Recent Submissions

  • Relationship between autonomic arousal and attention orienting in children and adolescents with ADHD, autism and co-occurring ADHD and autism

    Arora, Iti; Kochhar, Puja; Hollis, Chris P.; Groom, Madeleine J. (2023)
    INTRODUCTION: Attention-Deficit/Hyperactivity Disorder (ADHD) and Autism Spectrum Disorder (ASD) may be characterized by different profiles of visual attention orienting. However, there are also many inconsistent findings emerging from the literature, probably due to the fact that the potential effect of autonomic arousal (which has been proposed to be dysregulated in these conditions) on oculomotor performance has not been investigated before. Moreover, it is not known how visual attention orienting is affected by the co-occurrence of ADHD and autism in people with a double diagnosis. METHODS: 99 children/adolescents with or without ADHD and/or autism (age 10.79 ± 2.05 years, 65% boys) completed an adapted version of the gap-overlap task (with baseline and overlap trials only). The social salience and modality of stimuli were manipulated between trials. Eye movements and pupil size were recorded. We compared saccadic reaction times (SRTs) between diagnostic groups and investigated if a trial-by-trial association existed between pre-saccadic pupil size and SRTs. RESULTS: Faster orienting (shorter SRT) was found for baseline compared to overlap trials, faces compared to non-face stimuli and-more evidently in children without ADHD and/or autism-for multi-modal compared to uni-modal stimuli. We also found a linear negative association between pre-saccadic pupil size and SRTs, in autistic participants (without ADHD), and a quadratic association in children with ADHD (without autism), for which SRTs were slower when intra-individual pre-saccadic pupil size was smallest or largest. CONCLUSION: Our findings are in line with previous literature and indicate a possible effect of dysregulated autonomic arousal on oculomotor mechanisms in autism and ADHD, which should be further investigated in future research studies with larger samples, to reliably investigate possible differences between children with single and dual diagnoses.
  • Specificity and sensitivity of the social communication questionnaire lifetime screening tool for autism spectrum disorder in a UK CAMHS service

    Staton, Amelia; McGrath, Barbara (2023)
    INTRODUCTION: The Social Communication Questionnaire is used to identify children and young people (CYP) who may require formal ASD assessment. However, there is a paucity of research on its utility in Children and Adolescent Mental Health Services. This evaluation aimed to determine the sensitivity and specificity of the Social Communication Questionnaire (SCQ) in a UK, Midlands CAMHS service. METHOD: Forty young people (mean age 13.75 years) were screened using the caregiver reported SCQ before completing 'gold standard' assessment. RESULTS: The SCQ had a sensitivity of 80% and a specificity of 25.7%. ROC curve analysis indicated low diagnostic accuracy. Differences in predictive accuracy of SCQ and diagnostic standard were statistically significant (p < 0.0001). CONCLUSION: This evaluation builds on previous research suggesting that the SCQ may not be an efficient screening tool in CAMHS settings.
  • Understanding the impact of home confinement on children and young people with ADHD and ASD during the COVID-19 pandemic

    Hall, Charlotte L.; Valentine, Althea Z.; Sayal, Kapil (2023)
    To understand whether the mental health of children and young people (CYP) with and without attention-deficit/hyperactivity disorder (ADHD) and/or autism spectrum disorder (ASD) were differentially affected by COVID-19. We analysed data (n = 6507) from the Co-Space study, a UK web-based longitudinal survey. CYP with ADHD (n = 160;2.5%), ASD (n = 465;7%), and ADHD + ASD (n = 155;2.4%) were compared with a reference group (n = 5727;88%) using parent-completed questionnaires [Strengths and Difficulties Questionnaire (SDQ) & Pandemic Anxiety Scale (PAS)]. Baseline to 1-month follow-up differences were compared using linear regression models. CYP with ADHD and/or ASD had higher scores at baseline than other CYP. At follow-up, CYP with ASD showed small but significant improvements in symptoms (SDQ), compared with the reference group. CYP with ASD experienced a worsening of disease anxiety (PAS) and CYP with ADHD a deterioration in functional impairment. These findings indicate a mixed pattern of pandemic-related impact for CYP with ADHD and/or ASD.
  • Exploring the experiences of parents whose child has received a diagnosis of autistic spectrum disorder in adulthood

