Views on sharing mental health data for research purposes: qualitative analysis of interviews with people with mental illness.

BACKGROUND: Improving the ways in which routinely-collected mental health data are shared could facilitate substantial advances in research and treatment. However, this process should only be undertaken in partnership with those who provide such data. Despite relatively widespread investigation of public perspectives on health data sharing more generally, there is a lack of research on the views of people with mental illness. METHODS: Twelve people with lived experience of mental illness took part in semi-structured interviews via online video software. Participants had experience of a broad range of mental health conditions including anxiety, depression, schizophrenia, eating disorders and addiction. Interview questions sought to establish how participants felt about the use of routinely-collected health data for research purposes, covering different types of health data, what health data should be used for, and any concerns around its use. RESULTS: Thematic analysis identified four overarching themes: benefits of sharing mental health data, concerns about sharing mental health data, safeguards, and data types. Participants were clear that health data sharing should facilitate improved scientific knowledge and better treatments for mental illness. There were concerns that data misuse could become another way in which individuals and society discriminate against people with mental illness, for example through insurance premiums or employment decisions. Despite this there was a generally positive attitude to sharing mental health data as long as appropriate safeguards were in place. CONCLUSIONS: There was notable strength of feeling across participants that more should be done to reduce the suffering caused by mental illness, and that this could be partly facilitated by well-managed sharing of health data. The mental health research community could build on this generally positive attitude to mental health data sharing by following rigorous best practice tailored to the specific concerns of people with mental illness.

Language function following preterm birth: prediction using machine learning.

BACKGROUND: Preterm birth can lead to impaired language development. This study aimed to predict language outcomes at 2 years corrected gestational age (CGA) for children born preterm. METHODS: We analysed data from 89 preterm neonates (median GA 29 weeks) who underwent diffusion MRI (dMRI) at term-equivalent age and language assessment at 2 years CGA using the Bayley-III. Feature selection and a random forests classifier were used to differentiate typical versus delayed (Bayley-III language composite score <85) language development. RESULTS: The model achieved balanced accuracy: 91%, sensitivity: 86%, and specificity: 96%. The probability of language delay at 2 years CGA is increased with: increasing values of peak width of skeletonized fractional anisotropy (PSFA), radial diffusivity (PSRD), and axial diffusivity (PSAD) derived from dMRI; among twins; and after an incomplete course of, or no exposure to, antenatal corticosteroids. Female sex and breastfeeding during the neonatal period reduced the risk of language delay. CONCLUSIONS: The combination of perinatal clinical information and MRI features leads to accurate prediction of preterm infants who are likely to develop language deficits in early childhood. This model could potentially enable stratification of preterm children at risk of language dysfunction who may benefit from targeted early interventions. IMPACT: A combination of clinical perinatal factors and neonatal DTI measures of white matter microstructure leads to accurate prediction of language outcome at 2 years corrected gestational age following preterm birth. A model that comprises clinical and MRI features that has potential to be scalable across centres. It offers a basis for enhancing the power and generalizability of diagnostic and prognostic studies of neurodevelopmental disorders associated with language impairment. Early identification of infants who are at risk of language delay, facilitating targeted early interventions and support services, which could improve the quality of life for children born preterm.

Transdiagnostic research and the neurodiversity paradigm: commentary on the transdiagnostic revolution in neurodevelopmental disorders by Astle et al.

In their comprehensive and articulate paper on the Transdiagnostic Revolution in Neurodevelopmental Disorders, Astle, Holmes, Kievit and Gathercole (2021) 'consider how well current classifications of neurodevelopmental disorders serve our understanding'. They examine the lack of mapping between clinical diagnoses such as ADHD or autism and research data at other levels of explanation, including genetics, neural structure and function, and cognition. The authors come to the conclusion that, if our goal is to explain variability and complexity, understand mechanisms and guide support decisions, 'diagnostic taxonomies that classify individuals in terms of discrete categories are ill-suited'. In this commentary, I explore alignment between their account of the transdiagnostic revolution and the neurodiversity paradigm and identify how transdiagnostic methods may promote neurodiversity-affirmative research and practice.

Social gaze in preterm infants may act as an early indicator of atypical lateralization.

