Search

Background Differences in the way autistic children experience the world can contribute to anxiety and stress. Carol Gray’s Social Stories™ are a highly personalised intervention to support children by providing social information about specific situations in an individual story. Objectives This randomised controlled trial aimed to establish whether Social Stories are clinically effective and cost-effective in improving social responsiveness and social and emotional health in children on the autism spectrum in schools. Design A multisite pragmatic cluster randomised controlled trial comparing Social Stories with care as usual. Setting Eighty-seven schools (clusters) across Yorkshire and the Humber. Participants Two hundred and forty-nine children were randomised via a bespoke system hosted at York Trials Unit (129 Social Stories and 120 care as usual). Recruitment was completed in May 2021. Participants were children aged 4–11 years with a diagnosis of autism, alongside teachers, interventionists and caregivers. Recruitment was via schools, NHS trusts, support groups and local publicity. Intervention The intervention included training for educational professionals and caregivers covering psychoeducation and implementation of Social Stories. Stories were written around contextualised goals around the child’s need for social information. Interventionists read the Social Story™ with the child at least six times over 4 weeks during school. Main outcome measure The primary outcome was the Social Responsiveness Scale-2 completed by teachers at 6 months (the primary end point), which measures social awareness, cognition, communication and behaviour. Data were collected from caregivers and educational professionals at 6 weeks and 6 months through questionnaires. Blinding of participants was not possible. Results At 6 months, the estimated difference in expected teacher-reported Social Responsiveness Scale-2 T-score (the primary end point) was −1.61 (95% confidence interval −4.18 to 0.96, p = 0.220), slightly favouring the intervention group. The estimated differences for the parent-reported secondary outcomes at 6 months were small and generally favoured the control group except the measure of children’s quality-adjusted life-year (+ 0.001, 95% confidence interval −0.032 to 0.035) and parental stress (−1.49, 95% confidence interval −5.43 to 2.46, p = 0.460), which favoured the intervention group. Children in the intervention group met their individual goals more frequently than children who received usual care alone (0.97 confidence interval 0.21 to 1.73, p = 0.012). The intervention is likely to save small costs (−£191 per child, 95% confidence interval −767.7 to 337.7) and maintain a similar quality of life compared to usual care. The probability of Social Stories being a preferred option is 75% if the society is willing to pay £20,000 per quality-adjusted life-year gained. Limitations include considerable disruptions during the coronavirus disease 2019 pandemic. Conclusion Social Stories are used in schools and represent a low-cost intervention. There is no clinically evident impact on social responsiveness, anxiety and/or depression, parental stress or general health. Benefits were observed for specific behavioural goals as assessed by the teacher, and Social Stories may serve as a useful tool for facilitating dialogue between children and school staff to address specific behavioural challenges. Usage should be at the school’s discretion. Future work Given the uncertainty of the results in light of coronavirus disease 2019, further work to establish the impact of Social Stories is merited. Trial registration This trial is registered as ISRCTN11634810. Funding This award was funded by the National Institute for Health and Care Research (NIHR) Health Technology Assessment programme (NIHR award ref: 16/111/91) and is published in full in Health Technology Assessment; Vol. 28, No. 39. See the NIHR Funding and Awards website for further award information. Plain language summary Autism affects the way children experience the world, and some children find social situations stressful. We wanted to know whether Social Stories™, developed by Carol Gray, helped children with their social skills and behaviour in school and whether they offered value for money. A randomised controlled trial design was used, which gave schools an equal chance of being asked to deliver Social Stories or to continue providing care as usual. Two hundred and forty-nine children from 87 schools took part and we trained school staff and parents to write and deliver Social Stories. We agreed with teachers and parents, what each child needed help with and wrote stories with this in mind. Trained staff read the Social Story with the child at least six times over 4 weeks. Follow-up information was collected from parents and school staff at the start of the study, after 6 weeks and 6 months. After 6 months, teachers completed a questionnaire called the Social Responsiveness Scale-2 which measures the child’s social skills. Using these measures, the results suggest that Social Stories do not lead to any significant changes in social skills, mental health, parent stress, general health or quality of life but children in schools allocated to Social Stories met their goal more frequently and incurred less costs than children who did not. Parents and educational professionals found the Social Stories intervention and training beneficial. Based on our findings, Social Stories do not appear to improve general social skills in primary-aged autistic children. Benefits were observed for specific goals, and school-based costs were reduced. Scientific summary Sections of this summary have been adapted from the trial protocol by Wright et al. (Wright B, Teige C, Watson J, Hodkinson R, Marshall D, Varley D, et al. Autism Spectrum Social Stories In Schools Trial 2 (ASSSIST2): study protocol for a randomised controlled trial analysing clinical and cost effectiveness of Social Stories™ in primary schools. BMC Psychol 2020;8:60. https://doi.org/10.1186/s40359-020-00427-z). This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/4.0), which permits unrestricted use, distribution and reproduction in any medium provided the original work is properly credited. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article unless otherwise stated. Background Children on the autism spectrum experience a higher prevalence of mental health problems than typically developing children, including anxiety and low mood. Many children on the autism spectrum struggle to manage social anxiety and feelings of frustration, which can lead to behaviours that challenge them. The International Society for Autism Research (INSAR) has highlighted that more research evaluating early interventions for children on the autism spectrum is needed to ensure practitioners and policy-makers have robust data on intervention effectiveness and implementation to secure optimal outcomes for children. One intervention that attempts to alleviate social difficulties while not being intrusive, time-consuming or requiring extensive involvement from experts is Carol Gray’s Social Stories™. Social Stories are a highly personalised intervention aiming to share accurate, meaningful information about a particular goal or topic that the child needs help with in a positive and reassuring way. Social Stories can be written and delivered by both parents and professionals in a range of settings and represent a less time-consuming and intrusive intervention than alternatives. Previous studies examining the use of Social Stories have yielded mostly positive results but have largely been single-case studies with a lack of evidence from randomised controlled trials (RCTs). Despite the lack of rigorous evidence, numerous schools and families are already accessing Social Stories training and delivering the intervention with children and therefore a fully powered trial is timely. Schools have limited resources and limited access to specialist practitioner interventions, and therefore it is important that interventions such as Social Stories undergo robust evaluation. If they are found to be clinically effective and cost-effective, they can be delivered within schools on a day-to-day basis. Objectives The aim was to assess whether Social Stories alongside care as usual is clinically effective and cost-effective in improving child social impairment, reducing anxiety and improving social and emotional health in children on the autism spectrum in primary and special educational needs (SEN) schools when compared with care as usual alone. Primary objective The primary objective of the study was to establish whether Social Stories can improve social responsiveness in children on the autism spectrum in primary schools across Yorkshire and the Humber, when compared to children who have received care as usual only. Social responsiveness can be broadly defined as social awareness, social cognition, social communication, social motivation and mannerisms. Secondary objectives The secondary objectives of this trial were: to investigate whether Social Stories can reduce behaviours that challenge children on the autism spectrum in primary schools to investigate whether Social Stories can improve social and emotional health in children on the autism spectrum in primary schools to assess the cost effectiveness of Social Stories to examine the effects of Social Stories delivered in the classroom on general measures of health-related quality of life to examine whether Social Stories improve classroom attendance to assess sustainability of Social Stories in an educational setting across a 6-month period to examine any changes in parental stress to examine any associations between treatment preference and outcomes to examine how elements of session delivery (e.g. session frequency, length and any associated problems/adverse events) are associated with outcomes. Methods This trial was a multisite pragmatic cluster RCT comparing Social Stories and care as usual with a control group receiving care as usual alone. Care as usual is defined as the existing support routinely provided for a child with autism spectrum condition (ASC) from educational and health services such as specialist autism teacher teams, mental health teams or other associated professionals. The trial included an internal pilot, economic evaluation and a nested process evaluation. Setting The Social Stories intervention was primarily delivered within educational settings by educational professionals. Educational settings included both mainstream primary schools and SEN schools. Parents/caregivers were invited to receive Social Stories training and had the option of also delivering the intervention within the home. Participants Inclusion criteria The child was aged 4–11 years at the time of recruitment. The child attended a participating primary or SEN school within Yorkshire and the Humber. The child has a clinical diagnosis of ASC and daily challenging behaviour. Parents/guardians of the child were able to self-complete the English language outcome measures (with assistance if necessary). Exclusion criteria The school had used Social Stories for any pupil in the current or preceding school term. The child or interventionist teacher had taken part in the previous Social Stories feasibility study (ASSSIST-1). Schools that have taken part were not excluded. Where families were recruited but the child’s school was unwilling or unable to participate, families were notified by a telephone call and/or an e-mail. Where children were confirmed eligible and consent had been taken from all relevant parties, baseline questionnaires were distributed to parents/carers and educational professionals. A school was considered ‘ready to randomise’ once all consent forms and baseline questionnaires had been received by the trial team. Interventions Children in the intervention arm of the trial received the Social Stories intervention in addition to their care as usual. The Social Stories intervention was delivered by a trained educational professional (the interventionist) who was employed within each school allocated to the intervention arm. The interventionist varied between the schools [e.g. a teacher, teaching assistant (TA) or Special Educational Needs Coordinator (SENCO)] but was most typically a TA. A core aspect of the intervention was to first agree a goal around which the story would be set. The goal was typically a behavioural challenge the child was struggling with, for example, sharing with their teacher how they were feeling. This goal was agreed during a collaborative ‘goal-setting meeting’ attended by the child’s teacher, a parent/caregiver, a member of the research team and sometimes the child’s TA. Occasionally, the children themselves were able to feed into the goal-setting process if deemed appropriate. The intervention is designed to provide social information to the child, and so the goal sought to reflect this. In this way, many goals sought to reduce the child’s anxiety or frustration by equipping them with information or providing reassurance around appropriate behaviours within a given circumstance. We assessed goal attainment in terms of how frequently a child was able to implement the desired behaviours, for example, if a goal for a particular child was to use calming strategies when they were upset, we asked teachers to rate how often a child was able to do this. Interventionists were trained by members of the research team, who had received training via a cascade model overseen by child psychiatrist, Professor Barry Wright. The training of interventionists included some psychoeducation around the differences in children on the autism spectrum to facilitate understanding around what factors may be driving the observed behaviours associated with the behavioural goal. Training also provided key information on the design and implementation of Social Stories, with materials based on those developed in the preceding feasibility study with the support of Carol Gray and a Social Stories manual produced by Professor Barry Wright and a Clinical Psychologist with expertise in autism. During the training session, interventionists constructed a Social Story. Parents/guardians were also invited to attend these sessions. Following training, all Social Stories were assessed against a fidelity checklist by a member of the research team to ensure they conformed to the 10 established criteria central to Carol Gray’s Social Stories. They were then delivered to children in the intervention arm by the interventionist at least six times over a 4-week period. Sample size The primary outcome was that the teacher completed the Social Responsiveness Scale, Second Edition (SRS-2) T-score at 6 months. Within the pilot data, outcomes were measured at 6 and 16 weeks. The correlation between baseline and 6 weeks [r = 0.67, 95% confidence interval (CI) 0.44 to 0.80] was lower than that at 16 weeks (r = 0.83, 95% CI 0.68 to 0.91) for the pilot data. To be conservative, the lower 95% confidence limit was chosen for the lowest correlation between baseline and follow-up that we observed within our pilot data (r = 0.44). Assuming a difference of 3 points, standard deviation (SD) = 7, 5% alpha, 90% power, average cluster size 1.35, intracluster correlation coefficient (ICC) = 0.34, correlation = 0.44 and 25% attrition, a total sample size of 278 was required. Support was gained from the trial steering committee and funder to stop recruitment with 249 children, which we modelled would still retain at least 80% power under a variety of different scenarios. Randomisation Randomisation was completed by unblinded members of the trial team via a bespoke trial management system. Stratified blocked randomisation was used to allocate school clusters, with randomly varying block sizes (4, 6 and 8), stratification by school type (SEN school or mainstream school) and the number of participating children within a school (≤ 5 or > 5 participating children). There were no stipulations regarding the minimum number of participants per school cluster (i.e. any school with ≥ 1 eligible/consented child with available baseline data was eligible for randomisation). Main outcome measure The primary outcome of the trial was the SRS-2 at 6 months post randomisation, as reported by the child’s teacher. This was also collected at 6 weeks post randomisation. The SRS-2 identifies the presence and severity of social difficulty within the autism spectrum condition and consists of 65 questions. For each question, the person completing the form picks a score from 1 to 4 (1 = not true, 2 = sometimes true, 3 = often true, 4 = almost always true) that best describes the child’s behaviour. A T-score is calculated based on the sex of the child and the person completing the form (teacher). Economic evaluation The primary analysis for the economic evaluation was a within-trial cost-utility analysis conducted from a societal perspective. Combining costs and quality-adjusted life-years (QALYs), an incremental cost-effectiveness ratio (ICER) of cost per QALY was calculated and evaluated against the willingness-to-pay threshold of £20,000–30,000 per QALY gained to assess the cost effectiveness of Social Stories compared to usual care. Regression models on an intention-to-treat basis were used to compare mean costs and QALYs. To take uncertainty into consideration, a non-parametric bootstrap resampling method was used to produce CIs around the cost and QALY differences and ICER. The following sensitivity analyses were conducted to test assumptions made in the primary analysis: a complete case analysis; a sensitivity analysis from the UK NHS and personal social services (PSS) perspective; and a sensitivity analysis from the joint perspectives of the NHS/PSS and education perspectives to representative a global public sector perspective. Process evaluation The process evaluation was cross-sectional and longitudinal, encompassing all aspects of the Social Stories intervention. The aim of the process evaluation was to assess the fidelity of the programme, consider the views of various stakeholders and identify barriers and facilitators to successful implementation. We aimed to achieve this through a combination of data collection techniques, including interviews, focus groups, questionnaires, surveys and diaries (session logs). Statistical analyses For the primary outcome, differences in expected SRS-2 scores were estimated using a linear mixed-effect covariance pattern model with both post-randomisation time points (6 weeks and 6 months) included as outcomes and fixed effects for treatment group, time point and their interaction. Further fixed effects were included for the following cluster and participant-level baseline covariates: school SEN status (binary, SEN/non-SEN), number of consented children attending school (binary, ≤ 5/> 5), baseline score (linear term), age at randomisation (linear term) and sex (binary, female/male). Dependence between participants within a cluster was modelled using school cluster-level random intercepts, and dependence between repeated measurements within participants was modelled using an unstructured correlation matrix for the residual errors. Similar models were used to analyse the secondary outcomes. Results The primary analysis included all 249 randomised children. After 6 months, a reduction of 1.61 points was found on the SRS-2 in children on the autism spectrum in the intervention group (95% CI −4.18 to 0.96; p = 0.220). No statistically significant differences were found in overall symptoms of anxiety and/or depression, parental stress or general health. Children in the intervention group met their individual goals more frequently than children who received usual care alone, and this difference was statistically significant (0.97, CI 0.21 to 1.73; p = 0.012). The primary analysis was conducted under the principles of intention to treat. Coronavirus disease 2019 (COVID-19) impacted upon delivery in schools and school routines, and only 62.8% of the sample is known to have received the intervention as per protocol. Sensitivity analyses suggested that there may be a dose effect with improved clinical effects in those receiving the intervention as per protocol compared to those with fewer sessions. The economic evaluation showed that, compared to usual care, Social Stories slightly decreased the service use costs over the 6-month period by £191 (95% CI −337.7 to 767.7) per child and maintained similar QALYs. If society is willing to pay £20,000 for extra QALY gained, then the probability of Social Stories being a dominant and preferred option is 75%. The results of both primary and sensitivity analyses, which considered costs derived from various perspectives, are consistent but limited to the given data within the short study time frame, number of missing data and disruption of COVID-19. The qualitative results suggest parents and educational professionals found the Social Stories training and intervention beneficial. Limitations include considerable disruptions during the COVID-19 pandemic. Conclusion We found no impact of Social Stories on autistic children’s overall social responsiveness skills. There was some evidence that Social Stories are well supported by parents and teachers, and it may be effective at addressing a wider set of individual goals and could reduce costs. Based on the evidence generated through this trial, we cannot recommend Social Stories for the purposes of improving social skills, anxiety and/or depression, parental stress, general health and quality of life in autistic children. The COVID-19 pandemic had a large impact on schools during this trial, and sensitivity analyses suggested that poor compliance may have reduced the effectiveness of the intervention and that effects were better in those receiving Social Stories as per protocol. We did not find any negative effects, and Social Stories are already frequently used in schools to support autistic children and represent a low-cost and potentially cost-saving intervention. Despite limited evident impact on global social skills, based on the data elicited through the process evaluation, it appears that Social Stories may serve as a useful tool for facilitating dialogue between children and school staff to better understand the needs of autistic children, and usage should be at the school’s discretion. Trial registration This trial was registered as ISRCTN11634810. Funding This award was funded by the National Institute for Health and Care Research (NIHR) Health Technology Assessment programme (NIHR award ref: 16/111/91) and is published in full in Health Technology Assessment; Vol. 28, No. 39. See the NIHR Funding and Awards website for further award information.

