1. Nicolaidis C. What Does Inclusion Mean in Research and Scholarship on Autism in Adulthood ?. Autism in Adulthood. 2019 ; 1(2) : 79-81.

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2. Urbanowicz A, Nicolaidis C, Houting Jd, Shore SM, Gaudion K, Girdler S, Savarese RJ. An Expert Discussion on Strengths-Based Approaches in Autism. Autism in Adulthood. 2019 ; 1(2) : 82-9.

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3. Savarese DJ. Coming to My Senses. Autism in Adulthood. 2019 ; 1(2) : 90-2.

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4. Zisk AH, Dalton E. Augmentative and Alternative Communication for Speaking Autistic Adults : Overview and Recommendations. Autism in Adulthood. 2019 ; 1(2) : 93-100.

Lay Summary What is augmentative and alternative communication ? Augmentative and alternative communication (AAC) describes the ways people communicate without, or in addition to, speech. What do we know about AAC for autistic adults who can speak ? Research on AAC and autism has focused on nonspeaking children. However, autistic adults who use AAC sometimes tell each other about AAC. This community knowledge includes reasons AAC is important, useful AAC strategies, and barriers to AAC use. This article talks about autistic community knowledge about AAC and then makes suggestions. Why is AAC important for autistic adults who can speak ? Autistic adults, including those who talk, may not always be able to meet all their communication needs with speech alone. Autistic people who use speech may experience intermittent, unreliable, and/or insufficient speech. What AAC strategies do speaking autistic adults use ? The three main ways that autistic adults report on using AAC include : (1)Free or low-cost tools that are not specific to AAC (e.g., online chat rooms, text messaging applications, or handwriting). (2)Mobile applications designed for communication support. (3)Signed languages such as American Sign Language. What are some common barriers to AAC use for speaking autistic adults ? Several barriers may prevent AAC use. These include the following : Knowledge of AAC options Attitudes about who AAC is useful for Beliefs that the use of AAC should be decreased if a person can speak Cost of AAC devices and applications. What are our recommendations to autistic adults who might use AAC and their supporters ? Support autistics in defining their own communication needs, regardless of speech. Evaluate communication goals and match them with system features when making decisions about AAC. Prioritize all communication, not just speech. Explore a variety of options to support communication. Explore low- and no-cost options to support communication. What are some research questions that still need to be answered ? What communication strategies do autistic adults see as effective ? What AAC strategies are being used, in what environments, and by whom ? What prevents effective AAC use ? How can AAC specialists and autistic adults best collaborate to promote and evaluate AAC use ? How can communication supports be designed to better meet the needs of autistic adults ?

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5. Roux AM, Rast JE, Nye-Lengerman K, Purtle J, Lello A, Shattuck PT. Identifying Patterns of State Vocational Rehabilitation Performance in Serving Transition-Age Youth on the Autism Spectrum. Autism in Adulthood. 2018 ; 1(2) : 101-11.