    Gillott, Alinda (2022)
    There is a growing trend of adult diagnosis of Autism Spectrum Disorder (ASD). Research has found that diagnosis can prompt a process of sense-making which may be disrupted by lack of post-diagnostic support. Given the continued involvement of many parents in supporting their adult son or daughter with ASD, it is vital to understand their experiences to meet their needs in adapting to the diagnosis. Eleven parents of recently diagnosed adults participated in semi-structured interviews which were analysed thematically. Findings demonstrate that the new knowledge of diagnosis facilitates changes in attributions, interactions and relationships, but can result in unmet emotional and relational support needs. Findings are relevant to those involved in adult diagnosis, and the provision of post-diagnostic support.
  • Heart rate variability in children and adolescents with autism, ADHD and co-occurring autism and ADHD, during passive and active experimental conditions

    Bellato, Alessio; Arora, Iti; Kochhar, Puja; Hollis, Chris P.; Groom, Madeleine J. (2021)
    Despite overlaps in clinical symptomatology, autism and ADHD may be associated with opposite autonomic arousal profiles which might partly explain altered cognitive and global functioning. We investigated autonomic arousal in 106 children/adolescents with autism, ADHD, co-occurring autism/ADHD, and neurotypical controls. Heart rate variability was recorded during resting-state, a 'passive' auditory oddball task and an 'active' response conflict task. Autistic children showed hyper-arousal during the active task, while those with ADHD showed hypo-arousal during resting-state and the passive task. Irrespective of diagnosis, children characterised by hyper-arousal showed more severe autistic symptomatology, increased anxiety and reduced global functioning than those displaying hypo-arousal, suggesting the importance of considering individual autonomic arousal profiles for differential diagnosis of autism/ADHD and when developing personalised interventions.
  • A systematic review and meta-analysis of altered electrophysiological markers of performance monitoring in Obsessive-Compulsive Disorder (OCD), Gilles de la Tourette Syndrome (GTS), Attention-Deficit/Hyperactivity Disorder (ADHD) and Autism

    Bellato, Alessio; Idrees, Iman; Groom, Madeleine J. (2021)
    Altered performance monitoring is implicated in obsessive-compulsive disorder (OCD), Gilles de la Tourette syndrome (GTS), attention-deficit/hyperactivity disorder (ADHD) and autism. We conducted a systematic review and meta-analysis of electrophysiological correlates of performance monitoring (error-related negativity, ERN; error positivity, Pe; feedback-related negativity, FRN; feedback-P3) in individuals with OCD, GTS, ADHD or autism compared to control participants, or associations between correlates and symptoms/traits of these conditions. Meta-analyses on 97 studies (5890 participants) showed increased ERN in OCD (Hedge's g = 0.54[CIs:0.44,0.65]) and GTS (g = 0.99[CIs:0.05,1.93]). OCD also showed increased Pe (g = 0.51[CIs:0.21,0.81]) and FRN (g = 0.50[CIs:0.26,0.73]). ADHD and autism showed reduced ERN (ADHD: g=-0.47[CIs:-0.67,-0.26]; autism: g=-0.61[CIs:-1.10,-0.13]). ADHD also showed reduced Pe (g=-0.50[CIs:-0.69,-0.32]). These findings suggest overlap in electrophysiological markers of performance monitoring alterations in four common neurodevelopmental conditions, with increased amplitudes of the markers in OCD and GTS and decreased amplitudes in ADHD and autism. Implications of these findings in terms of shared and distinct performance monitoring alterations across these neurodevelopmental conditions are discussed. PROSPERO pre-registration code: CRD42019134612.
  • Is autonomic function during resting-state atypical in autism: A systematic review of evidence

    Arora, Iti; Bellato, Alessio; Hollis, Chris P.; Groom, Madeleine J. (2021)
    Background: Theories of differences in resting-state arousal in autistic individuals are influential. Differences in arousal during resting-state would impact engagement and adaptation to the environment, having a cascading effect on development of attentional and social skills. Objectives: We systematically evaluated the evidence for differences in measures of autonomic arousal (heart rate, pupillometry or electrodermal activity) during resting-state in autistic individuals; to understand whether certain contextual or methodological factors impact reports of such differences. Data sources: We searched PsycInfo, MEDLINE and EMBASE databases for papers published until 16th May 2019. Of 1207 titles initially identified, 60 met inclusion criteria. Results and Conclusions: Of the 51 studies that investigated group differences between neurotypical and autistic participants, 60.8 % found evidence of group differences. While findings of hyperarousal were more common, particularly using indices of parasympathetic function, findings of hypo-arousal and autonomic dysregulation were also consistently present. Importantly, experimental context played a role in revealing such differences. The evidence is discussed with regard to important methodological factors and implications for future research are described. (PsycInfo Database Record (c) 2021 APA, all rights reserved) (Source: journal abstract)
  • What is the effect of stimulus complexity on attention to repeating and changing information in autism?