Background One in 57 children are diagnosed with autism in the UK, and the estimated cost for supporting these children in education is substantial. Social Stories™ is a promising and widely used intervention for supporting children with autism in schools and families. It is believed that Social Stories™ can provide meaningful social information to children that can improve social understanding and may reduce anxiety. However, no economic evaluation of Social Stories has been conducted. Aims To assess the cost-effectiveness of Social Stories through Autism Spectrum Social Stories in Schools Trial 2, a multi-site, pragmatic, cluster-randomised controlled trial. Method Children with autism who were aged 4–11 years were recruited and randomised (N = 249). Costs measured from the societal perspective and quality-adjusted life-years (QALYs) measured by the EQ-5D-Y-3L proxy were collected at baseline and at 6-month follow-up for primary analysis. The incremental cost-effectiveness ratio was calculated, and the uncertainty around incremental cost-effectiveness ratios was captured by non-parametric bootstrapping. Sensitivity analyses were performed to evaluate the robustness of the primary findings. Results Social Stories is likely to result in a small cost savings (–£191 per child, 95% CI −767.7 to 337.7) and maintain similar QALY improvements compared with usual care. The probability of Social Stories being a preferred option is 75% if society is willing to pay £20 000 per QALY gained. The sensitivity analysis results aligned with the main study outcomes. Conclusions Compared with usual care, Social Stories did not lead to an increase in costs and maintained similar QALY improvements for primary-aged children with autism.

