STEPS: A Virtual Reality-based Intervention for Adults With Autism.

The primary outcome is level of social impairment is measured by the Social Responsiveness Scale, Second Edition, Adult version, Self-report (SRS-2A) at cessation of treatment at 3-months.

SRS-2A measures the presence and severity of social impairment in everyday life. The SRS-2A is a commonly used measure in autism spectrum research and has demonstrated good reliability and validity.

SRS-2A is a 65-item rating scale, scored on on a 4-point Likert Scale (0-3). Each item is scaled from 0 (never true) to 3 (almost always true), generating a total score ranging from 0 to 195. The SRS-2A is provides a continuous measure of social impairment, where a higher score reflects a greater degree of difficulties with social interactions in everyday life.

Follow-up assessments will comprise ratings of the previous two-week period.

Social Responsiveness Scale, Adult Version, Informant Report is a 65-item rating scale, scored on on a 4-point Likert Scale (0-3). Each item is scaled from 0 (never true) to 3 (almost always true), generating a total score ranging from 0 to 195. The SRS-2A is provides a continuous measure of social impairment, where a higher score reflects a greater degree of difficulties with social interactions in everyday life. Follow-up assessments will comprise ratings of the previous two-week period.

SIAS is a self-report questionnaire measuring social anxiety in social interaction. SIAS consists of 20 items that are rated on a 5-point Likert scale ranging from 0 (not at all characteristic of me) to 4 (extremely characteristic of me). Item 5, 9 and 11 are positively worded items and have reverse scoring. A total SIAS score is generated by summing the ratings ranging from 0 to 80. Higher scores reflects a higher degree of social anxiety in social interaction.

The Empathy Quotient (EQ) is a 60-item questionnaire designed to measure empathy in adults. Each item is scored on a 4-point scale (strongly agree, slightly agree, slightly disagree, strongly disagree).

Items 1, 6, 19, 22, 25, 26, 35, 36, 37, 38, 41, 42, 43, 44, 52, 54, 55, 57, 58, 59, and 60 are assigned two points if rated as 'strongly agree' and one point if rated 'slightly agree.'

Items 4, 8, 10, 11, 12, 14, 15, 18, 21, 27, 28, 29, 32, 34, 39, 46, 48, 49, and 50 are assigned two points if rated as 'strongly disagree' and one point if rated 'slightly disagree.'

The minimum score achievable is 0, and the maximum score is 80. A higher score indicates higher levels of empathy in adults.

The High Risk Social Challenge task (HiSoC) is a standardized, performance-based task assessing social skills in terms of affect, odd behaviour and language and social-interpersonal skills. Following a short verbal instruction, the participants are being video-taped for 45 seconds while performing a task.

HiSoC consists of 16 items that are rated on a 5-point Likert scale from 1 to 5. Smaller ratings reflect low levels of appropriate, effective social behavior. Larger ratings reflect high levels of appropriate, effective social behavior. A total HiSoC score is generated by summing the rating ranging from 16 to 80. Higher scores reflects a higher degree of social skills.

Computer-morphed images derived from the facial features of real individuals, each showing a specific emotion, are displayed on the screen, one at a time. Each face is displayed for 200ms and then immediately covered up to prevent residual processing of the image. The participant must select which emotion the face displayed from 6 options (sadness, happiness, fear, anger, disgust or surprise).The outcome measures for ERT cover percentage and number correct or incorrect and overall response latencies, which can be looked at either across individual emotions or across all emotions at once.

The Camouflaging Autistic Traits Questionnaire (CAT-Q) is a 25-item self-report measure of social camouflaging behaviours for individuals of age 16 and above. Each item is rated on a likert scale from 1 (Strongly Disagree) to 7 (Strongly Agree). The total score ranges from 25-175 with higher scores reflecting greater degree of camouflaging.

The SR-AS is a self-report instrument for sensory reactivity. It can be used for evaluation of sensory symptoms as described in DSM-5 for autism spectrum conditions. The instrument comprises statements about reactions to sensory input. The task is to self-rate the statements rated on a likert scale from 0 (Totally Disagree) to 3 (Totally Agree). Total scores ranges from 0 - 96.

The Beck Depression Inventory (BDI) is a 21-item, self-report rating inventory that measures characteristic attitudes and symptoms of depression. Each item is rated on a 4-point scale from 0 (symptom absent) to 3 (severe symptoms). The total score ranges from 0 to 63, with higher scores reflecting greater degree of depressive symptoms.

The General Alexithymia Factor Score (GAFS-8) is a 8-item, self-administered questionnaire that measures alexithymia.

Each item is scored on a 5-point Likert-type scale 1 (strongly disagree) to 5 (strongly agree). Total score is ranging from 8 to 4, with higher scores indicating greater impairment/challenges.

RBQ-3 is a 20-item self-report questionnaire that measures of restricted and repetitive behaviours and interests (RRBIs). All items are scored on a 4-point Likert-type scale ranging from 1 (Never or rarely) to 5 (30 or more times daily/Serious or extreme/Serious or severe).

RBQ-3 Mean Total Score is obtained adding each individual's score of 1, 2, 3 or 4 across every item in the questionnaire. This total is then divided by the number of items completed for each individual. A score of between1-4 is generated. A higher mean score reflects higher level of RRBIS.

The Adult ADHD Self-Report Scale (ASRS) is an 18-item self-report questionnaire designed to assess Attention Deficit Hyperactivity Disorder (ADHD) symptoms in adults.