Abstract Background : Transition-age youth on the autism spectrum (TAY-ASD) face many challenges when attempting to find and keep employment. Vocational rehabilitation (VR) is a key public source of support for employment for people with disabilities in the United States, and TAY-ASD increasingly use VR services. However, rates of VR service utilization and employment outcomes are known to vary dramatically across states for these youth, for reasons that are not fully understood. Methods : This study aimed to examine a set of indicators for measuring the state VR performance in serving TAY-ASD, compared with youth with other disabilities, and to identify classes of homogenous patterns of state performance across these indicators. We used latent profile analysis (LPA) to model patterns of state performance in serving TAY-ASD. Results : We identified five classes of states with unique patterns of performance across four key indicators (service receipt, early reach, timely services, and employment rates) and then matched states to each class based on their probability of inclusion. One class featured above average performance across all four indicators, and approximately one-fourth of states had a high probability of membership in this class. Conclusions : Identification of states with patterns of more efficient and effective VR service delivery for TAY-ASD will help target efforts to learn how states are delivering, organizing, and coordinating VR services for these youth. The use of methods like LPA may also be beneficial for examining performance within other autism-related service systems in the United States and internationally. Lay Summary Background : Achieving employment is an important milestone on the road to adulthood. Having a job is related to financial independence, health, and well-being but can also provide a sense of belonging and opportunities for inclusion. Transition-age youth on the autism spectrum (TAY-ASD) may find that getting and keeping a job is more difficult than it is for their peers with other types of disabilities. Vocational rehabilitation (VR) is a public source of support for employment for people with disabilities in the United States, and TAY-ASD are increasingly using VR services. However, whether youth receive VR services, and whether they gain employment following VR services, is highly dependent on which state they live in. We do not yet fully understand why state VR services vary so dramatically. About This Study : New federal legislation, the Workforce Innovation and Opportunity Act, aims to reach students with disabilities with vocational services during secondary school (junior high and high school). Few studies exist to help us understand how well VR services are reaching students and what are the effects of these services. We tested new ways to measure VR services for TAY-ASD and also tested whether we could group states according to their results on these measurements. We wondered whether any groups of states performed better than other groups. We used the VR data for the 50 states and Washington DC to test the following four things : how often TAY-ASD received VR services if they were eligible for them ; how often these youth applied for VR services during secondary school ; how often their employment plan was finished on time ; and how often they got a job after VR services. We compared youth on the autism spectrum with youth with other disabilities and found that they did about the same on these measures. What This Study Tells Us : We identified five groups of states, which each had a unique pattern of how they performed on these measures. We named the groups ?also called classes ?according to their strengths. Class 1 had above average employment rates but below average performance on other measures. Class 2 had timely services, meaning that these states finished youth’s employment plans on time, so that they could access services. Class 3 had both timely services and early reach to students, meaning that the students began services during secondary school. Class 4 had early reach o secondary students but low performance on other measures. Finally, Class 5 had above average performance on all measures. States in this class excelled at reaching students, developing employment plans quickly, enrolling students in services, and achieving employment by the time VR services ended. We then determined which states were most likely to belong in each class. This study gives us another way to think about how states are doing in delivering VR services to TAY-ASD. By studying states that have better overall performance, versus others, we can identify what states might be doing differently. Learning about how some states are adapting VR services for TAY-ASD and the innovations they are using is important information for other states who wish to improve their VR services. The methods we used may also be helpful for examining the performance of other autism-related service systems in the United States and internationally.

Background : Transition-age youth on the autism spectrum (TAY-ASD) face many challenges when attempting to find and keep employment. Vocational rehabilitation (VR) is a key public source of support for employment for people with disabilities in the United States, and TAY-ASD increasingly use VR services. However, rates of VR service utilization and employment outcomes are known to vary dramatically across states for these youth, for reasons that are not fully understood. Methods : This study aimed to examine a set of indicators for measuring the state VR performance in serving TAY-ASD, compared with youth with other disabilities, and to identify classes of homogenous patterns of state performance across these indicators. We used latent profile analysis (LPA) to model patterns of state performance in serving TAY-ASD. Results : We identified five classes of states with unique patterns of performance across four key indicators (service receipt, early reach, timely services, and employment rates) and then matched states to each class based on their probability of inclusion. One class featured above average performance across all four indicators, and approximately one-fourth of states had a high probability of membership in this class. Conclusions : Identification of states with patterns of more efficient and effective VR service delivery for TAY-ASD will help target efforts to learn how states are delivering, organizing, and coordinating VR services for these youth. The use of methods like LPA may also be beneficial for examining performance within other autism-related service systems in the United States and internationally. Lay Summary Background : Achieving employment is an important milestone on the road to adulthood. Having a job is related to financial independence, health, and well-being but can also provide a sense of belonging and opportunities for inclusion. Transition-age youth on the autism spectrum (TAY-ASD) may find that getting and keeping a job is more difficult than it is for their peers with other types of disabilities. Vocational rehabilitation (VR) is a public source of support for employment for people with disabilities in the United States, and TAY-ASD are increasingly using VR services. However, whether youth receive VR services, and whether they gain employment following VR services, is highly dependent on which state they live in. We do not yet fully understand why state VR services vary so dramatically. About This Study : New federal legislation, the Workforce Innovation and Opportunity Act, aims to reach students with disabilities with vocational services during secondary school (junior high and high school). Few studies exist to help us understand how well VR services are reaching students and what are the effects of these services. We tested new ways to measure VR services for TAY-ASD and also tested whether we could group states according to their results on these measurements. We wondered whether any groups of states performed better than other groups. We used the VR data for the 50 states and Washington DC to test the following four things : how often TAY-ASD received VR services if they were eligible for them ; how often these youth applied for VR services during secondary school ; how often their employment plan was finished on time ; and how often they got a job after VR services. We compared youth on the autism spectrum with youth with other disabilities and found that they did about the same on these measures. What This Study Tells Us : We identified five groups of states, which each had a unique pattern of how they performed on these measures. We named the groups ?also called classes ?according to their strengths. Class 1 had above average employment rates but below average performance on other measures. Class 2 had timely services, meaning that these states finished youth’s employment plans on time, so that they could access services. Class 3 had both timely services and early reach to students, meaning that the students began services during secondary school. Class 4 had early reach o secondary students but low performance on other measures. Finally, Class 5 had above average performance on all measures. States in this class excelled at reaching students, developing employment plans quickly, enrolling students in services, and achieving employment by the time VR services ended. We then determined which states were most likely to belong in each class. This study gives us another way to think about how states are doing in delivering VR services to TAY-ASD. By studying states that have better overall performance, versus others, we can identify what states might be doing differently. Learning about how some states are adapting VR services for TAY-ASD and the innovations they are using is important information for other states who wish to improve their VR services. The methods we used may also be helpful for examining the performance of other autism-related service systems in the United States and internationally.

