This initial idea was discounted due to the limited relevant and up-to-date research available. The risk of unintentional bias is high due to personal lived experience. Lived experience can prove invaluable in qualitative studies, but only if there is no bias or triggers for the researcher or the participants, as this can become unethical (Sanjari et al.,2014).

See Appendix 1 for a definition of Synaptic Pruning.

Many papers cite disrupted synaptic patterns as abnormal. However, the word abnormal was taken out of the question as it suggests something wrong with a person’s brain. This could be distressing for an affected person to read and could lead to the researcher inadvertently writing with an unintentional bias (Machi & McEvoy, 2016).

After further research, the question became, Can stress in infancy affect synaptic pruning and lead to autism in children and adolescents?

Ethics in Research are guidelines a researcher must follow to prevent harm to anyone participating in the study or the researcher (Halej, 2017). For instance, participants must have all the information about the study, including any risks to them and their well-being. The researchers must obtain informed consent from all participants before proceeding (University of Oxford, 2021). Taking this into account, even though a biological theme is present in the study, it would be unethical to conduct an MRI scan on a child or an infant presenting with autistic traits as they cannot give informed consent (Mezinska et al., 2021).

Transparency is essential as informed consent cannot be obtained if a participant is unaware of certain parts of the study, for instance, if the person is being recorded without their consent or knowledge. Not only does this damage the relationship between the researcher and the participant, but it will make any evidence unreliable. Trust is crucial for both parties to enable honest responses to questions (Malicki et al., 2023). Confidentiality is crucial to protecting participants' data (Kaiser, 2009).

Characteristics of autism include but are not limited to;

1.  Challenges with verbal and non-verbal communication.

2.  Difficulties reading social cues and challenges understanding or empathizing with others' thoughts and feelings.

3.  Becoming overwhelmed by bright lights, busy situations, and loud noises.

4.  Repetitive behaviours.

    5. Anxiety about unfamiliar situations or people (NHS, 2022).

Autism is different for every child. Some children may struggle with repetitive behaviours, while others may struggle with communication difficulties (Da Conceicao, 2017). These varying aspects are why autism is considered a spectrum disorder, as it manifests in many different severities and symptoms (NHS Inform, 2024). There are no specific medications for autism, but some children take medicines that help with anxiety and hyperactivity. These include antipsychotic medication such as Risperidone or Clozapine. A study in 2012 showed that 56% of children with autism take these medicines (Arky, 2024). Whilst these can lessen the mentioned symptoms, they can come with unpleasant side effects such as fatigue, stomach upset, nausea and constipation. For a child already overwhelmed, these effects could add to their distress (NHS, 2021). A 2012 drug trial on mice showed promising results for Rapamycin. This medication reversed disrupted synaptic patterns and resolved most of the traits of autism. Still, this drug has only been proven to work when the symptoms have become problematic (Sato, 2012). This research aims to intervene before symptoms become problematic by providing early psychosocial interventions for children who have faced trauma or stress in infancy. (Kotajima-Murakai et al., 2019;Autism Speaks, 2023). Linking disrupted synaptic pruning with autistic traits would provide scope for further research into different medicines.

Currently, children with autism can face severe challenges in school. This can be attributed to schools' strict academic targets, insufficient funding, and inadequate training (Mahajan, 2022). This can lead to children facing barriers to education as they are expected to perform alongside neurotypical children. This can lead to a child becoming overwhelmed and exhibiting undesired behaviours such as shouting, becoming destructive, screaming, crying or even violent outbursts if sensory overload continues (Aheidel, 2023). Children can then face punishment, bullying from peers and stigma. If teachers had adequate autism training, this could be avoided (National Autistic Society, 2024). If more research and education were available on triggers and reactions, policies could be implemented to serve children with Special Educational Needs (SEN) better. Again, if a link between stress and disrupted synaptic patterns could be proven, early interventions could help a child before these undesired behaviours are exhibited.

This literature review delves into potential associations between early life stress, disrupted synaptic pruning, and the emergence of autistic traits during childhood and adolescence. Initial findings suggest correlations between delayed or ineffective synaptic pruning and autistic traits prevalent throughout childhood and adolescence (Sakai, 2020; Tang et al.,2014; Fluery & Kemper, 2022). Moreover, this review aims to highlight gaps in existing literature, providing opportunities for further research and changes in current policies and procedures. Updating outdated policies and procedures could empower children and their caregivers while informing teachers and care practitioners on the best ways to approach and help children with SEN (Fluery & Kemper, 2022).

Several scholarly articles will be scrutinised using a data matrix (See Appendix 2) to evaluate research methodologies, derive themes, and identify existing research gaps. This evaluation will include four quantitative studies, three qualitative studies, and two mixed methods studies, ensuring a balanced analysis of these studies (Snyder, 2019).

This review explores potential causes of disrupted synaptic pruning, indicating that emerging research points to early life stress, maternal infections, and trauma at birth or infancy as potential causes (Weir, 2012;Silva, 2018;Bolton et al., 2022). This points towards biological and environmental factors in the development of autism (Bolton et al., 2022).

