View in EDS HTML Full Text PDF Full Text

Feasibility and Preliminary Efficacy of Behavioral Activation for Treatment of Depression in Autistic Adolescents

Saved in:
Bibliographic Details
Title: Feasibility and Preliminary Efficacy of Behavioral Activation for Treatment of Depression in Autistic Adolescents
Language: English
Authors: Michelle Menezes (ORCID 0000-0003-0155-8367), Christina Burroughs, Jessica Pappagianopoulos, Eleonora Sadikova, Emily Fuhrmann, Genevieve Bohac, Robert Cross, Lauren Witte, Gabrielle Brinkmann, Rachel Lemley, Denis G. Sukhodolsky (ORCID 0000-0002-5401-792X), Micah O. Mazurek (ORCID 0000-0001-7715-6538)
Source: Autism: The International Journal of Research and Practice. 2024 28(12):3021-3032.
Availability: SAGE Publications. 2455 Teller Road, Thousand Oaks, CA 91320. Tel: 800-818-7243; Tel: 805-499-9774; Fax: 800-583-2665; e-mail: journals@sagepub.com; Web site: https://sagepub.com
Peer Reviewed: Y
Page Count: 12
Publication Date: 2024
Document Type: Journal Articles
Reports - Research
Descriptors: Behavior Modification, Outcomes of Treatment, Depression (Psychology), Autism Spectrum Disorders, Adolescents, Intervention, Program Evaluation, Mental Health, Symptoms (Individual Disorders), Anxiety, Interpersonal Competence, Children, Child Behavior
Assessment and Survey Identifiers: Childrens Depression Inventory, Wechsler Abbreviated Scale of Intelligence, Social Skills Improvement System Rating Scales
DOI: 10.1177/13623613241252470
ISSN: 1362-3613
1461-7005
Abstract: Depression is common among autistic youth and is associated with worse quality of life in this group. Despite significant need for high-quality efficacious treatments, there has been very limited research on interventions for depression in autistic youth. This single-arm pilot study examined the feasibility and preliminary efficacy of a novel, behavior-based approach for treatment of depression symptoms in autistic adolescents without intellectual disability (i.e. Behavioral Activation for Autistic Adolescents, BA-A). BA-A is an individually delivered manualized 12-session treatment that utilizes established BA strategies and incorporates common mental health treatment adaptations for autistic young people. Of the 18 youth (11-16 years old) who enrolled, 15 completed all 12 treatment sessions, as well as pre-treatment, post-treatment, and follow-up assessment visits. Clinician treatment fidelity was quite high. Paired sample t-tests found that depression symptoms decreased pre- to post-BA-A according to multiple informants (i.e. self, caregiver, and independent evaluator), and treatment gains were maintained at 1-month follow-up. Paired sample t-tests also found that caregiver-reported anxiety symptoms and social skills improved pre-treatment to post-treatment. The results, although preliminary, indicate that BA-A may improve depression symptoms in autistic youth without intellectual disability. Furthermore, these promising findings suggest that a randomized controlled trial of BA-A is warranted.
Abstractor: As Provided
Entry Date: 2024
Accession Number: EJ1449942
Database: ERIC
Full text is not displayed to guests.
FullText Links:
  – Type: pdflink
    Url: https://content.ebscohost.com/cds/retrieve?content=AQICAHj0k_4E0hTGH8RJwT4gCJyBsGNe_WN95AvKlDbXJGqwxwEyJt9JzC_jyXJKHsBunjdhAAAA4jCB3wYJKoZIhvcNAQcGoIHRMIHOAgEAMIHIBgkqhkiG9w0BBwEwHgYJYIZIAWUDBAEuMBEEDJEscUWS6wDN21eCdAIBEICBmrMtEs5B7Jwg0xHzkEmhp_NZ69ANMZtPQUI6Nd5JEj80CvqzbIxYejifQo4mn6MvQVWWpsi2pcgUQG_Z-kHefjP6IwG5QVpoA15ZmugMoKIFTPnwQt1HRSlaow_V1ld23K5-5y8tr0wPla-tvaUT_jjaw4LpmYKJNL7GjXEoihKmETWgZlzfoAnSOJuYoSi9T-kA9HigKkNVXS0=
Text:
  Availability: 1
  Value: <anid>AN0180988100;f9d01dec.24;2024Nov22.02:17;v2.2.500</anid> <title id="AN0180988100-1">Feasibility and preliminary efficacy of behavioral activation for treatment of depression in autistic adolescents </title> <p>Depression is common among autistic youth and is associated with worse quality of life in this group. Despite significant need for high-quality efficacious treatments, there has been very limited research on interventions for depression in autistic youth. This single-arm pilot study examined the feasibility and preliminary efficacy of a novel, behavior-based approach for treatment of depression symptoms in autistic adolescents without intellectual disability (i.e. Behavioral Activation for Autistic Adolescents, BA-A). BA-A is an individually delivered manualized 12-session treatment that utilizes established BA strategies and incorporates common mental health treatment adaptations for autistic young people. Of the 18 youth (11–16 years old) who enrolled, 15 completed all 12 treatment sessions, as well as pre-treatment, post-treatment, and follow-up assessment visits. Clinician treatment fidelity was quite high. Paired sample t -tests found that depression symptoms decreased pre- to post-BA-A according to multiple informants (i.e. self, caregiver, and independent evaluator), and treatment gains were maintained at 1-month follow-up. Paired sample t -tests also found that caregiver-reported anxiety symptoms and social skills improved pre-treatment to post-treatment. The results, although preliminary, indicate that BA-A may improve depression symptoms in autistic youth without intellectual disability. Furthermore, these promising findings suggest that a randomized controlled trial of BA-A is warranted. This trial was pre-registered at ClinicalTrials.gov (NCT05018169). Depression is common among autistic youth and has a significant negative impact on quality of life and day-to-day functioning. Despite great