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6. Sedgewick F, Crane L, Hill V, Pellicano E. Friends and Lovers : The Relationships of Autistic and Neurotypical Women. Autism in Adulthood. 2018 ; 1(2) : 112-23.

Abstract Background : Little is known about the friendships and relationships of autistic adults, despite decades of research evidence showing the benefits of close relationships for neurotypical adults. Even less is known about the relationships of autistic women, or how their relationships compare with those of neurotypical women. This mixed-methods study, therefore, examined differences in the social relationships of autistic women in relation to their neurotypical counterparts. Methods : Thirty-eight women (19 autistic women, 19 neurotypical women), aged between 20 and 40 years, completed the Unidimensional Relationship Closeness Scale, The Awareness of Social Inference Test, and a semistructured interview about their current and former friendships and romantic relationships. Results : In many ways, the social relationships and experiences of autistic women were much like those of neurotypical women. Autistic women, however, had greater difficulty with social inference skills, and reported experiencing more negative social situations. This was particularly the case in terms of social and sexual vulnerability, a feature that the autistic women themselves linked to their difficulties with social inference. Despite these challenges, autistic women were happier and more self-assured in their adult relationships than they remembered being in adolescence. Conclusions : These findings highlight an urgent need for specific and tailored personal safety training and support for autistic women ?and, by extension, autistic girls ?to ensure that they can enjoy a safe transition to adulthood and positive adult relationships. Lay Summary Why was this study done ? At the moment, we know lots about adult friendships and relationships among neurotypical people, but we know very little about friendships and relationships for autistic adults. This is especially the case for autistic women, who are an understudied group and who are not often studied in their own right. What was the purpose of this study ? We wanted to find out whether autistic women have similar friendship and romantic relationship experiences to neurotypical women. We also wanted to know more about the ways these relationships had changed since adolescence ?whether any changes over time were similar or different to those of neurotypical women. What did the researchers do ? We included 38 women in the study. Half of them were autistic and half were neurotypical. They were aged between 20 and 40 years old. They completed a questionnaire measuring the closeness of their relationships, and a test of how well they understood social situations. They also took part in an interview where we asked them about their current and past friendships and romantic relationships, and if/how these had changed over time. What were the results of this study ? We found that autistic and neurotypical women had friendships and relationships that were very similar. Both groups had friends, and similar number of women in each group had partners and children. Autistic women, though, found it harder to interpret social situations, and generally reported having more difficult friendship/relationship experiences than neurotypical women. This was especially true in terms of social and sexual experiences, where autistic women reported that they were much more vulnerable to exploitation than neurotypical women. Autistic women themselves linked this to their difficulties interpreting social situations. Despite these difficulties though, autistic women were happier with their relationships and much more confident in their social skills in adulthood than they remembered being as teenagers. What do these findings add to what we already knew ? These findings give us new information about the social experiences of autistic women, giving them the opportunity to talk about things that have gone well alongside some of the difficulties they can face. The positive outcomes women talked about were different to those reported in autistic men (in previous research). This is important because it shows that gender shapes soc al experiences as much as being autistic itself. What are the potential weaknesses in the study ? We had to ask women to look back on their teenage years, so there is always a chance that people have misremembered things or are interpreting them differently in adulthood to how they felt at the time. Also, as only those comfortable being included as women were involved in this study, it was not possible to carry out direct comparisons between the friendships and relationships of women and men, or those of autistic nonbinary or trans people, who likely have unique experiences. How will these findings help autistic people now or in the future ? We hope that the findings of this research will help families and professionals to better support autistic girls and women in their relationships, particularly in terms of romantic and sexual relationships, as well as education on personal safety. It also goes some way toward dismissing popular myths about autistic people struggling to make real friendships by showing a variety of successful relationships among autistic women.