Historically, and even presently, children with undiagnosed or diagnosed autism are often labelled as naughty, attention-seeking and uncontrollable. This labelling is more prevalent in lower socioeconomic areas with limited access to diagnostic resources (Adams, 2023;Roman-Urrestarazu et al., 2021). These disparities highlight an urgent need to address health inequalities and enhance diagnostic measures in these areas to combat misdiagnosis and stigma. Back In the 1960s, children with these types of behaviours, such as trouble with social difficulties and problems with communication, were attributed to the child having an insecure attachment type (Bowlby, 1969). This theory places unwarranted blame on the mother (See Appendix 3 for detailed analysis). If the proposed links can be proven, this theory could be proven to be outdated. Unfortunately, this way of thinking is still prevalent today, with many people blaming the parents, especially mothers, for their children's autistic behaviours (Hollingsworth et al., 2023).

Approximately 70% of children with SEN attend mainstream schools, which can add even more adversity (Autism Education Trust, 2023). Children with autism can suffer from problems with communication, lack of social skills, and repetitive behaviours, with some relying on strict routines to avoid becoming overwhelmed (Center for Disease Control and Prevention, 2023;NHS, 2023). When a child does become overwhelmed, they can exhibit unwanted behaviours such as screaming, shouting, and crying. They may suffer violent outbursts, leading to punishments by untrained staff members, bullying from peers and further social withdrawal. Other parents can also stigmatise the child’s family if they are perceived as unable to control their child (Selman et al., 2017;Health Research Authority, 2023).

In the United Kingdom (UK), schools are expected to provide the first £6,000 out of their budget per child with SEN (York Sendiass, 2023). With 166,041 autistic children in schools around the UK, this amounts to just under £1 million schools must find annually (Autism Education Trust, 2023;Selman et al., 2017;Health Research Authority, 2023). Establishing a potential link between disrupted synaptic pruning and autism development provides an opportunity to optimize early psychosocial interventions. This could lead to an opportunity to explore pharmaceutical treatments that work on the synapses to help alleviate a child's symptoms (WHO, 2023;Autism Speaks, 2023). There has been evidence that the medicine Rapamycin reverses ineffective synaptic pruning and eliminates the social difficulties of autism in adult mice; the repetitive behaviours, however, persisted (Autism Speaks, 2023). Although mice share 92% of DNA with humans and share some identical genes, their genes and cells function in different ways which is why 90% of drugs tested and proven in animals do not make it to human trials (Zimmerman & Zucker, 2020;Magee, 2023).

In 2014, a study was published that aimed to prove that children with an autism diagnosis had far more synapses than a neurotypical child (Tang et al., 2014:Columbia University, 2014). This was a relatively small study given the limited number of specimens, but due to the way results were derived using numbers, measurements, and formulas, this was carried out using a quantitative methodology. No wider determinants were considered, such as early life adversity, socioeconomic status, and experiences (Denscombe, 2017). The study also took place on post-mortem brains. Whilst studies on post-mortem brains can be beneficial in recognising factors such as synaptic patterns, it is crucial to recognise that post-mortem tissue is not the same as living tissues, and these samples have often been subject to treatments with chemicals to freeze and preserve them, which could affect the validity (Stan et al., 2006).

Other papers use a qualitative approach through observational methods. Unlike quantitative studies, these methods examine socioeconomic status, genetics, immune system issues and life experiences. They seek to gain a deep understanding of factors that can lead to excess synapses. They do this by carrying out ethnographical studies, which involve a researcher immersing themselves into a person's life to seek out a well-rounded and comprehensive understanding of specific themes that arise within these studies. These include the immune system, early life adversity, and genetic predispositions (Aylward et al., 2021:Autism Speaks, 2023:Weir, 2012). Qualitative research does have a few drawbacks as it requires the researcher to be involved directly in a person's life. This may cause the researcher to develop a bias toward the people in the study. Because this methodology works by developing trust and rapport with people, ethical guidelines must be strictly adhered to avoid psychological harm to people in the study (Khankeh et al., 2015).

In conclusion, by examining different perspectives and evidence, this review aims to advance the understanding of the relationship between the themes mentioned (age, trauma, immune system, and synaptic pruning) and altered patterns of synaptic pruning. The knowledge gained can inform early interventions that empower children and their families/caregivers. Gaps in literature, such as the prevalence of misdiagnosis in deprived areas, warrant further research to ensure these children do not fall through the gaps.

For this project, an ethnographic study, a type of qualitative research, will be conducted. Ethnographical studies allow researchers to immerse themselves in participants' everyday lives (Allen, 2017). This approach aims to gain a comprehensive understanding of the daily functioning of parents and children with autistic traits, including the discrimination and stigma they may face (Turnock et al., 2022).