need for efficacious treatments, there are currently limited research-supported interventions for depression symptoms in autistic young people. This study tested a novel, behavior-based approach or psychotherapy for treatment of depression symptoms in autistic adolescents without intellectual disability (i.e. Behavioral Activation for Autistic Adolescents, BA-A) with 15 youth (11–16 years old). BA-A is an individually delivered 12-session therapy that was developed for and to meet the needs of autistic youth with depression. Results found that autistic youth and their caregivers were able to participate in BA-A therapy sessions, and clinicians were able to deliver BA-A in accordance with the treatment manual. Notably, results demonstrated that autistic youth depression symptoms significantly improved after participating in BA-A. Furthermore, anxiety symptoms and social skills significantly improved following BA-A.</p> <p>Keywords: anxiety; autism spectrum disorders; depression; interventions—psychosocial/behavioral; psychiatric comorbidity</p> <p>Most autistic[<reflink idref="bib5" id="ref1">5</reflink>] individuals meet criteria for one or more mental health conditions, such as depression ([<reflink idref="bib26" id="ref2">26</reflink>]; [<reflink idref="bib40" id="ref3">40</reflink>]). Characterized by debilitative sadness and lack of interest or pleasure ([<reflink idref="bib2" id="ref4">2</reflink>]), depressive disorders (e.g. major depressive disorder) are prevalent among autistic youth ([<reflink idref="bib21" id="ref5">21</reflink>]; [<reflink idref="bib26" id="ref6">26</reflink>]). Autistic youth are at greater risk for depression than their neurotypical peers ([<reflink idref="bib21" id="ref7">21</reflink>]; [<reflink idref="bib40" id="ref8">40</reflink>]). In addition, depression symptoms have significant negative impacts on day-to-day functioning and quality of life for children and adolescents on the autism spectrum ([<reflink idref="bib25" id="ref9">25</reflink>]); and are associated with many physical and psychological problems ([<reflink idref="bib40" id="ref10">40</reflink>]; [<reflink idref="bib53" id="ref11">53</reflink>]), including insomnia ([<reflink idref="bib53" id="ref12">53</reflink>]), anxiety ([<reflink idref="bib23" id="ref13">23</reflink>]), and suicidality ([<reflink idref="bib33" id="ref14">33</reflink>]; [<reflink idref="bib61" id="ref15">61</reflink>]). Critically, depression symptom severity may be the most significant predictor of suicidal behavior in young people with autism ([<reflink idref="bib33" id="ref16">33</reflink>]), and suicide is a leading cause of premature death for autistic individuals ([<reflink idref="bib18" id="ref17">18</reflink>]). Therefore, effective treatment of depression in this population is crucial.</p> <p>Despite the importance of this issue, there is currently very limited evidence on the efficacy of treatment for depression in youth on the autism spectrum ([<reflink idref="bib39" id="ref18">39</reflink>]; [<reflink idref="bib66" id="ref19">66</reflink>]). Several studies have investigated the potential efficacy of cognitive-behavioral therapy (CBT; e.g. [<reflink idref="bib28" id="ref20">28</reflink>]; [<reflink idref="bib38" id="ref21">38</reflink>]; [<reflink idref="bib57" id="ref22">57</reflink>]), but results have been mixed ([<reflink idref="bib39" id="ref23">39</reflink>]; [<reflink idref="bib66" id="ref24">66</reflink>]). As some autistic youth have difficulty with metacognition and identifying emotion-related thoughts ([<reflink idref="bib7" id="ref25">7</reflink>]; [<reflink idref="bib16" id="ref26">16</reflink>]), identification and disputing of irrational or maladaptive thoughts (as in CBT) may be challenging and less effective for this group of autistic youth ([<reflink idref="bib13" id="ref27">13</reflink>]). As some traditional CBT approaches may not be neurodivergence-informed and well-matched for autistic youth, a recent study by Schwartzman and colleagues (2023) sought to address this. Their community-guided single-arm trial of group-based CBT targeted emotion dysregulation and negative self-esteem to reduce depression symptoms in autistic 11- to 17-year-olds ([<reflink idref="bib60" id="ref28">60</reflink>]). Intervention content included emotion recognition and regulation through relaxation exercises, improving self-esteem through cognitive reappraisal of cognitive distortions, and applying emotion regulation and self-esteem skills in social situations. Results indicate preliminary efficacy for this group-based CBT approach. Nonetheless, more research is needed. Depression intervention research with autistic youth has been quite limited.</p> <p>In addition, as autistic youth vary greatly in their cognitive, communication, and behavioral presentations (which likely influences treatment preferences), there remains a need to explore other treatment modalities for reducing depression symptoms among autistic youth. Some clinicians and researchers have proposed that behavior-based approaches, such as behavioral activation (BA), may hold promise for treating depression among youth with autism ([<reflink idref="bib48" id="ref29">48</reflink>]; [<reflink idref="bib59" id="ref30">59</reflink>]). As youth on the spectrum may benefit from an increased emphasis on behavioral change to improve mood as opposed to cognitive techniques, exploration of the potential efficacy of BA to reduce depression symptomatology among autistic youth is needed.