evaluation of the effectiveness of this intervention in a full scale randomised controlled trial is now warranted.

Gender dysphoria is distress due to a discrepancy between one's assigned gender and gender identity. Adults who wish to access gender clinics are assessed to ensure they meet the diagnostic criteria for gender dysphoria. Therefore, the definition of gender dysphoria has a significant impact on the lives of individuals who wish to undergo physical gender transition. This systematic review aimed to identify and synthesize all existing qualitative research literature about the lived experience of gender dysphoria in adults. A pre-planned systematic search identified 1491 papers, with 20 of those meeting full inclusion criteria, and a quality assessment of each paper was conducted. Data pertaining to the lived experience of gender dysphoria were extracted from each paper and a meta-ethnographic synthesis was conducted. Four overarching concepts were identified; distress due to dissonance of assigned and experienced gender; interface of assigned gender, gender identity and society; social consequences of gender identity; internal processing of rejection, and transphobia. A key finding was the reciprocal relationship between an individual's feelings about their gender and societal responses to transgender people. Other subthemes contributing to distress were misgendering, mismatch between gender identity and societal expectations, and hypervigilance for transphobia., Highlights • A systematic review of all papers on the lived experience of gender dysphoria • Twenty papers with 1606 participants were included in a meta-ethnographic synthesis. • Distress was due to gender and sex incongruence, as well as social factors. • Results give new insights into the relationships between factors causing distress.

This article highlights the advantages, opportunities and risks of mobile working for health visitors and organisations, drawing on the experience of a small social enterprise that adopted mobile working among the health visiting workforce. Using methodology from the NHS Institute for Innovation and Improvement's Productive Community Services (PCS) programme, a hybrid module was developed using PCS modules specifically relevant to mobile working to assist the implementation of the project. Important insights are offered into what works well and what issues may need to be resolved, as well as the lessons learnt in the transition to mobile working for health visitors. Findings from this small case study highlight awareness of the wider implications of mobile working and health visiting practice. The study found that the approach taken to support the behavioural and cultural change required to embed mobile working is key and can lead to a continual cycle of improvement.

Background: Experience-based co-design (EBCD) is a methodology for service improvement and development, which puts service-user voices at the heart of improving health services.Aims: The aim of this paper was to implement the EBCD methodology in a mental health setting, and to investigate the challenges which arise during this process.Method: In order to achieve this, a modified version of the EBCD methodology was undertaken, which involved listening to the experiences of the people who work in and use the mental health setting and sharing these experiences with the people who could effect change within the service, through collaborative work between service-users, staff and managers.Results: EBCD was implemented within the mental health setting and was well received by service-users, staff and stakeholders. A number of modifications were necessary in this setting, for example high levels of support available to participants.Conclusions: It was concluded that EBCD is a suitable methodology for ser...

Background: Health anxiety (HA), or hypochondriasis, is a psychological problem characterized by a preoccupation with the belief that one is physically unwell. A 2007 Cochrane review (Thomson and Page, 2007) found cognitive behavioural therapy (CBT) to be an effective intervention for individuals with HA. Similar findings were reported in a recent meta-analysis (Olatunji et al., 2014), which did not employ a systematic search strategy. The current review aimed to investigate the efficacy of CBT for HA, and to update the existing reviews. Method: A systematic search was conducted following Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidance, including randomized controlled trials that compared CBT with a control condition for people with HA. Five hundred and sixty-seven studies were found in the original search, of which 14 were included in the meta-analysis. Results: Meta-analysis was conducted on 21 comparisons and a large effect size for CBT compared with a control condition was found at post therapy d = 1.01 (95% confidence interval 0.77–1.25), as well as at 6- and 12-month follow-up. Conclusions: This systematic review and meta-analysis provides support for the hypothesis that CBT is an effective intervention for HA when compared with a variety of control conditions, e.g. treatment-as-usual, waiting list, medication, and other psychological therapies.

IntroductionHigh rates of co-occurring depression are reported in autism spectrum disorder (ASD), a neurodevelopmental condition characterised by social communication impairments and repetitive behaviours. Cognitive-behavioural interventions adapted for ASD have been effective for anxiety problems. There have been evaluation studies of group cognitive-behavioural therapy for co-occurring depression, but no randomised trials investigating low-intensity psychological interventions as recommended in clinical guidelines for mild-moderate depression.Methods and analysisA feasibility study comprising a randomised controlled trial (RCT) and nested qualitative evaluation is under way as preparation for a definitive RCT. Participants (n=70) will be randomised to Guided Self-Help: a low-intensity psychological intervention based on behavioural activation adapted for ASD or treatment as usual. Outcomes including depression symptoms, anxiety, social function and service use will be measured at 10, 16 and 24 weeks postrandomisation and will be blind to group allocation for measures that are not self-administered. The analysis will aim to establish the rates of recruitment and retention for a larger-scale RCT as well as the most appropriate measure of depression to serve as primary outcome. The qualitative study will purposively sample up to 24 participants from each treatment group to consider the acceptability and feasibility of the intervention and the trial design.Ethics and disseminationEthical approval has been received from WALES REC 3 (IRAS project ID: 191558) and the Health Research Authority with R&D approval from Avon and Wiltshire Mental Health Partnership and Northumberland, Tyne and Wear Foundation NHS Trusts. To our knowledge, this is the first study of a low-intensity intervention for depression in adults with autism. The results will inform the design of a definitive RCT. Dissemination will include peer-reviewed journal publications reporting the quantitative and qualitative research findings of the study and presentations at national and international conferences.Trial registration numberISRCTN54650760; Pre-results.

Background Sex workers were targeted for HIV prevention work from the mid-1980s and budgets were allocated for services and projects with a specific component of HIV prevention. We look at changing trends in service provision in the UK during the 1990s. Methods Two surveys of services for sex workers were conducted: one in 1995 and the other in 1999. We documented different approaches to health promotion through questionnaire and telephone interview at these two points in time, as well as associated funding and support. Results Eighty-one services were identified in 1995 and 124 in 1999. There was an increase in services for young people and those based in genitourinary medicine clinics. Most services conducted outreach and shared a common approach to health promotion, based on harm minimisation. Funding did not change significantly and the major source of support continued to be local health authorities. Conclusion Despite the fact that sex workers are no longer a general priority for HIV prevention work, services have proved to be surprisingly resilient. Projects have developed a holistic approach, linking community intervention to specific health promotion, a model that may prove useful for new government initiatives in relation to health inequalities and social exclusion.