Background : Little is known about the friendships and relationships of autistic adults, despite decades of research evidence showing the benefits of close relationships for neurotypical adults. Even less is known about the relationships of autistic women, or how their relationships compare with those of neurotypical women. This mixed-methods study, therefore, examined differences in the social relationships of autistic women in relation to their neurotypical counterparts. Methods : Thirty-eight women (19 autistic women, 19 neurotypical women), aged between 20 and 40 years, completed the Unidimensional Relationship Closeness Scale, The Awareness of Social Inference Test, and a semistructured interview about their current and former friendships and romantic relationships. Results : In many ways, the social relationships and experiences of autistic women were much like those of neurotypical women. Autistic women, however, had greater difficulty with social inference skills, and reported experiencing more negative social situations. This was particularly the case in terms of social and sexual vulnerability, a feature that the autistic women themselves linked to their difficulties with social inference. Despite these challenges, autistic women were happier and more self-assured in their adult relationships than they remembered being in adolescence. Conclusions : These findings highlight an urgent need for specific and tailored personal safety training and support for autistic women ?and, by extension, autistic girls ?to ensure that they can enjoy a safe transition to adulthood and positive adult relationships. Lay Summary Why was this study done ? At the moment, we know lots about adult friendships and relationships among neurotypical people, but we know very little about friendships and relationships for autistic adults. This is especially the case for autistic women, who are an understudied group and who are not often studied in their own right. What was the purpose of this study ? We wanted to find out whether autistic women have similar friendship and romantic relationship experiences to neurotypical women. We also wanted to know more about the ways these relationships had changed since adolescence ?whether any changes over time were similar or different to those of neurotypical women. What did the researchers do ? We included 38 women in the study. Half of them were autistic and half were neurotypical. They were aged between 20 and 40 years old. They completed a questionnaire measuring the closeness of their relationships, and a test of how well they understood social situations. They also took part in an interview where we asked them about their current and past friendships and romantic relationships, and if/how these had changed over time. What were the results of this study ? We found that autistic and neurotypical women had friendships and relationships that were very similar. Both groups had friends, and similar number of women in each group had partners and children. Autistic women, though, found it harder to interpret social situations, and generally reported having more difficult friendship/relationship experiences than neurotypical women. This was especially true in terms of social and sexual experiences, where autistic women reported that they were much more vulnerable to exploitation than neurotypical women. Autistic women themselves linked this to their difficulties interpreting social situations. Despite these difficulties though, autistic women were happier with their relationships and much more confident in their social skills in adulthood than they remembered being as teenagers. What do these findings add to what we already knew ? These findings give us new information about the social experiences of autistic women, giving them the opportunity to talk about things that have gone well alongside some of the difficulties they can face. The positive outcomes women talked about were different to those reported in autistic men (in previous research). This is important because it shows that gender shapes soc al experiences as much as being autistic itself. What are the potential weaknesses in the study ? We had to ask women to look back on their teenage years, so there is always a chance that people have misremembered things or are interpreting them differently in adulthood to how they felt at the time. Also, as only those comfortable being included as women were involved in this study, it was not possible to carry out direct comparisons between the friendships and relationships of women and men, or those of autistic nonbinary or trans people, who likely have unique experiences. How will these findings help autistic people now or in the future ? We hope that the findings of this research will help families and professionals to better support autistic girls and women in their relationships, particularly in terms of romantic and sexual relationships, as well as education on personal safety. It also goes some way toward dismissing popular myths about autistic people struggling to make real friendships by showing a variety of successful relationships among autistic women.

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7. Russell G, Kapp SK, Elliott D, Elphick C, Gwernan-Jones R, Owens C. Mapping the Autistic Advantage from the Accounts of Adults Diagnosed with Autism : A Qualitative Study. Autism in Adulthood. 2019 ; 1(2) : 124-33.

