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Autistic people are overrepresented in gender clinic settings, but limited evidence is available to guide clinical decision making for this patient group. We aimed to generate a comprehensive understanding of the phenomenology of gender dysphoria in autistic people.We conducted a multi-perspectival interpretative phenomenological analysis (IPA), from five different perspectives; autistic young people and adults with experience of gender dysphoria, parents of young people, and clinicians working with autistic people with gender dysphoria in both adult and young person settings (n = 68).IPA analysis resulted in two themes, 'discovering gender identity' and 'the complexities of moving towards gender comfort'. Participants agreed that there was often an interaction between gender dysphoria and features of autism such as sensory sensitivities. There was relative consensus across groups about the need for autism adaptations to be made in gender clinics. Autistic adults were more likely to see autism as an important identity than young people, but both groups were clear that autism did not impair their understanding of gender. In contrast, some parents and clinicians working with young people expressed concern that autism did impact self-understanding.While the groups tended to agree on the ways in which particular features of autism can compound gender dysphoria, there were a range of perspectives on the ways in which autism impacted on self-knowledge.Recommendations for adaptations when working with autistic people with gender dysphoria are presented.

Autism is increasingly seen as a social identity, as well as a clinical diagnosis. Evidence suggests that autistic adults who have stronger autism social identification have better psychological well-being. Autism is a condition which impacts on social interactions, and so one’s sense of autism identification may be particularly important for reducing social anxiety, which is common in autistic adolescents. We aimed to investigate how the subcomponents of autism identification relate to social anxiety in autistic young people. We hypothesised that autistic young people who had a higher satisfaction with their autism identity, and more solidarity with other autistic people, would have better psychological well-being and lower social anxiety. 121 autistic young people between the ages of 15–22 completed questionnaires measuring self-reported autism traits, social anxiety, psychological well-being, and different components of autism social identification. We conducted regression analyses controlling for age, gender, and autism traits. We found that higher autism satisfaction was associated with higher psychological well-being and lower social anxiety. Young people with higher autism solidarity had higher psychological well-being, but there was no significant relationship between solidarity and social anxiety. We conclude that it is important to support autistic young people to develop autism social identification. Lay abstract Autism is a diagnosis given to individuals by professionals but is also increasingly seen as an identity which an individual can choose for themselves. We wanted to explore how having autism as an identity affects autistic young people. There is evidence that autistic adults have better psychological well-being when they feel more solidarity with other autistic people and feel positively about being autistic. We know that autistic teenagers often feel anxious in social situations. Having a positive autism identity might help alleviate social anxiety associated with being autistic. We wanted to find out if autistic young people who felt more solidarity with other autistic people, and had more positive feelings about autism, had better psychological well-being and less social anxiety. We asked 121 autistic people aged 15–22 years to complete some questionnaires. These questionnaires asked about the young person’s autism traits, social anxiety, and psychological well-being. The questionnaires also asked how satisfied they felt to be autistic (satisfaction) and how much solidarity they felt with the autism community (solidarity). We found that autistic young people who had higher autism satisfaction had better psychological well-being and lower social anxiety. Young people who felt more solidarity with other autistic people had higher psychological well-being. There was no association between autism solidarity and social anxiety. We conclude that is important to support autistic young people to develop positive feelings about autism and to feel solidarity with other autistic people.

When post-traumatic stress disorder (PTSD) co-occurs with obsessive compulsive disorder (OCD), symptoms of the former can interfere with evidence-based treatment of the latter. As a result, exposure-based treatments are recommended for both OCD and PTSD, potentially facilitating a concurrent treatment approach. This case study describes the application of concurrent cognitive behaviour therapy (CBT including exposure and response prevention; ERP) for OCD and narrative exposure therapy to treat a patient whose PTSD symptoms of intrusive images of memories and hyperarousal were interfering with standard CBT (including ERP) treatment for OCD. Following this concurrent approach, the patient’s symptoms of OCD reduced to non-clinical levels and showed reliable improvement in PTSD symptoms. Whilst further methodologically robust research is required, this case study highlights that this approach may be beneficial to the treatment of OCD where PTSD symptoms are impacting on treatment. Key learning aims (1) To explore the literature considering explanations of the co-occurrence of OCD and PTSD symptomology. (2) To consider how symptoms of two mental health conditions can maintain one another and attenuate the effectiveness of evidence-based treatment for the other mental health condition. (3) Consider the use of concurrent therapeutic approaches to treat co-occurring mental health conditions.

