Dr Umar Toseeb Hello, welcome to the Papers Podcast series for the Association for Child and Adolescent Mental Health, or ACAMH for short. I'm Umar Toseeb, Professor of Psychology. My research focuses on special educational needs and mental health in childhood and adolescence. Today, I'll be speaking to the authors of the paper, "Autism Spectrum Social Stories in Schools Trial 2 (ASSSIST-2) a Pragmatic Randomised Controlled Trial of the Social Stories Intervention to Address the Social and Emotional Health of Autistic Children in UK Primary Schools," published in the Child and Adolescent Mental Health Journal. The paper will be the focus of today's podcast. Thank you all for joining me. Shall we go round and have a round of introductions? We'll start with Jane. Dr Jane Blackwell Hi, and first of all, thank you very much for inviting us onto this podcast. We're really pleased to be here today. My name is Jane Blackwell. I'm a Research Fellow based within York Trials Unit at the University of York. I was one of the Trial Co-ordinators working on the study that we're talking about today. My background is in developmental psychology and my PhD was focused on sleep disorders in children and the impact on cognitive function and psychosocial wellbeing. I also have a very strong interest in autism research and I worked on this trial when I joined Barry's team in 2019. Dr Umar Toseeb Thank you. Kerry? Dr Kerry Bell Hi there, I am - I'm Kerry Bell. I'm an Assistant Professor within the York Trials Unit, the Department of Health Sciences at the University of York. My background is also in developmental psychology and I have substantial experience overseeing research within educational settings. So, my research typically centres around child health, education and wellbeing, particularly supported children with additional needs in schools. So, the ASSSIST trial was perfect for me because it ticks all of my boxes. I was one of the Trial Co-ordinators with Jane, and I also joined the project in 2020, so it was partway through when I joined the project. Dr Umar Toseeb Thank you. Emma? Emma Standley Hi there, I'm Emma Standley. I'm a Research Fellow at the York Trials Unit, in the Department of Health Sciences the - at the University of York. I was a Research Assistant on the ASSSIST-2 study and I continue to work in child and adolescent mental health randomised controlled trials. I'm particularly interested in the family wellbeing in families with children with disabilities and additional needs. Dr Umar Toseeb Thank you, and finally, Barry. Professor Barry Wright Oh, hi, thanks for inviting us to do this podcast. My name's Professor Barry Wright. I'm a recently retired Professor of Child Mental Health from the University of York. I also worked in the NHS since 1985 and as a Child Psychiatrist in the NHS for 26 years, in York, as part of a multidisciplinary team, and also services for deaf children. And worked as part of a group that was, in terms of research, that was looking to find much more up-to-date interventions that were child friendly, for children with child mental health problems. And that's part of this research that that came from that, sort of, bank of research. Dr Umar Toseeb Thank you. Let's start with some definitions, so - and the paper is about autism. Do you just want to start with a definition of what autism is and what some of the characteristics of autism look like in childhood? Professor Barry Wright Shall I - I'll kick that one off. So, the question is, what is autism? Well, I guess back in the 30s, there were people like Kanner and Asperger, who first noticed that there were differences in people, neurological and behavioural differences, and began to wonder what this might be. And they both started noting communication differences and some strengths, and together with people like Anni Weiss and Georg Frankl, they began to describe what that might be. And then, the World Health Organization, eventually, and the American Psychiatric Association, picked that up and turned them into diagnoses. I think today, we probably see it much more in terms of neuro-difference, or neurodiversity, and the two main areas, I guess, that people often talk about, which are social differences, so differences in socialisation and learning, social learning and differences in behaviours and interaction with the environment. So, the social differences are, for example, differences in the way that people socialise. So, they tend to choose much smaller functional groups of friendships around activities or interests, rather than large groups of social acquaintances. They have differences in the way of - people with autism have differences in the way that they pick up social information. So, it tends to be - but the social learning is different. Tends to be more cognitive and less intuitive or emotional. They perhaps have some challenges reading social cues, such as prosody, so facial expressions. They, of course, can be very compassionate and creative and they do want friendships, but they may struggle with those kinds of social communication. So, that's one area. The second area is differences in behaviour and interactions, so a liking for structure and routine. Sensory processing differences that mean they may become overwhelmed in environments where there s too much or lots of sensory information. They often have intensely focused interests that keeps them interested and calm. They have a number of strengths. Often, they