Abstract Background : Autism has been associated with specific cognitive strengths. Strengths and weaknesses have traditionally been conceptualized as dichotomous. Methods : We conducted 28 semi-structured interviews with autistic adults. Maximum variation sampling was used to ensure diversity in relation to support needs. We asked which personal traits adults attributed to their autism, and how these have helped in the workplace, in relationships, and beyond. Data were collected in two stages. Responses were analyzed using content and thematic techniques. Results : The ability to hyperfocus, attention to detail, good memory, and creativity were the most frequently described traits. Participants also described specific qualities relating to social interaction, such as honesty, loyalty, and empathy for animals or for other autistic people. In thematic analysis we found that traits associated with autism could be experienced either as advantageous or disadvantageous dependent on moderating influences. Moderating influences included the social context in which behaviors occurred, the ability to control behaviors, and the extent to which traits were expressed. Conclusions : Separating autistic strengths from weaknesses may be a false dichotomy if traits cannot be isolated as separate constructs of strengths or deficits. If attempts to isolate problematic traits from advantageous traits are ill conceived, there may be implications for interventions that have reduction in autistic traits as a primary outcome measure. Lay Summary Why was this study done ? The study was done to find out what autistic adults could tell us about their own abilities. They told us about their abilities and how these abilities had helped them in their everyday lives : at work, in their relationships with other people, and at home. What was the purpose of this study ? To tell a story about what aspects of their autism adults thought were of benefit, when going about their daily lives. What did the researchers do ?The researchers interviewed 24 adults who had an autism diagnosis. Some lived in residential care and others lived alone in rented apartments. Some people were interviewed twice. Most people said they enjoyed the experience of being interviewed. Once the interviews were done, they were typed up and the researchers tried to figure out what were the common themes over all the stories they had heard. They thought about the themes, then did some more interviews with autistic adults to check they were on the right lines. After discussing them, they wrote the story. What were the results of the study ? Hyper focus, attention to detail, and the ability to remember were the abilities that autistic people said benefitted them most often. But autistic adults who were interviewed said although their autistic traits were sometimes helpful, at other times they hindered their progress. So the same trait might be useful in some circumstances and unhelpful in other situations. For example, hypersensitivity led one person to enjoy nature, but was difficult to cope with in crowded streets. The study highlights this interchangeability. What do these findings add to what was already known ? Before, autistic people were known to have both strengths and challenges, but studies tended to separate autistic strengths and weaknesses as different things. We theorize that some traits are expressed as behaviors that may serve to improve or hinder autistic people’s progress, but this depends on their situation (context). What are potential weaknesses in the study ? Because the researchers used interviews, they did not include any nonverbal autistic people in the study. How will these findings help autistic adults now or in the future ? It could be useful to think about autism in a way that does not focus on deficits and this study will help us to do that. Plus, if an autistic trait can give people an advantage or a disadvantage, interventions aimed at reducing autistic behaviors might risk dampening advantageous traits as they seek to help with difficulties. That means, autisti adults and children might lose useful abilities when and if they are treated for traits that can also be problematic. The researchers hope their study will lead to more discussion about these types of ideas.