    Arora, Iti; Bellato, Alessio; Kochhar, Puja; Hollis, Chris P.; Groom, Madeleine J. (2021)
    Slower habituation to repeating stimuli characterises Autism, but it is not known whether this is driven by difficulties with information processing or an attentional bias towards sameness. We conducted eye-tracking and presented looming geometrical shapes, clocks with moving arms and smiling faces, as two separate streams of stimuli (one repeating and one changing), to 7-15 years old children and adolescents (n = 103) with Autism, ADHD or co-occurring Autism+ADHD, and neurotypical children (Study-1); and to neurotypical children (n = 64) with varying levels of autistic traits (Study-2). Across both studies, autistic features were associated with longer looks to the repeating stimulus, and shorter looks to the changing stimulus, but only for more complex stimuli, indicating greater difficulty in processing complex or unpredictable information.
  • Developing pretend play in autistic children using the playboxes joint play approach as part of ongoing practice

    Cockayne, Rachael (2021)
    A repeated measures single subject design was used to examine the effectiveness of a joint play approach embedded in professional practice, in supporting pretend play for autistic children. Seven autistic children, aged 5-8 years, with a placement within a specialist educational provision, and who demonstrated restricted play, participated in weekly sessions using the Playboxes approach over a period of 3 months. Pre- and post-approach pretend play abilities were assessed using the Symbolic Play Test and the Test of Pretend Play. Every child gained increased age-equivalent scores on the Test of Pretend Play, ranging from + 8 to + 30 months. Pretend Play abilities can support developmental outcomes and incorporation of this approach into regular practice could be of value for autistic children.
  • Patient and Family-Centred Care (PFCC) as an evidence-based framework for optimising the acute healthcare experiences of families of young people with autism

    Clifford, Adam; Standen, Penny J. (2020)
    Commentary on: Nicholas DB, Muskat B, Zwiagenbaum L, et al. Patient- and Family-Centered Care in the emergency department for children with autism. Pediatrics 2020;145 (Supp 1) S93–8.
  • Socio-economic and demographic factors associated with adaptive behaviour among children diagnosed with autism spectrum disorder in Egypt

    Ng, Fiona (2020)
    Background: Adaptive behaviour among children diagnosed with autism spectrum disorder determines wide range of self-independent and autonomous activities. Adaptive behaviour is a clearly defined measurable variable that can be used as an outcome, hence impacts intervention and training programs. The current study aims to determine the socio-economic and demographic factors that are associated with adaptive behaviour among children diagnosed with autism spectrum disorder in Egypt. In this observational cross sectional study, caregivers’ reports on their children with a confirmed diagnosis of autism spectrum were obtained. Vineland Adaptive Behaviour Scale was used to assess adaptive behaviour among children aged 3–6 years and admitting at the outpatient clinic. Socioeconomic Status Scale was used to assess family socioeconomic status. Results: Participants in the current study scored low in domains of adaptive behaviour. Older children scored low in adaptive behaviour compared to younger children. There was significant positive correlation between daily living activities subdomain of adaptive behaviour and education, occupation, family possessions, and home sanitation and health care domains of socioeconomic status scale. There were significant positive correlations between socialization subdomain of adaptive behaviour and education, occupation, family, and family possessions and home sanitation domains of the socioeconomic status scale. The motor functioning subdomain of adaptive behaviour correlates significantly with the following SES domains: education (r =.268), occupation (r =.274), family possessions (r =.232), economic (r =.195) and health care (r =.291). Results of the current study revealed that high socioeconomic status correlates with higher adaptive functioning in daily living skills, socialisation and motor skills domains of adaptive behaviour. Conclusion: The correlations detected in the current study between adaptive behaviour and some social determinants of health can influence stakeholders’ decisions in planning and implementation of autism specific interventions. © 2020, The Author(s).
  • Atypical electrophysiological indices of eyes-open and eyes-closed resting-state in children and adolescents with ADHD and autism