</p> <p>BA assumes that individuals feel depressed when too few of their interactions with their environment yield positive outcomes (e.g. pleasure and a sense of achievement) and when too many of their interactions with their environment yield negative outcomes ([<reflink idref="bib13" id="ref31">13</reflink>]). Therefore, the goal of BA therapy is to increase the individual's engagement in activities that result in pleasure and/or align with personal values, and to decrease their engagement in activities that maintain low mood ([<reflink idref="bib11" id="ref32">11</reflink>]; [<reflink idref="bib13" id="ref33">13</reflink>]). To achieve this, clinicians may utilize a variety of behavioral strategies, including monitoring of activities and mood, activity scheduling, instruction in relaxation, and social skills training ([<reflink idref="bib11" id="ref34">11</reflink>]; [<reflink idref="bib13" id="ref35">13</reflink>]). Although the aforementioned therapeutic techniques are not specific to BA, the approach is defined by its reliance on behavioral principles and particular focus on behavior change ([<reflink idref="bib13" id="ref36">13</reflink>]). Meta-analytic data indicate that BA is an effective treatment for depression in neurotypical adults ([<reflink idref="bib11" id="ref37">11</reflink>]; [<reflink idref="bib22" id="ref38">22</reflink>]; [<reflink idref="bib35" id="ref39">35</reflink>]) and youth ([<reflink idref="bib32" id="ref40">32</reflink>]; [<reflink idref="bib62" id="ref41">62</reflink>]). In addition, meta-analyses have found that BA is as effective as CBT in improving depression symptoms in neurotypical individuals ([<reflink idref="bib22" id="ref42">22</reflink>]; [<reflink idref="bib35" id="ref43">35</reflink>]).</p> <p>While BA is considered an effective treatment for depression among neurotypical individuals, Bal and colleagues (2023) suggest BA may need to be adapted for autistic people. They describe that many people on the spectrum experience a disconnect between daily activities and mood, which challenges the positive reinforcement mechanism underlying BA. Thus, greater understanding of how specific activities counter depression through reward mechanisms is important; value-guided and goal-directed activities should be emphasized over purely enjoyable activities. Nonetheless, many characteristics of BA appear well-suited for autistic youth. As executive functioning challenges are common for autistic youth and can hinder the generation and planning of new activities ([<reflink idref="bib51" id="ref44">51</reflink>], [<reflink idref="bib52" id="ref45">52</reflink>]) BA may reduce cognitive demands and provide structure while expanding activities that produce positive emotions ([<reflink idref="bib55" id="ref46">55</reflink>]). Furthermore, BA teaches skills and strategies that may increase the likelihood of obtaining environmental reinforcement and positive outcomes for behavior ([<reflink idref="bib13" id="ref47">13</reflink>]). This includes identifying activities that increase one's sense of purpose or identity, contribution to society, and social connectedness with others to reduce feelings of loneliness or isolation ([<reflink idref="bib3" id="ref48">3</reflink>]).</p> <p>Despite its promise as a potentially effective therapeutic approach for autistic youth, there have been no previous studies of the efficacy of BA in this group. However, the preliminary results from a pilot trial of BA in autistic adults are promising, indicating that BA is feasible and acceptable as a treatment for depression symptoms for adults on the autism spectrum. Russell and colleagues (2020) developed a BA-based intervention for autistic adults with depression and conducted a pilot randomized controlled trial (RCT) comparing BA to treatment as usual (TAU). Although efficacy was not reported (the trial was not powered to detect differences between treatment groups), findings reveal good feasibility and acceptability ([<reflink idref="bib19" id="ref49">19</reflink>]; [<reflink idref="bib56" id="ref50">56</reflink>]). Attrition was lower in BA than TAU with 86% (<emph>n</emph> = 30/35) of participants in the BA group having attended the pre-defined dose of five sessions of treatment and 71% (<emph>n</emph> = 25/35) having attended all nine treatment sessions ([<reflink idref="bib56" id="ref51">56</reflink>]). Qualitative evaluation further indicated that BA was preferred over TAU ([<reflink idref="bib19" id="ref52">19</reflink>]). Participants reported appreciating that the intervention was developed for autistic adults, had a concrete and structured approach, and utilized visuals for teaching of concepts ([<reflink idref="bib19" id="ref53">19</reflink>]). These preliminary findings further indicate that BA may be well-suited for autistic adolescents with depression.</p> <hd id="AN0180988100-2">Current study</hd> <p>Given the significant need for evidence-based treatments for depression in youth with autism, and potential promise of BA for this population, the present study aimed to pilot a BA protocol (referred to hereafter as BA-A) for autistic adolescents with clinically significant depression symptoms. The study examined feasibility and preliminary efficacy of BA-A for treatment of depression symptoms in adolescents on the autism spectrum without intellectual disability in a single-arm or open trial. As previous research has indicated an association between depression symptoms and anxiety symptoms ([<reflink idref="bib23" id="ref54">23</reflink>]), and depression symptoms and social skills challenges ([<reflink idref="bib47" id="ref55">47</reflink>]) in autistic youth, changes in anxiety and social skills from pre-treatment