We evaluated proportions of autism screening outcomes among adults accessing crisis mental health services in Sussex, UK, and examined associations with quality of life and joint hypermobility as an indicator of physiological complexity. Fifty-five participants (mean age 35.7 years, 56% male, 85% White) completed autism and hypermobility screening questionnaires and the Mental Health Quality of Life Questionnaire. Forty-three participants (78%) scored above screening threshold for autism, although only eight had a prior diagnosis, and 27% scored above the published autistic median. Higher Ritvo Autism and Asperger Diagnostic Scale (RAADS-14) scores were associated with lower quality of life (p < 0.001) and poorer well-being (p < 0.01). Those screening positive for hypermobility also had higher RAADS-14 scores (p = 0.01), suggesting a possible biological contribution to distress. Findings indicate high frequency of possible autism in crisis services and a need for tailored, biopsychosocially informed support.

Philosopher Ian Hacking noted that people respond to being placed in categories – setting up an iterative process that leads to (sometimes radical) changes in the features used to diagnose group membership. Hacking called this process making up people, and the interactions that were its underlying mechanism he called looping effects, which he saw as an important means both to advocacy and overdiagnosis. Hacking was sceptical of the idea of an autistic spectrum, not least because it carried a risk of overdiagnosing people with few symptoms. These are important messages for the current debate about diagnosis in autism.

All-age autism and attention-deficit hyperactivity disorder pathway reform in England is often framed around waiting lists and capacity. However, backlog data alone cannot show how people move through referral, triage, assessment, support and follow-up, or where inequities and unmet need are hidden. Current data also struggle to distinguish confirmed diagnosis, suspected diagnosis, disclosure, self-identification and co-occurring needs. This creates pathway blindness: systems can see pressure, but not flow, fairness or diagnostic visibility. We argue that reform should begin with structured system mapping, agreed definitions and a realistic minimum data-set before dashboards or predictive analytics are used to guide service change.

Autism is marked by substantial heterogeneity in cognitive, affective, behavioral, and neural profiles. This heterogeneity among diagnosed individuals is also reflected in the broad spread of autistic traits in the general population. Moving beyond a narrow focus on social-communication and/or repetitive-behavior differences, contemporary accounts increasingly emphasize multidimensional and transdiagnostic processes and the need to integrate evidence across levels of analysis, from self-report and cognitive measures to neuroimaging and computational models. The contributions in this Special Issue collectively advance this agenda by providing insights into individual differences in autistic traits and autism-relevant phenotypes, clarifying their measurement and stability, and proposing mechanistic frameworks that can help explain why diverse profiles emerge. In this conclusion piece, we summarize the manuscripts included in the special issue, highlight shared themes and discuss remaining issues and future directions, particularly related to naturalistic, interactive neuroscience. Ultimately, we hope this work will contribute to the development of more precise and inclusive models of autism.

Low-intensity cognitive behavioural therapy (LICBT) services are a key component of mental health provision for children and young people (CYP) in England. Given the elevated prevalence of mental health difficulties among autistic populations, these services are likely to receive referrals for autistic CYP. However, evidence regarding the suitability of LICBT protocols for this group is limited, and little is known about practitioners’ experiences supporting autistic youth. This qualitative study explored LICBT practitioner perspectives on working with autistic CYP, including what helps prepare or support them in this work. Semi-structured interviews were conducted with Children’s Wellbeing Practitioners and Education Mental Health Practitioners (n = 13) working in LICBT services across England. Data were analysed using reflexive thematic analysis. Two over-arching themes were generated: (1) Delivering LICBT on Unstable Foundations, and (2) Navigating Organisational Challenges. Practitioners described feeling under-prepared by core training and uncertain about the suitability of LICBT interventions for autistic CYP. Successful intervention was perceived to depend on autism-specific adjustments and wider systemic support that were not always available. Organisational pressures, unclear role boundaries, and limited alternative service provision contributed to ethical discomfort and emotional strain. Many practitioners reported independently seeking additional training and informally extending their roles to bridge gaps in care. Findings suggest a misalignment between the LICBT service model and the realities of supporting autistic CYP in practice. Addressing this requires strengthening the evidence for LICBT with autistic populations, closer integration between LICBT and autism-specific services, and flexibility within practitioner workplans to support equitable and appropriate care.