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

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

Gender dysphoria is distress in relation to incongruence between an individual’s gender and sex assigned at birth. Gender clinics offer support for gender dysphoria, and there is a higher prevalence of autism in young people attending such clinics than in the general population. We aimed to investigate the lived experiences of autistic young people who have experienced gender dysphoria, and their parents, using a multi-perspectival IPA design. Young autistic people aged 13–17 years (n = 15), and their parents (n = 16), completed in-depth interviews about the young person’s experience of gender dysphoria. We analysed each individual transcript to generate individual themes, and for each of the dyads, developed themes which acknowledged the similarities and differences in parent–child perspectives. The first superordinate theme was coping with distress which had two subordinate themes; understanding difficult feelings and focus on alleviating distress with external support. This theme described how young people were overwhelmed by negative feelings which they came to understand as being about gender incongruence and looked to alleviate these feelings through a gender transition. The second superordinate theme was working out who I am which had two subordinate themes: the centrality of different identities and needs and thinking about gender. This theme described how young people and their parents focused on different needs; while young people more often focused on their gender-related needs, parents focused on autism-related needs. We conclude that young people and parents may have different perspectives and priorities when it comes to meeting the needs of autistic young people who experience gender dysphoria.

The impact of drug-foods (tobacco and cane sugar, cocoa and caffeine) and the consequences of their production on the health of both public and planet are wide ranging and increasing from obesity to pressure on water supply. The world’s food system is dominated by a small number of global corporations making and promoting drug-foods in myriad forms. The use of sugar-substitute non-sugar sweeteners, and their design of products, are specifically formulated to be ‘moreish’, to stimulate pleasure responses above and beyond the natural pleasure of eating. In the UK we can identify these foods, and the corporations that make them, since Value Added Tax (VAT) is applied. We suggest that, for food and drink upon which UK VAT is levied, advertising and product placement should be prohibited and controls put on branding and packaging. We further suggest action is taken to: (i) restrain the activities of the companies making these products, (ii) prohibit their sponsorship and/or partnership with government bodies such as schools and NHS, (iii) ensure these corporations pay the full fiscal and environmental costs of drug-foods. Our urgent challenge is to act against the sociopathic power of such corporations, for the public health and that of the planet.

Autistic people are over-represented at gender clinics, but there is limited research to guide clinical practice with this group. We investigated the perspectives of clinicians working with autistic patients who experience gender dysphoria. We asked clinicians about the relationship between autism and gender dysphoria, and whether they work differently with this patient group. We recruited clinicians from young person and adult gender clinics and autism services ( n = 16). We analysed the interview transcripts using interpretative phenomenological analysis (IPA). The first overarching theme was clinician understanding of the intertwined experiences of patients, with four subthemes: (a) coming to an individualised understanding of autism, gender dysphoria, and mental health; (b) different ways of thinking about gender; (c) social differences as barriers and facilitators to gender comfort; (d) the challenge of sensory sensitivities and puberty. The second overarching theme was mismatch of patient and clinician communication styles and goals, with three subthemes: (a) different communication of gender needs; (b) changing clinical sessions to overcome barriers; (c) tension between clinician and patient aims and thinking styles. We conclude that autism adaptations should be made in gender settings, by increasing clinician understanding of how autism and gender dysphoria can intersect, as well as by making adjustments to clinic processes. Lay Abstract Autistic people are more likely to have a gender identity which does not match their sex assigned at birth. Some people experience distress about their sex and gender not matching, which is called gender dysphoria. Such individuals may wish to attend a gender clinic to access healthcare support for gender dysphoria. Currently, there is limited evidence to help clinicians best support autistic people who need healthcare for gender dysphoria. We wanted to find out what healthcare clinicians think about working with autistic patients with gender dysphoria. We interviewed 16 clinicians who work in healthcare services with adults and young people who are autistic and experience gender dysphoria. We recorded the interviews and carefully analysed the content to find key themes. We found that clinicians worked with patients to try and better understand their experiences of gender dysphoria. Clinicians identified features of autism that they believed were related to gender identity and dysphoria including different thinking styles, social differences, and sensory sensitivities. Clinicians noticed that autistic people spoke about their gender in different ways to non-autistic people. Clinicians tried to adapt their practice to better meet the needs of their autistic patients. These adaptations tended to focus on differences in the assessment process, for example, offering longer or shorter appointments and changing their communication style. We conclude that clinicians were offering an individualised approach to autistic patients experiencing gender dysphoria. However, these clinicians were particularly interested in working with autistic people, and so may not be representative of the wider clinician population. Clinicians working in this area should receive training on autism adaptations and the intersection of autism and gender dysphoria.