re very good at attention to detail and pattern recognition and things like that, and I think our group has tended to want to see autism as a neuro-difference, really, in the sense that the World Health Organization tends to talk about deficits in its description of autism spectrum conditions. Whereas we would perhaps try and see them in broader terms and often sometimes quite positive terms, cause there are many strengths that people on the autism spectrum bring to society. So, I think that s a, sort of, a broad encapsulation of autism spectrum conditions or autistic people. Dr Umar Toseeb So, I suppose a follow-up question I have there is, if you re viewing, and your group in your research, views these characteristics of autism as a difference, why then is there a need to intervene and do interventions at the individual level? Professor Barry Wright I think it s a that s a fantastic question. Obviously, our group isn t wanting to change autistic people in the sense of, you know, the interventions aren t trying to make people neurotypical. Now, that would be impossible and not ethical. However, children in schools often get very stressed or anxious or are challenged by the social environment. And I think what this intervention does is it gives autistic children, it gives them social information that they can make use of that can reduce their level of stress and therefore, make them more likely to engage, socially more likely to engage in learning and enjoy their environment, to have fun in their environment, rather than being stressed by it. Dr Umar Toseeb Excellent, thank you and that, kind of, answers the second part of the next question that I was going to ask, but is there evidence that interventions for autistic children work? The I mean, we re going to talk about the one that the paper s about, but in general, on the whole, do autism interventions work? Professor Barry Wright I think obviously, it depends on the goal of the intervention, but a lot of intervention for autistic children can be very helpful, for example, giving parents information about what to expect and what differences children may have, the way they process information differently. I think some of those interventions have been absolutely pivotal in helping children and helping their learning environment as they re growing up in the home, and the same with Teachers. I think equipping Teachers with an understanding of autism and the way that children may perceive the environment or engage with the environment differently is really important. For children themselves, yes, I think trying to help children reduce their levels of anxiety and stress in environments is very important, so changing the educational environment to make it more to make it a calmer and more acceptable and an environment in which a child can learn, that s very important. So, I think, as I said before, the intention of interventions isn t really to turn autistic children into neurotypical children. It is to help them to reduce their levels of stress and anxiety and engage with their environment in a way that is enjoyable for them. Dr Umar Toseeb Thank you, and this paper s about a particular type of Social Story, and I think I first came across Social Stories maybe during the pandemic, when I was hearing about them a lot. But honestly, I never quite understood what Social Stories were and now that I ve read your paper, I understand them a bit more. So, do you just want to tell us what are Social Stories and, like, what are the key ingredients of a Social Story? Professor Barry Wright Social Stories is a broad description that could be anything. So, if somebody writes a story about going to the Dentist, that could be described as a Social Story. Social Stories, in terms of what we re doing, is a trademarked Social Story by a woman from America called Carol Gray, who wrote ten clear criteria for what a Social Story should include within it. The whole point of this piece of research was to test that particular group of Social Stories, because those Social Stories had good qualitative evidence and had some very small studies where they did, you know, a number of children and looked at outcomes. Whereas, this is the first large randomised controlled trial. Dr Jane Blackwell Yes, just to add to that, so the Carol Gray Social Stories are formed based on a specific goal for the child. So, in our study, one of the main elements was to bring together the child s Teacher, who was usually their main class Teacher, their parents and carers, and where possible, the child, to think about an issue that the child may be struggling with and may require more information about to help support them in the school environment. And we found that bringing together this conversation about the child and why they may be struggling with it, and what information they may be missing, was, kind of, a really key ingredient. And parents and carers and the Teachers found it really useful having that opportunity to come together and focus on the child. And as Barry said, these stories are written in a very positive way. They re tailored they re highly tailored to the needs of the child in terms of their attention span, the language they can understand, the types of pictures they would like within them. And so, we were very careful to make sure that this intervention was a very positive experience for the child and that we had gathered all the relevant information from the key people who are