to post-treatment and one-month follow-up were examined as exploratory aims and secondary outcomes of interest. Results from this BA pilot trial will directly inform the design of a more rigorous RCT. The sequential progression from pilot study to efficacy trial is aligned with established frameworks for development and testing of behavioral interventions ([<reflink idref="bib9" id="ref56">9</reflink>]; [<reflink idref="bib12" id="ref57">12</reflink>]; [<reflink idref="bib45" id="ref58">45</reflink>]). The present study had the following specific aims: (<reflink idref="bib1" id="ref59">1</reflink>) Investigate feasibility of BA-A participation for autistic youth, (<reflink idref="bib2" id="ref60">2</reflink>) Investigate feasibility of BA-A implementation for therapists, (<reflink idref="bib3" id="ref61">3</reflink>) Examine preliminary efficacy of BA-A for depression symptoms in youth with autism, and (<reflink idref="bib4" id="ref62">4</reflink>) Examine preliminary efficacy of BA-A on secondary outcomes of anxiety and social skills in youth on the autism spectrum. We hypothesized that BA-A participation would be feasible for autistic youth and that that BA-A implementation would be feasible for therapists. Regarding preliminary efficacy, we hypothesized that youth with autism would exhibit improvements in depression symptoms, anxiety symptoms, and social skills at post-treatment and 1-month follow-up as compared to pre-treatment.</p> <hd id="AN0180988100-3">Methods</hd> <p></p> <hd id="AN0180988100-4">Participants and procedures</hd> <p>Adolescents with autism and depression symptoms were recruited from an existing autism research registry, university-affiliated autism clinics, outreach to community organizations (e.g. schools), and social media. Inclusion criteria were (<reflink idref="bib1" id="ref63">1</reflink>) being 10–17 years of age; (<reflink idref="bib2" id="ref64">2</reflink>) having a previous diagnosis of autism by a qualified health care provider (as determined by documentation of autism diagnosis (e.g. autism diagnostic report)); (<reflink idref="bib3" id="ref65">3</reflink>) Children's Depression Inventory, Second Edition (CDI 2; [<reflink idref="bib24" id="ref66">24</reflink>]) parent-report and/or self-report <emph>T</emph>-score ⩾ 65 (if either informant CDI 2 <emph>T</emph>-score was ⩾ 65, inclusion criteria was met; parent-child concordance was not required); (<reflink idref="bib4" id="ref67">4</reflink>) Wechsler Abbreviated Scale of Intelligence, Second Edition (WASI-II; [<reflink idref="bib64" id="ref68">64</reflink>]) Full-Scale IQ, Two-Subtest Form (FSIQ-2) ⩾ 85; (<reflink idref="bib5" id="ref69">5</reflink>) having no significant aggression, psychotic symptoms, manic symptoms, and/or imminent risk of suicide; (<reflink idref="bib6" id="ref70">6</reflink>) for those taking medication for mood, anxiety, and/or behavior, being stable for at least three months and no planned medication changes during study period; (<reflink idref="bib7" id="ref71">7</reflink>) not receiving another psychotherapy during study period; and (<reflink idref="bib8" id="ref72">8</reflink>) the child and at least one caregiver being able to attend and participate in all treatment and assessment visits.</p> <p>A pre-screening phone call was conducted to assess the above inclusion criteria based on caregiver report. If pre-screening suggested that an adolescent may meet criteria for inclusion in the study, the family was invited to participate in an in person visit to determine eligibility. The in person visit included administration of CDI 2 parent-report and self-report, WASI-II FSIQ-2, suicide risk screen/clinical interview, and a background/demographic survey (that included questions about co-occurring conditions) to ensure eligibility. Twenty-three youth on the autism spectrum participated in an (in person) eligibility/baseline assessment visit (see Figure 1). Eighteen youth were enrolled. Reasons for exclusion/non-enrollment were CDI 2 parent-report and self-report <emph>T</emph>-score < 65 (<emph>n</emph> = 2), WASI-II FSIQ-2 < 85 (<emph>n</emph> = 2), and unknown/lost contact before start of treatment/therapy sessions (<emph>n</emph> = 1).</p> <p>DIAGRAM: Figure 1. Modified CONSORT diagram for single-arm trial of BA-A.</p> <p>Fifteen participants completed all 12 therapy sessions of BA-A, as well as pre-treatment, post-treatment, and one-month follow-up assessment visits. One autistic adolescent withdrew after session 1 (reason unknown/lost contact), another withdrew after session 2 (caregiver unable to participate), and a third withdrew after session 6 (time commitment). All assessment visits were conducted by independent evaluators not involved in development and/or implementation of BA-A. Mean age for the final sample of 15 participants was 14.33 years (<emph>SD</emph> = 1.88, range = 11–16; see Table 1). Eighty percent of the sample identified as male (gender) (<emph>n</emph> = 12). Eighty percent of the sample identified as White (<emph>n</emph> = 12). Ten participants completed BA-A in person, and five participants completed BA-A via telehealth. Participants were compensated US$75 after baseline visit, US$50 after post-treatment visit, and US$50 after follow-up visit.</p> <p>Table 1. Sample characteristics (n = 15).