Background : Autism has been associated with specific cognitive strengths. Strengths and weaknesses have traditionally been conceptualized as dichotomous. Methods : We conducted 28 semi-structured interviews with autistic adults. Maximum variation sampling was used to ensure diversity in relation to support needs. We asked which personal traits adults attributed to their autism, and how these have helped in the workplace, in relationships, and beyond. Data were collected in two stages. Responses were analyzed using content and thematic techniques. Results : The ability to hyperfocus, attention to detail, good memory, and creativity were the most frequently described traits. Participants also described specific qualities relating to social interaction, such as honesty, loyalty, and empathy for animals or for other autistic people. In thematic analysis we found that traits associated with autism could be experienced either as advantageous or disadvantageous dependent on moderating influences. Moderating influences included the social context in which behaviors occurred, the ability to control behaviors, and the extent to which traits were expressed. Conclusions : Separating autistic strengths from weaknesses may be a false dichotomy if traits cannot be isolated as separate constructs of strengths or deficits. If attempts to isolate problematic traits from advantageous traits are ill conceived, there may be implications for interventions that have reduction in autistic traits as a primary outcome measure. Lay Summary Why was this study done ? The study was done to find out what autistic adults could tell us about their own abilities. They told us about their abilities and how these abilities had helped them in their everyday lives : at work, in their relationships with other people, and at home. What was the purpose of this study ? To tell a story about what aspects of their autism adults thought were of benefit, when going about their daily lives. What did the researchers do ?The researchers interviewed 24 adults who had an autism diagnosis. Some lived in residential care and others lived alone in rented apartments. Some people were interviewed twice. Most people said they enjoyed the experience of being interviewed. Once the interviews were done, they were typed up and the researchers tried to figure out what were the common themes over all the stories they had heard. They thought about the themes, then did some more interviews with autistic adults to check they were on the right lines. After discussing them, they wrote the story. What were the results of the study ? Hyper focus, attention to detail, and the ability to remember were the abilities that autistic people said benefitted them most often. But autistic adults who were interviewed said although their autistic traits were sometimes helpful, at other times they hindered their progress. So the same trait might be useful in some circumstances and unhelpful in other situations. For example, hypersensitivity led one person to enjoy nature, but was difficult to cope with in crowded streets. The study highlights this interchangeability. What do these findings add to what was already known ? Before, autistic people were known to have both strengths and challenges, but studies tended to separate autistic strengths and weaknesses as different things. We theorize that some traits are expressed as behaviors that may serve to improve or hinder autistic people’s progress, but this depends on their situation (context). What are potential weaknesses in the study ? Because the researchers used interviews, they did not include any nonverbal autistic people in the study. How will these findings help autistic adults now or in the future ? It could be useful to think about autism in a way that does not focus on deficits and this study will help us to do that. Plus, if an autistic trait can give people an advantage or a disadvantage, interventions aimed at reducing autistic behaviors might risk dampening advantageous traits as they seek to help with difficulties. That means, autisti adults and children might lose useful abilities when and if they are treated for traits that can also be problematic. The researchers hope their study will lead to more discussion about these types of ideas.

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8. Maskey M, Rodgers J, Ingham B, Freeston M, Evans G, Labus M, Parr JR. Using Virtual Reality Environments to Augment Cognitive Behavioral Therapy for Fears and Phobias in Autistic Adults. Autism in Adulthood. 2019 ; 1(2) : 134-45.

Abstract Fears and phobias are common in people on the autism spectrum and can impact on their ability to undertake usual daily activities. Graded exposure to the anxiety-provoking stimulus is a recognized method of treatment for fears/phobias in the nonautistic population but may pose specific difficulties for autistic people. For example, real-life exposure can be too anxiety-provoking to allow treatment to take place, and imaginal exposure can be problematic. To address this, we developed an intervention that combines cognitive behavioral therapy (CBT) with immersive virtual reality (VR) exposure to reduce anxiety. Following successful trials of this intervention with young people on the autism spectrum, we report a pilot study using the same intervention with autistic adults. Eight adults (aged 18 ?57 years) received one psychoeducation session and then four 20-minute sessions of graded exposure with a therapist in an immersive VR room (known as the Blue Room). Each participant completed all sessions showing that the intervention is feasible and acceptable. Outcomes were monitored at 6 weeks and 6 months postintervention. Five of the eight participants were classified as intervention responders and at 6 months after the end of intervention were experiencing real-life functional improvements. These preliminary findings show that VR-graded exposure alongside CBT may be an effective treatment for autistic people with phobias. Lay Summary Why was this study done ? Anxiety is common in autistic adults. For some people, fears and phobias regarding everyday objects and situations occur frequently affecting everyday life. The main method to treat fears and phobias for people without autism is gradual exposure to the situation that causes anxiety. However, this method may be challenging for people on the autism spectrum. We wanted to test a new method of treatment that uses cognitive behavioral therapy (CBT) delivered with gradual exposure in a fully immersive virtual reality (VR) environment. What was the purpose of this study ? We have already delivered this treatment successfully with autistic children. We wanted to test if this treatment would work for autistic adults. Changing traditional psychological treatments, such as CBT, to make it more suitable for autistic people is recommended by the National Institute for Health and Care Excellence. What did the researchers do ? We recruited eight autistic adults (aged 18 ?57 years) with a fear/phobia and their supporter (parent/friend/support worker). Each adult had one session with a therapist to learn anxiety management techniques. They then had four 20-minute sessions of graded exposure with a therapist in an immersive VR room (known as the Blue Room). Each participant had a computer-generated scene designed for their specific anxiety-provoking situation. After four sessions, the participant tried real-life exposure with their supporter. We measured progress at 6 weeks and 6 months after the last VR session. What were the results of this study ? Each participant completed all four sessions. This shows that the intervention was possible to deliver and acceptable to autistic people and therapists. Participants completed assessments at 6 weeks and 6 months after the VR sessions. Five of the eight participants were ?responders ? to the intervention. This means that 6 months after the last VR session, they still had real-life day-to-day improvements in relation to their phobia. What do these findings add to what was already known ? We had not delivered this intervention to autistic adults previously. The findings show that this VR intervention has the potential to be an effective treatment for anxiety in autistic adults. What are the potential weaknesses in the study ? This is a small study and future work will be a larger trial of this treatment ?comparing results from people who get the intervention with people who do not. We would also want to have an outcome assessor who did not know whether people had received the intervention or not. How will these findings help autistic adult now or in the future ? This new intervention has the potential to help autistic adults manage their anxiety in stressful situations and therefore may improve their quality of life.