involved in the child s care, sometimes including the child themselves, where possible. Dr Umar Toseeb Thank you, and I think you ve and Barry mentioned this a short while ago around the evidence base and that it this particular version of Social Stories was lacking an evidence base. Do you just want to expand on that? Like, what evidence gap are you trying to address in this paper? Professor Barry Wright So, the evidence gap we re trying to address here is that Social Stories, trademarked tro Social Stories, as designed by Carol Gray, have been tested qualitatively and they ve there have been some small case series and small studies, but there s been no large, fully powered, randomised controlled trial, and that s what we ve done. And the other thing that s quite important is that it s a pragmatic trial, so it s happening in the real world, in schools. They re in very large numbers of schools across the North of England. So, the evidence gap is that we don t know whether they work and how and what they might achieve, and that s what we ve been trying to address. Dr Umar Toseeb And that brings us nicely to the methods. So, you ve mentioned that this is a pragmatic trial and you ve explained what that is, but can you just talk us through the rest of the methods? So, what did you do, how many schools were involved and what were the demographics of the participants? Emma Standley I m happy to take that one. So, we used a randomised controlled trial, which is a type of methodology where we look at the effectiveness of an intervention and that s compared through at least two groups. So, one group continues to receive their support and care as usual. So, the Teachers in the schools would continue to deliver the support that they usually would to the children participating in our trial, and that s compared with the Social Stories, where the schools will contin will deliver the Social Stories alongside their usual care, as well. So, the participants get allocated to either group, usually on a computer programme, and that s randomised at a 50% chance of being allocated to one tri one arm or the other. So, we used a cluster randomisation model, where the full school got allocated to either the intervention arm or the control arm. So, all of the children in the schools in the intervention arm were receiving the Social Stories and all of the children in the control arm were continuing with their usual care. So, the schools that were involved in the project, so we had schools across Yorkshire and the Humber. We recruited 249 children and they all had corresponding professionals, so a Teacher and a Interventionist. So, that was 254 Teachers and 192 Interventionists, and they took part across 87 schools across Yorkshire and the Humber. Our inclusion criteria, so we recruited children that were aged four to 11. So, as we ve said about tailoring the stories, you can imagine that that was quite a breadth of different types of stories, with adhering to different understandings and different needs, and so they were four to 11, at primary school. The children had a clinical diagnosis of autism spectrum condition and displayed daily behaviours that challenged, and the parents and guardians had to complete to have a level of English language understanding to be able to complete our outcome measures. The schools that we didn t recruit into the trial were schools that had used Social Stories, so the Carol Gray Social Story method, in the past. So, they d had to have received no training to be involved in the trial, and if they had taken part in our feasibility study, they were excluded, as well. Dr Umar Toseeb Thank you, and what was the outcome that you were interested in? So, I saw in the paper that you had a primary outcome and then a series of secondary outcomes. What were they? Emma Standley So, the main outcome, the primary outcome that we looked at, was the Social Responsiveness Scale 2. So, that was completed by the child s Teacher. The main one that we looked at was at the six months post-randomisation and that measures social difficulties and in particular, social awareness, cognition, communication and behaviour. Alongside that, we looked at a goal-based outcome measure, a couple of other questionnaires looking at social and emotional health, health-related quality of life, classroom attest attendance and parental stress, as well as looking at the associated costs. Dr Umar Toseeb So, you said six months as the outcome measure. That, to me, suggests that either the intervention went on for six months or you ve had the intervention and then you ve had a period of let s see the long-term effects of this. What happens and when and to whom and for how long? Dr Jane Blackwell So, when schools were randomised to the intervention group, Trainers, prior to COVID-19, were able to go into schools and offer Interventionist training in how to write and deliver a Social Story. So, that was Kerry and I and also a previous Child Co-ordinator, and we received training from Professor Barry Wright, who is an expert in autism and Social Stories. So, as part of the training in-person, we would deliver a psychoeducation presentation, which covered, sort of, some basic information about autism and why autistic individuals may be different in terms of their social communication and their understanding. And we actually had some feedback that this was particularly useful for the Interventionists, who may be TAs or SENCOs or classroom Teachers, who