Visual field biases have been identified as markers of atypical lateralization in children with developmental conditions, but this is the first investigation to consider early lateralized gaze behaviors for social stimuli in preterm infants. Eye-tracking methods with 51 preterm (33 male, 92.1% White) and 61 term-born (31 male, 90.1% White) infants aged 8-10 months from Edinburgh, UK, captured the development of visual field biases, comparing gaze behavior to social and non-social stimuli on the left versus right of the screen. Preterm infants showed a significantly reduced interest to social stimuli on the left versus right compared to term children (d = .58). Preterm children exhibit early differential orienting preferences that may be an early indicator of atypical lateralized function.

Commentary: What conflicts of interest tell us about autism intervention research-a commentary on Bottema-Beutel et al. (2020).

Bottema-Beutel, Crowley, Sandbank, and Woynaroski (Journal of Child Psychology and Psychiatry, 2020) have performed a Herculean and invaluable task in their investigation of conflicts of interest (COIs) in nonpharmacological early autism intervention research. Drawing on a meta-analysis of 150 articles reporting group designs, they found COIs in 105 (70%), only 6 (5.7%) of which had fully accurate COI statements. Most reports had no COI statements, but among the 48 (32%) which did, the majority of those declaring no COIs had detectable COIs (23 of 30; 77%). Thus, COI reporting in the literature examined is routinely missing, misleading, and/or incomplete; accurate reporting is the exception rather than the rule. That 120 of the 150 reports were published in 2010 or later, compared to 6 pre-2000, tells us this is not about practices confined to decades past. Instead, it reflects and is a telling indictment of established standards in autism intervention research.

Eye-tracking for longitudinal assessment of social cognition in children born preterm.

BACKGROUND AND OBJECTIVES: Preterm birth is associated with atypical social cognition in infancy, and cognitive impairment and social difficulties in childhood. Little is known about the stability of social cognition through childhood, and its relationship with neurodevelopment. We used eye-tracking in preterm and term-born infants to investigate social attentional preference in infancy and at 5 years, its relationship with neurodevelopment and the influence of socioeconomic deprivation. METHODS: A cohort of 81 preterm and 66 term infants with mean (range) gestational age at birth 28+5 (23+2 -33+0 ) and 40+0 (37+0 -42+1 ) respectively, completed eye-tracking at 7-9 months, with a subset re-assessed at 5 years. Three free-viewing social tasks of increasing stimulus complexity were presented, and a social preference score was derived from looking time to socially informative areas. Socioeconomic data and the Mullen Scales of Early Learning at 5 years were collected. RESULTS: Preterm children had lower social preference scores at 7-9 months compared with term-born controls. Term-born children's scores were stable between time points, whereas preterm children showed a significant increase, reaching equivalent scores by 5 years. Low gestational age and socioeconomic deprivation were associated with reduced social preference scores at 7-9 months. At 5 years, preterm infants had lower Early Learning Composite scores than controls, but this was not associated with social attentional preference in infancy or at 5 years. CONCLUSIONS: Preterm children have reduced social attentional preference at 7-9 months compared with term-born controls, but catch up by 5 years. Infant social cognition is influenced by socioeconomic deprivation and gestational age. Social cognition and neurodevelopment have different trajectories following preterm birth.

Preterm birth is associated with atypical social orienting in infancy detected using eye tracking.

BACKGROUND: Preterm birth is closely associated with neurocognitive impairment in childhood including increased risk for social difficulties. Eye tracking objectively assesses eye-gaze behaviour in response to visual stimuli, which permits inference about underlying cognitive processes. We tested the hypothesis that social orienting in infancy is altered by preterm birth. METHODS: Fifty preterm infants with mean (range) gestational age (GA) at birth of 29(+1) (23(+2) -33(+0) ) weeks and 50 term infants with mean (range) GA at birth 40(+2) (37(+0) -42(+3) ) weeks underwent eye tracking at median age of 7 months. Infants were presented with three categories of social stimuli of increasing complexity. Time to first fixate (TFF) and looking time (LT) on areas of interest (AoIs) were recorded using remote eye tracking. RESULTS: Preterm infants consistently fixated for a shorter time on social content than term infants across all three tasks: face-scanning (fixation to eyes minus mouth 0.61s vs. 1.47s, p = .013); face pop-out task (fixation to face 0.8s vs. 1.34s, p = .023); and social preferential looking (1.16s vs. 1.5s p = .02). Time given to AoIs containing social content as a proportion of LT at the whole stimulus was lower in preterm infants across all three tasks. These results were not explained by differences in overall looking time between the groups. CONCLUSIONS: Eye tracking provides early evidence of atypical cognition after preterm birth, and may be a useful tool for stratifying infants at risk of impairment for early interventions designed to improve outcome.