Background Social skills interventions are commonly recommended to help children and young people with autism spectrum disorder develop social skills, but some struggle to engage in these interventions. LEGO® (LEGO System A/S, Billund, Denmark) based therapy, a group social skills intervention, aims to be more interesting and engaging. Objective To evaluate the clinical effectiveness of LEGO® based therapy on the social and emotional skills of children and young people with autism spectrum disorder in school settings compared with usual support. Secondary objectives included evaluations of cost-effectiveness, acceptability and treatment fidelity. Design A cluster randomised controlled trial randomly allocating participating schools to either LEGO® based therapy and usual support or usual support only. Setting Mainstream schools in the north of England. Participants Children and young people (aged 7–15 years) with autism spectrum disorder, their parent/guardian, an associated teacher/teaching assistant and a facilitator teacher/teaching assistant (intervention schools only). Intervention Schools randomised to the intervention arm delivered 12 weekly sessions of LEGO® based therapy, which promotes collaborative play and encourages social problem-solving in groups of three children and young people with a facilitator (trained teacher or teaching assistant). Participants received usual support from school and community services. Participants in the control arm received usual support only. Research assistants and statisticians were blind to treatment allocation. Main outcome measure The social skills subscale of the Social Skills Improvement System (SSIS), completed by the children and young people’s unblinded teacher pre randomisation and 20 weeks post randomisation. The SSIS social skills subscale measures social skills including social communication, co-operation, empathy, assertion, responsibility and self-control. Participants completed a number of other pre- and post-randomisation measures of emotional health, quality of life, loneliness, problem behaviours, academic competence, service resource utilisation and adverse events. Results A total of 250 children and young people from 98 schools were randomised: 127 to the intervention arm and 123 to the control arm. Intention-to-treat analysis of the main outcome measure showed a modest positive difference of 3.74 points (95% confidence interval –0.16 to 7.63 points, standardised effect size 0.18; p = 0.06) in favour of the intervention arm. Statistical significance increased in per-protocol analysis, with a modest positive difference (standardised effect size 0.21; p = 0.036). Cost-effectiveness of the intervention was found in reduced service use costs and a small increase in quality-adjusted life-years. Intervention fidelity and acceptability were positive. No intervention-related adverse events or effects were reported. Conclusions The primary and pre-planned sensitivity analysis of the primary outcome consistently showed a positive clinical difference, with modest standardised effect sizes of between 0.15 and 0.21. There were positive health economics and qualitative findings, corroborated by the difference between arms for the majority of secondary outcomes, which were not statistically significant but favoured the intervention arm. Post hoc additional analysis was exploratory and was not used in drawing this conclusion. Given the small positive change, LEGO® based therapy for children and young people with autism spectrum disorder in schools should be considered. Limitations The primary outcome measure was completed by an unblinded teacher (rather than by the facilitator). Future work The study team recommends future research into LEGO® based therapy, particularly in school environments. Trial registration This trial is registered as ISRCTN64852382. Funding This award was funded by the National Institute for Health and Care Research (NIHR) Public Health Research programme (NIHR award ref: 15/49/32) and is published in full in Public Health Research; Vol. 11, No. 12. See the NIHR Funding and Awards website for further award information. Plain language summary Autism spectrum disorder is characterised by difficulties with social relationships and communication, which can make it difficult to make friends. Social skills training is commonly used to help children and young people learn different social skills, but some children and young people do not enjoy these therapies. LEGO® (LEGO System A/S, Billund, Denmark) based therapy takes a new approach by focusing on making the process interesting and fun. This research investigated the effect of LEGO® based therapy groups in schools on the social and emotional abilities of children and young people with autism spectrum disorder. It was a randomised controlled trial, so each school that was taking part was randomly chosen to provide either usual support (from the school or NHS services) or 12 sessions of LEGO® based therapy with a trained school staff member as well as usual support. Children and young people played one of three roles – the ‘engineer’ (gives instructions), the ‘supplier’ (finds the pieces) or the ‘builder’ (builds the model) – and worked together. Questionnaires completed by children and young people, their parents/guardians and teachers were used to look at the intervention’s effects. The main objective was to see if there was a change in social skills measured by a teacher-completed questionnaire. Results showed that the social skills of children and young people in the LEGO® based therapy groups did improve a little. We found that the intervention is not very costly for schools to run. Many parents/guardians and teachers thought that the intervention was beneficial and that the children and young people enjoyed it. Scientific summary Background Autism spectrum disorder (ASD) is a neurodevelopmental condition currently estimated to affect 1.00–1.16% of children and young people (CYP) in the UK. Autistic CYP typically experience developmental differences in social communication and may have strong specific interests/preferences and repetitive behaviours. Impacts are often seen in social functioning, general mental health and long-term social and educational outcomes into adulthood. Social learning through friendships is an important part of a child or young person’s development. It is an area in which many autistic CYP struggle because they tend to initiate and engage in social interactions differently from typically developing peers. They may prefer solitary activities with structured rules and less co-operative play and emotional exchange, which may mean that they find social interactions more challenging. Over time, autistic CYP may feel socially isolated. A number of social interventions aim to help autistic CYP to develop these skills. CYP often find it difficult to transfer skills learnt in one context to other areas of their lives. LEGO® (LEGO System A/S, Billund, Denmark) based therapy is a group social skills intervention designed for autistic CYP to facilitate the learning and flexible practising of social skills with peers. It is designed to make social interactions interesting by using a structured and predictable toy with which CYP are often already familiar and intrinsically motivated to play. The use of LEGO® based therapy in the UK is increasing following reported potential benefits. However, the evidence base for LEGO® based therapy is limited, with only a small number of studies assessing its use for autistic CYP. Among these, only one small study used a randomised controlled trial design to compare LEGO® based therapy with a similar social skills intervention, the Social Use of Language Programme (SULP). This study had several limitations, including a small sample size and a lack of fully randomised allocation. A scoping review of the research in this area conducted in 2017 concluded that more robustly designed studies with larger sample sizes and standardised outcome measures are needed to properly evaluate the effectiveness of LEGO® based therapy in this population. Objectives Primary objective To examine the clinical effectiveness of LEGO® based therapy groups on the social and emotional competence (specifically perceived social skills) of autistic CYP in schools, compared with usual support for autistic CYP, at 20 weeks after randomisation. Secondary objectives To examine the clinical effectiveness of LEGO® based therapy groups on the perceived social isolation of autistic CYP in schools, compared with usual support for, at 20 and 52 weeks. To examine the clinical effectiveness of LEGO® based therapy groups on the academic competence of autistic CYP in schools, compared with usual support for autistic CYP, at 20 and 52 weeks. To examine the clinical effectiveness of LEGO® based therapy groups on assertion, social control, externalising and internalising in autistic CYP in the school setting, compared with usual support for autistic CYP, at 20 and 52 weeks. To examine the cost-effectiveness of LEGO® based therapy groups, compared with usual support for autistic CYP, at 52 weeks. To examine the emotional and behavioural symptoms in those receiving LEGO® based therapy, compared with usual support for autistic CYP, at 20 and 52 weeks. To determine if the impact of LEGO® based therapy is sustainable into the next academic year by comparing effectiveness on social and emotional competence (specifically perceived social skills) at 52 weeks after randomisation. To examine the acceptability of the intervention at follow-up points using a purpose-designed questionnaire and telephone interviews at 20 weeks. To examine treatment fidelity through independent observation of treatment sessions across schools and a self-report measure completed by the facilitator [i.e. a trained teacher or teaching assistant (TA)] after each session. Setting The setting was mainstream primary and secondary schools in the north of England. Participants Participants were CYP in mainstream schools between the ages of 7 and 15 years with a diagnosis of ASD, a parent or guardian of the CYP and a teacher or TA in the child or young person’s school who knew them well (i.e. an associated teacher). Another school staff member was recruited in schools allocated to the intervention arm to run the LEGO® based therapy sessions (i.e. a facilitator teacher). Participants were recruited by contact with mainstream primary and secondary schools following meetings to explain the study and confirmation of eligible CYP in their schools. Participants were included if they met study inclusion criteria and provided fully informed consent to participate. Methods The trial used a pragmatic cluster randomised controlled trial design. Remote randomisation of each school using stratified randomisation lists was provided by a blinded statistician from the Clinical Trials Research Unit, School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK. All participants completed a set of baseline questionnaires. Once baseline measures were completed for all participants in a school, the school was randomly allocated to one of two trial arms. Participating CYP in schools allocated to the intervention arm received 12 sessions of LEGO® based therapy in addition to usual support from their school, their general practitioner and other professionals. In schools allocated to the control arm, participating CYP received usual support only. Training was provided for intervention school staff by members of the study team and experienced local authority members trained by experts in the field. All participants were followed up 20 and 52 weeks after their school was randomised and were asked to complete similar questionnaires to those completed at baseline and questionnaires around their health resource use. Acceptability of the interventions was assessed using a purpose-designed questionnaire and telephone interviews with parents and facilitators. Fidelity was assessed using questionnaires and video-recordings when possible. The study team ensured the involvement of patients and the public throughout the study, including a parent of an autistic child and groups such as the Young Dynamos research advisory group (Bradford District Care NHS Foundation Trust, Shipley, UK) and the National Autistic Society (London, UK) in initial study design and specific discussions throughout the study. Intervention LEGO® based therapy LEGO® based therapy is a social skills intervention designed to support CYP with social communication difficulties, such as autistic CYP, by offering playful opportunities to practise social skills. It was created by Daniel LeGoff, who observed that autistic CYP may be particularly drawn to LEGO bricks, perhaps because of their interests and strengths in systemising. In the intervention, CYP, usually in groups of three, build LEGO sets. The CYP take turns to play one of three roles: the ‘engineer’, who has the instructions and communicates them to the group; the ‘supplier’, who finds the correct bricks; and the ‘builder’, who builds the model. CYP then progress to collaborative ‘freestyle’ building, in which they build models of their own design together. Sessions aim to be CYP led, following their interests as far as possible. Many skills are practised throughout, including communication, joint attention, problem-solving, emotion regulation and compromise. The intervention uses a naturalistic play setting, meaning that CYP learn how to collaborate with others through doing, rather than through didactic teaching. Sessions are facilitated by an adult, who aims to guide the CYP rather than direct them explicitly. Adults are encouraged to allow CYP to solve their own challenges and to promote social problem-solving skills, stepping in to prompt through open questions when needed. CYP are encouraged to practise and role-play new social strategies discovered in the sessions. The adult’s role is also to praise and highlight the positive things happening in a session, using rewards such as stickers and certificates as motivation. Procedure The intervention was provided in school by teachers or TAs, termed ‘facilitators’, who were provided with a 3-hour face-to-face training session on how to deliver the intervention. Training was provided by members of the study team and experienced professionals from each recruiting site’s local authority who had been ‘trained to train’ school staff members by co-applicant Gina Gomez de la Cuesta and expert colleagues. Facilitators were also provided with a brief guide specifically designed for this study, which describes the essential elements of the intervention and how to facilitate sessions successfully. Schools were given all materials needed to run their sessions, including a range of LEGO sets with instructions and freestyle bricks, funded by the research. Groups were also given ‘brick club’ materials, including group rules, role cards (i.e. supplier, builder or engineer), free-play building ideas and a points system chart, all of which they were encouraged to use. Schools were asked to run 12 sessions of LEGO® based therapy over a 12-week period. It was recommended that sessions were run for 1 hour once per week for the 12-week period; however, multiple sessions in 1 week due to illness and time constraints were acceptable. Sessions less than 1 hour in duration were also acceptable, but facilitators were encouraged to run groups for at least 45 minutes. Fidelity Intervention fidelity was assessed via two methods: (1) completion of the self-report fidelity checklist after each session of LEGO® based therapy by all facilitators and (2) video-recording of a subset of sessions where consent to be video-recorded was obtained. Video-recordings were stratified to include sessions from three time points: early intervention sessions (sessions 1–4), mid-point intervention sessions (sessions 5–8) and later intervention sessions (sessions 9–12). The self-report fidelity checklist was designed by experts on the team and mapped onto the main components of the intervention identified in the manual and previous publications. It asked the facilitator to identify which components of the intervention had taken place. Video-recordings were completed in schools where all participating CYP, their parents/guardians and the facilitator consented to the recording. These were then independently reviewed and assessed for fidelity to the intended intervention delivery method against the fidelity checklist. Sixteen sessions were double rated to ensure rating accuracy. Results The clinical effectiveness of LEGO® based therapy for autistic CYP was analysed using intention-to-treat (ITT) analysis of the teacher-completed social skills subscale of the Social Skills Improvement System (SSIS) at 20 weeks. A total of 250 participants were consented and randomised to the trial, and the primary outcome ITT analysis comprised 217 CYP (86.8%) with complete baseline and primary outcome data, with 116 in the intervention arm (91.3%) and 101 in the control arm (82.1%). The SSIS is a behaviour rating scale widely used in national portfolio studies and has been shown to be sensitive to change. A modest positive difference on this scale of 3.74 points [95% confidence interval (CI) –0.16 to 7.63 points, p = 0.06; standardised effect size 0.18] was found for CYP in the intervention arm compared with the control arm. A per-protocol analysis, which included CYP in the intervention arm who had attended six or more intervention sessions, was also carried out and showed a slightly greater, statistically significant, difference (4.23 points, 95% CI 0.27 to 8.19 points; p = 0.036). Between-group differences in both analyses did not reach the pre-specified minimum clinically important difference (MCID) of a 9- to 10-point increase on the social skills subscale of the SSIS. The health economics analysis showed cost-effectiveness of the intervention through both reduced service use costs and a small but significant increase in quality-adjusted life years (QALYs). There was a small reduction in school-based intervention costs and intervention costs on the whole (with reduced NHS child mental health service costs) in the intervention arm compared with the control arm. Mean QALYs as reported by parents/guardians and CYP were shown to be marginally higher (by 0.03 QALYs) in the intervention arm than in the control arm. Fidelity to the intended intervention delivery method was measured via self-report and independent reviewers. Levels of self-reported fidelity were very good, with 99% of the core content of the intervention delivered and 91% of all content being reported as delivered. Levels of fidelity assessed by independent reviewers using video-recordings were good, with 83% of core content and 77% of all content being rated as delivered. Qualitative analysis showed good levels of acceptability of the intervention by CYP, parents/guardians and facilitators, with many schools continuing to run the intervention after the study ended. Discussion Limitations of the study included the fact that the primary outcome measure was completed by a teacher who did not deliver the intervention but who was not necessarily blind to the intervention. Although we obtained qualitative data from parents/carers and educators/facilitators, we had no direct impressions from the CYP themselves, although the adults consistently reported high levels of satisfaction on the part of the CYP. Analysis of the primary outcome showed modest positive improvements in social skills, although this analysis and sensitivity analyses did not show large enough changes in social skills scores for CYP in the intervention arm to reach the pre-specified MCID. However, the primary and pre-planned sensitivity analysis of the primary outcome consistently showed a positive clinical difference, with modest standardised effect sizes between 0.15 and 0.21, and there were positive health economics and qualitative findings. This is corroborated to some extent by the fact that the difference between arms for the majority of secondary outcomes, although not statistically significant, favoured the intervention arm. The post hoc additional analysis was exploratory and was not used in drawing this overall conclusion. Conclusions Given the positive findings of the health economics and qualitative analyses, and the presence of a small yet positive change in social skills, consideration should be given to LEGO® based therapy and its contribution to the social skills of autistic CYP when run in a school setting. The study team recommends future research into LEGO® based therapy, particularly when run in school environments. Additional analysis showed possible avenues for exploration, including whether or not there is a greater impact of the intervention for autistic CYP in secondary schools, or for those with less severe ASD symptomatology, and when there is more than one autistic child or young person in each therapy session. Trial registration This trial is registered as ISRCTN64852382. Funding This award was funded by the National Institute for Health and Care Research (NIHR) Public Health Research programme (NIHR award ref: 15/49/32) and is published in full in Public Health Research; Vol. 11, No. 12. See the NIHR Funding and Awards website for further award information.