may or may not have had training in autism. And it helped them to think about why the children they re supporting may be struggling in the educational environment. So, that was really positive. So, after the psychoeducation element of the presentation, we would move on to talk about the Carol Gray 10 criteria for writing a Social Story. We would think about the goal that had been set for that individual child and we would support the Interventionist to start forming a story, which would start would have like a normal story, would have an introduction, a middle and an end. The introduction would also would always celebrate the child and be really positive, so it was something that the child would want to read. The middle would, kind of, narrow down to the specific challenge the child was facing, and then there would be maybe one or two what we call coaching sentences , which gently guide the child with something that they may be struggling with. But we never set up the child to fail. So, in terms of a coaching sentence, you might say, I will try to tell my Teacher how I m feeling when I m upset, but we would never say, I must tell my Teacher how I m feeling when I m upset. And we would add a lot of social context to why they might be feeling upset, that it s okay to feel like this and that others feel like that - this too. And then, we would put in some perspective sentences about how they may feel if they d managed to achieve their goal of telling their Teacher how they feel and how others may feel. So, we might bring in how mum and dad would feel or how the Teachers would feel and we might talk about rewards or celebrations for working towards this goal. At the end of the Social Stories training session, the Interventionists would go away and they would personalise the story with photos, maybe of the child s specific classroom or things that the child really likes, so their favourite thing on TV or their favourite subject. And then, after that, the stories would be submitted to the Research Team and we would ensure that they met the Carol Gray 10 criteria before they were implemented with the child. So, we checked that all the language was positive, that it was tailored to the understanding level of the child and that there was nothing negative in there, before delivery. The Interventionists were then asked to deliver the intervention at least six times over four weeks and they were asked to record these sessions in a session record log. This would record how long the session was, were there any problems in the session that they needed to report? And any other information that would be useful to the Research Team. So, that was the model prior to COVID-19. During COVID-19, the elements were still the same, but it moved to an online virtual model, where Interventionists would watch the training presentation in advance of a live meeting with the Trainers to write individual stories for the children. Dr Umar Toseeb Thank you. So, that s it seems like a very personalised intervention, which I think we re I m going to pick up on later on, but let s get to the findings. What did you find? Dr Kerry Bell Yes, so I can go over that. If I summarise all of the main findings first and then maybe we can touch on why we think that we found what we found and some of the challenges that we faced during the trial. Because as Jane has alluded to there, the trial took place during the COVID-9 [means COVID-19] pandemic and as you can imagine, that had significant impact on the trial. So, in terms of our primary outcome, the Social Responsiveness Scale 2, after six months, a reduction of 1.61 points was found on the scale for children in the intervention group. So, although the effect was in the right direction, so a reduction in points is indicative of fewer challenges, this fell short of the three-point difference that we assumed that we might achieve at the outset of the trial, and the result did not reach statistical significance. So, we can t be sure that the result wasn t due to chance, but it is in the right direction, so that is positive. In terms of the secondary outcomes that Emma outlined earlier, no statistically significant differences were found in terms of overall symptoms of anxiety or depression, parental stress or general health. However, we did find an increase in the frequency that children who received Social Stories were able to meet their behavioural goal that was set at the outset of the trial, that the story was based around, compare to children who received usual care alone. And this was a statistically significant finding, so that s really positive. In terms of the cost, two types of costs were explored in this analysis, so the cost of delivering the intervention and then the service use cost for the participating children. These were collected from both parents, carers and Teachers. So, we were able to look at costs both inside the school and outside the school, as well. So, the actual intervention we found can be delivered at a relatively low cost per child. So, we estimated this to be around 15 per session. This cost was largely driven by the cost of training, which is a, sort of, frontloaded cost. If we break that down and look at the just the cost of delivering a session, this was closer to around 3 per session, which is quite a cheap intervention. So, over time, the more children an Interventionist is able to deliver the Social Stories intervention to, the, sort of, cheaper it becomes per