Francesca Happé

Background: Biological factors affecting motor, sensory, and integrative processing may predispose to functional neurological disorder (FND) and functional somatic symptoms. While early-life influences have traditionally been conceptualized within psychological frameworks, the contribution of early-life biological vulnerabilities to symptom expression remains unclear. Methods: Using TriNetX, a large electronic health records database, we assessed proportions of inherited, congenital, perinatal, and neurodevelopmental diagnoses, capturing a range of early-life conditions. We compared 188,868 individuals with FND and 406,202 with functional somatic symptoms to demographically matched migraine and depression cohorts. Subgroup analyses contrasted motor FND with functional seizures and system-predominant functional somatic symptom clusters (e.g. bowel and bladder) with the general cluster. Results: Compared with migraine and depression, individuals with FND and functional somatic symptoms showed higher proportions of multiple inherited and early-life vulnerability factors. Congenital and inherited conditions, including Ehlers – Danlos syndrome (OR = 2.1 – 3.6 across comparisons), congenital musculoskeletal malformations (1.7 – 2.0), and chromosomal abnormalities (2.5 – 3.2), were more prevalent. Perinatal factors such as low birth weight (1.8 – 2.4) were enriched, alongside neurodevelopmental disorders, including intellectual disability (1.9 – 5.4) and autism spectrum disorder (1.2 – 3.5). Subgroup analyses revealed phenotype-specific patterns: joint hypermobility and musculoskeletal malformations were more common in functional motor disorder and musculoskeletal functional somatic symptoms, whereas neurodevelopmental disorders were enriched in functional seizures and the general functional somatic symptom cluster. Conclusions: Inherited and early-life biological vulnerabilities were more common in FND and functional somatic symptom cohorts. Their prevalence differed among phenotypes. Our findings suggest that developmental variation in brain–body systems may influence the risk and clinical expression of functional symptoms.

Background: Neurodiversity is becoming a more widely used term amongst the general population, recognising neurodivergent people outside of traditional deficit‐based models of neurodevelopmental conditions such as autism, ADHD, dyslexia and dyspraxia. Although neurodevelopmental conditions have been associated with a variety of externalising behaviours, including substance misuse, there is limited research looking at whether the broader neurodivergent population may also share these risks. This study's primary aim was to understand the relationship between self‐reported neurodivergence and different forms of substance misuse in adolescents. Methods: This study uses data from the 2023 wave of the OxWell Student Survey, analysing responses from 21 749 secondary school‐aged children in England. Firth logistic regression was used to analyse the relationship between self‐reported neurodivergence and frequent use of substances (vapes, cigarettes, alcohol and recreational drugs). Models were adjusted for demographic variables (gender, age, ethnicity, socioeconomic status and family history of substance use) and psychological variables (well‐being scores, anxiety/depression measures). Results: 25.1% of our sample identified as neurodivergent. Our analyses demonstrate that although levels of frequent substance misuse are generally low amongst school‐aged children (< 10%), neurodivergent children were significantly more likely to be in higher substance use categories (daily vaping/smoking, frequent drinking, binge drinking and lifetime illicit substance use). Conclusions: Our findings provide preliminary evidence that children who identify as neurodivergent are at greater risk of substance misuse, even after adjusting for other known risk factors. Furthermore, this study supports the need for scalable school‐based substance use preventive interventions that are applicable for neurodivergent young people.