Interventions based on the Theory of Mind cognitive model for autism spectrum disorder (ASD).

BACKGROUND: The 'Theory of Mind' (ToM) model suggests that people with autism spectrum disorder (ASD) have a profound difficulty understanding the minds of other people - their emotions, feelings, beliefs, and thoughts. As an explanation for some of the characteristic social and communication behaviours of people with ASD, this model has had a significant influence on research and practice. It implies that successful interventions to teach ToM could, in turn, have far-reaching effects on behaviours and outcome. OBJECTIVES: To review the efficacy of interventions based on the ToM model for individuals with ASD. SEARCH METHODS: In August 2013 we searched CENTRAL, Ovid MEDLINE, Embase, CINAHL, PsycINFO, ERIC, Social Services Abstracts, AutismData, and two trials registers. We also searched the reference lists of relevant papers, contacted authors who work in this field, and handsearched a number of journals. SELECTION CRITERIA: Review studies were selected on the basis that they reported on an applicable intervention (linked to ToM in one of four clearly-defined ways), presented new randomised controlled trial data, and participants had a confirmed diagnosis of an autism spectrum disorder. Studies were selected by two review authors independently and a third author arbitrated when necessary. DATA COLLECTION AND ANALYSIS: Risk of bias was evaluated and data were extracted by two review authors independently; a third author arbitrated when necessary. Most studies were not eligible for meta-analysis, the principal reason being mis-matching methodologies and outcome measures. Three small meta-analyses were carried out. MAIN RESULTS: Twenty-two randomised trials were included in the review (N = 695). Studies were highly variable in their country of origin, sample size, participant age, intervention delivery type, and outcome measures. Risk of bias was variable across categories. There were very few studies for which there was adequate blinding of participants and personnel, and some were also judged at high risk of bias in blinding of outcome assessors. There was also evidence of some bias in sequence generation and allocation concealment. Not all studies reported data that fell within the pre-defined primary outcome categories for the review, instead many studies reported measures which were intervention-specific (e.g. emotion recognition). The wide range of measures used within each outcome category and the mixed results from these measures introduced further complexity when interpreting results.Studies were grouped into four main categories according to intervention target/primary outcome measure. These were: emotion recognition studies, joint attention and social communication studies, imitation studies, and studies teaching ToM itself. Within the first two of these categories, a sub-set of studies were deemed suitable for meta-analysis for a limited number of key outcomes.There was very low quality evidence of a positive effect on measures of communication based on individual results from three studies. There was low quality evidence from 11 studies reporting mixed results of interventions on measures of social interaction, very low quality evidence from four studies reporting mixed results on measures of general communication, and very low quality evidence from four studies reporting mixed results on measures of ToM ability.  The meta-analysis results we were able to generate showed that interventions targeting emotion recognition across age groups and working with people within the average range of intellectual ability had a positive effect on the target skill, measured by a test using photographs of faces (mean increase of 0.75 points, 95% confidence interval (CI) 0.22 to 1.29 points, Z = 2.75, P < 0.006, four studies, N = 105). Therapist-led joint attention interventions can promote production of more joint attention behaviours within adult-child interaction (mean increase of 0.55 points, 95% CI 0.11 to 0.99 points, Z = 2.45, P value = 0.01, two studies, N = 88). Further analysis undermines this conclusion somewhat by demonstrating that there was no clear evidence that intervention can have an effect on joint attention initiations as measured using a standardised assessment tool (mean increase of 0.23 points, 95% CI -0.48 to 0.94 points, Z = 0.63, P value = 0.53, three studies, N = 92). No adverse effects were apparent. AUTHORS' CONCLUSIONS: While there is some evidence that ToM, or a precursor skill, can be taught to people with ASD, there is little evidence of maintenance of that skill, generalisation to other settings, or developmental effects on related skills. Furthermore, inconsistency in findings and measurement means that evidence has been graded of 'very low' or 'low' quality and we cannot be confident that suggestions of positive effects will be sustained as high-quality evidence accumulates. Further longitudinal designs and larger samples are needed to help elucidate both the efficacy of ToM-linked interventions and the explanatory value of the ToM model itself. It is possible that the continuing refinement of the ToM model will lead to better interventions which have a greater impact on development than those investigated to date.