child within that setting. So, the economic evaluation that we conducted showed that compared to usual care, the Social Stories intervention decreased service use cost, both inside school and outside school. So, children had fewer community-based services, hospital-based services and medication costs. So, they also incurred less costs in school-based services, so less School Nurse visit less visits with the Educational Psychologist and required less one-to-one support from Teachers and staff, which is, obviously, a really positive finding for schools because that can be quite a time intensive and costly thing. So, although there were no QALY differences, so the Quality-Adjusted Life Years, the potential resource use savings could mean that the intervention is considered cost effective. So, they re the, sort of, headline results, so a bit of a mixed bag of chips there, really. But as we mentioned, it would be unjust to discuss the findings without touching upon the context of the pandemic that we conducted the trial within. Analyses were all conducted under the principles of intention-to-treat, which means that participants were analysed according to how they were randomised. So, children allocated to the intervention group were analysed within that group regardless of whether or not they ultimately received the intervention. And we found that because of COVID, a lot of children either didn t receive the intervention at all, or received a very, sort of, shortened version. So, we had a couple of children who d literally just started, they maybe had one session and then, the school shut, so that was the, sort that was the end for them. So, that, obviously, has a massive impact in terms of the data that we received. So, schools obviously closed and the trial grounds to a complete halt and as Jane outlined earlier, we had to make some significant changes in terms of the training model and how we collected data and the timelines. So many things had to change because of the pandemic and then this new, sort of, world that we were trying to run this research in. So, in light of all of the changes and things that we d made, we conducted some exploratory analyses to look at the effect of COVID and the effect of compliance and how this may have impacted the results that we found. And all of these exploratory analyses that we did seemed to support the idea that we probably would ve seen a larger effect size if the trial had been delivered as intended. So, if we look just at those children who received the intervention as they should ve done, or received it prior to the COVID lockdown, we found much greater effect sizes. So, it s important to keep that in mind when we re thinking about what this trial means and what the implications are for the educational professionals, because it s really difficult for us to draw firm conclusions because of all the uncertainty that COVID brought into the data that we had. Dr Umar Toseeb Thank you. I suppose I ve got two follow-up questions. The first is, if the intervention, or the Social Story, was tailored to each child s needs and goals, could it then be that the reason why you haven t found an effect, if you look at it overall with the intention-to-treat version, is because people s the outcomes that the intervention targets is different for each child and actually, you ve used one broad measure? So, it might be that the intervention is working for these children, but the outcome measure that you have is not sensitive enough to capture the different types of needs that you ve intervened in. Professor Barry Wright Yeah, and I ll pick that up. I think that s a really, really important point. We spent probably about 15 months before we were funded, having a discussion with the funder about the out the main outcome measure. We had really wanted it to be a goal-based outcome measure from the outset, because we felt that that s much more specific. Because we were writing a story with a social and emotional goal, we felt a goal-based outcome measure would measure that. The funder was very, very keen that we had a broader based, social skills based, outcome measure that had a lot of validation in autistic children. And we at one point, we were arguing, Well, can we have two main outcome measures? But the funder didn t like that and, you know, in randomised controlled trials from the National Institute for Health Research, they tend to like one key main outcome measure because they feel that s honest, which I agree with. So, we slipped it in to become a secondary outcome measure, but it was always the one that certainly I was most interested in, because it was the one you know, and you re absolutely right. If you re divining in a if you re designing a specialised, tailored intervention for a child that s focused around a social/emotional goal, you ve got to be able to measure that and that s got to be the thing you re really interested in. And that was the thing that was statistically significantly different, even though the intervention was diluted by COVID, really. And I think the other thing that s really important to mention is that Social Stories in the real world, when you re using them, they don t have to be just one story and then you stop and you never do another Social Story. You can build on them. You can write one Social Story around a particular social misunderstanding that a child has and they grasp that, but there may be other bits of social information they need, and you