Discussion
anxiety, cognitive and behavioral avoidance, cognitive and behavioral inflexibility, psychiatric, depressive symptoms, autistic, reduced psychological inflexibility, SRS, autism
SECONDARY
The current randomized controlled pilot study evaluated the feasibility and preliminary effectiveness of an adapted NeuroACT for autistic adults in a psychiatric outpatient setting. Results indicated overall good treatment feasibility, where most participants completed the treatment alongside high treatment credibility ratings and satisfactory measurement fulfillment. Analyses of effects showed statistically significantly improved primary outcomes of perceived stress and quality of life, with moderate to large effect sizes, in the NeuroACT group compared with the TAU group. In the secondary outcomes, reduced psychological inflexibility, cognitive fusion, cognitive and behavioral avoidance, and AM were statistically significant, with moderate to large effect sizes, in the NeuroACT group compared with the TAU group. Moreover, clinically significant changes in perceived stress and quality of life were observed in favor of the NeuroACT group compared with the TAU group. However, no statistically significant differences were observed between the two groups in depressive symptoms, anxiety, sleep problems, the second quality of life measure, functional impairment, social aspects of autism, or executive difficulties. Furthermore, dropout rates were slightly higher in the NeuroACT group compared with the TAU group. Where significant changes were found, the largest effect sizes were noticed in perceived stress, cognitive and behavioral avoidance, and cognitive fusion (Cohen’s To our knowledge, this is the first RCT to indicate that autistic adults with high perceived stress and reduced quality of life could benefit from ACT. The improvements in several outcomes are in line with research on CBT and mindfulness practice for autistic adults, suggesting that psychological treatments could positively influence mental health and improve quality of life (The overall significant interaction effect of the SWLS but not the QOLI, both measuring quality of life, may be associated with the more durable sub-areas of the QOLI, such as economic status, neighborhood well-being, and family-related concerns. The SWLS measures subjective quality of life and overall well-being, potentially reflecting a more general sense of meaning and purpose than the QOLI. Replication studies and prolonged follow-up might further evaluate the eventual effects of using these instruments in autistic adults.While no statistically significant changes were observed in social aspects of autism, such as social cognition, social awareness, or communication, significant improvements were found in AM, related to cognitive and behavioral inflexibility. The finding is in line with research on modified CBT for autistic individuals, which has observed changes in the SRS subscales of social motivation and AM but not overall social functioning (Moreover, in ACT for autistic individuals, the goal is not to “treat autism,” but to alleviate some core challenges that are thought to be exacerbated by mental health problems. ACT aims to change how the individual perceives his or her autistic functioning. By doing this, the individual may be able to act more flexibly in the presence of autism. Consequently, the observed changes in one subscale of the self-rated version of the SRS, as a result of the intervention, may reflect an altered perception but not necessarily an actual change in autistic core difficulties. Future studies may further evaluate these two treatment approaches in autistic individuals; social skills training, developing skills to handle thoughts and emotions, or a combination of both.Although promising, the current study has limitations. First, a small sample size reduces statistical power and increases the risk of type 2 error. Second, there might be a risk of type 1 error regarding the statistically significant efficacy measures due to the vast number of measures included, increasing the risk of a multiple testing effect. However, several outcome measures’ changes align with previous research, suggesting that the results do not depend just on chance. Third, the outcome measures relied on participant’s self-report, and no objective or independent criteria were used, increasing the risk of over- or underestimating individual progress. Fourth, the study was conducted within a psychiatric outpatient clinic, so the generalizability outside this setting may be limited. Fifth, the study design did not control for group effects. Therefore, changes observed may not be entirely due to ACT but an effect of the intervention’s group setting. Sixth, the participants included in the study all had average or above-average intellectual capacity, so generalization of the results to autistic adults with lower intellectual capacity cannot be made.