Abstract Background In the UK, around 93,000 (0.8%) children and young people (CYP) are experiencing specific phobias that have a substantial impact on daily life. The current gold-standard treatment—multi-session cognitive behavioural therapy (CBT) – is effective at reducing specific phobia severity; however, CBT is time consuming, requires specialist CBT therapists, and is often at great cost and limited availability. A briefer variant of CBT called one session treatment (OST) has been found to offer similar clinical effectiveness for specific phobia as multi-session CBT. The aim of this study was to assess the cost-effectiveness of OST compared to multi-session CBT for CYP with specific phobias through the Alleviating Specific Phobias Experienced by Children Trial (ASPECT), a two-arm, pragmatic, multi-centre, non-inferiority randomised controlled trial. Methods CYP aged seven to 16 years with specific phobias were recruited nationally via Health and Social Care pathways, remotely randomised to the intervention group (OST) or the control group (CBT-based therapies) and analysed (n = 267). Resource use based on NHS and personal social services perspective and quality adjusted life years (QALYs) measured by EQ-5D-Y were collected at baseline and at six-month follow-up. Incremental cost-effectiveness ratio (ICER) was calculated, and non-parametric bootstrapping was conducted to capture the uncertainty around the ICER estimates. The results were presented on a cost-effectiveness acceptability curve (CEAC). A set of sensitivity analyses (including taking a societal perspective) were conducted to assess the robustness of the primary findings. Results After adjustment and bootstrapping, on average CYP in the OST group incurred less costs (incremental cost was -£302.96 (95% CI -£598.86 to -£28.61)) and maintained similar improvement in QALYs (QALYs gained 0.002 (95% CI − 0.004 to 0.008)). The CEAC shows that the probability of OST being cost-effective was over 95% across all the WTP thresholds. Results of a set of sensitivity analyses were consistent with the primary outcomes. Conclusion Compared to CBT, OST produced a reduction in costs and maintained similar improvement in QALYs. Results from both primary and sensitivity analyses suggested that OST was highly likely to be cost saving. Trial registration ISRCTN19883421 (30/11/2016).

Background: Attachment refers to an infant’s innate tendency to seek comfort from their caregiver. Research shows that attachment is important in promoting healthy social and emotional development. Many parenting interventions have been developed to improve attachment outcomes for children. However, numerous interventions used in routine practice have a limited evidence base, meaning that we cannot be sure if they are helpful or harmful. Objectives: This research aimed to conduct a large-scale survey to identify what interventions are being used in UK services to improve child attachment; conduct a systematic review to evaluate the evidence for parenting attachment interventions; and develop recommendations for future research and practice. Design and methods: We worked closely with our Expert Reference Group to plan a large-scale survey focused on relevant UK services. We then conducted two systematic reviews. One searched for all randomised controlled trial evidence for any attachment parenting intervention. The second searched for all research for the top 10 routinely used interventions identified from the survey. Results: The survey collected 625 responses covering 734 UK services. The results identified the 10 most commonly used interventions. The responses showed a limited use of validated measures and a wide variety of definitions of attachment. For the first review, seven studies were included from 2516 identified records. These were combined with results from previous reviews conducted by the team. Meta-analyses showed that, overall, parenting interventions are effective in reducing disorganised attachment (pooled odds ratio 0.54, 95% confidence interval 0.39 to 0.77) and increasing secure attachment (pooled odds ratio 1.85, 95% confidence interval 1.36 to 2.52). The second review searched the literature for the top 10 routinely used interventions identified by the survey; 61 studies were included from 1198 identified records. The results showed that many of the most commonly used interventions in UK services have a weak evidence base and those with the strongest evidence base are not as widely used. Conclusions: There is a need for better links between research and practice to ensure that interventions offered to families are safe and effective. Possible reasons for the disparity include the cost and accessibility of training. There is also a need for improved understanding by professionals regarding the meaning of attachment. Limitations: Although the survey had good geographical spread, most respondents were based in England. For review 2 we were unable to access a large number of papers; however, we conducted extensive reference checking to account for this. Future work: There is a need for robust research to test the efficacy of routinely used attachment interventions. Research could also explore why routinely used interventions are not consistently subject to thorough evaluation; how to embed dissemination, cost-effectiveness, fidelity and sustainability into research; and how to keep clinical practice up to date with research developments. Study registration: This study is registered as PROSPERO CRD42019137362. Funding: This project was funded by the National Institute for Health and Care Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 27, No. 2. See the NIHR Journals Library website for further project information.