</p> <p>Graph</p> <p> <ephtml> <table><colgroup><col align="left" /><col align="char" char="." /></colgroup><thead><tr><th /><th align="left"><italic>M</italic> (<italic>SD</italic>), range/Frequency (<italic>n</italic>)</th></tr></thead><tbody><tr><td>Age</td><td>14.33 (1.88), 11–16</td></tr><tr><td colspan="2">Gender</td></tr><tr><td> Male</td><td>80.00% (12)</td></tr><tr><td> Non-binary</td><td>6.67% (1)</td></tr><tr><td> Other gender identity<xref ref-type="table-fn" rid="tfn1">a</xref></td><td>13.33% (2)</td></tr><tr><td colspan="2">Transgender</td></tr><tr><td> Transgender</td><td>20.00% (3)</td></tr><tr><td> Cisgender</td><td>80.00% (12)</td></tr><tr><td colspan="2">Race</td></tr><tr><td> White</td><td>80.00% (12)</td></tr><tr><td> Black</td><td>6.67% (1)</td></tr><tr><td> Indigenous</td><td>6.67% (1)</td></tr><tr><td> Asian</td><td>6.67% (1)</td></tr><tr><td colspan="2">Ethnicity</td></tr><tr><td> Hispanic or Latino</td><td>13.33% (2)</td></tr><tr><td colspan="2">Caregiver participant</td></tr><tr><td> Biological mother</td><td>93.33% (14)</td></tr><tr><td> Biological father</td><td>6.67% (1)</td></tr><tr><td colspan="2">Household income</td></tr><tr><td> <$50,000</td><td>6.67% (1)</td></tr><tr><td> $50,000–$74,999</td><td>13.33% (2)</td></tr><tr><td> $75,000–$99,999</td><td>13.33% (2)</td></tr><tr><td> ⩾$100,000</td><td>66.67% (10)</td></tr><tr><td colspan="2">Co-occurring mental health diagnoses</td></tr><tr><td> Attention-deficit/hyperactivity disorder (ADHD)</td><td>33.33% (5)</td></tr><tr><td> Anxiety disorder</td><td>46.67% (7)</td></tr><tr><td colspan="2">Medication</td></tr><tr><td> Antidepressant</td><td>40.00% (6)</td></tr><tr><td> Stimulant</td><td>26.67% (4)</td></tr><tr><td> Antipsychotic</td><td>20.00% (3)</td></tr><tr><td> Antihistamine</td><td>13.33% (2)</td></tr><tr><td> Mood stabilizer</td><td>6.67% (1)</td></tr><tr><td colspan="2">Previous therapy for depression</td></tr><tr><td> Yes</td><td>46.67% (7)</td></tr><tr><td> No</td><td>53.33% (8)</td></tr><tr><td>FSIQ</td><td>109.00 (12.80), 89–135</td></tr><tr><td colspan="2">Autism terminology preference</td></tr><tr><td> Autistic adolescent</td><td>13.33% (2)</td></tr><tr><td> Adolescent with autism</td><td>20.00% (3)</td></tr><tr><td> Adolescent on the autism spectrum</td><td>13.33% (2)</td></tr><tr><td> No preference</td><td>53.33% (8)</td></tr></tbody></table> </ephtml> </p> <p>1 One participant identified as transgender female, and one participant identified as transgender.</p> <p>Study procedures were approved by the university Institutional Review Board. Caregivers provided written informed consent, and youth provided verbal assent. This trial was pre-registered at ClinicalTrials.gov (NCT05018169). Community members were not involved in the present study.</p> <hd id="AN0180988100-5">BA-A intervention</hd> <p>The BA-A treatment protocol and accompanying clinician manual and parent and adolescent handbooks were designed specifically for this study by the first author (M.M.) with collaborative guidance from other members of the study team. M.M. completed training in behavioral activation and possesses expertise in autism-adapted mental health treatment. The BA-A protocol was developed based on established BA strategies ([<reflink idref="bib11" id="ref73">11</reflink>]; [<reflink idref="bib13" id="ref74">13</reflink>]), evidence-based social skills training procedures ([<reflink idref="bib20" id="ref75">20</reflink>]; [<reflink idref="bib27" id="ref76">27</reflink>]), and empirically supported therapeutic modifications for youth with autism ([<reflink idref="bib39" id="ref77">39</reflink>]; [<reflink idref="bib41" id="ref78">41</reflink>]; [<reflink idref="bib63" id="ref79">63</reflink>]). Modifications included the following:</p> <p></p> <ulist> <item> Increased depression/emotion psychoeducation with concrete explanations of feelings was included (e.g. "depression is feeling sad and having low energy much of the time) and use of metaphors/abstract concepts was reduced.</item> <p></p> <item> Visuals were included to depict session content (e.g. visual feelings thermometer with numerical ratings (1–10) and associated cartoon facial expressions were used to anchor mood reporting).</item> <p></p> <item> Simplified behavioral tracking forms were provided with times of the day pre-filled out to reduce confusion and documentation demands. Participants listed the activity and associated mood rating.</item> <p></p> <item> A greater focus on social skills training was incorporated, including coaching to identify sources of friends based on the participant's interests, assessing peer acceptance/rejection, steps for entering/leaving in-person and online conversations, and detailed steps for handling disagreements with peers ([<reflink idref="bib27" id="ref80">27</reflink>]).</item> <p></p> <item> Increased opportunities for repetition/practice were integrated to aid skill acquisition and generalization. Each session included a cumulative content review and consistent terminology was used throughout the intervention.</item> <p></p> <item> Caregivers of participants served in a supportive role throughout the intervention to aid the generalization of skills outside of sessions and support homework completion and adaptive coping. At the end of each session, participants described intervention content and associated homework to their parent. BA-A providers were available to parents for trouble-shooting and additional support throughout the BA-A intervention.</item> <p></p> <item> Participants were prompted to discuss areas/topics of special interest each session to increase treatment engagement and provide opportunities for conversation practice.