Designing AAC systems for children with autism: evidence from eye tracking research.

Autism is associated with a range of language difficulties that impact communication, behaviour management, and education. Consequently, a variety of augmentative and alternative communication (AAC) strategies may be employed to support people with autism to communicate. There is a growing body of evidence concerning the visual attention of individuals with autism, which may be relevant to AAC interventions. This review draws on evidence from eye tracking research specifically to inform the design of AAC systems for people with autism. In addition, we discuss the future of AAC for individuals with autism in light of relevant technological developments, and raise questions for future research.

The Associations Between Camouflaging, Autistic Traits, and Mental Health in Nonautistic Adults.

Background: Camouflaging is frequently reported in autistic people and entails the disguising of autistic traits in social situations. Camouflaging is associated with poor mental health in autistic people. This study examined the manifestation of camouflaging in a nonautistic sample, examining the relationship between autistic traits, self-reported camouflaging, gender, and mental health. Method: In total 110 nonautistic adults completed standardized self-report questionnaires that measured autistic traits, mental health symptoms, and camouflaging behaviors. Hierarchical multiple linear regression models were used to analyze data and examine the unique contributions of autistic traits and camouflaging to mental health. Results: Self-reported autistic traits were associated with increased symptoms of poor mental health. However, autistic traits were not associated with mental health symptoms when controlling for self-reported camouflaging, and self-reported camouflaging predicted increased mental health symptoms over and above the effects of autistic traits. Women had poorer mental health than men in our sample, and in women there was a stronger relationship between camouflaging and mental health than in men. Conclusions: Camouflaging may contribute to poor mental health outcomes in the general population, just as it does for autistic people, to the extent that camouflaging more clearly relates to mental health profile than self-reported autism traits. This suggests camouflaging is an important construct for understanding mental health in general, and for exploring the complex relationship between autism and autistic traits.

Why was this study done?: Some autistic individuals report trying to hide their autistic traits to blend in with others, referring to this as "camouflaging" or "masking." Many autistic people who camouflage describe it as being a very difficult and distressing process, which can be harmful to their mental health. In nonautistic people, a higher level of autistic traits is related to poor mental health. Nonautistic people have also reported camouflaging autistic traits, but we know less about whether this might also impact their mental health. What was the purpose of this study?: We did this study to find out more about the relationship between mental health and camouflaging of autistic traits in nonautistic people. What did the researchers do?: We asked 110 nonautistic adults to complete a series of questionnaires. These questionnaires asked them about their autistic traits, their camouflaging behaviors, and their mental health. We then used statistical tests to look at the relationships between autistic traits, camouflaging, gender, and mental health. What were the results of the study?: We found that people who camouflaged more had poorer mental health, including symptoms of anxiety, depression, and stress. People with more autistic traits also had poorer mental health. When we looked at both of these relationships at the same time, only camouflaging was related to poor mental health, and not autistic traits. When we also looked at gender, we found that women in our study had poorer mental health than men, and the relationship between camouflaging and mental health was stronger for women. What do these findings add to what was already known?: These findings help us understand the relationship between autistic traits and mental health by demonstrating that it may be the camouflaging of autistic traits that is related to poorer mental health. These findings also help us better understand camouflaging by showing that the negative consequences of camouflaging for mental health may apply to both autistic and nonautistic people. What are the potential weaknesses in the study?: Our study only looked at the relationship between autistic traits, camouflaging, gender, and mental health. It is possible that there are other factors our study did not investigate, such as ethnicity or sexual identity, which also play an important role. Our study also cannot tell us whether or not camouflaging is the cause of poor mental health, only that there is a relationship between camouflaging and mental health. How will these findings help autistic adults now or in the future?: By studying camouflaging in different groups and seeing what is shared and what is unique between autistic and nonautistic people, we can develop a better understanding of camouflaging. Knowledge of the mental health consequences of camouflaging can help mental health services to reduce the negative impact of camouflaging for autistic and nonautistic people. Our findings also show an important similarity between autistic and nonautistic people, showing that both groups of people may camouflage, and this negatively impacts mental health. Acknowledgment of this shared experience may help to reduce the discrimination and stigma that autistic people face.

