Sertraline for anxiety in adults with a diagnosis of autism (STRATA): study protocol for a pragmatic, multicentre, double-blind, placebo-controlled randomised controlled trial.

BACKGROUND: Selective serotonin reuptake inhibitors (SSRIs) are commonly prescribed to manage anxiety in adults with an autism diagnosis. However, their effectiveness and adverse effect profile in the autistic population are not well known. This trial aims to determine the effectiveness and cost-effectiveness of the SSRI sertraline in reducing symptoms of anxiety and improving quality of life in adults with a diagnosis of autism compared with placebo and to quantify any adverse effects. METHODS: STRATA is a two-parallel group, multi-centre, pragmatic, double-blind, randomised placebo-controlled trial with allocation at the level of the individual. It will be delivered through recruiting sites with autism services in 4 regional centres in the United Kingdom (UK) and 1 in Australia. Adults with an autism diagnosis and a Generalised Anxiety Disorder Assessment (GAD-7) score ≥ 10 at screening will be randomised 1:1 to either 25 mg sertraline or placebo, with subsequent flexible dose titration up to 200 mg. The primary outcome is GAD-7 scores at 16 weeks post-randomisation. Secondary outcomes include adverse effects, proportionate change in GAD-7 scores including 50% reduction, social anxiety, obsessive-compulsive symptoms, panic attacks, repetitive behaviours, meltdowns, depressive symptoms, composite depression and anxiety, functioning and disability and quality of life. Carer burden will be assessed in a linked carer sub-study. Outcome data will be collected using online/paper methods via video call, face-to-face or telephone according to participant preference at 16, 24 and 52 weeks post-randomisation, with brief safety checks and data collection at 1-2, 4, 8, 12 and 36 weeks. An economic evaluation to study the cost-effectiveness of sertraline vs placebo and a QuinteT Recruitment Intervention (QRI) to optimise recruitment and informed consent are embedded within the trial. Qualitative interviews at various times during the study will explore experiences of participating and taking the trial medication. DISCUSSION: Results from this study should help autistic adults and their clinicians make evidence-based decisions on the use of sertraline for managing anxiety in this population. TRIAL REGISTRATION: ISRCTN, ISRCTN15984604 . Registered on 08 February 2021. EudraCT 2019-004312-66. ANZCTR ACTRN12621000801819. Registered on 07 April 2021.

Disclosing an autism diagnosis improves ratings of candidate performance in employment interviews.

LAY ABSTRACT: Employment interviews are challenging for many autistic people, for example, due to difficulties with interpreting questions. Autistic people also have differences in non-verbal communication, such as emotional expression, eye-contact, and gestures, with research showing that these factors negatively affect first impressions. Some studies have shown that perceptions of autistic people are more positive when the person observing them, such as an interviewer, is already aware of their diagnosis. However, previous research has not studied how disclosing one's autism diagnosis affects perceptions of a candidate undergoing a full employment interview. Participants in this study acted as raters, who watched a video of an autistic person undergoing a mock employment interview with a researcher, and then rated their overall impressions of them on factors important to real-world hiring decisions, such as confidence, motivation, and knowledgeability. Prior to watching the interview, raters were either (1) not aware of the interviewee's diagnosis, (2) made aware of their diagnosis, or (3) made aware of their diagnosis and provided with additional information about autism, such as differences in behaviours and communication. The results show that disclosing an autism diagnosis improved ratings compared to not disclosing the diagnosis. Providing additional information about autism alongside the diagnostic label did not improve ratings further. The findings are important for employers and autistic people; employers should consider improving procedures by which autistic people can disclose their diagnosis prior to interview should they wish, and autistic people may wish to consider the potential benefits of disclosing their diagnosis.

Supporting autistic adults' episodic memory recall in interviews: The role of executive functions, theory of mind, and language abilities.

LAY ABSTRACT: Autistic people have difficulties recalling episodic memories (memories of specific events) compared to typically developing people. However, being able to effectively recall such memories is important in many real-world situations, for example, in police interviews, during medical consultations, and in employment interviews. Autistic people's episodic memory difficulties are most noticeable when they are responding to open, unsupportive questions. However, the 'Task Support Hypothesis' indicates that autistic people are able to recall as much information as typically developing people, as long as they are asked more supportive questions. Autistic people also experience difficulties with executive functioning (cognitive abilities which allow us to plan, hold information in mind, inhibit interruptions, etc.), theory of mind (the ability to understand others' perspectives and intentions), and spoken language. The current study aimed to investigate the impact of these cognitive abilities on memory recall in two previous studies which compared autistic and typically developing adults on how specific their recall was in police, healthcare, and employment interviews, and the quality of responses during an employment interview when both unsupportive and supportive questioning was used. The results show that while typically developing people may rely on theory of mind abilities, autistic people may rely more on language abilities when performing in interviews, potentially to compensate for their episodic memory difficulties, and that this effect is most apparent during more unsupportive recall (e.g. when a brief, open question is asked) compared to when open questions are followed by prompts (e.g. 'tell me about who as there', 'what happened?', etc.).