Background: School exclusion is linked to poor educational, social, and health outcomes. This study explored self-reported school exclusion among self-identified neurodivergent (e.g. autistic and attention deficit hyperactivity disorder [ADHD]) versus neurotypical peers. Methods: Cross-sectional data came from the 2023 OxWell Student Survey of 15,012 secondary school pupils (aged 11–19 years) in England. Participants self-identified as neurodivergent ( n = 3,081) or neurotypical ( n = 11,931) and reported an exclusion history and special educational needs (SEN) support. Chi-square tests assessed group differences, and logistic regressions tested whether neurodivergence predicted exclusion beyond other risk factors, with an exploratory analysis of permanent exclusion. Results: Neurodivergent students were nearly four times more likely to report exclusion (14.6% vs. 4.1%), and more likely to report permanent exclusion specifically (2.3% vs. 0.4%) than neurotypical peers. Elevated risk persisted across genders and school years. SEN support was not associated with reduced exclusion among neurodivergent students. Neurodivergence remained an independent predictor of exclusion after accounting for gender, ethnicity, age, and socio-economic deprivation; this estimated effect was even higher for permanent exclusion specifically (odds ratio = 4.75). Conclusions: Neurodivergent young people experience disproportionately high exclusion rates, representing a particularly vulnerable group. Findings highlight the need to identify modifiable factors that could inform policy and practice to reduce exclusion. Lay Previous research has shown that autistic students and students with ADHD are more likely to experience difficulties at school, including a higher risk of school exclusion. However, this work has largely focused on specific diagnoses, meaning that many young people who think and learn differently, particularly those without a formal diagnosis or who do not use diagnostic labels, are often overlooked. This study examines school exclusion in relation to self-identified neurodivergence using a large national survey of secondary school students in England. Instead of asking about specific conditions, students were asked whether they considered themselves neurodivergent, reflecting current thinking in the neurodiversity field and allowing a broader range of experiences to be included. The study explored both factors linked to a higher risk of exclusion and factors that might help protect against it, while also considering differences in students’ backgrounds, such as gender, ethnicity, and experiences of special educational needs (SEN) support at school. The findings show that students who identify as neurodivergent are more likely to be excluded from school, highlighting the need for change across education systems. For schools, this emphasises the importance of recognising and responding to students’ needs early, treating disruptive behaviour as a sign that a student needs more support rather than grounds for punishment, and ensuring that SEN support is timely, appropriate, and tailored to individual needs – rather than relying solely on formal diagnoses to determine who receives that support. For researchers, the results point to looking beyond specific diagnoses to better understand the wider range of neurodivergent experiences and the factors that increase or reduce the risk of exclusion. For policymakers, the findings support the development of policies that prioritise early support and effective school-based practices to reduce preventable school exclusion and improve outcomes for neurodivergent young people.

Sex/gender-related measurement bias in autism measures has been proposed as a factor contributing to the underdiagnosis of autistic women, yet research in this area remains limited. This study builds on the small but growing body of work addressing this gap by using a modified Delphi methodology to reach consensus among autistic women and academics/clinicians on the most relevant items from five measures of autistic traits: Autism Spectrum Quotient (AQ-50), Broad Autism Phenotype Questionnaire (BAPQ), Comprehensive Autistic Trait Inventory (CATI), Girls Questionnaire for Autism Spectrum Condition (GQ-ASC), and Ritvo Autism and Asperger Diagnostic Scale-14 (RAADS-14), and to evaluate each measure’s suitability for autistic women in their current form.Thirty-three autistic women and thirty-three academics/clinicians participated in the study. Each participant was asked to rate the relevance of individual items to the experiences of autistic women and to indicate whether each measure comprehensively captured experiences relevant to this group. Agreement on relevance was calculated separately for each group using the item-level content validity index (I-CVI) and the modified kappa statistic (k*), with scale-level content validity indices (S-CVI/Ave) derived for each measure.The findings showed broad consistency in relevance evaluations between the two groups. The RAADS-14 was rated as the most relevant measure for assessing autistic traits in women, followed by the CATI, while the remaining questionnaires were associated with lower perceived relevance. However, none fully captured experiences relevant to autistic women, indicating construct underrepresentation that warrants further investigation. Items assessing masking were identified as valuable for inclusion to enhance the relevance of autism measures for women. In contrast, items related to attention to detail and imagination appeared less useful for assessing autism more broadly or for capturing subtler presentations of autistic traits, or may not be suitably phrased for autistic women. The most relevant items identified across the five measures can be considered valid across clinical, academic, and lived-experience contexts, providing a foundation for refining existing scales to better capture the experiences of individuals with subtler presentations of autistic traits.