Key learning aims

1. (1) To explore Children’s Wellbeing Practitioners’ and Education Mental Health Practitioners’ perspectives and experiences of supporting autistic children and adolescents within low-intensity cognitive behavioural therapy (LICBT) services.

2. (2) To examine what works well and the challenges encountered in practice by these practitioners when supporting autistic children and adolescents.

3. (3) To identify what may be needed to sustainably meet the needs of autistic children and adolescents referred to LICBT services, including factors that may support the accessibility and effectiveness of LICBT for this client group.

Multilingualism provides many benefits for the cognitive and communicative development of non-autistic children, including the development of lexical-semantic abilities. In contrast, the influence of multilingualism is less clear for autistic children, who often experience challenges in the development of language abilities. We present data from 345 autistic and non-autistic children (3–12 years) from semantic and phonemic verbal fluency (VF) tasks. Children’s monolingualism or multilingualism was operationalised as the continuous measure of language exposure entropy. Our study is the first to monitor both semantic and phonemic VF in multilingual autistic children. Non-autistic children show clear benefits of multilingualism for VF emerging with increasing age. For autistic children, there are neither negative nor positive effects of multilingualism on VF. Follow-up analyses reveal that this is independent of the strength of social-communicative autism symptoms. Taken together, our findings reveal that multilingualism is not detrimental for the development of lexical abilities of autistic children.

Autistic youth commonly experience co-occurring mental health conditions. Core autism features have been linked to internalizing and externalizing symptoms, yet longitudinal pathways remain unclear. This study examined how ritualistic and social diagnostic features predict later internalizing and externalizing behaviors in school-age autistic children. Caregivers reported ritualistic behavior (PDDBI), social diagnostic features (SRS-2), and internalizing and externalizing behaviors (CASI-5; BASC-3) at two time points (baseline Mage = 8.50, SD = 1.62, range = 6.0–11.5; follow-up Mage = 12.67, SD = 1.79, range = 8.7–16.1). Children (n = 139) were 79.1% male (n = 110), 20.9% female (n = 29), 5% African American/Black (n = 7), 0.7% American Indian/Alaska Native (n = 1), 7.2% Asian (n = 10), 17.3% Mixed Race (n = 24), 1.4% Other (n = 2), 68.3% White (n = 95), 17.3% Hispanic/Latinx (n = 24), and 82.7% non-Hispanic/Latinx (n = 115). Ritualistic behavior and social diagnostic features were associated at baseline (r = .590). Baseline ritualistic behavior predicted later internalizing behaviors, while neither social diagnostic features nor ritualistic behavior predicted later externalizing behaviors. Findings underscore the importance of examining specific core autism features, particularly ritualistic behavior, as early indicators of internalizing and externalizing challenges across development.

Daily living skills (DLS) predict adult success for autistic individuals. However, most research on DLS in autism relies on cross-sectional data and DLS summary scores, limiting understanding of how specific skills across development relate to adult outcomes. Using longitudinal data from autistic adults (n = 232, 19% female, 69% White) followed from early childhood into their early thirties (mage = 32.6 years, SD = 7.58, range 19–35), this study used machine learning techniques to identify item-level DLS from ages 5 (n = 123), 9 (n = 152), 14 (n = 154), and 18 (n = 143) that predicted adult employment, residential status, social relationships, and well-being. DLS items demonstrated predictive utility for employment (age 9 model R2 = .557) and social relationships (age 14 model ROC AUC = .839). Notably, DLS measured at age 5 explained a large proportion of variance in adult vocational outcomes (R2 = .507). Predictive strength for residential status increased across development (age 18 model ROC AUC = .906), whereas DLS showed limited association with subjective well-being (age 14 model R2 = .096). Community-based skills (e.g., money use, telephone skills) consistently emerged as top predictors. Findings are interpreted within a developmental cascade framework, highlighting how DLS competencies in childhood and adolescence may inform experiences for autistic adults.