While quantitative research could provide valuable insights, a smaller sample will be studied here. In quantitative studies, the impersonal and structured questions may inhibit honesty among the participants; this could affect the credibility of a quantitative approach (Weller et al., 2018) By conducting face-to-face interviews, the researcher can ask semi-structured questions, which allows for a person to respond with as much or as little information as they are comfortable with. This could help build trust and rapport with the interviewer.

Participants will be selected by gathering data from primary schools in the North Yorkshire region (See Appendix 6 for an initial timeline of this study). Families identified with children who have a diagnosis or are awaiting an assessment for autism will receive a letter explaining the research and inviting them to take part. The school will distribute the letters to protect the addresses and confidentiality of the potential participants.

The researchers ' contact details will be provided on the invites for people to enquire. This initial phase will be carried out over 2 months to give people ample time to determine whether or not they wish to participate (UK Research and Innovation, 2021). After this, the participants who want to participate will be contacted by providing their contact details or through the school, and they will be invited to an initial focus group (See Appendix 5 for a sample letter). Provisions for childcare will made available for children with autistic traits. Understanding that routine is often essential, appointments will be conducted consistently to minimize distress (NHS, 2022).

The initial focus groups aim to recognise any links between ACEs, trauma, or problems in pregnancy with autistic traits in the children. Given the sensitivity of these discussions, questions will be worded emphatically, and counselling will be available for any participants who may become distressed (Iphofen, n.d.).

John Bowlby (1907-1990) proposed a theory in 1958 that maternal deprivation can affect how a child attaches themselves to those around them. Bowlby (1958) proposed that an infant needs a maternal figure through the ages of 6-30 months. Failure to establish this bond with a mother or the disruption of an existing attachment could result in severe and irreversible damage to a child's emotional, social and cognitive development. A child with an insecure attachment type can exhibit traits consistent with autism, such as social difficulties, avoiding contact with people and challenges controlling their emotions (Tizard, 2009). Bowlby's theory emphasises the significance of a secure and loving environment and its effect on a child's development. However, this theory overlooks the role of other caregivers and environmental factors. Bowlby (1958) places the blame for developmental difficulties entirely on the mother, discounting any reasons for maternal absence or neglect (Cardwell & Flanagan, 2015).

This theory intersects with disrupted synaptic pruning as it identifies the same critical development period; synaptic pruning is most prevalent between 18 months and 2 years. There is also a similarity in that both concepts state that stressful events can affect development, whether that is maternal deprivation or trauma at birth. Synaptic pruning focuses on the biological development of the brain with the added stresses of adequate caregiving, maternal infections or stresses (Sakai, 2020).

Analyzing Bowlby's theory of maternal deprivation and synaptic pruning provides valuable insights into the effects of social experiences and neurobiological processes on child development. While his theory has deepened the understanding of attachments, caregiving, and their impact on growth, new and ongoing research is needed to address the interconnected social and biological processes of early childhood experiences and their implications for health and well-being (Barnes et al., 2018).

Dear Participant,

I am writing to invite you to participate in a research study on synaptic pruning and autism. This study aims to ascertain if there are any links between premature or late synaptic pruning and autism.

If you choose to go ahead with this project, please be aware that some of the data collection, such as interviews and questionnaires, may be sensitive. If at any time you feel distressed, please let the person carrying out the interview know, and the interview will be stopped, and appropriate support will be arranged for you. Please see the end of this letter for agencies that can help with mental well-being.

The study will run for approximately 12 months. Participation in this study is entirely voluntary, and you can withdraw your consent at any time during the study. If you choose to withdraw from this study, any information collected from you will be destroyed.

Any information acquired from you will be kept strictly confidential, and any personal information, such as names, will be replaced with pseudonyms to ensure absolute confidentiality.

If you have any concerns about this study, please do not hesitate to contact Dr Fiona George at 07689942002 or Fiona.George@gmail.com. Mental health support is available at Hull & East Yorkshire MIND at 01482 489766. If you do not feel comfortable reaching out yourself, please let the researcher know, and support will be put in place for you.

By signing this letter, you confirm that you understand the information outlined in this letter and consent to participate in this study voluntarily.

Signature:

Printed Name:

Date:

(Fraizer, 2023;Curran et al., 2018).

1.  To explore the relationship between early life stresses and altered patterns of synaptic pruning. These stresses can include but are not limited to maternal infections in pregnancy, outside influences such as adverse childhood events (ACEs) and factors such as the broader determinants of health, for example, low socioeconomic status or health problems in infancy and altered patterns of synaptic pruning (Hoover & Kaufman, 2018).

2.  To ascertain if early life stresses can disrupt the immune system and, if so, can the immune system alter the synapse patterns (Krystal et al., 2017).

3.  To find out if it is possible to predict autistic traits and the severity in children who have been exposed to trauma in early life and if this can be proved, find a way to help those children by working on strengthening synaptic pathways that have been disrupted (Halperin & Healey, 2011).

This type of research is used to examine amounts; for instance, a method here would be a survey sent out to a whole community. The results would then be analysed in potentially large generalised quantities (St. Petersburg College, 2022).