    Bellato, Alessio; Arora, Iti; Kochhar, Puja; Hollis, Chris P.; Groom, Madeleine J. (2020)
    Investigating electrophysiological measures during resting-state might be useful to investigate brain functioning and responsivity in individuals under diagnostic assessment for attention deficit hyperactivity disorder (ADHD) and autism. EEG was recorded in 43 children with or without ADHD and autism, during a 4-min-long resting-state session which included an eyes-closed and an eyes-open condition. We calculated and analyzed occipital absolute and relative spectral power in the alpha frequency band (8-12 Hz), and alpha reactivity, conceptualized as the difference in alpha power between eyes-closed and eyes-open conditions. Alpha power was increased during eyes-closed compared to eyes-open resting-state. While absolute alpha power was reduced in children with autism, relative alpha power was reduced in children with ADHD, especially during the eyes-closed condition. Reduced relative alpha reactivity was mainly associated with lower IQ and not with ADHD or autism. Atypical brain functioning during resting-state seems differently associated with ADHD and autism, however further studies replicating these results are needed; we therefore suggest involving research groups worldwide by creating a shared and publicly available repository of resting-state EEG data collected in people with different psychological, psychiatric, or neurodevelopmental conditions, including ADHD and autism.
  • Clinical and cost effectiveness of staff training in the delivery of Positive Behaviour Support (PBS) for adults with intellectual disabilities, autism spectrum disorder and challenging behaviour - randomised trial

    Bosco, Alessandro (2020)
    BACKGROUND: Although Positive Behaviour Support (PBS) is a widely used intervention for ameliorating challenging behaviour (CB), evidence for its use in adults with intellectual disability (ID) and comorbid autism (ASD) is lacking. We report a planned subsidiary analysis of adults with both ASD and ID who participated in a randomised trial of PBS delivered by health professionals. METHODS: The study was a multicentre, cluster randomised trial conducted in 23 community ID services in England, participants were randomly allocated to either the delivery of PBS (n = 11 clusters) or to treatment as usual (TAU; n = 12). One-hundred and thirteen participants (46% of all participants in the trial) had a diagnosis of ID, autism spectrum disorder and CB (ASD+); (47 allocated to the intervention arm, and 66 to the control). CB (primary outcome) was measured with the Aberrant Behaviour Checklist total score (ABC-CT). Secondary outcomes included mental health status, psychotropic medication use, health and social care costs and quality adjusted life years (QALYs) over 12 months. RESULTS: There were no statistically significant differences in ABC-CT between ASD+ groups randomised to the two arms over 12 months (adjusted mean difference = - 2.10, 95% CI: - 11.3 7.13, p = 0.655) or other measures. The mean incremental cost of the intervention per participant was pound628 (95% CI - pound1004 to pound2013). There was a difference of 0.039 (95% CI - 0.028 to 0.103) for QALYs and a cost per QALY gained of pound16,080. CONCLUSIONS: Results suggest lack of clinical effectiveness for PBS delivered by specialist ID clinical teams. Further evidence is needed from larger trials, and development of improved interventions. TRIAL REGISTRATION: NCT01680276.
  • Building a community forensic service for people with intellectual disabilities and autism in the age of Transforming Care

    Wooster, Leah; Lamb, Fiona (2019)
    The Community Forensic Intellectual Developmental Disability Service (CFIDD) is part of the Low Secure and Community Forensic Directorate for Nottinghamshire Healthcare NHS Foundation Trust. The team is established and commissioned to work with adults with a recognised intellectual disability and or autism who present with a forensic risk across Nottinghamshire (City & County). The aim of the service is to work alongside our Trust colleagues in both Learning Disability and Adult Mental Health services in supporting and identifying appropriate care pathways for those individuals identified under The Transforming Care Agenda. The service was commissioned in March 2019. The maximum capacity for the service for community complex case management at any one time is 24 cases.
  • The effectiveness of web-based interventions delivered to children and young people with neurodevelopmental disorders: Systematic review and meta-analysis