Infant attachment does not depend on neonatal amygdala and hippocampal structure and connectivity.

Infant attachment is an antecedent of later socioemotional abilities, which can be adversely affected by preterm birth. The structural integrity of amygdalae and hippocampi may subserve attachment in infancy. We aimed to investigate associations between neonatal amygdalae and hippocampi structure and their whole-brain connections and attachment behaviours at nine months of age in a sample of infants enriched for preterm birth. In 133 neonates (median gestational age 32 weeks, range 22.14-42.14), we calculated measures of amygdala and hippocampal structure (volume, fractional anisotropy, mean diffusivity, neurite dispersion index, orientation dispersion index) and structural connectivity, and coded attachment behaviours (distress, fretfulness, attentiveness to caregiver) from responses to the Still-Face Paradigm at nine months. After multiple comparisons correction, there were no significant associations between neonatal amygdala or hippocampal structure and structural connectivity and attachment behaviours: standardised ß values - 0.23 to 0.18, adjusted p-values > 0.40. Findings indicate that the neural basis of infant attachment in term and preterm infants is not contingent on the structure or connectivity of the amygdalae and hippocampi in the neonatal period, which implies that it is more widely distributed in early life and or that network specialisation takes place in the months after hospital discharge.

Ethical considerations in public engagement: developing tools for assessing the boundaries of research and involvement.

Public engagement with research (PEwR) has become increasingly integral to research practices. This paper explores the process and outcomes of a collaborative effort to address the ethical implications of PEwR activities and develop tools to navigate them within the context of a University Medical School. The activities this paper reflects on aimed to establish boundaries between research data collection and PEwR activities, support colleagues in identifying the ethical considerations relevant to their planned activities, and build confidence and capacity among staff to conduct PEwR projects. The development process involved the creation of a taxonomy outlining key terms used in PEwR work, a self-assessment tool to evaluate the need for formal ethical review, and a code of conduct for ethical PEwR. These tools were refined through iterative discussions and feedback from stakeholders, resulting in practical guidance for researchers navigating the ethical complexities of PEwR. Additionally, reflective prompts were developed to guide researchers in planning and conducting engagement activities, addressing a crucial aspect often overlooked in formal ethical review processes. The paper reflects on the broader regulatory landscape and the limitations of existing approval and governance processes, and prompts critical reflection on the compatibility of formal approval processes with the ethos of PEwR. Overall, the paper offers insights and practical guidance for researchers and institutions grappling with ethical considerations in PEwR, contributing to the ongoing conversation surrounding responsible research practices.

Short report: Autistic adults' recommendations on how to improve autistic portrayals in TV-series and movies.

BACKGROUND: TV-series and movies are important sources of knowledge about autism for the general public. AIMS: This study's purpose was to elicit autistic adults' opinions on portrayals of autistic characters in film and television productions and how this can be improved. METHODS AND PROCEDURE: In this study, we examined the recommendations of autistic adults (n = 798, Mage = 30.3, 48% female) and non-autistic adults (n = 1463, Mage = 35.0, 62% female) from 90 countries on how film and television productions can improve autistic portrayals. OUTCOMES AND RESULTS: Autistic adults rated three improvement factors as most important: (1) Appointing autistic writers, (2) Having an autistic consultant, and (3) Representing greater diversity in autistic characters. Compared to the non-autistic groups, autistic adults rated "Appointing autistic writers" as more important. Autistic participants also endorsed "Having an autism-expert consultant" and "Making the character display all relevant diagnostic criteria" significantly less than non-autistic groups. CONCLUSIONS AND IMPLICATIONS: Participants strongly endorsed that autistic adults should to a much larger extent be included as writers, consultants and actors to enhance the making of autistic characters in film and TV.

Innovation through neurodiversity: Diversity is beneficial.

