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The Autism
Research Group

An Evidence Based Guide to

Anxiety in Autism
Sebastian B Gaigg,
Autism Research Group
City, University of London
Jane Crawford,
Autism and Social Communication Team
West Sussex County Council
Helen Cottell,
Autism and Social Communication Team
West Sussex County Council

www.city.ac.uk
November 2018
Foreword

Over the past 10-15 years, research has confirmed what many parents and
teachers have long suspected – that many autistic children often experience
very significant levels of anxiety. This guide provides an overview of what is
currently known about anxiety in autism; how common it is, what causes it,
and what strategies might help to manage and reduce it. By combining the
latest research evidence with experience based recommendations for best
practice, the aim of this guide is to help educators and other professionals
make informed decisions about how to promote mental health and well-being
in autistic children under their care.

3
 Contents

What do we know about anxiety in autism? 5

What is anxiety? 5
How common is anxiety and what does it look like in autism? 6
What causes anxiety in autism? 7-9
Implications for treatment approaches 10
Cognitive Behaviour Therapy 10
Coping with uncertainity 11
Mindfulness based therapy 11
Tools to support the management of anxiety in autism 12
Sensory processing toolbox 12-13
Emotional awareness and alexithymia toolbox 14-15
Intolerance of uncertainty toolbox 16-17
Additional resources and further reading 18-19

A note on language in this guide

There are different preferences among members of the autism community
about whether identity-first (‘autistic person’) or person-first (‘person
with autism’) language should be used to describe individuals who have
received an autism spectrum diagnosis. A survey by Kenny et al., (2016)
suggests that many autistic individuals prefer the use of identity-first
language, which will therefore be the language adopted in this guide.

4
What do we know about anxiety in autism?

Unfortunately, for some people, feelings of

What is anxiety? anxiety can arise so frequently, persistently
Anxiety is a feeling of worry or fear that we and with such unusual intensity, that
experience when we expect that a situation they interfere with a person’s day-to-day
might have adverse consequences for our functioning and general quality of life.
psychological or physical well-being. This For instance, children may be so worried
may include situations such as preparing for about failing a test or being teased that they
an exam or test (for fear of failure), travelling resist going to school or any social events.
during rush hour (for fear of being late or Others may have such persistent fears of
having an accident), preparing for a public dogs that they refuse to go to parks or visit
speech (for fear of being judged negatively), friends who own a dog. And others still may
or travelling to new places and meeting generally worry so much about something
new people (for fear of the unknown). In bad happening that they are constantly in
many such situations, feelings of anxiety a state of heightened arousal and vigilance.
are completely normal and even important When anxiety interferes with life in such
because the associated increase in our levels ways for prolonged periods, we recognise it
of arousal (e.g. increased heart rate) and as an anxiety disorder and depending on the
general vigilance prepares us for dealing specific nature of the anxiety, different forms
with whatever a situation might throw at us. can be distinguished including Generalised
Anxiety Disorder, Social Anxiety Disorder,
Specific Phobias (e.g. heights or spiders), Panic
Disorders and Separation Anxiety Disorder.

5
 Unfortunately, it can be difficult to identify
How common is anxiety and what anxiety disorder in autism because it
does it look like in autism? frequently presents in an unusual way
(Kerns et al., 2014). For example, social
A considerable body of evidence now shows anxiety is often associated with a fear of
that anxiety disorders are substantially being embarrassed or humiliated in front
more common in autism than in the general of others but autistic individuals often
population. Whilst around 10-15% of the experience social anxiety because they find
general population have an anxiety disorder it difficult to navigate social situations, not
at some point in their life (most commonly a because they worry about what others might
specific phobia; Kessler et al., 2012), around think or say about them. Similarly, many
40% of autistic children, adolescents and autistic individuals worry excessively that
adults are thought to have at least one and certain routines might be disrupted or that
often more anxiety disorders (van Steensel they might be prevented from engaging in
et al., 2011), with specific phobias and social certain (potentially repetitive) activities
anxiety among the most common forms. or behaviours. This sounds similar to
It is important to appreciate that anxiety Obsessive Compulsive Disorder (OCD), but
disorder is not simply a part of autism but in the case of OCD individuals engage in
an independently co-occurring disorder repetitive behaviours to relieve distress
that can be addressed and treated in its own caused by persistent, intrusive and unwanted
right. This is important because it means that thoughts, not because of a desire to pursue
accurately identifying anxiety can provide a routine. Finally, autistic individuals may
an opportunity to bring about significant experience excessive fear of unusual and
improvements in an individual’s quality of highly idiosyncratic objects or events (e.g.,
life and daily functioning. the happy birthday song, TV sets or walking
through doors) that would not commonly be
associated with a specific phobia.
Since most clinical assessments and
screening tools have been developed on the
basis of what anxiety typically looks like, the
unusual presentations of anxiety in autism
may often be overlooked. This problem
is compounded by something known
as diagnostic overshadowing whereby
symptoms of anxiety are simply regarded
as part of autism rather than signs of a
co-occurring anxiety disorder.
Fortunately, awareness is growing that