    Khan, Kareem; Hall, Charlotte L.; Davies, E. Bethan; Hollis, Chris P.; Glazebrook, Cris (2019)
    BACKGROUNDThe prevalence of certain neurodevelopmental disorders, specifically autism spectrum disorder (ASD) and attention deficit hyperactivity disorder (ADHD), has been increasing over the last four decades. Nonpharmacological interventions are available that can improve outcomes and reduce associated symptoms such as anxiety, but these are often difficult to access. Children and young people are using the internet and digital technology at higher rates than any other demographic, but although Web-based interventions have the potential to improve health outcomes in those with long-term conditions, no previous reviews have investigated the effectiveness of Web-based interventions delivered to children and young people with neurodevelopmental disorders.OBJECTIVEThis study aimed to review the effectiveness of randomized controlled trials (RCTs) of Web-based interventions delivered to children and young people with neurodevelopmental disorders.METHODSSix databases and one trial register were searched in August and September 2018. RCTs were included if they were published in a peer-reviewed journal. Interventions were included if they (1) aimed to improve the diagnostic symptomology of the targeted neurodevelopmental disorder or associated psychological symptoms as measured by a valid and reliable outcome measure; (2) were delivered on the Web; (3) targeted a youth population (aged ≤18 years or reported a mean age of ≤18 years) with a diagnosis or suspected diagnosis of a neurodevelopmental disorder. Methodological quality was rated using the Joanna Briggs Institute Critical Appraisal Checklist for RCTs.RESULTSOf 5140 studies retrieved, 10 fulfilled the inclusion criteria. Half of the interventions were delivered to children and young people with ASDs with the other five targeting ADHD, tic disorder, dyscalculia, and specific learning disorder. In total, 6 of the 10 trials found that a Web-based intervention was effective in improving condition-specific outcomes or reducing comorbid psychological symptoms in children and young people. The 4 trials that failed to find an effect were all delivered by apps. The meta-analysis was conducted on five of the trials and did not show a significant effect, with a high level of heterogeneity detected (n=182 [33.4%, 182/545], 5 RCTs; pooled standardized mean difference=-0.39; 95% CI -0.98 to 0.20; Z=-1.29; P=.19 [I2=72%; P=.006]).CONCLUSIONSWeb-based interventions can be effective in reducing symptoms in children and young people with neurodevelopmental disorders; however, caution should be taken when interpreting these findings owing to methodological limitations, the minimal number of papers retrieved, and small samples of included studies. Overall, the number of studies was small and mainly limited to ASD, thus restricting the generalizability of the findings.TRIAL REGISTRATIONPROSPERO International Prospective Register of Systematic Reviews: CRD42018108824;
  • Systemic-attachment formulation for families of children with autism

    Hudson, Mark (2017)
    Purpose Case formulation has gained increasing prominence as a guide to intervention across a range of clinical problems. It offers a contrasting orientation to diagnosis and its value is considered in the context of clinical work with autistic spectrum disorders (ASD). The purpose of this paper is to argue that case formulation integrating attachment, systemic and narrative perspectives offers a valuable way forward in assisting people with the diagnosis and their families. Design/methodology/approach The literature on ASD and related conditions is reviewed to examine levels of co-morbidity, consider the role of parental mental health difficulties and explore the issues inherent with current approaches to diagnosis. Findings ASD is found to have a high level of co-morbidity with other difficulties, such as anxiety and insecure attachment. Research findings, alongside the authors own clinical experience, are developed to suggest that formulation can allow the possibility of early intervention based on a holistic appraisal of the array of difficulties present prior to a diagnosis. Originality/value It is argued that the use of this systemic-attachment formulation approach could offset the exacerbation in ASD and related conditions, and deterioration in families' mental health, whilst they face long waiting times for a diagnosis.
  • Autistic traits in treatment-seeking transgender adults

    Nobili, Anna; Glazebrook, Cris; Bouman, Walter P.; Glidden, Derek; Arcelus, Jon (2018)
    The present study aimed to compare prevalence of autistic traits measured by the self-reported autism spectrum quotient-short (AQ-short) in a transgender clinical population (n = 656) matched by age and sex assigned at birth to a cisgender community sample. Results showed that transgender and cisgender people reported similar levels of possible autistic caseness. Transgender people assigned female were more likely to have clinically significant autistic traits compared to any other group. No difference was found between those assigned male. High AQ scores may not be indicative of the presence of an autism spectrum condition as the difference between groups mainly related to social behaviours; such scores may be a reflection of transgender people's high social anxiety levels due to negative past experiences.
  • Brief report: Autism spectrum disorder: A comprehensive survey of randomized controlled trials

