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This chapter provides an overview of neurodevelopmental disorders (NDDs) in children and young people. The definition and classification of NDDs is discussed, including key differences between ICD-10 and ICD-11 and the problematic use of language in diagnostic classifications, which is at odds with the social model of disability. Important stages of a multidisciplinary assessment of NDDs include a detailed developmental history, a psychosocial history, observation of the child, an assessment of the child’s communication and learning and supplementary rating scales. The role of professionals such as Community Paediatricians, Speech and Language Therapists, Occupational Therapists, teachers and Educational Psychologists is highlighted. Features of the main NDDs are outlined, including Autism Spectrum Disorder, Attention Deficit Hyperactivity Disorder, Specific Disorders of Development and Language and Tic disorders. Finally, an overview of treatment approaches and their evidence base is explored.
Autistic adolescents are at higher risk of self-harm, suicidal behaviours, and emotion dysregulation compared with their non-autistic peers. Dialectical behaviour therapy (DBT) is an evidence-based treatment for self-harm and suicidal behaviour with emerging literature of the application of DBT for autistic populations. Despite this, no qualitative research has investigated the experiences of autistic adolescents of standard DBT. Therefore, this study aimed to explore autistic adolescents’ experiences of non-adapted DBT. Ten adolescents who had or were seeking an autism diagnosis, and were in a DBT programme, completed semi-structured interviews. Qualitative data from the interviews were analysed using reflexive thematic analysis. Themes were generated for each objective. Objective 1 included themes about the lived experience of autistic adolescents accessing DBT, including: ‘The impact of invalidation’, ‘Fostering acceptance and understanding’, ‘What does autism mean to me?’, and ‘Autism and mental health difficulties’. The themes regarding Objective 2 were about the experiences of the various modes of DBT and were organised by each client-facing mode. Objective 3 included themes highlighting the experience of utilising DBT skills in daily life, which included: ‘Barriers to skills use’, ‘Supporting skills use’, and ‘Skills practice or masking?’. Finally, Objective 4 included themes regarding the recommendations participants had for optimising DBT for autistic people: ‘Improving written materials’ and ‘General accessibility advice’. These findings suggest for DBT therapists to embody cultural humility, curiosity, validation, and flexibility when building neuro-affirmative competencies for supporting autistic individuals. Results are discussed in relation to the application and acceptability of DBT for this group.
Key learning aims
(1) Recent publications (e.g. Keenan et al., 2023) have explored the experience of autistic adults accessing DBT and highlighted the need for clinicians to work collaboratively with clients and make reasonable adjustments to improve autistic adults’ understanding and adherence to DBT.
(2) To date, no qualitative studies have explored the experience of autistic adolescents accessing the Rathus and Miller (2015) Adolescent DBT model. The current study explores the views of autistic adolescents on how autism is discussed and considered by clinicians when supporting them to access different components of DBT when describing the strengths and barriers they experience.
(3) Adopting a bottom-up approach, we identify key themes from adolescents’ perspectives on how to support them to access and engage with different DBT components, ranging from making environmental adaptations to meet individual sensory needs to improve accessibility, to providing more opportunities for personalised learning using neuro-affirmative examples that can improve generalisability of skills in everyday life. We provide recommendations for clinicians to consider on ways of adapting the process and content of DBT to increase accessibility and engagement for autistic adolescents in treatment.
Autistic high school students overwhelmingly have a poor experience of school. Research into this stage of life is limited, and researchers have tended not to talk to autistic students directly, instead hearing from non-autistic observers such as teachers and parents. This study aimed to address this gap in our knowledge by interviewing autistic students in mainstream high schools about their experience of school and their ideas for how this could be improved. Ten autistic students (13 to 20 years old) in Australian high schools were interviewed. Students overwhelmingly reported a negative experience. Most said their ideal school would be one where teachers and peers had greater understanding about autism and teachers had training in autism. By including the student voice, this research makes a valuable contribution to our understanding of autistic students’ school experience, adding depth and detail, and including what they would like to see changed. Importantly, the interview data also challenged misconceptions about what autistic students prioritised. The voice of autistic teens can make an important contribution to policies and practices aimed at improving their experience of school.
Health and mental health professionals often lack knowledge and confidence to provide quality healthcare to people with intellectual disability and those on the autism spectrum. Educational interventions are proposed as solutions, but their effectiveness and optimal characteristics remain unclear.
Aims
To evaluate the effectiveness of educational interventions in improving health professionals’ knowledge, skills, attitudes, confidence and/or self-efficacy in providing care to people with intellectual disability and those on the autism spectrum.