40% of autistic
children, adolescents and
anxiety is a major mental health concern
for many autistic children and adults and
therefore diagnostic screening tools are being
developed that are specifically designed to
identify different forms of anxiety in autism
adults are thought to have (e.g. Rodgers et al., 2016; see also the online
at least one and often resources section on page 18).
more than one anxiety
disorder.
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 Briefly, frequent sensory processing
What causes anxiety in autism? differences and difficulties in understanding
Over the past decade, research has made one’s own emotions (which is known as
substantial progress toward identifying the alexithymia) are thought to make the world
key mechanisms that seem to be responsible more uncertain and unpredictable for autistic
for the high levels of anxiety in autism, and individuals, which can be difficult to tolerate.
that are now increasingly becoming the The resulting intolerance of uncertainty,
focus of interventions and treatment. Figure therefore, causes high levels of anxiety, which
1 below, provides an overview of current autistic individuals may attempt to manage
thinking, which places an ‘Intolerance of by engaging in repetitive behaviours (to make
Uncertainty’ at the heart of anxiety disorders the world more predictable). In parallel,
in autism. alexithymia may also contribute to anxiety
by making it difficult for the individual to
effectively regulate their emotions.

Sensory Repet tive

Processing Behaviours

Intolerance of
Uncertainty

Alexithymia ANXIETY

Maladaptive
Emotion
Regulation

Figure 1: A model of anxiety in Autism (adapted from South & Rodgers 2017 and Maisel et al., 2016)
7
 A closer look at the role of sensory In addition to helping us make sense of
processing differences the world, sensory prediction processes
are also important for filtering incoming
Our brains are continuously exposed to sensory information. Specifically our brains tend
input from our external (e.g., smells, sounds, to suppress expected sensory input whilst
etc.) and internal (e.g., body temperature, amplifying unexpected events so that we can
arousal levels) environment. This sensory deal effectively with new situations. This is
input is often incomplete or ambiguous and illustrated by the fact we cannot generally
therefore our brains do not only simply tickle ourselves whilst others can. When we
receive information but also try to make try to tickle ourselves, our brains generate
predictions about what is most likely going to very good predictions about what it will feel
be experienced next. This sensory prediction like and therefore the expected sensation is
is very important for helping us make sense of suppressed. However, when others tickle us,
the world around us. For instance, when we our sensory predictions are less accurate and
talk to someone in a noisy environment, we therefore the tickling feels considerably more
may not hear every single word but the gist of intense.
the conversation lets us fill in the gaps unless
the conversation takes an unexpected turn. Sensory prediction processes also generally
Similarly, when we try to make out objects in alert us to new and unexpected events so
a poorly lit room we use our expectations to that we can deal with them effectively. As our
see what we can’t quite see – a round object in brains make predictions about our sensory
a fruit-bowl will look like an orange or apple environment, they also continuously compare
whereas the same shape next to a tennis racket them to the actual information that our
will look like a tennis ball. senses receive. Any mismatch between the
predictions and our actual experiences tends
to be associated with a mild sense of anxiety
that helps us deal with the unexpected event
until the uncertainty is resolved.
It is well known that sensory processing
differences constitute part of the clinical
characteristics of autism and recent evidence

sensory
suggests that differences in sensory
prediction processes are partly responsible

prediction (Sinha et al., 2014; Pellicano & Burr, 2012).