may give them that social information through a whole series, a whole sequence of Social Stories that build on each other. So, I think whilst we weren t able to do that because of the way the study was designed and the funding, that would be probably something to do in another study in the future. And we certainly believe that that s the way forward in terms of how you use the intervention. Dr Umar Toseeb Thank you, and I suppose my second follow-up question is, kind of, related and it might the answer might be the same. Which is, let s just assume that the effect the null effect, as in the fact that you didn t find an effect, let s just assume that s the true effect, or the true no effect or the true finding. It s interesting that service use in other areas was down, and which to me suggests that either the intervention is having an effect and just not measured, and that and which is what we ve talked about, or there s something about the perception of it being helpful that s then reducing interactions with other services. I just wondered what your thoughts were on that. Like, what does that mean? What does that finding mean, the part about the reduced service use costs? Professor Barry Wright Well, I d I mean, I m happy for anybody else to answer that, but I think that s a difficult question because there are so many children involved. One of when we tried to as Kerry described, we tried to, sort of, unpick it a bit by doing a range of sensitivity analyses and looking more closely at the data. It s only a relatively small number of children, but there were less admissions to hospital, for example. And it does feel like, even though the intervention is designed to give social and emotional information and reduce anxiety in children on the autistic spectrum, it also probably reduces concerns and anxieties of Teachers and parents, too. And that can make people around the child calmer and perhaps because everybody s calmer, you need less intervention. You re less likely to call in the Educational Psychologist or refer them to the Child Psychiatrist or for additional help. So, we don t fully know, but we assume that that s what s going on. We think that that s what s going on. The other thing that s really important, Jane gave a really lovely description of the intervention and how it has to be positive. I think sometimes there s a temptation for people to think of Social Stories as a way of telling children what to do, and that isn t at all what it s about, and Jane described that beautifully. They are written in a very positive and patient tone and they re written for the child. But the other thing that they do is they require parents and Teachers, and the children, where possible, to come together and talk about what s going on and talk about why is the child becoming distressed and what does the child need? And that, in itself, is a very powerful part of the intervention, because it enables people to think about and focus on the child s needs, and that isn t always the case when parents and Teachers are very busy and, you know, they perhaps aren t doing that. So, I think that that s a really that s another really important part of the intention. Dr Umar Toseeb Thank you, and I suppose the next part of the question links to what you ve said already, this is about what are the implications of what you ve found, for educational professionals? What does this all this mean for them? Cause as for me, if there s a if the finding was this definitely works, then I think it d be a bit more clearer, but what we re saying is this potentially works, but there are a number of reasons why we probably didn t find that effect. So, what does that mean for people on the ground? Dr Kerry Bell So, I think one of the important things to bear in mind here is that Social Stories are already frequently used as a means of supporting autistic children within primary schools and they are already recommended by the National Autistic Society. So, educational professionals were already using these before we conducted this research and will probably continue to use these regardless of what we found. Because of the challenges that we faced and the uncertainty that was in the data, we can t get up on a pedestal and say absolutely educational professionals should be using these Social Stories to improve social skills in autistic children. However, positive benefits were seen in terms of the individual goals and broader skills. The potential cost savings that were evident were also very attractive. And we found some, you know, additional unexpected things via the process evaluation in terms of staff finding them, like, a really useful vehicle for opening dialogue with children and talking about difficult topics in a way that s really accessible for the child. So, we re talking about a story in a really, sort of, positive way, rather than, you know, sitting a child down and trying to have to have this, sort of, really difficult nitty-gritty conversation. So, I think maybe it would be useful here if Emma comes in a little bit and talks a bit about the process evaluation and some of the things that we picked out of that. Emma Standley Yeah, thank you, Kerry. So, we conducted the process evaluation with parents, educational professionals and the Research Team, as well. So, we found quite a lot of positive findings from that. So, we found that educational professionals in particular, really enjoyed using the Social Stories. They felt that they