Method
A mixed-methods systematic review was conducted searching six major databases, adhering to PRISMA guidelines (PROSPERO CRD42022309194). Studies were included if they assessed outcomes of educational interventions aimed at improving health professionals’ capacity to provide care to people with intellectual disability and/or those on the autism spectrum.
Results
We identified 34 studies: five focused on intellectual disability, two on intellectual and developmental disabilities, and 27 on autism. All reported positive findings, although heterogeneity of measures limited synthesis. Most studies (30 out of 34) employed single group pre-test/post-test designs, with only nine using validated outcome measures. Only eight studies reported co-design or co-delivery involving people with lived experience.
Conclusions
Educational interventions demonstrate positive effects on heath professionals’ capacity to provide care. Significant gaps include limited evidence for adult-focused interventions, uncertainty about optimal delivery modes and duration, and minimal inclusion of people with lived experience in intervention design and delivery. Future interventions should involve people with lived experience in design and delivery, and incorporate validated outcome measures to enhance evidence quality.
The surge of online psychological assessments have brought the autism research community both opportunities and challenges: while they enable rapid large-scale data collection and more power to characterize individual differences, they also bring concerns about data quality, generalizability beyond online samples, and whether autistic traits can be reliably characterized with self-report measures administered online. Here we tackle these concerns by providing a systematic characterization of the autistic traits variability across individuals in a large cross-sectional dataset (N = 2826) as well as its temporal reliability within individuals in a test-retest dataset (N = 247), with both online and in-lab samples. We measured autistic traits using the Social Responsiveness Scale, 2nd version, Adult Self Report (SRS-2-ASR) – a tool that quantifies individual differences in autistic traits along a continuum for the general adult population. Across individuals, we found elevated SRS scores in online samples and were able to trace this effect to specific subsets of SRS items. SRS scores also covaried with internalizing symptoms, decreased with age, and were lower in women compared to other genders. Within individuals, we find moderate-to-good test-retest reliability of SRS scores over long intervals, with no difference between online and in-lab samples, suggesting robust temporal stability. We conclude that there are systematic differences in autistic traits between online and in-lab samples that are partly explained by systematic population-level differences in internalizing symptoms, particularly social anxiety. Future studies that sample across different populations should measure, control for, or stratify with respect to these factors.
Social rewards (e.g. smiles) powerfully shape human behavior, starting from early childhood. Yet, the neural architecture that enables differential processing of social and nonsocial rewards remains largely unknown. Few previous studies that directly compared social vs nonsocial stimuli have used stimuli that have low ecological validity or are not matched on low-level stimulus parameters – limiting the scope of inference. To address this gap in knowledge, social and nonsocial reward images taken from the real world were matched on valence, arousal, and key low-level stimulus properties and presented to 37 adults in a functional magnetic resonance imaging (fMRI) study. Individual self-reported preference for social images was associated with the functional connectivity between the left anterior insula (LAI) and medial orbitofrontal cortex (mOFC), as well as that between the left Fusiform Gyrus (LFG) and the Anterior Cingulate Cortex (ACC). Autistic traits negatively modulated LAI – mOFC connectivity and LFG – ACC connectivity. Reduced functional connectivity between these regions may contribute to the lower social reward responsivity in individuals with high autistic traits, as also noted from their lower valence ratings to social rewards. This study provides evidence for a new experimental paradigm to test social reward processing at a behavioral and neural level, which can contribute to potential transdiagnostic biomarkers for social cognitive processes.
This paper describes the evaluation of a simple service adaptation and associated brief training for NHS Talking Therapies for Anxiety and Depression (NHS TTad) staff on working with autistic people. A simple question regarding whether clients identified themselves as autistic and an associated data system flag was introduced to an NHS TTad service. A brief training regarding the use of the flag, a brief overview of autism and a consideration of general adaptations that might help autistic people was developed. Core outcomes of confidence and therapy self-efficacy were reported for pre-training, immediately post-training and at three months post-training. At three-month follow-up, six therapists were interviewed to explore changes in practice following the training. There were significant changes in confidence and therapeutic self-efficacy post-training that were maintained at three-month follow-up. Therapists report several changes to practice that they related to the training. This is the first paper to describe and evaluate training for therapists in NHS TTad on working with autistic people.
Key learning aims
(1) To describe some of the challenges to NHS TTad services in working with autistic people.
(2) To describe the system adaptation and therapist training introduced to this service and the approach to evaluation.