As a result, autistic individuals may always
perceive the world as more uncertain
and unpredictable, leading to the more
persistent states of anxiety that interfere
with day-to-day functioning rather than
facilitate adaptation to new situations (Green
& Ben-Sasson, 2010; Black et al., 2017).

Sensory prediction is very

important for helping us make
sense of the world around us.
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Many autistic individuals (around 50%)
also have difficulties identifying and
describing their own emotions.

A closer look at alexithymia In addition, alexithymia is thought to

contribute to anxiety by making it more
In addition to the common sensory processing difficult for autistic individuals to regulate
difficulties associated with autism, many their emotions, for example, by trying to
autistic individuals (around 50%) also worry less about a certain situation or by
have difficulties identifying and describing accepting that a certain degree of worrying
their own emotions. As illustrated in Figure 1 is okay in a given situation (thus preventing
, it is thought that this alexithymia an escalation of anxiety). Such strategies of
contributes to anxiety through two reappraisal or emotional acceptance, are
independent routes. On the one hand usually very effective in managing difficult
alexithymia has been linked to difficulties in feelings such as anxiety or stress. However,
accurately sensing the internal signals for someone who struggles to identify and
of arousal that often accompany emotional describe their emotions, it is generally
experiences, such as changes in heart rate more difficult to use such adaptive emotion
or a rush of adrenalin (Gaigg et al., 2018; regulation strategies effectively. As a result
Garfinkel et al., 2015). This can make internal people with alexithymia often engage in
sensations confusing and unpredictable, maladaptive emotional suppression, which
leading to anxiety in a similar way to how aims to push the confusing feelings away,
sensory processing difficulties do. In other only to make general feelings of anxiety
words, differences in sensory prediction worse in the long-run.
processes may not only render the external
sensory environment more uncertain for
autistic individuals but also the internal
sensory environment.

9
 Implications for treatment:
how to help someone with ASD and anxiety?

emotions. Other adaptations serve to reduce

Cognitive Behaviour Therapy the demands of interacting with a therapist,
Cognitive Behaviour Therapy (CBT) is a such as communicating via an internet chat
form of psychological therapy that is widely rather than face-to-face.
used in the general population to treat The evidence suggests that CBT generally
anxiety by guiding individuals to change leads to a moderate decrease in anxiety and
their thoughts and beliefs about the objects an improvement in well-being in autism
and situations that elicit excessive anxiety. (Lang et al., 2010), but the approach can be
CBT starts by making a person aware of the very resource intense due to the need for a
thought patterns involved in their anxiety. trained therapist. Moreover, traditional CBT
The person is then exposed to situations that primarily targets a person’s emotion regulation
trigger anxiety, whilst giving them tools to skills as a way of reducing anxiety, which may
manage it, for example through relaxation be problematic for the large number of autistic
methods, or by examining the realistic individuals who experience alexithymia.
outcomes of a particular situation. Because Because of these limitations, some researchers
examining thoughts and understanding have therefore begun to examine whether
emotions are often a source of difficulty for treatments could also be helpful that target
autistic individuals, several adaptations some of the other factors that contribute to
have been recommended for making CBT anxiety in autism such as the intolerance
more accessible and effective for them. These of uncertainty, alexithymia and sensory
adaptations include the use of visual aids processing differences as shown in Figure 1
and social stories to explain complex social (page 7).
situations, and to support understanding of

CBT
generally leads
to a moderate
decrease in
anxiety and an
improvement
in well-being in
autistic people.