AimsTo identify differential expression of shorter non-coding RNA (ncRNA) genes associated with autism spectrum disorders (ASD).BackgroundncRNA are functional molecules that derive from non-translated DNA sequence. The HUGO Gene Nomenclature Committee (HGNC) have approved ncRNA gene classes with alignment to the reference human genome. One subset is microRNA (miRNA), which are highly conserved, short RNA molecules that regulate gene expression by direct post-transcriptional repression of messenger RNA. Several miRNA genes are implicated in the development and regulation of the nervous system. Expression of miRNA genes in ASD cohorts have been examined by multiple research groups. Other shorter classes of ncRNA have been examined less. A comprehensive systematic review examining expression of shorter ncRNA gene classes in ASD is timely to inform the direction of research.MethodsWe extracted data from studies examining ncRNA gene expression in ASD compared with non-ASD controls. We included studies on miRNA, piwi-interacting RNA (piRNA), small NF90 (ILF3) associated RNA (snaR), small nuclear RNA (snRNA), small nucleolar RNA (snoRNA), transfer RNA (tRNA), vault RNA (vtRNA) and Y RNA. The following electronic databases were searched: Cochrane Library, EMBASE, PubMed, Web of Science, PsycINFO, ERIC, AMED and CINAHL for papers published from January 2000 to May 2022. Studies were screened by two independent investigators with a third resolving discrepancies. Data was extracted from eligible papers.ResultsForty-eight eligible studies were included in our systematic review with the majority examining miRNA gene expression alone. Sixty-four miRNA genes had differential expression in ASD compared to controls as reported in two or more studies, but often in opposing directions. Four miRNA genes had differential expression in the same direction in the same tissue type in at least 3 separate studies. Increased expression was reported in miR-106b-5p, miR-155-5p and miR-146a-5p in blood, post-mortem brain, and across several tissue types, respectively. Decreased expression was reported in miR-328-3p in bloods samples. Seven studies examined differential expression from other classes of ncRNA, including piRNA, snRNA, snoRNA and Y RNA. No individual ncRNA genes were reported in more than one study. Six studies reported differentially expressed snoRNA genes in ASD. A meta-analysis was not possible because of inconsistent methodologies, disparate tissue types examined, and varying forms of data presented.ConclusionThere is limited but promising evidence associating the expression of certain miRNA genes and ASD, although the studies are of variable methodological quality and the results are largely inconsistent. There is emerging evidence associating differential expression of snoRNA genes in ASD. It is not currently possible to say whether the reports of differential expression in ncRNA may relate to ASD aetiology, a response to shared environmental factors linked to ASD such as sleep and nutrition, other molecular functions, human diversity, or chance findings. To improve our understanding of any potential association, we recommend improved and standardised methodologies and reporting of raw data. Further high-quality research is required to shine a light on possible associations, which may yet yield important information.

Background: Up to 10% of children and young people have a specific phobia that can significantly affect their mental health, development and daily functioning. Cognitive–behavioural therapy-based interventions remain the dominant treatment, but limitations to their provision warrant investigation into low-intensity alternatives. One-session treatment is one such alternative that shares cognitive–behavioural therapy principles but has a shorter treatment period. Objective: This research investigated the non-inferiority of one-session treatment to cognitive–behavioural therapy for treating specific phobias in children and young people. The acceptability and cost-effectiveness of one-session treatment were examined. Design: A pragmatic, multicentre, non-inferiority randomised controlled trial, with embedded economic and qualitative evaluations. Settings: There were 26 sites, including 12 NHS trusts. Participants: Participants were aged 7–16 years and had a specific phobia defined in accordance with established international clinical criteria. Interventions: Participants were randomised 1 : 1 to receive one-session treatment or usual-care cognitive–behavioural therapy, and were stratified according to age and phobia severity. Outcome assessors remained blind to treatment allocation. Main outcome measures: The primary outcome measure was the Behavioural Avoidance Task at 6 months’ follow-up. Secondary outcomes included the Anxiety Disorder Interview Schedule, Child Anxiety Impact Scale, Revised Children’s Anxiety and Depression Scale, a goal-based outcome measure, Child Health Utility 9D, EuroQol-5 Dimensions Youth version and resource usage. Treatment fidelity was assessed using the Cognitive Behaviour Therapy Scale for Children and Young People and the One-Session Treatment Rating Scale. Results: A total of 274 participants were recruited, with 268 participants randomised to one-session treatment (n = 134) or cognitive–behavioural therapy (n = 134). A total of 197 participants contributed some data, with 149 participants in the intention-to-treat analysis and 113 in the per-protocol analysis. Mean Behavioural Avoidance Task scores at 6 months were similar across treatment groups when both intention-to-treat and per-protocol analyses were applied [cognitive–behavioural therapy: 7.1 (intention to treat), 7.4 (per protocol); one-session treatment: 7.4 (intention to treat), 7.6 (per protocol); on the standardised scale adjusted mean difference for cognitive–behavioural therapy compared with one-session treatment –0.123, 95% confidence interval –0.449 to 0.202 (intention to treat), mean difference –0.204, 95% confidence interval –0.579 to 0.171 (per protocol)]. These findings were wholly below the standardised non-inferiority limit of 0.4, which suggests that one-session treatment is non-inferior to cognitive–behavioural therapy. No between-group differences in secondary outcome measures were found. The health economics evaluation suggested that, compared with cognitive–behavioural therapy, one-session treatment marginally decreased the mean service use costs and maintained similar mean quality-adjusted life-year improvement. Nested qualitative evaluation found one-session treatment to be considered acceptable by those who received it, their parents/guardians and clinicians. No adverse events occurred as a result of phobia treatment. Limitations: The COVID-19 pandemic meant that 48 children and young people could not complete the primary outcome measure. Service waiting times resulted in some participants not starting therapy before follow-up. Conclusions: One-session treatment for specific phobia in UK-based child mental health treatment centres is as clinically effective as multisession cognitive–behavioural therapy and highly likely to be cost-saving. Future work could involve improving the implementation of one-session treatment through training and commissioning of improved care pathways. Trial registration: This trial is registered as ISRCTN19883421. Funding: This project was funded by the National Institute for Health and Care Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 26, No. 42. See the NIHR Journals Library website for further project information.

Background: Looked-after children are at risk of suboptimal attachment patterns and reactive attachment disorder. However, access to interventions varies widely and there are no evidence-based interventions for this disorder. Objectives: (1) To adapt an existing video-feedback intervention to meet the specific needs of foster children in the UK with reactive attachment symptoms, (2) to conduct a case series to road-test the treatment manual and study procedures, (3) to conduct a scoping study of the key hurdles in a pilot trial and (4) to conduct a pilot randomised controlled trial of the adapted intervention to determine the feasibility of a future full-scale trial. Design: This was a mixed-methods study. The adapted treatment manual was developed with expert input and tested on a small case series. Qualitative interviews with key stakeholders were used in the scoping study in preparation for the trial and later with foster carers who received the new intervention. The final stage was a feasibility and pilot randomised controlled trial of the new intervention, compared with usual care. Researchers assessing the outcomes were blinded to group assignment. Setting: The study was set in outpatient child and adolescent mental health services and partner social services departments. Sites included urban and rural/semirural areas. Participants: Participants were foster carers with children aged ≤ 6 years presenting with difficulties in the domain of reactive attachment disorder. Key stakeholders included children’s services managers and mental health service practitioners in the scoping study. Foster carers who received the modified intervention participated in qualitative interviews. Intervention: The video-feedback intervention to promote positive parenting and sensitive discipline is an extensively evaluated and effective treatment approach. This intervention was modified (based on the adapted version for foster care in the Netherlands) to suit the needs of young children with reactive attachment symptoms in foster care in the UK and was delivered to improve the sensitive responding of foster carers, foster carer–child relationships and child outcomes. The modified intervention was delivered in-home by trained mental health professionals over a period of 4–6 months. Main outcome measure: The main outcome was reactive attachment symptom scores on the Disturbances of Attachment Interview. Results: A series of minor changes to the intervention programme were introduced, which focused on improving its suitability for the UK foster care context. Challenges in recruitment meant that, despite numerous modifications to the protocol and the inclusion of additional sites, only 30 families (target, n = 40) were recruited to the randomised controlled trial (15 allocated to each group). However, most other trial parameters were deemed feasible and acceptable, particularly the high levels of data and treatment completeness. All randomised families were available for baseline analyses, but two in the treatment arm were not available for post-treatment analyses. The revised intervention was positively received by practitioners and foster carers. Limitations: Only three-quarters of the target sample size was recruited. Furthermore, the sites’ own exclusion of potential participants and the low return rates of screening questionnaires raise the possibility of non-randomness of non-responses. Conclusion: A larger-scale trial may be feasible, but only if recruitment barriers can be overcome. Dedicated resources to support recruitment within local authorities and wider inclusion criteria are recommended. Central resourcing of intervention capacity to supplement NHS staff is also recommended. Trial registration: This trial is registered as ISRCTN18374094. Funding: This project was funded by the National Institute for Health and Care Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 26, No. 35. See the NIHR Journals Library website for further project information.