Fears and phobias are common in people on the autism spectrum and can impact on their ability to undertake usual daily activities. Graded exposure to the anxiety-provoking stimulus is a recognized method of treatment for fears/phobias in the nonautistic population but may pose specific difficulties for autistic people. For example, real-life exposure can be too anxiety-provoking to allow treatment to take place, and imaginal exposure can be problematic. To address this, we developed an intervention that combines cognitive behavioral therapy (CBT) with immersive virtual reality (VR) exposure to reduce anxiety. Following successful trials of this intervention with young people on the autism spectrum, we report a pilot study using the same intervention with autistic adults. Eight adults (aged 18 ?57 years) received one psychoeducation session and then four 20-minute sessions of graded exposure with a therapist in an immersive VR room (known as the Blue Room). Each participant completed all sessions showing that the intervention is feasible and acceptable. Outcomes were monitored at 6 weeks and 6 months postintervention. Five of the eight participants were classified as intervention responders and at 6 months after the end of intervention were experiencing real-life functional improvements. These preliminary findings show that VR-graded exposure alongside CBT may be an effective treatment for autistic people with phobias. Lay Summary Why was this study done ? Anxiety is common in autistic adults. For some people, fears and phobias regarding everyday objects and situations occur frequently affecting everyday life. The main method to treat fears and phobias for people without autism is gradual exposure to the situation that causes anxiety. However, this method may be challenging for people on the autism spectrum. We wanted to test a new method of treatment that uses cognitive behavioral therapy (CBT) delivered with gradual exposure in a fully immersive virtual reality (VR) environment. What was the purpose of this study ? We have already delivered this treatment successfully with autistic children. We wanted to test if this treatment would work for autistic adults. Changing traditional psychological treatments, such as CBT, to make it more suitable for autistic people is recommended by the National Institute for Health and Care Excellence. What did the researchers do ? We recruited eight autistic adults (aged 18 ?57 years) with a fear/phobia and their supporter (parent/friend/support worker). Each adult had one session with a therapist to learn anxiety management techniques. They then had four 20-minute sessions of graded exposure with a therapist in an immersive VR room (known as the Blue Room). Each participant had a computer-generated scene designed for their specific anxiety-provoking situation. After four sessions, the participant tried real-life exposure with their supporter. We measured progress at 6 weeks and 6 months after the last VR session. What were the results of this study ? Each participant completed all four sessions. This shows that the intervention was possible to deliver and acceptable to autistic people and therapists. Participants completed assessments at 6 weeks and 6 months after the VR sessions. Five of the eight participants were ?responders ? to the intervention. This means that 6 months after the last VR session, they still had real-life day-to-day improvements in relation to their phobia. What do these findings add to what was already known ? We had not delivered this intervention to autistic adults previously. The findings show that this VR intervention has the potential to be an effective treatment for anxiety in autistic adults. What are the potential weaknesses in the study ? This is a small study and future work will be a larger trial of this treatment ?comparing results from people who get the intervention with people who do not. We would also want to have an outcome assessor who did not know whether people had received the intervention or not. How will these findings help autistic adult now or in the future ? This new intervention has the potential to help autistic adults manage their anxiety in stressful situations and therefore may improve their quality of life.