</item> </ulist> <p>BA-A is an individually delivered manualized 12-session intervention with a caregiver support component. Session duration is 60–90 min for the initial session and 45–60 min for all other sessions. Throughout treatment, clinicians meet with the adolescent alone, adolescent and caregiver together, and caregiver alone with the amount of time for each determined by the key elements of the session (e.g. more time spent with caregivers when session focused on parental support of adolescent during treatment). Nonetheless, most sessions are spent predominantly with the adolescent alone (25–35 min).</p> <p>The first BA-A session consists of rapport-building; discussion of treatment expectations; and psychoeducation regarding identifying and labeling emotions, defining and understanding depression, and the BA framework. Participants are introduced to the intervention handbooks (printout/paper format for in person participants and electronic format for telehealth participants), which contains visuals for intervention concepts (e.g. emotions, depression, and mood thermometer) and mood/activity monitoring forms used to track behaviors and associated emotions throughout the course of treatment. Sessions 2–8 adhere to the following structure: review of mood/activity monitoring form (i.e. homework review), review of content and introduction of new intervention concept, and homework discussion and session review. Intervention concepts covered in Sessions 2–8 include behavioral contingencies, identifying enjoyable/important activities, finding sources of friends, values assessment and goal setting, in person and electronic communication, overcoming avoidance and identifying barriers, handling disagreements, problem-solving, coping strategies, and strategies for caregivers to support adolescent depression treatment. Sessions 9–11 are flexibly focused on the practice and application of cumulative intervention concepts, and session 12 consists of information related to relapse prevention and termination (see Table 2).</p> <p>Table 2. Outline of Behavioral Activation for Adolescents with Autism (BA-A) session content.</p> <p>Graph</p> <p> <ephtml> <table><colgroup><col align="left" /><col align="char" char="." /></colgroup><thead><tr><th align="left">Session</th><th align="left">Description of content</th></tr></thead><tbody><tr><td>1</td><td>Depression/Emotion psychoeducation; treatment overview and rationale; activity monitoring</td></tr><tr><td>2</td><td>Activity monitoring; review treatment rationale; parenting strategies (rewards, limiting accommodation)</td></tr><tr><td>3</td><td>Activity monitoring; pleasurable activities; sources of friends</td></tr><tr><td>4</td><td>Activity monitoring; values assessment; goal-setting/activity ranking and selection</td></tr><tr><td>5</td><td>Activity monitoring and scheduling; in person and electronic communication</td></tr><tr><td>6</td><td>Activity monitoring and scheduling; overcoming avoidance; identifying barriers</td></tr><tr><td>7</td><td>Activity monitoring and scheduling; handling disagreements; problem-solving</td></tr><tr><td>8</td><td>Activity monitoring and scheduling; teaching relaxation strategies and adaptive coping skills</td></tr><tr><td>9</td><td>Practice and application of all learned skills</td></tr><tr><td>10</td><td>Practice and application of all learned skills</td></tr><tr><td>11</td><td>Practice and application of all learned skills</td></tr><tr><td>12</td><td>Relapse prevention and termination</td></tr></tbody></table> </ephtml> </p> <p>The BA-A intervention was delivered by four doctoral students (M.M., C.B., J.P., and E.S.) in clinical psychology under supervision of a licensed clinical psychologist (M.O.M.) with expertise in mental health treatment for adolescents on the autism spectrum. All BA-A clinicians had at least a year (range = 1–3) of doctoral-level clinical psychology training in provision of mental health services for autistic youth before implementing the intervention. In addition, all BA-A clinicians completed a 1-day training program led by intervention developer (M.M.) during which clinicians were educated on the treatment framework, BA strategies, and use of the clinician manual and adolescent and caregiver handbooks. BA-A therapists additionally met weekly for group supervision throughout the study. Treatment implementation was assessed by independent raters (i.e. research assistants trained by J.P.) who watched video recordings and completed fidelity checklists for all therapy sessions (see Supplementary Appendix A for sample fidelity checklist). Percent adherence to treatment session components was evaluated.</p> <hd id="AN0180988100-6">Telehealth procedures</hd> <p>Due to COVID-19 infection risk and infection control policies, necessity of physical proximity to the clinic, and more families becoming accustomed to telehealth services, BA-A assessment and treatment visits were conducted in person and via telehealth. All telehealth study visits were conducted through HIPAA-compliant Zoom. Assessment stimuli were presented via screen, and procedures were implemented in line with publisher's guidelines for telepractice. Similarly, all adolescent and caregiver materials included in the BA-A manuals were presented via screen.</p> <hd id="AN0180988100-7">Measures</hd> <p></p> <hd id="AN0180988100-8">Demographic characteristics</hd> <p>Caregivers provided demographic information related to adolescent age, gender, race, ethnicity, co-occurring conditions, and medications, as well as household income via a demographic survey developed for this study.