Fatigue is common in adolescence and can be highly disabling if experienced persistently, with adverse psychosocial outcomes. There is a need to better understand what nonpharmacological treatments are available for adolescents suffering with persistent fatigue. The current review systematically identified, synthesised, and evaluated the evidence regarding nonpharmacological interventions for fatigue in adolescents, focusing on evaluating effectiveness, describing intervention components, and mapping interventions onto the behaviour change technique taxonomy (BCTT).CENTRAL, EMBASE, PsycINFO, PubMed, and Web of Science were systematically searched for articles including (1) adolescents aged 10-19 years old, (2) fatigue as a primary or secondary outcome, (3) nonpharmacological interventions, and (4) randomised controlled trials. Study screening, data extraction, quality assessment, and BCTT mapping were performed independently by two reviewers. Findings were presented as a narrative synthesis, with interventions ranked by promise.5626 papers were identified and double-screened, resulting in the inclusion of 21 articles reporting 16 trials. Five interventions were classified as likely promising. Interventions often involved psychoeducation, cognitive behavioural therapy, and/or physical activity, incorporating various BCTT domains, most commonly shaping knowledge, repetition and substitution, and goals and planning. However, there did not seem to be any observable differences between fatigue-targeted and non-fatigue-targeted interventions. Overall study quality was mixed, particularly in relation to power and outcome measures.There are several promising nonpharmacological interventions for adolescent fatigue, although further work is needed to determine effectiveness. Future trials need to ensure design rigour, focusing on adequate powering, validated outcome measures, and adhering to best practice reporting guidelines.

BackgroundHigh rates of depression are frequently reported in autistic adults. There have been no randomised trials investigating low-intensity psychological interventions for mild-moderate depression adapted for autistic adults.MethodThis qualitative evaluation investigated the acceptability of the ADEPT pilot randomised controlled trial (RCT) design and guided self-help intervention. Participants (autistic adults with a diagnosis of depression (PHQ-9 score ≥ 10)) were randomised to Guided Self-Help (GSH): low intensity psychological intervention based on Behavioural Activation adapted for autistic adults, or Treatment as Usual (TAU). 21 trial participants (14 GSH and 7 TAU), and 5 low intensity psychological therapists or ‘coaches’ were interviewed, and transcripts analysed thematically.ResultsAll participants and coaches welcomed an intervention for depression adapted for autistic adults due to current lack of provision in mainstream services. Interviews highlighted participants' preference for GSH over TAU. Dissatisfaction with prior experience of TAU was identified as a potential driver for differential attrition from the TAU arm. Participants who received GSH appreciated the coaches having a good understanding of autistic adults and were positive towards the aim and structure of the GSH intervention. Suggested improvements include more regularly checking progress with therapy goals.ConclusionsA full scale RCT to evaluate the effectiveness of this intervention is now warranted. Future trial study design needs to address potential for differential rate of participant recruitment and attrition between the treatment and comparison groups due to negative prior experience of TAU.