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9. Raymaker DM, Kapp SK, McDonald KE, Weiner M, Ashkenazy E, Nicolaidis C. Development of the AASPIRE Web Accessibility Guidelines for Autistic Web Users. Autism in Adulthood. 2019 ; 1(2) : 146-57.

Websites figure predominantly in everyday life. However, many websites remain inaccessible to autistic people, and existing efforts to improve accessibility are in early stages, do not directly include autistic users in their development, or have not been empirically evaluated. The Academic Autism Spectrum Partnership in Research and Education (AASPIRE) used a community-based participatory research approach to create a website to improve health care access for autistic adults. We used the creation of that website as a ?living laboratory ? to develop the AASPIRE Web Accessibility Guidelines for Autistic Web Users. Our guidelines are grounded in accessibility theory, had autistic end-user involvement at all stages, and were empirically evaluated through a usability study and evaluation surveys. We incorporated what we learned into the design of the website, and compiled the accessibility information into a set of guidelines. The guidelines offer recommendations for increasing the physical, intellectual, and social acceptability of websites for use by autistic adults. In the evaluation of the website by 170 autistic end users, nearly all indicated it was easy to use (97%), easy to understand (95%), important (97%), and useful (96%). Ninety-two percent would recommend it to a friend, and 95% would recommend it to a health care provider. There were no significant associations between usability or understandability and education level, receipt of help using the site, browser type (e.g., IE or Safari), or device type (e.g., PC or tablet). We recommend using the guidelines to improve website accessibility for autistic Internet users. Lay Summary AASPIRE Web Accessibility Guideline : This guideline is a summary of the accessibility features we identified and implemented during the course of our study. None of these items were difficult or expensive for us to implement. They did not require special expertise beyond basic web programming and technical communications skills. We recommend that anyone seeking to create accessible websites for autistic users follow the Academic Autism Spectrum Partnership in Research and Education (AASPIRE) Web Accessibility Guideline in addition to broader web and communications standards and principles. Physical accessibility : Provide at least one low-contrast neutral color palette option to accommodate sensitive vision. Provide a selection of color palettes, including one with a dark background and one with a light background, again to accommodate color and contrast sensitivity. Provide a no-style option (i.e., no cascading style sheets (CSS) to accommodate browser customization and users who prefer no stylistic formatting. Provide simple consistent navigation and highly consistent site behavior for increased ease of operation. Avoid textured backgrounds, moving images, decorative elements that do not convey information, and other visual and/or sonic ?clutter ? ; these types of elements may make the site difficult or impossible to comprehend. Provide smaller font sizes in addition to larger ones ; large font sizes may make the page appear cluttered and difficult to read. Use a plain accessible sans-serif font (e.g., Arial) for ease of readability. Intellectual accessibility : Use the simplest interface possible for ease of understanding. Use simple concrete icons or images to communicate redundant information with text, and accommodate multiple ways of understanding information. Clearly label site elements with their purpose everywhere on the site, even if it seems redundant, to make navigation and site functionality easier to follow. Provide concrete examples where applicable to accommodate difficulties in understanding abstractions or generalizations. Minimize scrolling so the user does not need to rely on assumptions about content to guess what might be on the page. Show all important features and site navigation (as opposed to within combo box drop-down areas) so the user does not need to rely on assumptions to guess whether the item exists and how to access it. For example, completely visible l st boxes or radio buttons can be used instead of combo boxes. Make content as short as possible without sacrificing precision and specificity, to reduce cognitive burden. Social accessibility : Be specific and precise in language use ; avoid colloquialisms, idioms, and ambiguity to accommodate difficulties with language pragmatics. Explain the reason behind any nonstandard instructions or unusual information ; provide additional pragmatic context to accommodate difficulties with language pragmatics. Provide alternatives to definitive response items on surveys and forms, for example, ?do not know, ? ?do not wish to say, ? or ?not applicable, ? to reduce frustration for not being able to produce an exact answer. Use FAQ formats to organize complex information to enhance clarity as to why the information might be useful to the user and how it connects to their life. Define terms that might have different meanings depending on social context, or which might be jargon related to a specialized field (e.g., ?drug interactions ? and ?health care providers ?), to accommodate difficulties with language pragmatics. Be mindful of autistic culture and community preferences, including the language used to describe autism and how community-based symbols and history might influence content and perception of site credibility.

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