</p> <hd id="AN0180988100-9">Cognitive ability</hd> <p>The Wechsler Abbreviated Scale of Intelligence, Second Edition (WASI-II; [<reflink idref="bib64" id="ref81">64</reflink>]) was utilized to estimate cognitive ability. Participants were administered the Vocabulary and Matrix Reasoning Subtests which comprise the FSIQ-2 composite score. The WASI-II has excellent validity, and it has been validated against other tests of intelligence, including the Wechsler Intelligence Scale for Children ([<reflink idref="bib65" id="ref82">65</reflink>]).</p> <hd id="AN0180988100-10">Depression symptoms</hd> <p></p> <hd id="AN0180988100-11">Children's Depression Inventory</hd> <p>The Children's Depression Inventory, Second Edition (CDI 2; [<reflink idref="bib24" id="ref83">24</reflink>]) includes self-report (CDI 2:SR) and parent-report (CDI 2:P) versions. The CDI-2: SR is a 28-item questionnaire completed by youth 7–17 years old that assesses cognitive, affective, and behavioral depressive symptoms over the previous 2 weeks. Items are rated on a 3-point Likert-type scale. The CDI 2:P contains items that correspond to those on the CDI 2:SR and consists of 17 items rated on a 3-point Likert-type scale. Total <emph>T</emph>-scores on the CDI 2:P and CDI 2:SR ⩾ 65 are considered clinically elevated. Good internal consistency for the CDI 2:P (α = 0.88) and CDI 2:SR (α = 0.91) has been demonstrated in neurotypical youth ([<reflink idref="bib24" id="ref84">24</reflink>]), and the CDI 2 has been utilized as an outcome measure in autism treatment studies ([<reflink idref="bib4" id="ref85">4</reflink>]). Internal consistency (for baseline values) in the current sample was adequate for CDI 2:SR (α = 0.70) and CDI 2:P total scores (α = 0.62).</p> <hd id="AN0180988100-12">Children's Depression Rating Scale, Revised</hd> <p>The Children's Depression Rating Scale, Revised (CDRS-R; [<reflink idref="bib50" id="ref86">50</reflink>]) is a clinician-administered 17-item interview with a child and/or a caregiver. Items are rated on 5-point or 7-point Likert-type scales. As recommended by assessment developers, adolescents and caregivers were interviewed separately for this study, and reported <emph>T</emph>-scores are based on adolescent interview (CDRS-R; [<reflink idref="bib50" id="ref87">50</reflink>]). Total <emph>T</emph>-scores ⩾ 65 are considered clinically elevated. The CDRS-R demonstrates good internal consistency (α = 0.85; [<reflink idref="bib50" id="ref88">50</reflink>]). In addition, it has been frequently used in youth depression treatment studies ([<reflink idref="bib62" id="ref89">62</reflink>]) and utilized in depression research with autistic youth ([<reflink idref="bib34" id="ref90">34</reflink>]). Internal consistency (for baseline values) in the current sample was good (α = 0.80).</p> <hd id="AN0180988100-13">Anxiety symptoms</hd> <p>The parent-report version of the Spence Children's Anxiety Scale (SCAS; [<reflink idref="bib43" id="ref91">43</reflink>]) was utilized to measure anxiety symptoms. This measure consists of 39 items, and respondents endorse symptoms on a 4-point Likert-type scale. As recommended by the assessment developer, raw scores are reported in this study ([<reflink idref="bib43" id="ref92">43</reflink>]). The SCAS has demonstrated good internal consistency (α = 0.89) and strong discriminant validity ([<reflink idref="bib43" id="ref93">43</reflink>]). The SCAS is widely used as an outcome measure in treatment studies with autistic youth (e.g. [<reflink idref="bib8" id="ref94">8</reflink>]; [<reflink idref="bib29" id="ref95">29</reflink>]). Internal consistency (for baseline values) in the current sample was strong for SCAS total score (α = 0.90).</p> <hd id="AN0180988100-14">Social skills</hd> <p>The Social Skills Improvement System (SSIS) Rating Scales (Gresham & Elliot, 2008) includes a 52-item parent-report questionnaire that measures social skills and problem behaviors. The measure is commonly used to evaluate treatment outcomes for social skills training interventions in children and adolescents with autism ([<reflink idref="bib20" id="ref96">20</reflink>]). Standard scores are generated (i.e. with a mean of 100 and a standard deviation of 15) for composite scales (e.g. social skills scale) with higher scores reflecting better overall social functioning. The SSIS has demonstrated construct validity, correlating significantly with other established measures of child social behaviors, and strong internal consistency (α =.94–.96 for composite scales) and test–retest reliability (median <emph>r</emph> = 0.87 for composite scales; Gresham & Elliot, 2008). Internal consistency (for baseline values) in the current sample was strong for SSIS social skills standard score (α = 0.91).</p> <hd id="AN0180988100-15">Data analysis plan</hd> <p>To investigate feasibility of BA-A participation for adolescents with autism, treatment session attendance was examined and percentage of participants that completed the BA-A protocol (i.e. attrition) was calculated. To investigate feasibility of BA-A implementation for therapists, percent adherence of therapists to treatment fidelity checklists was calculated. To examine preliminary efficacy of BA-A, two-tailed matched pairs (within-subject) <emph>t</emph>-tests were utilized to compare pre-treatment to post-treatment and follow-up scores on CDI 2, CDRS-R, SCAS, and SSIS. Effect sizes (Cohen's <emph>d</emph> for paired-samples <emph>t</emph>-test) were additionally calculated.</p> <hd id="AN0180988100-16">Results</hd> <p></p> <hd id="AN0180988100-17">Feasibility of BA-A participation for autistic youth</hd> <p>Of the 18 youth who enrolled, 15 (83.33%) completed all 12 therapy sessions. One autistic adolescent withdrew after session 1 (reason unknown/lost contact), another withdrew after session 2 (caregiver unable to participate), and a third withdrew after session 6 (time commitment). Results indicate that BA-A participation is feasible for adolescents on the autism spectrum.