were gaining a lot of knowledge about the children that they were working with, a better understanding of what autism is and understanding the child and their needs. We found quite a lot of practical considerations for if schools like Kerry says, we know that schools will probably continue to use Social Stories anyway. In our process evaluation paper that we re aiming to publish this year, we outlined some practical considerations based on what educational professionals said, which includes things like having a Social Stories Champion in the school. So, identifying someone that will maintain training and upkeep and that other staff can go to for advice and making sure that the Social Story is in line with the Carol Gray criteria and that kind of thing. Another couple of things that came out was having a quiet, safe space, for the Social Story to be read to the child. So, again, like we ve been saying, it s a tool for facilitating conversation. It s not just, sort of, sitting down and reading it. It s allowing the child to chip in and talk about how certain situations make them feel, and that creates that safe space to be able to do that. Having protected time, which we know is always important, but difficult to get in schools. So, allowing Teachers and Teaching Assistants to have that protected time to write the story, to really consider the underlying reasons for the child s challenges and difficulties and getting to the bottom of that in a Social Story, and then having some allocated, but flexible, time to be able to deliver that. So, there s quite a lot of considerations that schools might find beneficial from the findings that we got. Dr Umar Toseeb What should we expect from you guys in this space? Have you got anything else coming up that we should look out for? Professor Barry Wright I think one of the main things we ve been trying to focus on, and in an environment where money s been very tight since, you know I don t know, going back to 2008, for child mental health, it s been a really difficult climate. And also the number of interventions for children with child mental health problems tends to be relatively small, so and they tend to be often focused around what works in adults, like medication and sitting in a room talking to somebody. But a lot of children don t really want to sit down and talk to somebody. So, our whole raison d tre has been to try and find interventions that are child friendly and child-oriented and can be delivered at lower cost, perhaps, so that they re not that they re cheap, but they can you know, they re not very expensive. So, things like using arts and nature and we ve done a randomised controlled trial of Lego-based therapy. And things like social prescribing, behavioural activation, activity scheduling, you know, ena enga helping children engage in things that they enjoy doing, as mechanisms for interventions to help children with anxiety or low mood, or other child mental health problems. So, those are the things we re interested in, and Kerry may want to add some of the stuff around educational research, cause there s a lot more now going on in this space, which is really wonderful to see. Dr Kerry Bell Yeah, I mean, we so, Emma, Jane and I are all working on a new study together, which is also an NIHR funded research project, and it s not focused on autism, it s focused on children with profound and multiple learning disabilities. So, it s looking at intensive interaction as an as a means to improve their social comm - skills and allowing them to communicate better with their, sort of, caregivers. So, that s really exciting, and I know that Jane and Emma have been working on other projects, as well. Emma Standley Yeah, so, behavioural activation was mentioned by you there, Barry, so I m working on a couple of behavioural activation studies with adolescents who struggle with depression. So, one study is the ComBAT trial, which is based in communities and schools, that s delivering behavioural activation in those settings. And then, the BAY trial as well, which is based in CAMHS, and that s for moderate to severe depression, again, looking at activity scheduling and benefiting from engaging in activities that young people enjoy and then trying to improve low mood. Dr Umar Toseeb Thank you, and then finally, do you have a take home message for our listeners? Professor Barry Wright I d say Social Stories aren t a panacea, but they are a very helpful tool in the armoury for autistic children. But I think a lot of the stuff that everybody s put spoken about, but Jane spoke about, is the intervention is very cleverly and carefully designed so that it s, you know, it s not just as simple as writing a story. It involves people and thinking about the child. It s got a clear social and emotional goal. It seeks to understand what, when, where, why and how the child is struggling with social information. It s tailored to the child, positive and kind. It s a kind intervention. You can review and refine it and, you know, it s just a nice intervention. Children enjoy it, parents and Teachers enjoy it and it s relatively low cost. So and we would say it is helpful for some children and it should be in the armoury for autistic children, of interventions that might be helpful. Dr Umar Toseeb Thank you, so, a very nice note to end on. So, thank you all for taking the time to speak to me. That s been a really nice conversation. 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