Abstract Background Maternal iodine requirements increase during pregnancy to supply thyroid hormones essential for fetal brain development. Maternal iodine deficiency can lead to hypothyroxinemia, a reduced fetal supply of thyroid hormones which, in the first trimester, has been linked to an increased risk of autism spectrum disorder (ASD) in the child. No study to date has explored the direct link between maternal iodine deficiency and diagnosis of ASD in offspring. Methods Urinary iodine concentrations (UIC) and iodine/creatinine ratios (I:Cr) were measured in 6955 mothers at 26–28 weeks gestation participating in the Born in Bradford (BiB) cohort. Maternal iodine status was examined in relation to the probability of a Read (CTV3) code for autism being present in a child’s primary care records through a series of logistic regression models with restricted cubic splines. Results Median (inter-quartile range) UIC was 76 μg/L (46, 120) and I:Cr was 83 μg/g (59, 121) indicating a deficient population according to WHO guidelines. Ninety two children (1·3%) in our cohort had received a diagnosis of ASD by the census date. Overall, there was no evidence to support an association between I:Cr or UIC and ASD risk in children aged 8–12 years (p = 0·3). Conclusions There was no evidence of an increased clinical ASD risk in children born to mothers with mild-to-moderate iodine deficiency at 26 weeks gestation. Alternative functional biomarkers of exposure and a wider range of conditions may provide further insight.

Between 2015 and 2020 the Alleviating Specific Phobias Experienced by Children Trial (ASPECT) was conducted in the UK to examine the non-inferiority of One-Session Treatment in comparison to Cognitive Behavioural Therapy based interventions for children and young people with specific phobias. A nested qualitative evaluation was conducted as part of this trial to examine the acceptability of One-Session Treatment. Qualitative interviews were conducted with children and young people taking part in the trial, their parents/guardians, and clinicians delivering the intervention, about their experiences and the acceptability of One Session Treatment. Interviews were digitally recorded and transcribed verbatim. Analysis followed a qualitative framework approach, a widely used method of analysing primary qualitative data pertaining to healthcare practices with policy relevance. Stakeholder groups found One Session Treatment to be an acceptable intervention and barriers and facilitators for its implementation into services were also identified. Potential barriers included challenges to patient flow and treatment scepticism, whilst facilitators included adopting a child-centred approach, child readiness and suitability, opportunity for increased momentum, parental support and involvement, and proximal and distal gains. For One Session Treatment’s successful implementation into services, consideration of these barriers is needed and suitability guidance for its use in this population should be developed. Further research exploring children and young people’s experiences of receiving Cognitive Behavioural Therapy and its acceptability in comparison to One Session Treatment would be welcomed.

We investigated whether Father Christmas has a distinguishable facial phenotype by performing a cross-sectional cohort study examining the facial feature vectors of all publicly available photographs obtained from a google image search of individuals meeting our eligibility criteria presenting as Father Christmas compared with other adult and elderly bearded men. Facial feature vectors were determined using the open-source OpenFace facial recognition system and assessed by support vector machines (SVM). SVM classifiers were trained to distinguish between the facial feature vectors from our groups. Accuracy, precision, and recall results were calculated and the area under the curve (AUC) of the receiver operating characteristic (ROC) were reported for each classifier. SVM classifiers were able to distinguish the face of Father Christmas from other adult men with a high degree of accuracy and could discriminate Father Christmas from elderly bearded men but with lower accuracy. Father Christmas appears to have a distinct facial phenotype when compared to adult men and elderly bearded men. This will be reassuring to children who may be keen to recognise him but raises some interesting questions about the careful use of two-dimensional facial analysis, particularly when employed to explore the relationships between genotype and facial phenotype in a clinical dysmorphology setting.

Abstract Background In response to the growing prevalence of physical and emotional burnout amongst medical students and practicing physicians, we sought to find a new methodology to scope a five-year undergraduate curriculum in detail to assess for teaching, learning objectives and experiences that seek to promote resilience in medical students. This was undertaken to test whether this methodology would enable curriculum discussions to enhance training for future cohorts through the introduction of a curriculum dedicated to the development of resilience and resourcefulness. Methods Based on literature review, a rating-scale was devised to generate quantitative data in four key areas of resilience; internal resources, lifestyle factors, external resources (self-mediated) and external resources (agent mediated). This scale was used to evaluate the entire five-year undergraduate curriculum of a medical school in the north of England through systematic evaluation of learning outcomes and planned activities. The methodology used was a four-stage process including i) identifying the learning objectives, ii) mapping them onto the criteria outlined, iii) assessing them against clear objective standards (planned, explicit, universal and quantifiable), and iv) rating data collected. Results The evaluation provided a clear, quantitative overview of the curriculum in terms of resilience building. Strengths and gaps were identified and work was undertaken leading to suggestions for change. This facilitated helpful discussions with course leaders and planners, received universally positive feedback and led to new learning objectives, activities and experiences that have been identified and begun to be implemented. Conclusions “The HYMS CARE Criteria” and our methodology for assessing it in a medical school curriculum context, offers a valuable perspective to aid the planning of improvements in curricula. This model for scoping and structuring resilience related learning experiences is offered for consideration by other schools.

Objectives This was a pilot study to explore whether the Early Years Foundation Stage Profile (EYFSP) carried out by UK teachers within the ‘reception’ year, combined with the Social Communication Questionnaire (SCQ), can lead to early identification of children with autism spectrum disorders (ASD) and early access to intervention and can reduce inequity in access to assessment and intervention.Design Pragmatic prospective cohort.Setting Ten primary schools from the SHINE project in Bradford.Participants 587 pupils from 10 schools who transitioned from reception to year 1 in July 2017 and had the EYFSP completed were included in the final study.Interventions The assessment involved a multidisciplinary team of three staff who completed Autism Diagnostic Interview–Revised, Autism Diagnostic Observation Schedule Version 2, classroom observations with an ASD checklist, a teacher-based ASD questionnaire and a final consensus meeting.Primary outcome measure National Institute for Health and Care Excellence guideline-compliant clinical diagnosis of ASD.Secondary outcome measures Age of diagnosis, demographic data and feasibility parameters.Results Children with low scores on the EYFSP were more likely to score above the SCQ threshold of 12, indicating potential autism (50% compared with 19% of children with high scores on the EYFSP (p

BackgroundComputerised cognitive–behavioural therapy (CCBT) in the care pathway has the potential to improve access to psychological therapies and reduce waiting lists within Child and Adolescent Mental Health Services, however, more randomised controlled trials (RCTs) are needed to assess this.AimsThis single-centre RCT pilot study compared a CCBT program (Stressbusters) with an attention control (self-help websites) for adolescent depression at referral to evaluate the clinical and cost-effectiveness of CCBT (trial registration: ISRCTN31219579).MethodThe trial ran within community and clinical settings. Adolescents (aged 12–18) presenting to their primary mental health worker service for low mood/depression support were assessed for eligibility at their initial appointment, 139 met inclusion criteria (a 33-item Mood and Feelings Questionnaire score of ≥20) and were randomised to Stressbusters (n = 70) or self-help websites (n = 69) using remote computerised single allocation. Participants completed mood, quality of life (QoL) and resource-use measures at intervention completion, and 4 and 12 months post-intervention. Changes in self-reported measures and completion rates were assessed by group.ResultsThere was no significant difference between CCBT and the website group at 12 months. Both showed improvements on all measures. QoL measures in the intervention group showed earlier improvement compared with the website group. Costs were lower in the intervention group but the difference was not statistically significant. The cost-effectiveness analysis found just over a 65% chance of Stressbusters being cost-effective compared with websites. The 4-month follow-up results from the initial feasibility study are reported separately.ConclusionsCCBT and self-help websites may both have a place in the care pathway for adolescents with depression.

A Delphi consensus methodology was used to adapt a screening tool, the Social Responsiveness Scale- 2 (SRS-2), for use with deaf children including those whose preferred communication method is sign language. Using this approach; 27 international experts (The Delphi International Expert Panel), on the topic of autism spectrum disorder (ASD) in deaf people, contributed to the review of item content. A criterion for agreement was set at 80% of experts on each item (with 75% acceptable in the final fourth round). The agreed modifications are discussed. The modified SRS-2 research adaptation for deaf people (referred to here as the "SRS-2 Deaf adaptation") was then translated into British Sign Language using a robust translation methodology and validated in England in a sample of 198 deaf children, 76 with Autism Spectrum Disorders (ASD) and 122 without ASD. The SRS-2 Deaf adaptation was compared blind to a NICE (National Institute for Health and Care Excellence) guideline standard clinical assessment. The area under the Receiver Operating (ROC) curve was 0.811 (95% CI: 0.753, 0.869), with an optimal cut-off value of 73, which gave a sensitivity of 82% and a specificity of 67%. The Cronbach Alpha coefficient was 0.968 suggesting high internal consistency. The Intraclass Correlation Coefficient was 0.897, supporting test-retest reliability. This performance is equivalent to similar instruments used for screening ASD in the hearing population.