Quantitative research could be potentially helpful in this research project as a small sample is needed, but this could be achieved by sending out surveys or questionnaires to narrow down people diagnosed with autism in certain areas. This numerical data could then be used to run focus groups with a small sample size (Watson, 2015).

This methodology, whilst sometimes helpful, could also prove difficult as it relies on people being honest. It also can discount diversity, ethical issues, and bias. Some of the questions that need to be answered could be triggering or too intrusive for some people, and with quantitative research, these ethical issues may be missed (Watson, 2015).

Qualitative Research

Unlike quantitative research, qualitative research is used on a larger sample. This aims to grasp a deep and rich understanding of participants' experiences within their everyday contexts (Denscombe, 2017). Qualitative researchers can gather data by immersing themselves in the lived experiences of individuals. They achieve this by observing participants as they go about their everyday lives. By doing this, they gain invaluable insights, which could not be achieved with quantitative research as people can act differently if they feel pressured or fill out a questionnaire in a rush. This could make the data inaccurate (UK Research and Innovation, 2024). In this project, an Ethnographic study would be most beneficial. Ethnographical studies are a type of qualitative research. This methodology uses unstructured interviews, focus groups, observations, and journal-keeping. By doing this type of study, researchers can also observe participants' mental well-being and tailor questions not to upset or trigger a person, they can also respond quickly and effectively to any ethical issues that may arise (Office for Health Improvement and Disparities, 2020;Fomby & Sastray, 2019). A consent letter must be filled out to ensure participants know this study may be triggering and upsetting. This letter will include numbers of organisations to call if they need any help, and also, they will have the right to pull out at any time in the study.

Mixed Methods

This consists of a researcher using qualitative and quantitative methods to gather and analyse data. This methodology could answer questions that qualitative and quantitative methods could not answer solely. For example, for a question that asks for an extensive study of children with autism, quantitative research could be used here as an initial questionnaire. Then, qualitative research could be used to conduct focus groups. The process of mixing two different methods could prove too complex and too time-consuming. It can, however, help narrow down large samples to a more focused group ( Shorten & Smith, 2017).

Semi-structured interviews will collect data by inviting people to share their experiences. The questions will be open-ended so the person can choose how much information they want to give. This can help build rapport and trust with the researchers. Again, the questionnaires used in these interviews will be numbered instead of named. This data will be password-protected in an electronic spreadsheet to ensure confidentiality (Office for Health Improvement and Disparities, 2020:Kaiser, 2009). Focus groups will also be used. These groups will take place weekly, and teachers, children, and caregivers will be invited to these sessions to comprehensively understand each individual's different challenges (O.Nyumba et al., 2018). These group sessions will be voluntary, and a moderator will attend to guide the conversations to minimise the risks of distress or heated discussion (Pickering & Watts, 2016).

A helpful software package for Qualitative data is NVivo. This software allows the input of different data formats, such as video files, interviews, audio files, and spreadsheets (University of Cambridge, 2024). This is useful as qualitative studies use several different tools to collect data. Once the data is put into this software, it can be used to identify themes by coding. This means highlighting words that appear throughout the data set. This helps the researcher identify patterns and themes for thematic analysis (University of Surrey, 2023). This software is also helpful for mixed methods as it allows several different data formats, such as questionnaires and interviews, to be put in and analysed alongside data tools such as focus groups (Dhakal, 2022). Although this could be useful here, Nvivo is a very complex software, and a user needs a good level of familiarity with it to use it effectively. This can be highly time-consuming. It is also costly, with an annual licence costing £986.56 (Capterra, 2024).

Manual thematic analysis is the preferred method for this study, given the costs and training needed to use NVivo. It also allows the researcher to adapt their approach to the unique characteristics of each set of data (Naeem et al., 2023). To analyse evidence of a link between disrupted synaptic pruning and autistic traits, themes must be identified and analysed to identify patterns and correlations with adverse life events (Braun & Clarke, 2014). Once all the data is collected, the researcher must familiarise themselves with it by reading, listening, and using visual aids numerous times. This can assist with spotting errors, duplications, or incomplete data. This familiarity can also help the user notice certain consistently used words. For instance, words such as stress, ACEs, Autism, age, and immune system are themes that will be looked for (Coates et al., 2021). Once this initial analysis has been conducted, it would be helpful to make a data matrix to assist in noticing patterns, similarities, and themes. Once all the data has been coded and reviewed, the themes will be applied back to the research question (Nowell et al., 2017). Finally, the findings will be written up. For instance, a narrative of each theme will be written and linked back to the data. These findings will be added to existing literature, highlighting gaps and the need for further research (Damyanov, 2023).

Recommendations

Better education and training for teachers/carers/parents to recognise signs of stress, developmental difficulties and early interventions for children who have suffered early life stressors.

Further research into this subject should be encouraged as the more research, the more funding will be available for studies and to inform training and education on this subject.

Changes to policies at government levels to improve support and inclusive educational practices for autistic children and their families. This could include making more funds available for schools, training, and education.