The ASRS consists of an 18-item scale evaluating the dimensions of inattention and hyperactivity-impulsiveness subtypes of ADHD in adults.

The ASRS full edition consists of nine items that represent symptoms related to inattention (items 1-4 and 7-11), and nine items assessing symptoms of hyperactivity-impulsiveness (items 5-6 and 12-18). Each of the items is scored on a five-point Likert rating scale with 0="never", 1="rarely", 2="sometimes", 3="often", and 4="very often" based on the participant's experiences over the last 6 months. A high score indicates a greater severity of self-reported ADHD symptoms.

Assessments will comprise ratings of the previous 1-month period.

The SSPA is a performance-based test, that measure social behaviour. SSPA consists of two communication scenarios: One that involves the participants introducing themselves to a new neighbour and one that involves the participants requesting their landlord to fix a leak after the landlord had previously agreed to fix the leak but had never completed the task.

The test is measuring both social competence and appropriateness and is scored on 17 items in total.

All items are rated on a five-point (1-5) scale, with 1 as the lowest and 5 as the highest score.

In scenario one the minimum score is 1*8=8. The maximum score: 5*8=40.

In scenario two, the minimum score: 1*9=9. Maximum score: 5*9=45.

The SSPA Total score ranges from 17 to 85. Higher scores reflect higher social competence and appropriateness.

WHO-5 is a self-report questionnaire assessing subjective psychological well-being. The questionnaire consists of 5 items and is scored from 0 (At no time) to 5 (all of the time).

The total raw score, ranging from 0 to 25, is multiplied by 4 to give the final score, with 0 representing the worst imaginable well-being and 100 representing the best imaginable well-being.

GSE is a self-report questionnaire assessing perceived self-efficacy. GSE consists of 10 items rated on a Likert scale ranging from 1 (not at all true) to 4 (exactly true). Higher scores indicate greater self-efficacy. Total score ranges from 10 to 40.

EQ-5D is a self-report questionnaire measuring health-related quality of life. The questionnaire is a description of the subject's current health in 5 dimensions i.e., mobility, self-care, usual activities, pain/discomfort and anxiety/depression. The subject is asked to grade their own current level of function in each dimension into one of three degrees of disability (severe, moderate or none). The combination of these with the conditions "death" and "unconscious" enables description of 245 different health states.

The EQ-5D will be used for health outcomes studies and economic analyses

PSP is a a semi-structured interview assessing daily life social functioning in the domains social relations, job/education, personal hygiene, aggressive behaviour.

Scores ranging from 1-100, with a score of 100 reflecting the best personal and social functioning

DACOBS is a self-report questionnaire measuring cognitive biases. 42 Items are rated on a 7-point Likert scale, ranging from 1 (Strongly disagree) to 7 (Strongly agree) with higher scores indicating more strongly held cognitive biases.

Total scores ranging from 42-294.

The TASIT-S is a measure of emotion perception and Theory of Mind.

The TASIT-S part 2 Social Inference - Minimal is a Theory of Mind task, that is comprised of 9 video clips depicting sincere (4 items) and sarcastic interactions (5items) between two actors.

For each video 4-items is scored. Total scores ranging from 4*0 = 0 to 4*9=36.

BRIEF-A is a self-report questionnaire, that includes 75 items assessing executive function. Participants rate whether a specific behavior is a problem on a 3-point Likert scale (0 = Never, 1 = Sometimes, 2 = Often). The global score (General Executive Function) ranges from 0-225. Higher scores indicate more problems with executive functioning.

CSQ is an 8 item self-report measuring client satisfaction with the intervention. All items are scored on a 4-point Likert scale ranging from bad (1) to excellent (4). Higher scores indicate higher satisfaction.

NEQ is a 32-item self-report questionnaire measuring negative events and outcomes in the participants life during the intervention period.

All items are rated on a 5-point Likert scale ranging from 0 (not at all) to 4 (very much). Higher score reflects higher rate of negative events.

MPS-MSDV is a self-report questionnaire measuring presence in virtual reality. The modified, shortened Danish Version consist of 10 selected items scored on a 5-point Likert Scale ranging from 1 (Strongly disagree) to 5 (Strongly agree). Higher scores reflect higher degree of presence in Virtual Reality. The MPS-MSDV will be administered only to participants in the experimental group.

SSQ is a is a self-report questionnaire measuring simulator sickness. The SSQ consist of 16 items rated on a 4-point Likert Scale ranging from 0 (none) to 3 (severe). Higher scores reflect higher degree of simulator sickness related to being exposed to virtual reality. The SSQ will be administered only to participants in the experimental group.

RTQ is a 6-item self-report questionnaire measuring the participants positive attitude and preparedness to enter therapy for the purpose of resolving problems. Each item is scored on a 5-point Likert scale ranging from strongly disagree (0) to strongly agree (4). Item 2, 3 and 6 are reversed scored. A higher score indicated greater readiness for therapy. The RTQ will be administered only to participants in the experimental group.

I-VAS assess level of insight into challenges related to social interaction. Participants and therapists will indicate, on a scale from 1 to 10, the extent to which the intervention has increased the participant's awareness of their challenges with social interaction, with 1 representing no increased awareness and 10 indicating the highest possible increase in awareness. I-VAS will be administered by the therapists in the intervention and only to participants in the experimental group upon completion of the intervention.