Autistic people are more likely to be transgender, which means having a gender identity different to one’s sex assigned at birth. Some transgender people experience distress about this incongruence or gender dysphoria. Few studies have aimed to understand the inner experiences of this group. In this study, we used Interpretive Phenomenological Analysis to understand the lived experience of gender dysphoria. Twenty-one autistic adults were interviewed about their experience of incongruence between their gender identity and sex assigned at birth, and any associated distress. The interviews were transcribed and analysed using Interpretive Phenomenological Analysis. Participants described significant distress because their bodies did not match their gender identities, their need to understand their identities more broadly and to manage complex intersecting needs. Participants experienced distress due to living in a world which is not always accepting of gender- and neuro-diversity. Participants described barriers in accessing healthcare for their gender needs. Some participants felt being autistic had facilitated their understanding of their gender identity. Other participants described challenges such as a tension between their need to undergo a physical gender transition versus a need for sameness and routine. In conclusion, there can be both positive experiences and additional challenges for autistic transgender people. Lay Abstract Autistic people are more likely to be transgender, which means having a gender identity different to one’s sex assigned at birth. Some transgender people experience distress about their gender and sex assigned at birth not matching which is called gender dysphoria. Research has focused on finding out why autistic people are more likely to have gender dysphoria, and less on what the experience of gender dysphoria is like for autistic people. We interviewed 21 autistic adults about their experience of incongruence between their gender identity and sex assigned at birth, and any associated distress. We carefully read the transcripts of the interviews, focusing on how participants understood their experiences. We found a range of themes from the interviews. Participants were distressed because their bodies did not match their gender identities. Participants told us they had to work hard to understand themselves and who they were, and to manage having multiple different needs such as mental health needs. It was upsetting for participants to experience discrimination because of being autistic and/or transgender. Some participants said it was more difficult to get transgender healthcare as an autistic person. Some participants thought being autistic had helped them understand their gender identity more than non-autistic people. Other participants found it was challenging to be both autistic and transgender. For example, most participants wanted to change their bodies to match their gender identity, but some participants were nervous about making changes to themselves and their routine due to being autistic. We conclude that autism can in some ways be helpful and other ways contribute to challenges for transgender autistic people.

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

Background:Post-traumatic stress disorder (PTSD) is commonly experienced by asylum seekers and refugees (ASR). Evidence supports the use of cognitive behavioural therapy-based treatments, but not in group format for this population. However, group-based treatments are frequently used as a first-line intervention in the UK.Aims:This study investigated the feasibility of delivering a group-based, manualised stabilisation course specifically developed for ASR. The second aim was to evaluate the use of routine outcome measures (ROMs) to capture psychological change in this population.Method:Eighty-two participants from 22 countries attended the 8-session Moving On After Trauma (MOAT) group-based stabilisation treatment. PHQ-9, GAD-7, IES-R and idiosyncratic outcomes were administered pre- and post-intervention.Results:Seventy-one per cent of participants (n = 58) attended five or more of the treatment sessions. While completion rates of the ROMs were poor – measures were completed at pre- and post-intervention for 46% participants (n = 38) – a repeated-measures MANOVA indicated significant improvements in depression (p = .001, ηp2 = .262), anxiety (p = .000, ηp2 = .390), PTSD (p = .001, ηp2 = .393) and idiosyncratic measures (p = .000, ηp2 = .593) following the intervention.Conclusions:Preliminary evidence indicates that ASR who attended a low-intensity, group-based stabilisation group for PTSD experienced lower mental health scores post-group, although the lack of a comparison group means these results should be interpreted with caution. There are significant challenges in administering ROMs to individuals who speak many different languages, in a group setting. Nonetheless, groups have benefits including efficiency of treatment delivery which should also be considered.

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

It has long been acknowledged that although the reign of Constantine (d. 337 c.e.) brought new prosperity to the Christian churches, it was also an age of ever-escalating division. This essay suggests that recent scholarship on populism can help us to understand the role of conflict in Constantinian Christianity. Structured conflict, we suggest, had a recognized value as a tool for cultivating the loyalty of a following. The creation of factional loyalty, rather than spiritual unity, seems to have been the aim of the fourth-century Christian bishops and clergy. Yet it is less clear whether this goal was shared by the emperor himself.

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

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

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

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

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

Accessible summary Network Training is a way that helps people to understand behaviour like hurting people or breaking things, called ‘challenging behaviour’. Network Training is where lots of people meet up to think about the person showing challenging behaviour. We did Network Training to help understand the behaviours of a boy who has a learning disability. His support workers, teachers and doctors came to think about what was making him show challenging behaviours. The people who came to the training thought that it was useful. Abstract Background: Network Training is an intervention that draws upon systemic ideas and behavioural principles to promote positive change in networks of support for people defined as having a learning disability. To date, there are no published case studies looking at the outcomes of Network Training. Materials and Methods: This study aimed to investigate the impact of Network Training on a network of support for a boy labelled as having learning disabilities and challenging behaviour, including sexually harmful behaviour. Participants in the Network training completed two questionnaires; one designed for this study and The Challenging Behaviours Attributions Scale at two baseline points and following the intervention. Results: Network Training led to positive changes in the confidence, understanding, strengths focus and joint working of the individual's network. There was no significant change in participants' CHABA scores. Conclusion: This case study provides preliminary evidence that Network Training may be of benefit to children labelled as having learning disabilities, and merits further investigation.