The aim was to investigate the agreement between the ADI-R Deaf adaptation and ADOS-2 Deaf adaptation overall diagnostic categorisation for autism (AUT) and a wider threshold to include autism spectrum (ASD) in a cohort of deaf children with and without ASD. We compared results of the instruments used on their own and when combined and propose standard criteria for the combined use of the ADI-R Deaf adaptation and ADOS-2 Deaf adaptation for use with deaf children. In total, 116 deaf children had a Gold standard NICE guideline assessment; 58 diagnosed with ASD and 58 without ASD, and for both groups a blinded informant based ADI-R Deaf adaptation and direct assessment using the ADOS-2 Deaf adaptation were separately completed. There was moderate agreement between the ADI-R Deaf adaptation and ADOS-2 Deaf adaptation for the wider threshold of ASD (Kappa, 0.433). To achieve the lowest number of false negatives, the most successful assessment tool approach is using the wider threshold of ASD with either ADI-R Deaf adaptation or ADOS-2-Deaf adaptation (95% sensitivity). This compares with 88% for the ADI-R Deaf adaptation alone and 74% for the ADOS-2-Deaf adaptation alone (wider threshold of ASD). To achieve a low number of false positives, the most successful assessment tool approach is a combination of ADI-R Deaf adaptation and ADOS-2- Deaf adaptation (using the narrow threshold of autism for both) (95% specificity). This compares with 83% for the ADI-R Deaf adaptation alone and 81% for the ADOS-2-Deaf adaptation (narrow threshold) alone. This combination is therefore recommended in specialist clinics for diagnostic assessment in deaf children.

BackgroundLeishmaniasis is a neglected tropical parasitic disease endemic in South Asia, East Africa, Latin America and the Middle East. It is associated with low socioeconomic status (SES) and responsible for considerable mortality and morbidity. Reports suggest that patients with leishmaniasis may have a higher risk of mental illness (MI), psychosocial morbidity (PM) and reduced quality of life (QoL), but this is not well characterised. The aim of this study was to conduct a systematic review to assess the reported impact of leishmaniasis on mental health and psychosocial wellbeing.MethodsA systematic review of the literature was carried out. Pre-specified criteria were applied to identify publications including observational quantitative studies or systematic reviews. Two reviewers screened all of the titles, abstracts and full-studies and a third reviewer was consulted for disagreements. Data was extracted from papers meeting the criteria and quality appraisal of the methods was performed using the Newcastle-Ottawa Scale or the Risk of Bias in Systematic Review tool.ResultsA total of 14 studies were identified from 12,517 records. Nine cross-sectional, three case-control, one cohort study and one systematic review were included. Eleven assessed MI outcomes and were measured with tools specifically designed for this; nine measured PM and 12 measured QoL using validated measurement tools. Quality appraisal of the studies showed that six were of good quality. Cutaneous leishmaniasis and post kala-azar dermal leishmaniasis showed evidence of associated MI and PM including depression, anxiety and stigma, while all forms of disease showed decreased QoL. The findings were used to inform a proposed model and conceptual framework to show the possible links between leishmaniasis and mental health outcomes.ConclusionThere is evidence that leishmaniasis has an impact on MI, PM or QoL of patients and their families and this occurs in all the main subtypes of the disease. There are however large gaps in the evidence. Further research is required to understand the full extent of this problem and its mechanistic basis.

In a special issue that focuses on complex presentations related to Autism, we ask the question in this editorial whether an Autism Spectrum Condition without complexity is a disorder, or whether it represents human diversity? Much research into Autism Spectrum Conditions (ASCs) over the years has focused on comparisons between neuro-typical people and people with Autism Spectrum Conditions. These comparisons have tended to draw attention to ‘deficits’ in cognitive abilities and descriptions of behaviours that are characterised as unwanted. Not surprisingly, this is reflected in the classification systems from the World Health Organisation and the American Psychiatric Association. Public opinion about ASC may be influenced by presentations in the media of those with ASC who also have intellectual disability. Given that diagnostic systems are intended to help us better understand conditions in order to seek improved outcomes, we propose a more constructive approach to descriptions that uses more positive language, and balances descriptions of deficits with research finding of strengths and differences. We propose that this will be more helpful to individuals on the Autism Spectrum, both in terms of individual self-view, but also in terms of how society views Autism Spectrum Conditions more positively. Commentary has also been made on guidance that has been adjusted for people with ASC in relation to the current COVID-19 pandemic.

BackgroundDisorganised attachment patterns in infants have been linked to later psychopathology. Services have variable practices for identifying and providing interventions for families of children with disorganised attachment patterns, which is the attachment pattern leading to most future psychopathology. Several recent government reports have highlighted the need for better parenting interventions in at risk groups.ObjectivesThe objective of this review and meta-analysis was to evaluate the clinical effectiveness of available parenting interventions for families of children at high risk of developing, or already showing, a disorganised pattern of attachment.MethodsPopulation: Studies were included if they involved parents or caregivers of young children with a mean age under 13 years who had a disorganised classification of attachment or were identified as at high risk of developing such problems. Included interventions were aimed at parents or caregivers (e.g. foster carers) seeking to improve attachment. Comparators included an alternative intervention, an attention control, treatment as usual or no intervention. The primary outcome was a disorganised pattern in childhood measured using a validated attachment instrument. Studies that did not use a true Randomised Controlled Trial (RCT) design were excluded from the review. Both published and unpublished papers were included, there were no restrictions on years since publication and foreign language papers were included where translation services could be accessed within necessary timescales.ResultsA comprehensive search of relevant databases yielded 15,298 papers. This paper reports a systematic review as part of an NIHR HTA study identifying studies pre-2012, updated to include all papers to October 2016. Two independent reviewers undertook two stage screening and data extraction of the included studies at all stages. A Cochrane quality assessment was carried out to assess the risk of bias. In total, fourteen studies were included in the review. In a meta-analysis of these fourteen studies the interventions saw less disorganised attachment at outcome compared to the control (OR = 0.50, (0.32, 0.77), p = 0.008). The majority of the interventions targeted maternal sensitivity. We carried out exploratory analyses to examine factors that may influence treatment outcome but these should be treated with caution given that we were limited by small numbers of studies.ConclusionsParenting interventions that target parental sensitivity show promise in reducing disorganised attachment. This is limited by few high quality studies and the fact that most studies are with mothers. More high quality randomised controlled trials are required to elucidate this further.

Various interventions are used in clinical practice to address insecure or disorganized attachment patterns and attachment disorders. The most common of these are parenting interventions, but not all have a robust empirical evidence base. We undertook a systematic review of randomized trials comparing a parenting intervention with a control, where these used a validated attachment instrument, in order to evaluate the clinical and cost-effectiveness of interventions aiming to improve attachment in children with severe attachment problems (mean age

Background: A Social Story™ (Carol Gray) is a child-friendly intervention that is used to give children with autism spectrum disorders (ASDs) social information in situations where they have social difficulties. Limited evidence mainly using single-case designs suggests that they can reduce anxiety and challenging behaviour. Objectives: The objectives were to conduct a systematic review, use this to develop a manualised intervention and run a feasibility trial to inform a fully powered randomised controlled trial (RCT) on their clinical effectiveness and cost-effectiveness in schools. Design: This is a three-stage study following the Medical Research Council framework for complex interventions. Specifically, it involved a theoretical phase, a qualitative stage and a feasibility trial stage. Setting: Qualitative interviews and focus groups took place in Child and Adolescent Mental Health Service and primary care settings. The feasibility study took place in 37 local mainstream schools. Participants: Fifty children (aged 5–15 years) in mainstream school settings with a diagnosis of ASD were entered into the trial. For each child, an associated teacher and parent was also recruited. Interventions: The intervention was a goal-setting session followed by a manualised toolkit (including a training session) for creating Social Stories™ for use with school-aged children. The comparator treatment was a goal-setting session followed by an attention control. Both arms received treatment as usual. Main outcome measures: Outcomes tested as part of the feasibility study included child- and proxy-completed questionnaires for mental health, quality of life and goal-based outcome measures. Adults additionally completed behaviour diaries and the parental stress index. Results: The review found that the research into social stories is predominantly based in the USA, carried out in under-12-year-olds and using single-case designs. Most studies either did not follow established Social Story criteria or did not report if they did. The assessment of effectiveness presents a largely positive picture but is limited by methodological issues. There were no adequate RCTs and insufficient information to assess a number of important sources of potential bias in most studies. A manualised intervention was produced using an iterative process between user focus groups and a writing team, and assessed in the feasibility study. All 50 participant groups were recruited within the study time frame. Two outcome measures, the Social Responsiveness Scale-2 and the custom-made goal-based measure, showed high levels of completion rates and appeared to be capturing social and behaviour skills targeted by the use of Social Stories. Detailed recommendations for a full trial are provided. Limitations: Blinding of participants was not feasible. Treatment fidelity was not assessed because of low levels of story return rates. Conclusions: The study showed that a fully powered RCT is feasible with an extended geographical footprint. A large amount of data and information has helped to inform the design of this RCT, which will be the subject of a future research grant application. Future work could focus on developing an appropriate blinded outcome measure for this population. Study registration: This study is registered as PROSPERO CRD42011001440. Trial registration: Current Controlled Trials ISRCTN96286707. Funding: This project was funded by the NIHR Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 20, No. 6. See the NIHR Journals Library website for further project information.