LAY ABSTRACT: Neurodivergences such as autism have been previously viewed from a negative, 'deficit', perspective. However, research is beginning to show the benefits of being autistic, and the positive outcomes of neurodiverse interactions. Diversity in the way we think can lead to diversity in the outcomes we produce. In this study, we asked independent raters to compare the similarity of towers built by autistic and non-autistic individuals in single-neurotype (both people were autistic or both people were non-autistic) and neurodiverse (one autistic person and one non-autistic person) pairs, to see whether people would be more or less likely to copy someone who shared their diagnostic status. Our results showed there was the least similarity in design in the neurodiverse pairs; people were less likely to copy the design of the previous builder if that person had a different autistic status to themselves. This could imply people felt more confident in copying someone with a similar neurotype, mirroring results from rapport studies where autistic individuals reported greater rapport with other autistic participants than with non-autistic participants. This also shows there was more evidence of creativity in designs, and innovation from stimulus design (the tower they had watched being built) when the pairs had different autistic diagnoses. This could inform practice and support involving autistic people, encouraging education and care providers to create more diverse methods and designs for support mechanisms, content delivery, and research data collection.

Short report: Evaluation of wider community support for a neurodiversity teaching programme designed using participatory methods.

LAY ABSTRACT: Children with diagnoses such as autism, attention-deficit/hyperactivity disorder (ADHD), dyslexia and so on often experience bullying at school. This group can be described as neurodivergent, meaning they think and process information differently from most people. Previous research suggests that increasing people's knowledge can be an effective way to reduce stigma and bullying. Therefore, we decided to create a primary school resource to teach about neurodiversity - the concept that all humans vary in how our brains work. Working with educators, our research team - which included neurodivergent people - developed plans for a teaching programme called Learning About Neurodiversity at School (LEANS). Next, we wanted to know whether these plans, developed by our small neurodiverse team, would be endorsed by the wider community. To find out, we conducted an online feedback survey about our plans for the resource. We analysed feedback from 111 people who participated. Most of them identified as neurodivergent (70%) and reported being familiar with neurodiversity (98%), meaning they could provide an informed opinion on our plans. Over 90% of people expressed support for the planned programme content described in the survey, and 73% of them approved our intended definition of the resource's core concept, neurodiversity. From these results, we concluded that there was a high level of support for the planned LEANS programme content across those from the wider community who completed the survey. Consequently, we continued developing the LEANS programme in line with the initial plans from our neurodiverse team. The completed resource is now available as a free download.

Attenuation of change blindness in children with autism spectrum disorders.

Change blindness refers to the difficulty most people find in detecting a difference between two pictures when these are presented successively, with a brief interruption between. Attention at the site of the change is required for detection. A number of studies have investigated change blindness in adults and children with autism spectrum disorders (ASD). Some have produced evidence that people with ASD find changes to social stimuli harder to detect and changes to non-social stimuli easier to detect, relative to comparison participants. However, other studies have produced entirely contradictory findings. There is a need for consistency in methodology to aid understanding of change blindness and attentional processes in ASD. Here, we replicate a change blindness study previously carried out with typically developing (TD) children and adults and with adults with ASD. Results reveal attenuated change blindness for non-social stimuli in children with ASD relative to TD norms. Our results are interpreted, alongside others' findings, as potentially indicative of a complex relationship between different influences on attention over time.

The Impact of Bilingualism on Everyday Executive Functions of English-Arabic Autistic Children: Through a Parent-Teacher Lens.

There is evidence that autistic children may have reduced executive function skills, contributing to day-to-day difficulties, but much remains unknown regarding the influence of bilingualism. We investigated its influence on sustained attention, interference control, flexible switching and working memory, in Arabic-English autistic (n = 27) and typically developing peers (n = 53) children, aged 5 to 12 years old. Parents and teachers completed rating measures assessing children's daily EF abilities. Results showed generalized positive effects for bilingual autistic children relative to their monolingual peers across all EF domains, but using parent ratings only. The findings indicate that bilingualism does not negatively impact the executive function skills of autistic children, and that it might mitigate difficulties faced on a day-to-day basis.

Investigating Markers of Rapport in Autistic and Nonautistic Interactions.