10
 Coping with Uncertainty
In the
Researchers at Newcastle University are Moment
developing a new programme that seeks
to teach parents how to help their autistic
children to cope better with uncertainties
in life (Rodgers et al., 2017). The main aim
of the CUES (Coping with Uncertainty in
Everyday Situations) programme is to Non-
gradually introduce children to uncertainty, Awareness
Judgement
and help them develop strategies for
tolerating it. For instance, a child who
might be anxious about possible changes
to a routine (e.g. preparing for school every
mindfulness
morning), might be encouraged to engage in
some role-play to explore what it might feel
Acceptance
like to change the routine. Parents learn how
to encourage their child to practise relaxation
techniques and other CBT based strategies
to regulate their feelings during this ‘safe’
exploration of uncertainties. Gradual
In the general population, a considerable
exposure to the anxiety-provoking situation
amount of evidence shows that MBT is effective
is increased until the child can independently
in reducing anxiety and stress and improving
tolerate it more readily.
well-being (Grossman et al., 2004; Strauss et al.,
Evidence from an initial pilot study suggests 2014) and programmes have been developed
that this parent-mediated programme can that are specifically tailored to young children.
reduce anxiety in both children and parents. MBT might be particularly useful for managing
Larger scale trials are now under way to test the anxiety in autism by targeting the type of
efficacy of this new programme more broadly. sensory processing difficulties and difficulties
introspecting on own emotions that play such
an important role in this group. Initial evidence
Mindfulness Based Therapy indicates that practising mindfulness does
indeed reduce anxiety in autistic adults (Kiep
At City, University of London, researchers et al., 2015) and parents of autistic children
are examining whether Mindfulness Based (Cachia et al., 2016). Moreover, the work by
therapies (MBT) might offer a fruitful researchers at City, University of London shows
alternative to standard CBT. Mindfulness that online-based self-help mindfulness tools
refers to the ability to focus on present are effective in reducing anxiety in autistic
moment experiences, including sensations adults (Gaigg et al., 2017), suggesting that
and feelings, and to accept them without this approach may be scalable and flexibly
judgement or reaction. Mindfulness can be adapted to different settings. Work is currently
increased through meditation-like practices underway to establish how MBT strategies can
such as focusing on the sensations in different be adapted effectively for autistic children, and
parts of the body, carefully exploring textures how such strategies might be integrated with
of objects, or attending to the different regular school activities.
thoughts that might come to mind without
trying to change them.

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 Tools to support the management
of anxiety in autism

Considering how important sensory processing difficulties and alexithymia are to

anxiety in autism, supporting children with these difficulties will play an important
role in looking after their mental health. A number of resources are already
available that those caring for autistic children can draw on in this context.
From this checklist, an individualised
Sensory processing toolbox programme of sensory activities can be
Given how variable sensory processing developed, which may include opportunities
differences are across autistic children, it to satiate hyposensitivities (e.g., to address
is important to identify individual sensory maladaptive sensory seeking behaviours),
profiles before considering what hyper- or de-sensitise hypersensitivities (e.g., to
or hypo- sensitivities might represent make unavoidable sensory experiences
appropriate targets for sensory related work. more tolerable). Objects and activities
A useful checklist, in this context, is the West that could be considered for developing
Sussex County Council sensory toolkit (see individualised sensory activities are listed
online resources on page 18). in the following box.

Visual resources
including blowing bubbles, kaleidoscopes, reflective/
transparent materials.

Tactile resources
including PlayDoh, Thera Putty, shaving foam, soft
and/or rough fabrics/materials.

Auditory resources
including access to music or other auditory stimuli through
headphones.

Taste and smell resources

including aromatherapy oils, foods and spices.

Proprioceptive activities
including rolling over an exercise ball, jumping on a trampette,
carrying heavy books, pushing against walls.

Vestibular resources
including access to climbing equipment that allows hanging upside
down or equipment that provide balancing opportunities.
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In the context of sensory hypersensitivities, by writing down 5 smells they noticed
resources such as ear defenders or tinted during lunch or 5 sensations they had during
glasses may also be useful to reduce the impact physical activity. These experiences could
of the sensory stimulation the individual finds then be shared to encourage communication
distressing. When facilitating desensitisation, about sensory processing differences.
it may be possible to gradually withdraw such Additional strategies for helping children
resources as the individual builds tolerance to manage their sensory processing differences
the relevant sensory stimuli. More generally, can be found in the following book resource.
gradual exposure to sensory stimuli is
important when facilitating desensitisation.
Sensory Strategies: Practical ways to help
In addition to developing individualised children and young people with autism learn
sensory programs, consideration should also and achieve
be given to the environment and whether Corinna Laurie (2014).
opportunities exist to make adaptations The National Autistic Society, London, UK.
that would benefit learners with sensory This book has a lot of practical solutions to help
processing differences irrespective of children who have sensory processing difficulties
their individual profiles. For instance, a that might result in difficult behaviours. As an
low arousal space with little visual and/or Occupational Therapist with expertise in Sensory
auditory sensory stimuli could be provided Processing Disorder, the author helps the reader
to serve as a ‘safe space’. Children and staff to identify possible sensory triggers to difficult
could also be encouraged to be mindful of behaviours and strategies for dealing with them.
sources of sensory stimulation, for example