    Adams, Clive E. (2018)
    We searched the Cochrane Central Register of Controlled Trials to provide an overview of evidence from randomized controlled trials (RCTs) of therapeutic interventions for autism spectrum disorders. From the final survey (529 RCTs), the mean size was 49 participants (standard deviation 50, range 1-479, median 36, mode 40), with a sharp increase in the number of RCTs from 2008. The most frequently evaluated intervention was antipsychotic treatment (n = 44, 3006 participants). The journal with the most RCTs was the Journal of Autism and Developmental Disorders (N = 104). Most trials were small in size, emphasising the need for research groups to collaborate to generate higher quality data with greater applicability to clinical practice.
  • The effectiveness of a psychoeducation intervention delivered via WhatsApp for mothers of children with Autism Spectrum Disorder (ASD) in the Kingdom of Saudi Arabia: A randomized controlled trial

    Hemdi, Alyaa; Daley, David (2017)
    BACKGROUND: Mothers of children with autism spectrum disorder (ASD) report high levels of stress and lower levels of well-being than parents of typically developing children. Current interventions for ASD typically focus on working with the child rather than delivering strategies to help support parents. OBJECTIVE: To evaluate the effectiveness of a psychoeducation intervention developed to support mothers of children with ASD in Saudi Arabia. METHOD: Sixty-two mothers (23-52 years) of children (26-78 months) were recruited to a multisite randomized controlled trials of the intervention. The intervention consisted of one face-to-face session (60 min) and four virtual sessions (30 min each) delivered using WhatsApp. Parenting stress was the primary outcome, with secondary outcomes focusing on maternal depression, anxiety, and happiness, and child behaviour problems and ASD symptoms. Data were collected at baseline T1, immediately postintervention T2 and 8-week follow-up T3. RESULTS: One-way analysis of covariance was used at T2 and T3 with T1 scores entered as a covariate. Improvements were found at T2 for stress (F = 234.34, p = .00, and d = -1.52) and depression (F = 195.70, p = .00, and d = -2.14) but not anxiety, and these results were maintained at T3. Changes in child behaviour problems were limited to improvements in hyperactivity at T2 (F = 133.66, p = .00, and d = -1.54). Although changes in stress and depression were statistically significant, change to clinically normal levels was limited to depression. None of the participants had recovered after the intervention (Parent Stress Index Short Form stress scores), whereas 23 mothers (71.87%) in the intervention group had recovered at T2 and 22 (68.75%) at T3 (Hospital Anxiety and Depression Scale depression scores). CONCLUSION: This intervention with WhatsApp support is beneficial but may need to be augmented with other forms of support for mothers of children with ASD including more condensed sessions on stress and interventions targeting anxiety.
  • Substance use disorder in Asperger syndrome: An investigation into the development and maintenance of substance use disorder by individuals with a diagnosis of Asperger syndrome

    Tickle, Anna C.; Gillott, Alinda (2016)
    BACKGROUND: Recent research has suggested that the prevalence of problematic substance use within the Asperger syndrome population has previously been underestimated. Furthermore, there is some indication that problematic substance use might take place to manage the traits of Asperger syndrome; however this possibility has yet to be examined in detail. This study aimed to address this omission by exploring individuals' perceptions of their substance use in relation to their diagnosis of Asperger syndrome. METHODS: Eight participants were recruited from either a specialist Asperger syndrome service or a drug and alcohol service. Participants were interviewed regarding their views of which factors led to their development and maintenance of problematic substance use, specifically in relation to their experience of having been diagnosed with Asperger syndrome. Thematic analysis was conducted on the interview transcripts. RESULTS: Six main themes were identified: self-medication; social facilitation; discrepancy between need and support; defining problematic substance use; substance use of peers, and recreational use of substances. The two themes of social facilitation and self-medication are focused on within this paper as they most closely reflect the more prominent bodies of literature in relation to the research aim. CONCLUSIONS: Participants reported that substances were used to act as a social facilitator to compensate for social deficits by increasing confidence in social settings and increasing participants' ease with which they communicate. The self-medication of psychological distress was reported and was associated with depression, anxiety and sleep difficulties. The study ends with a reflection on the method of data collection, the implications for clinical practice and suggestions for future research.

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