Education for the wider public on the potential link between early life stress, disrupted synaptic pruning and the manifestation of autistic traits.

Many papers cite that the disruption of the synaptic pruning process is abnormal (Bolton et al.,2022;Sakai, 2020;University of Cambridge, 2023;Weir 2012).

Allen, M. (2017). The SAGE Encyclopedia of Communication Research Methods. SAGE Publications, Inc. https://doi.org/10.4135/9781483381411

Arky, B. (2024). Autism and Medication. https://childmind.org/article/autism-and-medication/

Autism Education Trust. (2023). National Autistic Society Education Report. https://www.autismeducationtrust.org.uk/resources/national-autistic-society-education-report

Autism Speaks. (2023). Brain Study Finds Evidence that Autism Involves Too Many Synapses. https://www.autismspeaks.org/science-news/brain-study-finds-evidence-autism-involves-too-many-synapses

Aylward, B. S., Gal-Szabo, D. E., & Taraman, S. (2021). Racial, Ethnic, and Sociodemographic Disparities in Diagnosis of Children with Autism Spectrum Disorder. Journal of developmental and behavioral pediatrics : JDBP, 42(8), 682–689. https://doi.org/10.1097/DBP.0000000000000996

Barnes, G. L., Woolgar, M., Beckwith, H., & Duschinsky, R. (2018). John Bowlby and contemporary issues of clinical diagnosis. Attachment (London, England), 12(1), 35. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6287705/

Boksa P. (2012). Abnormal synaptic pruning in schizophrenia: Urban myth or reality?. Journal of psychiatry & neuroscience : JPN, 37(2), 75–77. https://doi.org/10.1503/jpn.120007

Bolton, J. L., Short, A. K., Othy, S., Kooiker, C. L., Shao, M., Gunn, B. G., Beck, J., Bai, X., Law, S. M., Savage, J. C., Lambert, J. J., Belelli, D., Tremblay, M. È., Cahalan, M. D., & Baram, T. Z. (2022). Early stress-induced impaired microglial pruning of excitatory synapses on immature CRH-expressing neurons provokes aberrant adult stress responses. Cell reports, 38(13), 110600. https://doi.org/10.1016/j.celrep.2022.110600

Braun, V., & Clarke, V. (2014). What can “thematic analysis” offer health and wellbeing researchers? International Journal of Qualitative Studies on Health and Well-Being, 9. https://doi.org/10.3402/qhw.v9.26152

Calman, L., Brunton, L., & Molassiotis, A. (2013). Developing longitudinal qualitative designs: Lessons learned and recommendations for health services research. BMC Medical Research Methodology, 13(14). https://doi.org/10.1186/1471-2288-13-14

Cancer Research UK. (2022). How long a new drug takes to go through clinical trials. https://www.cancerresearchuk.org/about-cancer/find-a-clinical-trial/how-clinical-trials-are-planned-and-organised/how-long-it-takes-for-a-new-drug-to-go-through-clinical-trials

Capterra. (2024). NVivo. https://www.capterra.co.uk/software/171501/nvivo

Cardwell & Flanagan. (2015). Psychology A Level, year 1 and AS (6^th Ed.). Oxford University Press.

Centers for Disease Control and Prevention. (2023) Autism Spectrum Disorder (ASD) https://www.cdc.gov/ncbddd/autism/signs.html

Coates, W. C., Jordan, J., & Clarke, S. O. (2021). A practical guide for conducting qualitative research in medical education: Part 2—Coding and thematic analysis. AEM Education and Training, 5(4). https://doi.org/10.1002/aet2.10645

Colizzi, M., Bortoletto, R., Costa, R., & Zoccante, L. (2021). Palmitoylethanolamide and Its Biobehavioral Correlates in Autism Spectrum Disorder: A Systematic Review of Human and Animal Evidence. Nutrients, 13(4), 1346. https://doi.org/10.3390/nu13041346

Columbia University Irving Medical Center. (2014). Children with Autism have extra synapses in brain. https://www.cuimc.columbia.edu/news/children-autism-have-extra-synapses-brain

Curran, D., Kekewich, M., & Foreman, T. (2018). Examining the use of consent forms to promote dissemination of research results to participants. Research Ethics, 15(1), 1-28. https://doi.org/10.1177/1747016118798877

Da Conceicao, D. (2017). Autism and diagnosis: advice for teachers. https://www.autism.org.uk/advice-and-guidance/professional-practice/teachers-diagnosis

Damyanov, M. (2023). How to do thematic analysis. https://dovetail.com/research/thematic-analysis/

Denscombe, M. (2017). The Good Research Guide (6^th Ed.). Open University Press.