13
 Emotional awareness and When My Worries Get Too Big
alexithymia toolbox Kari Dunn Buron (2013).
AAPC Publishing, Kansas, USA.
Supporting the development of children’s This illustrated children’s book is written to
emotional awareness and literacy is important help children who are overburdened with worry
for providing them with the foundations for and anxiety. It provides children opportunities
learning how to manage and regulate their to participate in developing their own self-
feelings. Both CBT and Mindfulness based calming strategies.
strategies for managing anxiety rest on the
assumption that an individual can identify Dealing with Feeling
and think about their feelings, either to try to Tina Rae (2008).
regulate them (as in CBT) or simply to accept SAGE Publications LTd., London, UK.
and observe them (as in MBT). The resources This book provides teachers of children aged
listed in this toolbox section provide a range of 7-14 with structured opportunities to develop
strategies that should prove useful for fostering their emotional literacy and emotional well-
children’s emotional awareness and literacy being, with a focus on developing an emotional
and their ability to develop strategies for vocabulary, empathy, tolerance, resilience and
managing their emotions. motivation.

The Zones of Regulation The Essential Guide to using Mindfulness

Leah M. Kuyper (2011). with Children & Young People
Think Social Publishing Inc, USA. Tina Rae, Jody Walshe & Jo Wood (2017).
The Zones of Regulation uses a cognitive Hinton House Publishers, Banbury, UK.
behaviour approach to help children become This book provides practical and user-friendly
more aware of, and independent, in controlling introductions to tried-and-tested mindfulness-
their emotions and impulses, managing their based strategies for promoting emotional and
sensory needs, and improving their ability to mental well-being in young people. The tools
problem solve conflicts. will help to prevent the escalation of difficulties
and will provide anyone wishing to develop a
When My Autism Gets Too Big programme of support with a range of problem-
Kari Dunn Buron (2004). solving ideas and techniques.
AAPC Publishing, Kansas, USA.
This book gives young children an opportunity
to explore, with parents or teachers, their own
feelings as they react to events, while learning
some useful relaxation techniques.

14
Starving the Anxiety Gremlin: The Homunculi Approach to Social and
A Cognitive Behavioural Therapy Workbook Emotional Wellbeing. A flexible CBT programme
on Anxiety Management for Young People for young people on the autism spectrum or
Kate Collins-Donnelly (2013). with emotional and behavioural difficulties
Jessica Kingsley, London, UK Anne Greig & Tommy Mackay (2013).
Starving the Anxiety Gremlin is a unique Jessica Kingsley, London UK.
resource to help young people understand The Homunculi are miniature agents with
different types of anxiety and how to problem-solving missions and special gadgets
manage them. Through cognitive who live inside the brain and help out with
behavioural principles, the techniques distressing thoughts, feelings and behaviours.
described help young people to understand By inventing their own Homunculi characters
why they get anxious and how they can and stories, children learn to cope with their
‘starve’ their anxiety gremlin in order to real-life problems. The book helps build social
manage their anxiety. This engaging and emotional resilience in children and young
workbook uses fun activities and real life people, aged 7 upwards and is particularly suited
stories, and can be used by young people to those with an autism spectrum diagnosis who
aged 10+ on their own or with a parent often have difficulty identifying troubling feelings
or practitioner. such as anger, fear and anxiety.