Background and objectives: Services have variable practices for identifying and providing interventions for ‘severe attachment problems’ (disorganised attachment patterns and attachment disorders). Several government reports have highlighted the need for better parenting interventions in at-risk groups. This report was commissioned to evaluate the clinical effectiveness and cost-effectiveness of parenting interventions for children with severe attachment problems (the main review). One supplementary review explored the evaluation of assessment tools and a second reviewed 10-year outcome data to better inform health economic aspects of the main review. Data sources: A total of 29 electronic databases were searched with additional mechanisms for identifying a wide pool of references using the Cochrane methodology. Examples of databases searched include PsycINFO (1806 to January week 1, 2012), MEDLINE and MEDLINE In-Process & Other Non-Indexed Citations (1946 to December week 4, 2011) and EMBASE (1974 to week 1, 2012). Searches were carried out between 6 and 12 January 2012. Review methods: Papers identified were screened and data were extracted by two independent reviewers, with disagreements arbitrated by a third independent reviewer. Quality assessment tools were used, including quality assessment of diagnostic accuracy studies – version 2 and the Cochrane risk of bias tool. Meta-analysis of randomised controlled trials (RCTs) of parenting interventions was undertaken. A health economics analysis was conducted. Results: The initial search returned 10,167 citations. This yielded 29 RCTs in the main review of parenting interventions to improve attachment patterns, and one involving children with reactive attachment disorder. A meta-analysis of eight studies seeking to improve outcome in at-risk populations showed statistically significant improvement in disorganised attachment. The interventions saw less disorganised attachment at outcome than the control (odds ratio 0.47, 95% confidence interval 0.34 to 0.65; p 0.7) and four studies for the reference tests (four with α > 0.7). Three carried out concurrent validity comparing the Strange Situation Procedure (SSP) with another assessment tool. These had good sensitivity but poor specificity. The Disturbances of Attachment Interview had good sensitivity and specificity with the research diagnostic criteria (RDC) for attachment disorders. In our supplementary review of 10-year outcomes in cohorts using a baseline reference standard, two studies were found with disorganised attachment at baseline, with one finding raised psychopathology in adolescence. Budget impact analysis of costs was estimated because a decision model could not be justifiably populated. This, alongside other findings, informed research priorities. Limitations: There are relatively few UK-based clinical trials. A 10-year follow-up, while necessary for our health economists for long-term sequelae, yielded a limited number of papers. Conclusions: Maternal sensitivity interventions show good outcomes in at-risk populations, but require further research with complex children. The SSP and RDC for attachment disorders remain the reference standards for identification until more concurrent and predictive validity research is conducted. A birth cohort with sequential attachment measures and outcomes across different domains is recommended with further, methodologically sound randomised controlled intervention trials. The main area identified for future work was a need for good-quality RCTs in at-risk groups such as those entering foster care or adoption. Study registration: This study is registered as PROSPERO CRD42011001395. Funding: The National Institute for Health Research Health Technology Assessment programme.

Background: There are an estimated 125,000 deaf people in the UK who use British Sign Language (BSL) as their main form of communication, but there are no child mental health screening instruments that are accessible to deaf children whose first or main language is BSL (or to deaf adults reporting on children). This study sought to develop a new BSL translation of a commonly used mental health screening tool (Strengths and Difficulties Questionnaire, SDQ), with versions available for deaf young people (aged 11–16 years), parents and teachers. The psychometric properties of this translation, and its validity for use with the deaf signing UK population, were also investigated. Objectives: (1) To translate the SDQ into BSL; and (2) to use this new version with a cohort of deaf children, deaf parents and deaf teachers fluent in BSL across England, and validate it against a ‘gold standard’ clinical interview. Methods: This study was split into two broad phases: translation and validation. The BSL SDQ was developed using a rigorous translation/back-translation methodology with additional checks, and we have defined high-quality standards for the translation of written/oral to visual languages. We compared all three versions of the SDQ (deaf parent, deaf teacher and deaf young person) with a gold standard clinical interview by child mental health clinicians experienced in working with deaf children. We also carried out a range of reliability and validity checks. Results: The SDQ was successfully translated using a careful methodology that took into account the linguistic and cultural aspects of translating a written/verbal language to a visual one. We recruited 144 deaf young people (aged 11–16 years), 191 deaf parents of a child aged either 4–10 or 11–16 years (the child could be hearing or deaf) and 77 deaf teachers and teaching assistants. We sought deaf people whose main or preferred language was BSL. We also recruited hearing participants to aid cross-validation. We found that the test–retest reliability, factor analysis and internal consistency of the three new scales were broadly similar to those of other translated versions of the SDQ. We also found that using the established multi-informant SDQ scoring algorithm there was good sensitivity (76%) and specificity (73%) against the gold standard clinical interview assessment. The SDQ was successfully validated and can now be used in clinical practice and research. Factor analysis suggests that the instrument is good for screening for mental health problems but not for the identification of specific disorders, and so should be used as a screening instrument. It will also enable outcomes to be monitored. Conclusions: A BSL version of the SDQ can now be used for national studies screening for mental health problems in deaf children. This will help us better understand the needs of deaf children and will enable earlier detection of mental health difficulties. It can also be used within clinical settings to monitor outcomes. Future work: Future work may focus on using the SDQ in epidemiological research, and developing new assessment instruments for deaf children to improve assessment methods in the deaf population. Funding: The National Institute for Health Research Health Services and Delivery Research programme.

Background: There is policy interest in the screening and treatment of mental health problems in young people who offend, but the value of such screening is not yet known. Objectives: To assess the diagnostic test accuracy of screening measures for mental health problems in young people who offend; to evaluate the clinical effectiveness and cost-effectiveness of screening and treatment; to model estimates of cost; to assess the evidence base for screening against UK National Screening Committee criteria; and to identify future research priorities. Data sources: In total, 25 electronic databases including MEDLINE, PsycINFO, EMBASE and The Cochrane Library were searched from inception until April 2011. Reverse citation searches of included studies were undertaken and reference list of included studies were examined. Review methods: Two reviewers independently examined titles and abstracts and extracted data from included studies using a standardised form. The inclusion criteria for the review were (1) population – young offenders (aged 10–21 years); (2) intervention/instrument – screening instruments for mental health problems, implementation of a screening programme or a psychological or pharmacological intervention as part of a clinical trial; (3) comparator – for diagnostic test accuracy studies, any standardised diagnostic interview; for trials, any comparator; (4) outcomes – details of diagnostic test accuracy, mental health outcomes over the short or longer term or measurement of cost data; and (5) study design – for diagnostic test accuracy studies, any design; for screening programmes, randomised controlled trials or controlled trials; for clinical effectiveness studies, randomised controlled trials; for economic studies, economic evaluations of screening strategies or interventions. Results: Of 13,580 studies identified, nine, including eight independent samples, met the inclusion criteria for the diagnostic test accuracy and validity of screening measures review. Screening accuracy was typically modest. No studies examined the clinical effectiveness of screening, although 10 studies were identified that examined the clinical effectiveness of interventions for mental health problems. There were too few studies to make firm conclusions about the clinical effectiveness of treatments in this population. No studies met the inclusion criteria for the assessment of the cost-effectiveness of screening or treatment. An exemplar decision model was developed for depression, which identified a number of the likely key drivers of uncertainty, including the prevalence of unidentified mental health problems, the severity of mental health problems and their relationship to generic measures of outcome and the impact of treatment on recidivism. The information evaluated as part of the review was relevant to five of the UK National Screening Committee criteria. On the basis of the above results, none of the five criteria was met. Limitations: The conclusions of the review are based on limited evidence. Conclusions are tentative and the decision model should be treated as an exemplar. Conclusions: Evidence on the clinical effectiveness and cost-effectiveness of screening for mental health problems in young people who offend is currently lacking. Future research should consider feasibility trials of clinical interventions to establish important parameters ahead of conducting definitive trials. Future diagnostic studies should compare the diagnostic test accuracy of a range of screening instruments, including those recommended for use in the UK in this population. These studies should be designed to reduce the decision uncertainty identified by the exemplar decision model. Registration: This study is registered as PROSPERO CRD42011001466. Funding: The National Institute for Health Research Health Technology Assessment programme.

BackgroundBehavioural studies have highlighted irregularities in recognition of facial affect in children and young people with autism spectrum disorders (ASDs). Recent findings from studies utilising electroencephalography (EEG) and magnetoencephalography (MEG) have identified abnormal activation and irregular maintenance of gamma (>30 Hz) range oscillations when ASD individuals attempt basic visual and auditory tasks.Methodology/principal findingsThe pilot study reported here is the first study to use spatial filtering techniques in MEG to explore face processing in children with ASD. We set out to examine theoretical suggestions that gamma activation underlying face processing may be different in a group of children and young people with ASD (n = 13) compared to typically developing (TD) age, gender and IQ matched controls. Beamforming and virtual electrode techniques were used to assess spatially localised induced and evoked activity. While lower-band (3-30 Hz) responses to faces were similar between groups, the ASD gamma response in occipital areas was observed to be largely absent when viewing emotions on faces. Virtual electrode analysis indicated the presence of intact evoked responses but abnormal induced activity in ASD participants.Conclusions/significanceThese findings lend weight to previous suggestions that specific components of the early visual response to emotional faces is abnormal in ASD. Elucidation of the nature and specificity of these findings is worthy of further research.

BACKGROUND: Urinary mercury concentrations are used in research exploring mercury exposure. Some theorists have proposed that autism is caused by mercury toxicity. We set out to test whether mercury concentrations in the urine of children with autism were significantly increased or decreased compared to controls or siblings. METHODS: Blinded cohort analyses were carried out on the urine of 56 children with autism spectrum disorders (ASD) compared to their siblings (n = 42) and a control sample of children without ASD in mainstream (n = 121) and special schools (n = 34). RESULTS: There were no statistically significant differences in creatinine levels, in uncorrected urinary mercury levels or in levels of mercury corrected for creatinine, whether or not the analysis is controlled for age, gender and amalgam fillings. CONCLUSIONS: This study lends no support for the hypothesis of differences in urinary mercury excretion in children with autism compared to other groups. Some of the results, however, do suggest further research in the area may be warranted to replicate this in a larger group and with clear measurement of potential confounding factors.