Dhakal, K. (2022). NVivo. Journal of the Medical Library Association : JMLA, 110(2), 270-272. https://doi.org/10.5195/jmla.2022.1271

Ferro, A., Auguste, Y. S., & Cheadle, L. (2021). Microglia, Cytokines, and Neural Activity: Unexpected Interactions in Brain Development and Function. Frontiers in Immunology, 12, 703527. https://doi.org/10.3389/fimmu.2021.703527

Fetit, R., Hillary, R. F., Price, D. J., & Lawrie, S. M. (2021). The neuropathology of autism: A systematic review of post-mortem studies of autism and related disorders. Neuroscience & Biobehavioral Reviews, 129, 35-62. https://doi.org/10.1016/j.neubiorev.2021.07.014

Fleury, V. P., & Kemper, T. (2022). An Examination of Education Profressionals’ Beliefs About Causes of Autism and Their Perceptions of Practices. Focus on Autism & Other Developmental Disabilities, 37(3), 189-198. DOI:10.1177/10883576211073685

Fomby, P., & Sastry, N. (2019). Data Collection on Sensitive Topics with Adolescents Using Interactive Voice Response Technology. Methoden, daten, analysen, 13(1), 91–110. https://doi.org/10.12758/mda.2018.05

Fraizer, E. (2023). Decisional capacity and informed consent, explained. https://www.spectrumnews.org/news/decisional-capacity-and-informed-consent-explained/

Garth, A. (2008). Analysing data using SPSS. https://students.shu.ac.uk/lits/it/documents/pdf/analysing_data_using_spss.pdf

Gillbrand, R., Lam, V., & O’Donnell. (2016). Developmental Psychology (2^nd Ed.). Pearson.

Goodall, C. (2018). ‘I felt closed in and like I couldn’t breathe’: A qualitative study exploring the mainstream educational experiences of autistic young people. Autism & Developmental Language Impairments. https://doi.org/10.1177/2396941518804407

Halperin, J. M., & Healey, D. M. (2011). The Influences of Environmental Enrichment, Cognitive Enhancement, and Physical Exercise on Brain Development: Can we Alter the Developmental Trajectory of ADHD? Neuroscience and Biobehavioral Reviews, 35(3), 621. https://doi.org/10.1016/j.neubiorev.2010.07.006

Health Research Authority. (2023). Is my child naughty or autistic? https://www.hra.nhs.uk/planning-and-improving-research/application-summaries/research-summaries/is-my-child-naughty-or-autistic/

Heidel, J. (2023). Navigating Autistic Meltdowns- A dos and don’t’s guide. https://www.thearticulateautistic.com/navigating-autistic-meltdowns-a-dos-and-donts-guide/

Hollingsworth, D., Ferguson, L., Schuab, J., & Kempson-Bryne, S. (2023). Autism and Parental Blame: A Systematic Literature Review. https://www.wm-adass.org.uk/media/veeekrna/autism-and-parental-blame-literature-review-final-version-feb-2024.pdf

Hoover, D. W., & Kaufman, J. (2018). Adverse Childhood Experiences in Children with Autism Spectrum Disorder. Current Opinion in Psychiatry, 31(2), 128. https://doi.org/10.1097/YCO.0000000000000390

Iphofen, R. (n.d.). Research Ethics in Ethnography/Anthropology. https://ec.europa.eu/research/participants/data/ref/h2020/other/hi/ethics-guide-ethnog-anthrop_en.pdf

Iphofen, R., & Tolich, M. (2018). The SAGE Handbook of Qualitative Research ethics. SAGE Publications Ltd. https://doi.org/10.4135/9781526435446

Kaiser, K. (2009). Protecting Respondent Confidentiality in Qualitative Research. Qualitative Health Research, 19(11), 1632. https://doi.org/10.1177/1049732309350879

Kelly, B., Williams, S., Collins, S., Mushtaq, F., Mon-Williams, M., Wright, B., Mason, D., & Wright, J. (2017). The association between socioeconomic status and autism diagnosis in the United Kingdom for children aged 5-8 years of age: Findings from the Born in Bradford cohort. Autism, 23(1). https://doi.org/10.1177/1362361317733182

Khankeh, H., Ranjbar, M., Khorasani-Zavareh, D., Zargham-Boroujeni, A., & Johansson, E. (2015). Challenges in conducting qualitative research in health: A conceptual paper. Iranian journal of nursing and midwifery research, 20(6), 635–641. https://doi.org/10.4103/1735-9066.170010

Kotajima-Murakami, H., Kobayashi, T., Kashii, H. Sato, A., Hagino, Y., Tanaka, M., Nishito, Y., Takamatsu, Y., Uchino, S, & Kazutaka, I. (2019).  Effects of rapamycin on social interaction deficits and gene expression in mice exposed to valproic acid in utero. Mol Brain, 12(3) https://doi.org/10.1186/s13041-018-0423-2

Kramer, M., & Adams, T. Communication and Media Studies, Sociology. The SAGE Encyclopedia of Communication Research Methods. https://doi.org/10.4135/9781483381411

Krystal, J. H., Abdallah, C. G., Averill, L. A., Kelmendi, B., Harpaz-Rotem, I., Sanacora, G., Southwick, S. M., & Duman, R. S. (2017). Synaptic Loss and the Pathophysiology of PTSD: Implications for Ketamine as a Prototype Novel Therapeutic. Current Psychiatry Reports, 19(10), 74. https://doi.org/10.1007/s11920-017-0829-z

Lodder, A., Papadopoulos, C., & Randhawa, G. (2020). SOLACE: A Psychosocial Stigma Protection Intervention to Improve the Mental Health of Parents of Autistic Children—A Feasibility Randomised Controlled Trial. Journal of Autism and Developmental Disorders, 50(12), 4477-4491. https://doi.org/10.1007/s10803-020-04498-0

Machi, L & McEvoy, B. (2016). The literature review six steps to success (3^rd Ed.). CORWIN.