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

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

Profiling progression and development of cancer is an important step for informing clinical decisions in the diagnosis, prognosis and treatment of cancer. The hallmarks of cancer progression are well established; for example, many studies have concluded that surveillance of gene expression relationships during cancer progression would inform diagnostic and treatment decisions. Differential network analysis offers a systems-level insight into cancer progression from a high-level point of view, and once further understood, could become a transformative approach for measuring cancer progression. In this work, we investigate an approach to measure pairwise change in network topology between cancer stages for four cancers, including thyroid carcinoma, colon and rectum adenocarcinoma, stomach adenocarcinoma, and kidney renal papillary cell carcinoma. We use a network-based approach to describe systems-level views of how a network model changes over the course of a four-stage disease progression in these cancers and examine how mutation rate corresponds to network structure. Lastly, we present a case study in comparing primary versus metastatic tumour network structure. The results of this study demonstrate the applicability of such an approach and provide insights into next steps that are needed for differential network comparison in cancer.

The fifth-century Christian writer Sozomen of Constantinople preserves a story told by certain pagans about the philosopher Sopater of Apamea, whom the emperor Constantine put to death in a.d. 333 on the advice of the Christian Flavius Ablabius, then Praetorian Prefect of the East. Constantine had consulted the philosopher — so the story goes — in an attempt to redress his guilt at having ordered the murder of some of his nearest relations, among them his son Crispus. But Sopater replied that such moral defilement could admit of no purification. Afterwards, on meeting some Christian bishops, Constantine was delighted to learn that the sins of those who truly repented could be washed away in Christian baptism. It was this that led him to adopt the faith, and to encourage his subjects to do the same.

The household was an ideological battleground in antiquity. To ‘turn a man against his father’ was to challenge deeply held convictions about how society should be constituted. For a free man to raise children in his own image was understood – by Jews, Greeks, and Romans alike – as a right and even a duty. The household was the acknowledged nerve centre for the processes of social control and social reproduction.

In carbonate aquifers, dissolved organic carbon from the surface drives heterotrophic metabolism, generating CO2 in the subsurface. Although this has been a proposed mechanism for enhanced dissolution at the water table, respiration rates and their controlling factors have not been widely evaluated. This study investigates the composition and concentration of dissolved organic carbon (DOC) reaching the water table from different recharge pathways on a subtropical carbonate island using a combination of DOC concentration measurements, fluorescence and absorption characterisation. In addition, direct measurements of the microbial response to the differing water types were made. Interactions of rainfall with the vegetation, via throughfall and stemflow, increase the concentration of DOC. The highest DOC concentrations are associated with stemflow, overland recharge and dissolution hole waters which interact with bark lignin and exhibit strong terrestrial-derived characteristics. The groundwater samples exhibit the lowest concentrations of DOC and are comprised of refractory humic-like organic matter. The heterotrophic response seems to be controlled by the concentration of DOC in the sample. The terrestrially sourced humic-like matter in the stemflow and dissolution hole samples was highly labile, thus increasing the amount of biologically produced CO2 to drive dissolution. Based on the calculated respiration rates, microbial activity could enhance carbonate dissolution, increasing porosity generation by a maximum of 1 % kyr−1 at the top of the freshwater lens.

The prison narrative attributed to the early third-century Christian martyr Perpetua of Carthage has long attracted attention because of its dramatic portrayal of a Roman father's failure to extract obedience from his adult daughter as he tries to dissuade her from allowing herself to be punished as an enemy of the Roman state. This study explores the alignment between paternal authority and the authority of the Roman procurator Hilarianus in Perpetua's narrative, considering how the civic spaces of forum and arena became theatres for both filial and civil disobedience.

1. Tab. Sulis 98, in Roger Tomlin, “The Curse Tablets,” in The Temple of Sulis Minerva at Bath, ii: The Finds from the Sacred Spring, ed. Barry Cunliffe (Oxford: Oxford University Committee for Archaeology, 1988), 59–280, at 232–33; trans. Caroline Humfress, “Law in Practice,” in Philip Rousseau, A Companion to Late Antiquity (Oxford: Wiley-Blackwell, 2009), 377–91, at 387 (slightly modified). Christianity, Private Power, and the Law from Decius to Constantine: The Minimalist View