Background: Autism is considered to entail a social impairment whereby autistic people experience difficulty interpreting others' mental states. However, recent research has shown that nonautistic people also have difficulty understanding the mental states of autistic people. This mismatch of understanding may explain lower rapport in interactions between autistic and nonautistic people. As mental states can be expressed externally through socially normed signals, it is important to investigate the role of such signals in autistic, nonautistic, and mixed interactions. This study explores variability in two social signals between autistic, nonautistic, and mixed interactions, and how their use may affect rapport within interactions. Methods: Videos from a previous study of autistic, nonautistic, and mixed pair interactions in a diffusion chain context in which participants were aware of others' diagnostic status were video coded for mutual gaze and backchanneling as candidate indicators of interactional rapport. Results: Although use of mutual gaze and backchanneling was lower in mixed pairs than in nonautistic pairs, corresponding to lower ratings of interactional rapport, less backchanneling in autistic pairs of both nonverbal and verbal subtypes corresponded to higher ratings of rapport. Conclusions: We observed differences in the use of candidate rapport markers between autistic, mixed, and nonautistic interactions, which did not map onto patterns of rapport scores, suggesting differences in reliance on these cues between autistic and nonautistic people. These results suggest that visible markers of rapport may vary by neurotype or pairing and give clues to inform future investigations of autistic interaction.

Why is this an important issue?: When someone is autistic, society generally assumes they have difficulty interacting with others. Social difficulties between autistic and nonautistic people are thought to be due to the autistic person not being able to interact using nonautistic social behaviors. This belief can lead to many autistic people feeling alienated. However, recent research supports what autistic people have been saying for a long time: that autistic people are capable of having successful and rewarding interactions with other autistic people. This suggests that social difficulties between autistic and nonautistic people may be due to a mismatch in social norms leading to difficulty for both people, not just the autistic person. What was the purpose of this study?: In this study, we wanted to investigate whether certain social signals are used differently between autistic and nonautistic people. We also questioned whether using these signals helped or hurt the interaction depending on who was involved. What did the researchers do?: We recorded people passing a story down a chain of people, like the game telephone, to see how they interacted with each other. Afterward, people wrote down scores for how much they enjoyed their interaction. We focused on two parts of the interaction: how much people were looking at each other and when they made short verbal responses such as "mhm" to show they were listening (backchanneling). We watched the recordings back and analyzed how long or how many times these actions were occurring. What were the results of the study?: We found that when one autistic and one nonautistic person were interacting, they looked at each other and backchanneled less than two nonautistic people. This seemed to be linked with a less enjoyable interaction for them. However, backchanneling seemed to matter less in interactions between two autistic people. They backchanneled less while still having enjoyable interactions. What do these findings add to what was already known?: Research has previously suggested that different social norms exist between autistic and nonautistic people. This study shows specific examples of this and how they may affect the interaction in a natural setting. What are potential weaknesses in the study?: This study has some weaknesses. For example, we measured when people looked at each other's faces rather than eye contact specifically, which can only be done with an eye tracker. Also, the people in the study knew whether the person they were talking to was autistic. This can be similar to normal life, as people do sometimes know this, although we would also be interested to see what the effect of not knowing would be. How will these findings help autistic adults now or in the future?: This line of research has important implications for how autistic people can be supported in society. Not only will understanding of social differences between autistic and nonautistic people help the way autistic people are perceived, but it will also help nonautistic people better understand and support the autistic people in their lives.

Patient satisfaction with mental and physical health services: Findings from a UK-wide online survey.

Introduction - Despite extensive debate surrounding mental health services in the UK, there is little empirical evidence regarding the views of those who use them. We therefore used data collected as part of a wider survey to examine satisfaction amongst those seeking treatment from mental and physical health services. Methods - An online survey designed with input from people with experience of mental illness was used to measure satisfaction with NHS mental and physical health services at first contact and in the previous 12 months. Results - A total of 2187 people responded. During the 12 months prior to the survey, 526 respondents had sought mental health care and 1379 had sought physical health care. Participants were significantly more satisfied with their most recent contact with mental health services (48.1% very/satisfied) than with their first contact (38.2% very/satisfied). More than 1 in 10 respondents who sought mental health care (11.4%) stated that they received no treatment/support from the NHS, compared to approximately 1 in 20 respondents who sought physical health care (4.6%). Of those who received the mental health treatment they requested (n = 424), most were satisfied or very satisfied with their care (54.7%), although this was lower than the corresponding figure (77.9%) for satisfaction with physical health care received (n = 1190). Conclusion -There was evidence that mental health services are satisfactory for a slim majority of users, but people were generally more satisfied with NHS physical health care. This survey was conducted in the year prior to the coronavirus disease 2019 pandemic. Future research could examine what influences satisfaction with care and whether this picture has changed following the emergence of the pandemic and consequent impact on health service delivery and daily life.