(3) To report outcomes from the evaluation of the training for NHS TTad therapists in working with autistic adults.
(4) To consider further research and practice in the processes to make NHS TTad services more accessible and effective for autistic adults.
Exposure to multiple languages may support the development of Theory of Mind (ToM) in neurotypical (NT) and autistic children. However, previous research mainly applied group comparisons between monolingual and bilingual children, and the underlying mechanism of the observed difference remains unclear. The present study, therefore, sheds light on the effect of bilingualism on ToM in both NT and autistic children by measuring language experiences with a continuous operationalization. We measure ToM with a behavioral, linguistically simple tablet-based task, allowing inclusive assessment in autistic children. Analyses revealed no difference between monolingual and bilingual NT and autistic children. However, more balanced exposure to different languages within contexts positively predicted first-order false belief understanding in NT children but not autistic children. Mediation analysis showed that the impact in NT children was a direct effect and not mediated via other cognitive skills.
Mirroring the general population, the number of medical students, doctors and, indeed, psychiatrists disclosing being neurodivergent is rising. These individuals commonly have a variety of strengths that can enhance their work, but these strengths may go unrecognised. All too often such individuals have been labelled ‘doctors in difficulty’. We begin this article with a review of contemporary thinking regarding neurodiversity, before considering specific issues facing neurodivergent doctors, specifically psychiatrists. We explore neurodivergent strengths and the evidence regarding career outcomes and mental health. We discuss the stigma that many neurodivergent psychiatrists face in the medical sphere and how difficulties may be reframed as unmet needs. We highlight initiatives that aim to change workplace culture, before discussing the concept of reasonable adjustments, alongside a wide range of practical suggestions of adjustments to consider, using the Autistic SPACE framework and the Royal College of Psychiatrists’ reasonable adjustments guidance. Finally, we consider how those in senior leadership roles can contribute to this field and provide role modelling and signposting to further information and support for neurodivergent doctors and their supervisors and line managers.
Social anxiety disorder (SAD) is one of the most prevalent co-occurring conditions amongst cognitively unimpaired autistic people. The evidence-based treatment for social anxiety known as cognitive therapy for SAD (CT-SAD) may to an extent be beneficial to autistic people, but adaptations for autistic people are recommended to increase its effectiveness. The present study aimed to co-produce and pilot an adapted SAD treatment protocol for autistic people based on the Clark and Wells (1995) model, including assessing its feasibility and acceptability. A bespoke 12-week CBT online group intervention was created to meet the needs of autistic people with a diagnosis of SAD. The treatment protocol was created collaboratively with autistic people. It was piloted with seven adult participants (three males, four females) with autism or self-identified autism who completed the group intervention targeting SAD symptoms. With regard to feasibility, we met our initial aims of recruiting our intended sample size of a minimum of six participants for the intervention with an attendance rate of at least 80% of sessions. The excellent completion and attendance rates, respectively 100% and 95%, indicate that the intervention was acceptable to our participants. These findings extend previous research and support the continued adaptation of CBT interventions for autistic people. Furthermore, the evidence of feasibility indicates that further study to evaluate the efficacy of this group intervention is warranted.
Key learning aims
(1) To reflect on social anxiety, autism and identify ways to improve the delivery of cognitive therapy for autistic people.
(2) To identify useful adaptations to cognitive therapy for autistic people.
(3) To learn how to deliver group cognitive therapy remotely for autistic people who present with social anxiety.
The transition from primary to secondary school, encompassing the pre-, during-, and post-transition stages, often poses significant challenges for students on the autism spectrum. This critical period has garnered growing research attention; however, the perspectives of Australian parents on the support their autistic children receive post-transition remain largely unexplored. Underpinned by a transcendental phenomenological epistemology and Kohler’s Taxonomy for Transition Programming, we explored Australian parents’ perspectives on the support being provided to their children on the autism spectrum and how these students experience this post-transition period. Four parents of high-school-aged children on the autism spectrum participated in interviews, conducted online via Zoom. A deductive content analysis of parents’ insights revealed overwhelming dissatisfaction with the post-transition support provided to their children on the autism spectrum, particularly surrounding home–school collaboration practices and the utilisation of personalised learning. The findings contribute a much-needed Australian perspective to the limited body of research focused on sustaining support for students on the autism spectrum beyond the initial transition to secondary school.