Background: Sex/gender-related measurement bias in autism measures has been proposed as a factor contributing to the underdiagnosis of autistic women, yet research in this area remains limited. This study builds on a small but growing body of work addressing this gap by using a modified Delphi methodology to reach consensus among autistic women and academics/clinicians on the most relevant items from five measures of autistic traits: Autism Spectrum Quotient (AQ-50), Broad Autism Phenotype Questionnaire (BAPQ), Comprehensive Autistic Trait Inventory (CATI), Girls Questionnaire for Autism Spectrum Condition (GQ-ASC), and Ritvo Autism and Asperger Diagnostic Scale-14 (RAADS-14), and to evaluate each measure’s suitability for autistic women in their current form. Methods: Thirty-three autistic women and thirty-three academics/clinicians participated in the study. Each participant was asked to rate the relevance of individual items to the experiences of autistic women and to indicate whether each measure comprehensively captured experiences relevant to this group. Agreement was calculated separately for each group using item-level content validity indices, from which scale-level indices were derived for each measure. Results: The RAADS-14 was rated as the most relevant measure for assessing autistic traits in women, followed by the CATI, while the remaining questionnaires were associated with lower perceived relevance. However, none fully captured experiences relevant to autistic women, indicating construct underrepresentation. Items assessing masking were identified as valuable for inclusion to enhance the relevance of measures for women, whereas items related to attention to detail and imagination appeared less useful for assessing autism more broadly or for capturing more nuanced presentations of autistic traits. Limitations: The sample was predominantly Western, White, and highly educated, limiting the generalisability of findings. Furthermore, the expert groups lacked sufficient homogeneity, as academics and clinicians were combined and participants evaluated different subsets of measures. Conclusions: Although the RAADS-14 and CATI were identified as the most relevant measures for autistic women, all instruments demonstrated incomplete coverage of the autism construct in this population. Items reaching consensus as most relevant across the five measures provide a foundation for refining existing scales to better capture the experiences of individuals with more nuanced presentations of autistic traits.

Adults often experience reduced social connectedness with increased age, and lack of social support can be associated with poorer quality of life. However, the social experiences and preferences of autistic adults in midlife and older age have not yet been qualitatively studied. A total of 33 autistic participants aged 40-78 years took part in our co-produced semi-structured interview study about their social preferences and experiences. Using thematic analysis, we created three themes. Themes 1 and 2, “The Impact of Ageing and Changes to Life Circumstances on Social Experiences” and "Consistency of Social Experiences Throughout Life”, directly contrasted. Theme 3 explored "Hopes and Concerns about the Present and Future”. These themes highlight the varied impact of ageing, resulting in the overarching sentiment that “one size does not fit all” when considering the social needs of autistic adults in midlife and older age. Although some aspects remained consistent, many reported reduced or more challenging social experiences with age, with many expressing concerns about the future. Motivations and barriers were also found to differ with age. These findings highlight targets for social support for older autistic adults, and the need for further research into specific age-related factors impacting their social experiences.

The propensity to teach is vital to human cultural evolution and to our ecological dominance of the planet, but its cognitive foundations remain poorly understood. Traditional explanations argue that teaching hinges on particular cognitive pre‐requisites, such as Theory of Mind. However, such explanations conflate the function of teaching—promoting learning in others—with how it is achieved, and overlook the role of comparatively simple mechanisms like the heuristics known to underpin teaching in some non‐human animals. We propose a novel framework integrating evolutionary and psychological perspectives to understand the diversity of teaching by focusing on the cognitive requirements for flexibility and sensitivity to pupil needs. Synthesizing theory and evidence across disciplines, our framework evaluates the contributions of different mechanisms in determining who and what is taught, and how teaching is achieved. This allows us to understand the cognitive foundations of teaching across different species, in diverse human societies, and neurodiverse populations.