Magee, C., (2023). Why do 90% of new drugs fail? https://www.understandinganimalresearch.org.uk/news/why-do-90-of-new-drugs-fail

Mahajan, S. (2022). Challenges faced by kids with autism in classrooms https://www.autismconnect.com/blogs/challenges-faced-by-kids-with-autism-in-classrooms/

Malički, M., Aalbersberg, I. J., Bouter, L., & Mulligan, A. (2023). Transparency in conducting and reporting research: A survey of authors, reviewers, and editors across scholarly disciplines. PLOS ONE, 18(3). https://doi.org/10.1371/journal.pone.0270054

Masuadi, E., Mohamud, M., Almutairi, M., Alsunaidi, A., Alswayed, A. K., & Aldhafeeri, O. F. (2021). Trends in the Usage of Statistical Software and Their Associated Study Designs in Health Sciences Research: A Bibliometric Analysis. Cureus, 13(1). https://doi.org/10.7759/cureus.12639

Mezinska, S., Gallagher, L., Verbrugge, M., & Bunnik, E. M. (2021). Ethical issues in genomics research on neurodevelopmental disorders: A critical interpretive review. Human Genomics, 15. https://doi.org/10.1186/s40246-021-00317-4

Michel, C., Thompson, K. N., Cavelti, M., Eaton, S., Betts, J. K., Fowler, C., Luebbers, S., Kaess, M., & Chanen, A. M. (2023). Neighbourhood characteristics and the treated incidence rate of borderline personality pathology among young people. Australian & New Zealand Journal of Psychiatry, 57(9). https://doi.org/10.1177/00048674231157274

Moisse, K. (2023). Preprint questions validity of post mortem brain studies. https://www.thetransmitter.org/postmortem-brains/preprint-questions-validity-of-postmortem-brain-studies/

Naeem, M., Ozuem, W., Howell, K., & Ranfagni, S. (2023). A Step-by-Step Process of Thematic Analysis to Develop a Conceptual Model in Qualitative Research. International Journal of Qualitative Methods, 22. https://doi.org/10.1177_16094069231205789

NHS. (2021). Risperidone. https://www.nhs.uk/medicines/risperidone/

NHS. (2022). Signs of autism in children. https://www.nhs.uk/conditions/autism/signs/children/

NHS. (2022). What is autism? https://www.nhs.uk/conditions/autism/what-is-autism/

NHS. (2023). Signs of autism in children https://www.nhs.uk/conditions/autism/signs/children/

Nowell, L. S., Norris, J. M., White, D. E., & Moules, N. J. (2017). Thematic Analysis. International Journal of Qualitative Methods 16(1). https://doi.org/10.1177/1609406917733847

O.Nyumba, T., Wilson, K., Derrick, C. J., & Mukherjee, N. (2018). The use of focus group discussion methodology: Insights from two decades of application in conservation. Methods in Ecology and Evolution, 9(1), 20-32. https://doi.org/10.1111/2041-210X.12860

Office for Health Improvement and Disparities. (2020). Ethnographic study: qualitative studies. https://www.gov.uk/guidance/ethnographic-study-qualitative-studies

Pagura, J., Stein, M. B., Bolton, J. M., Cox, B. J., Grant, B., & Sareen, J. (2010). Comorbidity of borderline personality disorder and posttraumatic stress disorder in the U.S. population. Journal of psychiatric research, 44(16), 1190–1198. https://doi.org/10.1016/j.jpsychires.2010.04.016

Pickering, A., & Watts C. (2016). Case study: The role of the moderators in focus group interviews: Practical considerations. https://web-archive.southampton.ac.uk/www.llas.ac.uk/resources/gpg/2399.html

Roman-Urrestarazu, A., Yang, J., Van Kessel, R., Warrier, V., Dumas, G., Jongsma, H., Gatica-Bahamonde, G., Allison, C., Matthews, F., Baron-Cohen, S., & Brayne, C. (2022). Autism incidence and spatial analysis in more than 7 million pupils in English schools: a retrospective, longitudinal, school registry study. The Lancet, 6(12), 857-868. https://doi.org/10.1016/S2352-4642(22)00247-4

Sakai, J. (2020). How synaptic pruning shapes neural wiring during development and, possibly, in disease. Proceedings of the National Academy of Sciences, 117(28), 16096-16099. https://doi.org/10.1073/pnas.2010281117