The Mental Health Bill, 2025, proposes to remove autism and learning disability from the scope of Section 3 of the Mental Health Act, 1983 (MHA). The present article represents a professional and carer consensus statement that raises concerns and identifies probable unintended consequences if this proposal becomes law. Our concerns relate to the lack of clear mandate for such proposals, conceptual inconsistency when considering other conditions that might give rise to a need for detention and the inconsistency in applying such changes to Part II of the MHA but not Part III. If the proposed changes become law, we anticipate that detentions would instead occur under the less safeguarded Deprivation of Liberty Safeguards framework, and that unmanaged risks will eventuate in behavioural consequences that will lead to more autistic people or those with a learning disability being sent to prison. Additionally, there is a concern that the proposed definitional breadth of autism and learning disability gives rise to a risk that people with other conditions may unintentionally be unable to be detained. We strongly urge the UK Parliament to amend this portion of the Bill prior to it becoming law.
The same developmental principles account for both normal and disturbed development. Disturbed behavior too is coherent and meaningful. Psychopathology is an outcome of development. This applies to common problems such as idealization or over-control; childhood disturbances such as ADHD; and to extreme symptoms, such as the stereotypes of autistic children and the dissociation and thought disturbances of adults. All of these become more understandable when looked at through the lens of meaning.
The puzzle at the outset of the book is how a fixed biological machinery (like the vocal organs and brain adaptations) could evolve despite the great diversity of languages. The interaction engine bridges the arch from the biological machinery to the cultural diversity of languages, by explaining how the variability is made possible through a uniform set of principles of communicative interaction which makes the learning of diverse languages possible. The book suggests that the enduring mysteries of language evolution are partly unravelled by studies of the interaction system that underlies language.
Narratives from autistic children, children with developmental language disorder (DLD) and typically developing children were compared for attributions of intentionality in descriptions of two animations, one inviting descriptions of social events like fighting, another one inviting descriptions of physical events like orbiting planets. The analysis was based on a semantic and syntactic classification of clauses in terms of whether the verbs require their arguments to refer to beings with subjective experience, that is, intentionality attribution as a first step in the understanding of others as beings with mental states and processes. The autistic children did not have difficulties attributing intentionality to geometric figures. Moreover, the children with DLD made more intentionality attributions in their descriptions of the physical animation than the typically developing peers. Both diagnostic groups reported fewer relevant events than the typically developing children, which is interpreted as difficulties with narrative macrostructure. The results are discussed in relation to earlier studies and with respect to what they tell us about intentionality attribution and narrative structure in autism.
At a fairly early age Lucy was admitted to a psychiatric hospital and then spent years in low-security psychiatric units. After an episode of neuroleptic malignant syndrome, she became physically unwell and stopped eating. When her life appeared to be danger, ECT was suggested. Lucy refused to have it and the first sessions were given under restraint. After eight sessions ECT hadn’t worked, and the team stopped it. A second course was started later, this time with Lucy’s agreement, and it worked. She gradually improved, had psychological treatment, engaged in rehabilitation and eventually was discharged home. She continued with maintenance ECT as an outpatient. She got married and started work as an Expert by Experience for the local hospital.
Describe how children can take different paths in development and reach similar destinations; understand the developmental differences between children as a set of strengths and challenges that are highly sensitive to environmental context; explore how events in children’s lives can trigger a cascade of later consequences.
The aim of this study was to investigate sensorimotor functions that require cerebellar processing, and visuospatial perception and visuospatial abilities in adult patients with attention deficit hyperactivity disorder (ADHD) and autism spectrum disorder (ASD).
Method:
We included patients with unmedicated ADHD (n = 52), medicated ADHD (n = 39), ASD (n = 33), the combination of unmedicated ADHD and ASD (n = 31) and controls (n = 78). A multimodal set of neurocognitive tests and motor tasks were administrated to evaluate cognitive and motor skills.
Results:
All patient groups exhibited significantly worse performances than controls in sensorimotor functions, visuospatial perception, and visuospatial abilities. We observed significant associations between sensorimotor functions and visuospatial perception and visuospatial abilities. We conducted a regression analysis to evaluate the impact of potential confounders on neurocognitive outcomes. The results indicated that age, level of education, and insomnia, but not anxiety or depression, affected the performance on some tests.
Conclusions:
Our results reveal deficits in sensorimotor functions, visuospatial perception, and visuospatial abilities in patients with neuropsychiatric disorders. Clear deficits emerged, despite the majority of patients showing a mild degree of severity index of ADHD/ASD across all groups (61–84%). The results are consistent with the idea that these disorders are linked to cerebellar deficits. Our results suggest that these objective tests have the potential to enhance clinical evaluations.