15
 it would be for certain aspects of the routine
Intolerance of uncertainty toolbox to be disrupted (e.g. is it a bigger deal to sit
To help children manage their intolerance of somewhere else during lunch than to eat with
uncertainty as a source of anxiety it is useful different cutlery?) before exploring how they
to make their lives more predictable. However, feel when the disruption actually occurs.
this can have the undesired consequence of Alternatively, staff can expose children
reinforcing maladaptive coping strategies such to uncertainties in play activities by, for
as insisting on routines that may interfere example, asking them to guess what is in a
with day-to-day life or even present health bag based only on exploring the texture of the
risks. Since uncertainties are impossible to hidden object.
avoid in day-to-day life, it is therefore equally Tools that can help to make the environment
important to help children build greater more predictable for children include visuals
tolerance of uncertainty. A useful strategy, in such as timetables, schedules and event
this context, is to gradually expose children sequences (e.g. for dressing, washing and
to uncertainty within an otherwise well daily routines) as well as resources that foster
structured environment and to encourage greater understanding of what to expect in
them to practice managing their anxiety different social situations (see the resources in
in these situations. For example, children this section). Tools that can help children learn
who tend to become distressed when certain ways of managing their anxiety, include those
routines are interrupted or prevented might described in the ‘Emotional awareness and
be encouraged to think about how big a deal alexithymia toolbox’ in the previous section.

16
The Incredible 5-point Scale Comic Strip Conversations Example
Kari Dunn Buron & Mitzi Curtis (2012).
AAPC Publishing, Kansas, USA. Child draws the incident...
A primary goal of the scale is to help autistic
children notice and functionally respond to
their own and others’ social behaviour. It
provides teachers and parents with a simple
way to teach social rules and expectations,
problem-solving skills in how to respond to
others, a way to troubleshoot past and future
social scenarios and support for creating plans
for self-management.

The New Social Story Book

Carol Gray (2015).
Future Horizons Inc., Texas, USA. Then adds details about the triggers and
Social StoriesTM provide an effective and thought bubbles to explain perspectives...
meaningful tool to support social understanding.
The book offers over 180 ready-to-use stories that
parents and educators can use to explain social
situations in ways children (and adults) with
autism understand, while teaching social skills.

Comic Strip Conversations

Carol Gray (1994).
Future Horizons Inc., Texas, USA.
This book combines stick-figures with
‘conversation symbols’ to illustrate what
people say and think during conversations.
Showing what people are thinking reinforces
that others have independent thoughts,
which autistic children often find difficult to
understand intuitively. It also helps children
understand that what people say is not always
what they mean.

Then draws alternative way of responding

17
 Additional resources and further reading

Online resources
The Anxiety Scale for Children with Autism Spectrum Disorder (ASC-ASD)
https://research.ncl.ac.uk/neurodisability/leafletsandmeasures/
anxietyscaleforchildren-asd
Social and Emotional Aspects of Learning
http://webarchive.nationalarchives.gov.uk/20110812101121/http://nsonline.
org.uk/node/87009
Autism Educational Trust Progression Framework: Assessment tool:
www.aettraininghubs.org.uk/schools/pf
West Sussex County Council Autism & Social Communication Team Sensory
Plan Toolkit:
https://westsussex-local-offer.s3.amazonaws.com/public/system/
attachments/1116/original/NEW_Sensory_Toolkit.pdf
Emotional Literacy Resources
www.elsa-support.co.uk
General Educational Resources (Social Skills; Emotion Regulation; etc.)
www.do2learn.com
Visual aids for learning
www.visualaidsforlearning.com

Useful Apps
National Autistic Society’s Brain in Hand App
www.autism.org.uk/services/education/brain-in-hand.aspx
Autistica’s Molehill Mountain app
www.autistica.org.uk/get-involved/molehill-mountain-app
The Smiling Mind App
www.smilingmind.com.au
Positive Penguins
positivepenguins.com

18
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Autism Research Group
Department of Psychology
City, University of London
Northampton Square
London EC1V 0HB

For more information about the work of

the Autism Research Group, visit:
www.city.ac.uk/arts-social-sciences/psychology/
research/autism-research-group
For more information about the work of
the Autism and Social Communication Team,
West Sussex County Council, visit:
https://westsussex.local-offer.org/services/
114-autism-and-social-communication-team

YOUR OPINION MATTERS!

We are committed to keeping this guide up to date and
will aim to revise it as significant new evidence and
practice guidance emerges. If you have any feedback
or comments regarding the contents of this guide,
please do not hesitate to e-mail Dr Sebastian Gaigg
([email protected]).
Or, if you have any questions for the Autism and Social
Communication Team of West Sussex County Council,
please send your query to
[email protected]

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London consists of 18 independent member institutions with outstanding global
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