Sanjari, M., Bahramnezhad, F., Fomani, F. K., Shoghi, M., & Cheraghi, M. A. (2014). Ethical challenges of researchers in qualitative studies: The necessity to develop a specific guideline. Journal of Medical Ethics and History of Medicine, 7. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4263394/

Schumann, C. M., & Nordahl, C. W. (2011). Bridging the Gap between MRI and Postmortem Research in Autism. Brain Research, 1380, 175. https://doi.org/10.1016/j.brainres.2010.09.061

Schuster, E. (1996). Ethical considerations when conducting ethnographic research in a nursing home setting. Journal of Aging Studies, 10(1), 57-67. https://doi.org/10.1016/S0890-4065(96)90017-1

Selman, L. E., Fox, F., Aabe, N., Turner, K., Rai, D., & Redwood, S. (2018). 'You are labelled by your children's disability' - A community-based, participatory study of stigma among Somali parents of children with autism living in the United Kingdom. Ethnicity & health, 23(7), 781–796. https://doi.org/10.1080/13557858.2017.1294663

Shorten, A., & Smith J. (2017). Mixed methods research: expanding the evidence base. Evidence-Based Nursing, 20(3), 74-75. https://doi.org/10.1136/eb-2017-102699

Silva, P. (2018) Do patterns of synaptic pruning underlie psychoses, autism and ADHD? https://www.cambridge.org/core/journals/bjpsych-advances/article/do-patterns-of-synaptic-pruning-underlie-psychoses-autism-and-adhd/10BB01A1F04C0D8EA449580DA5690144

Snyder, H., (2019). Literature review as a research methodology: An overview and guidelines. Journal of Business Research, 104, 333-339.https://doi.org/10.1016/j.jbusres.2019.07.039

Tizard, B. (2009). Looking Back: The making and breaking of attachment theory.https://www.bps.org.uk/psychologist/looking-back-making-and-breaking-attachment-theory

Tuan, L., Tsao, C., Lee, L. J. H., & Lee, L. (2021). Voluntary exercise ameliorates synaptic pruning deficits in sleep-deprived adolescent mice. Brain, Behavior, and Immunity, 93, 96-110. https://doi.org/10.1016/j.bbi.2020.12.017

Turnock, A., Langley, K., & Jones, R. G. (2022). Understanding Stigma in Autism: A Narrative Review and Theoretical Model. Autism in Adulthood: Challenges and Management, 4(1), 76-91. https://doi.org/10.1089/aut.2021.0005

UK Research and Innovation. (2021). What to expect as a research participant. https://www.ukri.org/councils/esrc/guidance-for-applicants/research-ethics-guidance/what-to-expect-as-a-research-participant/

UK Research and Innovation. (2024). What is social science? https://www.ukri.org/who-we-are/esrc/what-is-social-science/qualitative-research/

University of Cambridge. (2023). Problems with ‘pruning’ brain connections linked to adolescent mental health disorders. https://www.cam.ac.uk/research/news/problems-with-pruning-brain-connections-linked-to-adolescent-mental-health-disorders

University of Cambridge. (2024). NVivo an Introduction to Qualitative Research. https://training.cam.ac.uk/cctl/course/ucs-nvivio

University of Oxford. (2021). Informed Consent. https://researchsupport.admin.ox.ac.uk/governance/ethics/resources/consent

University of Surrey (2023). NVivo (Version 14) Distinguishing Features. https://www.surrey.ac.uk/sites/default/files/2023-06/nvivo-14-distinguishing-features.pdf

University of York. (2024). Cleaning data. https://subjectguides.york.ac.uk/data/cleaning

University of York. (2024). Quantitative data analysis. https://subjectguides.york.ac.uk/data/quantitative

Watson R. (2015). Quantitative research. Nursing standard, 29(31), 44-48. https://doi.org/10.7748/ns.29.31.44.e8681

Weir, K. (2012). The beginnings of mental illness. Autism, schizophrenia and other disorders may have roots in life’s earliest stages. https://www.apa.org/monitor/2012/02/mental-illness

Weller, S. C., Vickers, B., Bernard, H. R., Blackburn, A. M., Borgatti, S., Gravlee, C. C., & Johnson, J. C. (2018). Open-ended interview questions and saturation. PLoS ONE, 13(6). https://doi.org/10.1371/journal.pone.0198606

Westacott, L., (2017). The immune system and the brain: Complement or casualty? https://www.cardiff.ac.uk/news/view/729070-the-immune-system-and-the-brain-complement-or-casualty

World Health Organisation. (2023). Autism. https://www.who.int/news-room/fact-sheets/detail/autism-spectrum-disorders

York Sendiass. Special educational needs funding. https://www.yorksendiass.org.uk/SENDIASSFunding

Zimmerman, S, & Zucker. (2020). Why drugs tested in mice fail in human clinical trials. https://sitn.hms.harvard.edu/flash/2020/why-drugs-tested-in-mice-fail-in-human-clinical-trials/