"The Languages That You Know Draw the Boundary of Your World": A Thematic Analysis of the Experiences of Autistic Bilingual Adults Living in the United Kingdom.

Background: Although being bilingual (knowing two or more languages) is becoming a more common experience globally, little is known about the combined experience of bilingualism and autism. Research currently available focuses on quantifying language and cognitive development, and the only two qualitative accounts of first-hand experiences are from either bilingual children or highly multilingual adults (with four languages or more), which may not represent the wider autistic bilingual population. All other accounts focus on parents or practitioners. This qualitative study reports the experiences of autistic bi- and multilingual adults, focusing on barriers and enablers to language learning and the reported benefits of bilingualism. Methods: Thirty-nine U.K.-based autistic bilingual adults (41% female, mean age = 33.2 years, range = 16-61) with knowledge of two to seven languages (mean = 3.6, standard deviation = 1.4) completed an online Demographic and Language Questionnaire, including three open-ended questions about the interplay between autism and bilingualism. A thematic analysis was conducted on the responses to these open-ended questions. Results: Participants perceived many opportunities and benefits brought by bilingualism, in terms of relationships, hobbies, mobility, employment, education, and cultural insight. Respondents reported social communication as being a major benefit of being bilingual, and discussed how bilingualism had broadened their mindset, while identifying factors that had enabled or challenged their language learning journey. Conclusions: This study builds upon the few reports available to highlight the experiences that are shared by autistic bilingual people regardless of the number of languages they know. It is the first study to report the perspectives of U.K.-based autistic bilingual adults who, in most cases, grew up in a bilingual environment. Accounts of the factors that can facilitate or hinder language learning will inform the development of strategies to better support autistic people. These findings have implications for bilingual families and practitioners supporting autistic bilingual people.

Why is this an important issue?: At least half the world's population is bilingual or lives in a bilingual environment. However, the experiences of autistic bilingual people are rarely represented or acknowledged. So far, research in this field has concentrated primarily on parent perspectives and on the effects of bilingualism for autistic children's skills. Only one study to date has focused on understanding the experiences of autistic bilingual adults themselves, but this research focused on multilinguals with four or more languages. It is essential to represent the whole autistic bi- or multilingual community, including those with two or three languages. What was the purpose of this study?: The study explored the experiences of autistic bilingual people, focusing on the perceived benefits of bilingualism; the shared experiences of autism, bilingualism, especially regarding identity; and the elements that make language learning easier or more difficult. What did the researchers do?: Thirty-nine autistic bilingual adults completed an online questionnaire. The questionnaire included quantitative questions about the participants' language profile, and open-ended questions about their experiences of being autistic and bilingual. The answers were analyzed and summarized using a method called thematic analysis. What were the results of the study?: Participants reported that being bilingual had shaped their ability to communicate socially; it had helped them to understand the perspectives of others, and better express themselves. Participants also identified many additional opportunities and benefits of bilingualism in terms of relationships, hobbies, mobility, employment, education, and cultural insight. They discussed how bilingualism had influenced their self-understanding in terms of increased awareness of their own skills, and it had contributed to a broadened mindset. Participants also listed several difficulties in becoming bilingual that they considered linked to being autistic. Participants highlighted several elements that had made their language learning easier or harder, including the learning environment, opportunities for practice, or specific language competencies. What do these findings add to what was already known?: Previous studies describing the experiences of autistic bilingual people only represented people with four or more languages, and most of these studies only involved one or two people. This study is more representative of the wider autistic bilingual population. It shows that autistic people benefit from bilingualism in their daily life, even when they know "only" two languages. It highlights that being bilingual is a part of autistic bilingual people's identity. It reports that different autistic people need different learning strategies to best learn additional languages. What are potential weaknesses in the study?: Participants answered our pre-set questions online, and our questions had very few prompts. As a result, it is possible that many topics were not mentioned. Future research should build upon the topics presented here to describe them more specifically. How will these findings help autistic adults now or in the future?: There are still many barriers to equal access to additional language learning for autistic people. This study shows how valuable autistic people find bilingualism, and it supports autistic people's advocacy movement for equal rights and opportunities.