Background: There is growing awareness from qualitative research studies that menopause may be particularly challenging for autistic people. Research in the general population suggests that preexisting conditions may be a risk factor for negative experiences during menopause. However, there are limited studies examining variables associated with experiences of menopause symptoms for autistic people. Objectives: To explore whether pre-existing depression and anxiety symptoms impact menopause symptoms for autistic and non-autistic people. Design: The study design is classified as STROBE. Methods: Autistic (n=52) and non-autistic (n=28) people assigned female at birth participated in the longitudinal AgeWellAutism (AWA) study. They reported self-report depression and anxiety symptoms at baseline and menopause symptoms (Greene Climacteric Scale) at follow-up after 4.5 years. Age, autism diagnosis and autism characteristics of mentalising difficulties, sensory reactivity, and social anxiety (subscales from the self-reported Ritvo Autism and Asperger Diagnostic Scale, RAADS) were recorded. Results: Regression analyses were conducted with menopause symptoms as the dependent variable and as independent variables: Step 1, age; Step 2, baseline depression and anxiety symptoms, Step 3, autism diagnosis (alternative step 3, RAADS subscales). In the final regression model, younger age, higher baseline depression and autism diagnosis contributed significantly to explaining menopause symptom severity. In the alternative model (including subscales of the RAADS), younger age, higher baseline depression, mentalising difficulties and sensory reactivity contributed significantly to explaining menopause symptom severity. Conclusions: Results align with research from the general population suggesting that a history of depression symptoms increases risk of negative experiences during menopause, furthermore, being autistic confers additional risk. Further studies examining the influence of lifetime experiences on menopause symptoms for neurodivergent people are required to better understand and mitigate risk during this critical time.

Differences in visual sensory sensitivity/reactivity are documented in autism and ADHD. Measuring these differences could guide interventions and accommodations, improving quality of life. No current self-report questionnaires focus specifically on the range of affective and behavioural responses to visual stimuli reported in autism and ADHD. This study aimed to develop such a measure (ViPro-SR) for neurodivergent adults. Using online survey responses, psychometric properties of ViPro-SR were assessed, including factor structure, gender-related measurement invariance, internal consistency reliability and validity. An 11-item, stable 3-factor solution was derived, with factors representing: hypersensitivity to contrast, detail focus, and peripheral vision activation. Internal consistency reliability was satisfactory for the total scale (ω = 0.85) and each subscale (ω > 0.70). Evidence towards convergent validity of ViPro-SR was provided through highly significant, moderate to strong correlations with existing sensory measures. Discriminative validity was supported by significant differences in ViPro-SR total scores between autistic/ADHD groups and a not autistic/ADHD comparison group. ViPro-SR is a psychometrically sound instrument, currently recommended for subscale-level scoring, that could inform visual sensory accommodations and contribute to a research toolkit.

Retirement is a major life change affecting routines, finances and wellbeing. Autistic adults may face extra challenges during this transition due to employment barriers, limited support and planning difficulties. However, little is known about their retirement experiences compared to non-autistic adults. This mixed-methods study surveyed 517 adults from the United Kingdom (autistic n = 395), aged 40–90 years, about their retirement status, plans, experiences, employment history, income and financial security. Actual or expected retirement ages were similar across groups, but autistic adults were less likely to have made plans and more likely to have plans disrupted by financial, health or personal factors. They also reported lower rates of full-time work, reduced pensions and lower pre-retirement income. Many highlighted a lack of information about pensions and lifestyle planning. Concerns included isolation, loss of routine and financial worries, but some looked forward to more autonomy and time for self-care, leisure activities and interests. While there were many similarities between the autistic and non-autistic groups, our study found that autistic adults may reach retirement differently due to unique work histories, health needs and planning barriers. Tailored, accessible support is needed to help autistic adults plan for financial stability and meaningful post-retirement lives. Lay Retirement is a major life change, but very little is known about how autistic adults experience this transition. This study explored retirement experiences/expectations of both autistic and non-autistic adults, finding that retirement happened or was expected to happen at similar ages across groups. However, autistic adults were less likely to plan for retirement and often had more difficulties with jobs, money, pensions and their health. Many felt unsure how to prepare for retirement and wanted clearer information. While some had concerns about isolation and changes to routine, others looked forward to more freedom and time for hobbies. The findings highlight the need for better support to help autistic people plan for retirement.