A Quick Measure of Theory of Mind in Autistic Adults: Decision Accuracy, Latency and Self-Awareness.

Autistic adults often experience difficulties in taking the perspective of others, potentially undermining their social interactions. We evaluated a quick, forced-choice version of the Adult Theory of Mind (A-ToM) test, which was designed to assess such difficulties and comprehensively evaluated by Brewer et al. (2017). The forced-choice version (the A-ToM-Q) demonstrated discriminant, concurrent, convergent and divergent validity using samples of autistic (N = 96) and non-autistic adults (N = 75). It can be administered in a few minutes and machine-scored, involves minimal training and facilitates large-scale, live, or web-based testing. It permits measurement of response latency and self-awareness, with response characteristics on both measures enhancing understanding of the nature and extent of perspective taking difficulties in autistic individuals.

Ameliorating the disadvantage for autistic job seekers: An initial evaluation of adapted employment interview questions.

LAY ABSTRACT: Despite possessing valuable skills, differences in the way that autistic people understand and respond to others in social situations mean that they are frequently disadvantaged in job interviews. We examined how autistic and non-autistic adults compared on standard (unmodified) job interview questions, and then used these findings to develop and evaluate supportive adaptations to questions. Fifty adults (25 autistic, 25 non-autistic) took part in two mock job interviews. Interview 1 provided a baseline measure of performance when answering typical, unmodified interview questions. Employment experts (unaware of participants' autism diagnoses) rated all interviewees on their responses to each question and their overall impressions of them and then provided feedback about how interviewees could improve and how questions could be adapted to facilitate this. Interviewees also provided feedback about the interview process, from their perspective. Adaptations to the questions were developed, with Interview 2 taking place approximately 6 months later. Results demonstrated that, in Interview 1, employment experts rated autistic interviewees less favourably than non-autistic interviewees. Ratings of both autistic and non-autistic participants' answers improved in Interview 2, but particularly for autistic interviewees (such that differences between autistic and non-autistic interviewees' performance reduced in Interview 2). Employers should be aware that adaptations to job interview questions are critical to level the playing field for autistic candidates.

Lacking Pace but Not Precision: Age-Related Information Processing Changes in Response to a Dynamic Attentional Control Task.

Age-related decline in information processing can have a substantial impact on activities such as driving. However, the assessment of these changes is often carried out using cognitive tasks that do not adequately represent the dynamic process of updating environmental stimuli. Equally, traditional tests are often static in their approach to task complexity, and do not assess difficulty within the bounds of an individual's capability. To address these limitations, we used a more ecologically valid measure, the Swansea Test of Attentional Control (STAC), in which a threshold for information processing speed is established at a given level of accuracy. We aimed to delineate how older, compared to younger, adults varied in their performance of the task, while also assessing relationships between the task outcome and gender, general cognition (MoCA), perceived memory function (MFQ), cognitive reserve (NART), and aspects of mood (PHQ-9, GAD-7). The results indicate that older adults were significantly slower than younger adults but no less precise, irrespective of gender. Age was negatively correlated with the speed of task performance. Our measure of general cognition was positively correlated with the task speed threshold but not with age per se. Perceived memory function, cognitive reserve, and mood were not related to task performance. The findings indicate that while attentional control is less efficient in older adulthood, age alone is not a defining factor in relation to accuracy. In a real-life context, general cognitive function, in conjunction with dynamic measures such as STAC, may represent a far more effective strategy for assessing the complex executive functions underlying driving ability.

Interviewing autistic adults: Adaptations to support recall in police, employment, and healthcare interviews.

LAY ABSTRACT: During many types of interviews (e.g. in employment, with the police, and in healthcare), we need to recall detailed memories of specific events, which can be difficult for autistic people in response to commonly used questions. This is especially because these tend to be open questions (i.e. very broad). Autistic people have disproportionately high rates of physical and mental health conditions, are more likely to interact with police, and are the most underemployed disability group. However, interviewers are often unsure about how to adapt their communication for autistic people.Our research tested whether different types of prompts enabled autistic people to recall specific memories (memories of a single event within one day). Participants were asked about situations relating to witnessing a crime (e.g. at the bank), physical or mental health scenarios and employment interviews (e.g. a time you've met a deadline).We tested the following:Open questions: basic questions only (e.g. 'tell me about a time you went to the cinema'),Semantic prompting: a general prompt (e.g. 'do you enjoy going to the cinema?') before asking for a specific instance ('tell me about a time you went to the cinema?'),Visual-verbal prompting: asking participants to recall when it happened, who was there, the actions that occurred, the setting, and any objects.With visual-verbal prompting, autistic and typically developing participants' memories were more specific and detailed. Semantic prompting was also effective for employment questions. Our study shows that autistic people can recall specific memories when they are appropriately prompted. Visual-verbal prompting may be effective across different situations.