Cognitive behaviour therapy (CBT) requires baseline skills and knowledge that people possess to varying degrees. This includes the ability to accurately identify thoughts, feelings, and behaviours; interactions between these; and an understanding that change in one area may bring about change in another. Assessing these skills could help clinicians discern whether adaptations to CBT are required early in treatment. We report two studies about the development and validation of a novel measure, the CBT Skills Task (CBT-SKI). Study 1 investigates the internal consistency and convergent validity of a four-vignette paper-and-pencil version of the task with 72 neurotypical adolescents. Study 2 examines the factor structure of a two-vignette online version of the CBT-SKI with 300 young adults aged 18–30 from neurotypical and neurodivergent populations. Across studies, the task demonstrated adequate internal consistency. Relevant task items converged well with a validated self-report measure analysing one’s own emotions. Exploratory factor analyses indicated a three-factor structure for the CBT-SKI, which was supported by confirmatory factor analysis. However, the third factor had below-threshold internal consistency, indicating potential issues with its composition and that further refinement may be required. The CBT-SKI shows promise as a psychometrically sound measure of baseline CBT skills and clinical applications are discussed.

Key learning aims

1. (1) To understand the need for a standardised task-based measure of baseline CBT skills.

2. (2) To provide information about the development of the CBT Skills Task.

3. (3) To provide information about validation of the CBT Skills Task.

Franz Kafka has often been posthumously diagnosed with anorexia nervosa, but recent research impels a re-evaluation of his disordered eating. This study presents a qualitative analysis of Kafka’s diaries, correspondence, medical reports and fiction, focusing on appetite, diet, somatic symptoms, and cognitions concerning food and fasting. Diagnostic indicators are matched against DSM-5 criteria for anorexia nervosa and avoidant/restrictive food intake disorder. Kafka’s clinical profile, which is characterised by diminished appetite, anorexia, selective intake, obsessive mastication, low body weight and undernourishment needing repeated sanatorium admissions, suggests a presentation more consistent with avoidant/restrictive food intake disorder. These disturbances are reflected in his fiction, in which food operates as a symbolic register of alienation, ontological anxiety and existential resistance, most notably in The Metamorphosis and A Hunger Artist. Integration of medical and literary perspectives demonstrates the clinical value of phenomenological evidence in capturing lived experience of eating disorders, enriching diagnostic insight by foregrounding cognitive, psychosocial and cultural contexts.

The UK is experiencing increasing demand for autism assessments, placing severe pressure on the National Health Service (NHS) and private services. Policy responses remain unproven and cost-driven adaptations have compromised quality of some assessments. This risks misdiagnosis, inappropriate support and growing demand for reassessments, potentially creating greater long-term burden for individuals and services alike.

This paper outlines a prospective cognitive framework for understanding the intersectionality of gender diversity and neurodivergence (specifically being autistic). The framework aims to provide understanding of the overlap between being autistic and being transgender and gender diverse, where these two constructs intersect and where they are disparate. Within these two intersections, there is evidence that individuals may mask or camouflage parts of these intersections of their identity, which may in turn impact on emotional wellbeing. This framework aims to be supportive of staff and adult service users alike in understanding this intersectionality and to provide suggestions on how to use this framework within psychological therapy to support autistic transgender and gender diverse adults. Limitations, clinical implications and key messages are briefly included within the discussion. Due to the limited research in this area at present, it is likely that further research into this field is warranted and further evidence, service user feedback and trialling of the cognitive framework would be imperative to conclude its utility and efficacy in clinical practice.