Metacognitive Monitoring and Control of Eyewitness Memory Reports in Autism.

Providing eyewitness testimony involves monitoring one's memory to provide a detailed and accurate account: reporting details likely to be accurate and withholding potentially inaccurate details. Autistic individuals reportedly experience difficulties in both retrieving episodic memories and monitoring their accuracy, which has important implications for eyewitness testimony. Thirty autistic and 33 IQ-matched typically developing (TD) participants viewed a video of a mock bank robbery followed by three phases of questions (with judgments of confidence). In Phase 1, participants freely generated the granularity of their responses (i.e., fine- or coarse-grained). In Phase 2, participants answered the same questions but provided both a fine- and a coarse-grained answer. In Phase 3, participants were instructed to maximize accuracy over informativeness by selecting one of their Phase 2 answers as their final answer. They either received the questions socially (from the experimenter) or answered them online. There were no group differences in accuracy or metacognitive monitoring, with both autistic and TD witnesses demonstrating: (a) a strong preference for reporting fine-grained details at the expense of accuracy; (b) improved though still suboptimal grain size reporting when instructed to maximize accuracy over informativeness; (c) effective accuracy monitoring; and (d) higher overall accuracy when questions were delivered socially. There was, however, a subtle difference in metacognitive control, with autistic witnesses performing more poorly than TD witnesses when questions were delivered socially, but not when they were delivered online. These findings contrast with evidence suggesting that autism is marked by impairments in episodic memory and metacognitive monitoring and control. Autism Res 2020, 13: 2017-2029. © 2020 The Authors. Autism Research published by International Society for Autism Research published by Wiley Periodicals, Inc. LAY SUMMARY: Autistic people have been reported to experience subtle difficulties in monitoring and regulating their information reporting, which has important implications for providing eyewitness testimony. We found that autistic witnesses' testimony comprised a similar level of detail and accuracy as non-autistic witnesses' accounts. However, autistic people found it difficult to optimize their testimony when the questions were delivered socially-but not when they answered the questions online. © 2020 The Authors. Autism Research published by International Society for Autism Research published by Wiley Periodicals, Inc.

The measurement of approximate number system acuity across the lifespan is compromised by congruency effects.

Recent studies have highlighted the influence of visual cues such as dot size and cumulative surface area on the measurement of the approximate number system (ANS). Previous studies assessing ANS acuity in ageing have all applied stimuli generated by the Panamath protocol, which does not control nor measure the influence of convex hull. Crucially, convex hull has recently been identified as an influential visual cue present in dot arrays, with its impact on older adults' ANS acuity yet to be investigated. The current study therefore investigated the manipulation of convex hull by the Panamath protocol, and its effect on the measurement of ANS acuity in younger and older participants. First, analyses of the stimuli generated by Panamath revealed a confound between numerosity ratio and convex hull ratio. Second, although older adults were somewhat less accurate than younger adults on convex hull incongruent trials, ANS acuity was broadly similar between the groups. These findings have implications for the valid measurement of ANS acuity across all ages, and suggest that the Panamath protocol produces stimuli that do not adequately control for the influence of convex hull on numerosity discrimination.

Dot Display Affects Approximate Number System Acuity and Relationships with Mathematical Achievement and Inhibitory Control.

Much research has investigated the relationship between the Approximate Number System (ANS) and mathematical achievement, with continued debate surrounding the existence of such a link. The use of different stimulus displays may account for discrepancies in the findings. Indeed, closer scrutiny of the literature suggests that studies supporting a link between ANS acuity and mathematical achievement in adults have mostly measured the ANS using spatially intermixed displays (e.g. of blue and yellow dots), whereas those failing to replicate a link have primarily used spatially separated dot displays. The current study directly compared ANS acuity when using intermixed or separate dots, investigating how such methodological variation mediated the relationship between ANS acuity and mathematical achievement. ANS acuity was poorer and less reliable when measured with intermixed displays, with performance during both conditions related to inhibitory control. Crucially, mathematical achievement was significantly related to ANS accuracy difference (accuracy on congruent trials minus accuracy on incongruent trials) when measured with intermixed displays, but not with separate displays. The findings indicate that methodological variation affects ANS acuity outcomes, as well as the apparent relationship between the ANS and mathematical achievement. Moreover, the current study highlights the problem of low reliabilities of ANS measures. Further research is required to construct ANS measures with improved reliability, and to understand which processes may be responsible for the increased likelihood of finding a correlation between the ANS and mathematical achievement when using intermixed displays.