</p> <hd id="AN0180988100-18">Feasibility of BA-A implementation for clinicians</hd> <p>Based on fidelity checklists completed by independent raters for all therapy sessions (including participants who withdrew), average percent adherence to treatment session components was 98.21% (range = 80%–100%; in person completers <emph>M</emph> = 98.68%; telehealth completers <emph>M</emph> = 97.03%). Results demonstrate that treatment fidelity was quite high (across modalities), indicating that BA-A implementation is feasible for clinicians.</p> <hd id="AN0180988100-19">Preliminary efficacy of BA-A for depression symptoms in autistic youth</hd> <p>Paired sample <emph>t</emph>-tests found that self-reported depression symptoms significantly improved pre-treatment (<emph>M</emph> = 63.00, <emph>SD</emph> = 6.27) to post-treatment (<emph>M</emph> = 54.20, <emph>SD</emph> = 5.92, <emph>t</emph> = 4.56, <emph>p</emph> < 0.001) and follow-up (<emph>M</emph> = 51.73, <emph>SD</emph> = 11.30, <emph>t</emph> = 5.04, <emph>p</emph> < 0.001) according to CDRS-R total <emph>T</emph>-score (see Table 3). Similarly, paired sample <emph>t</emph>-tests demonstrated that parent-observed depression symptoms, as measured by CDI 2:P total <emph>T</emph>-score, significantly improved pre-treatment (<emph>M</emph> = 72.47, <emph>SD</emph> = 6.56) to post-treatment (<emph>M</emph> = 61.53, <emph>SD</emph> = 7.35, <emph>t</emph> = 7.63, <emph>p</emph> = < 0.001) and follow-up (<emph>M</emph> = 65.87, <emph>SD</emph> = 10.02, <emph>t</emph> = 2.36, <emph>p</emph> = 0.03). Paired sample <emph>t</emph>-tests further revealed that self-reported depression symptoms, as measured by CDI 2:SR total <emph>T</emph>-score, significantly improved pre- (<emph>M</emph> = 64.53, <emph>SD</emph> = 9.97) to post-treatment (<emph>M</emph> = 58.40, <emph>SD</emph> = 10.82, <emph>t</emph> = 2.99, <emph>p</emph> = 0.01); pre-treatment to follow-up (<emph>M</emph> = 60.33, <emph>SD</emph> = 15.71) CDI 2:SR total <emph>T</emph>-scores were not significantly different (<emph>t</emph> = 1.34, <emph>p</emph> = 0.20). Overall, these preliminary findings suggest that BA-A may be effective for reduction of depression symptoms in adolescents with autism.</p> <p>Table 3. Pre-treatment, post-treatment, and follow-up outcome measures (n = 15).</p> <p>Graph</p> <p> <ephtml> <table><colgroup><col align="left" /><col align="char" char="." /><col align="char" char="." /><col align="char" char="." /><col align="char" char="." /><col align="char" char="." /><col align="char" char="." /></colgroup><thead><tr><th /><th align="left">Pre-treatment<italic>M</italic> (<italic>SD</italic>)</th><th align="left">Post-treatment<italic>M</italic> (<italic>SD</italic>)</th><th align="left">1-month follow-up<italic>M</italic> (<italic>SD</italic>)</th><th align="left">Pre- to post-treatment</th><th align="left">Pre-treatment to 1-month follow-up</th><th align="left">Effect size<xref ref-type="table-fn" rid="tfn3">a</xref></th></tr></thead><tbody><tr><td colspan="7">Depression</td></tr><tr><td> CDRS-R total <italic>T</italic>-score</td><td>63.00 (6.27)</td><td>54.20 (5.92)</td><td>51.73 (11.30)</td><td><italic>t</italic> = 4.56, <italic>p</italic> < 0.001</td><td><italic>t</italic> = 5.04, <italic>p</italic> < 0.001</td><td>1.18</td></tr><tr><td> CDI 2:P total <italic>T</italic>-score</td><td>72.47 (6.56)</td><td>61.53 (7.35)</td><td>65.87 (10.02)</td><td><italic>t</italic> = 7.63, <italic>p</italic> < 0.001</td><td><italic>t</italic> = 2.36, <italic>p</italic> = 0.033</td><td>1.97</td></tr><tr><td> CDI 2:SR total <italic>T</italic>-score</td><td>64.53 (9.97)</td><td>58.40 (10.82)</td><td>60.33 (15.71)</td><td><italic>t</italic> = 2.99, <italic>p</italic> = 0.010</td><td><italic>t</italic> = 1.34, <italic>p</italic> = 0.200</td><td>.77</td></tr><tr><td colspan="7">Anxiety</td></tr><tr><td> SCAS total score</td><td>26.93 (13.67)<xref ref-type="table-fn" rid="tfn4">b</xref></td><td>17.07 (12.03)</td><td>19.86 (13.56)<xref ref-type="table-fn" rid="tfn4">b</xref></td><td><italic>t</italic> = 4.35, <italic>p</italic> < 0.001</td><td><italic>t</italic> = 3.26, <italic>p</italic> = 0.007</td><td>1.16</td></tr><tr><td colspan="7">Social Skills</td></tr><tr><td> SSIS social skills standard score</td><td>75.40 (11.91)</td><td>80.73 (12.84)</td><td>78.29 (11.93)<xref ref-type="table-fn" rid="tfn4">b</xref></td><td><italic>t</italic> = −3.14, <italic>p</italic> = 0.007</td><td><italic>t</italic> = −1.35, <italic>p</italic> = 0.199</td><td>.81</td></tr></tbody></table> </ephtml> </p> <ulist> <item>2 CDRS-R: Children's Depression Rating Scale, Revised; CDI 2:P: Children's Depression Inventory, Second Edition, Parent; CDI 2:SR: Children's Depression Inventory, Second Edition, Self-Report; SCAS: Spence Children's Anxiety Scale, Parent; SSIS: Social Skills Improvement System Rating Scales.</item> <item>3 Pre- to post-treatment Cohen's <emph>d</emph> for paired-samples <emph>t</emph>-test.</item> <item>4 Analyses include participants with complete data on measure (<emph>n</emph> = 14).</item> </ulist> <hd id="AN0180988100-20">Preliminary efficacy of BA-A for anxiety symptoms and social skills challenges in autistic yo...</hd> <p>Paired sample <emph>t</emph>-tests found that anxiety symptoms significantly improved pre-treatment (<emph>M</emph> = 26.93, <emph>SD</emph> = 13.67) to post-treatment (<emph>M</emph> = 17.14, <emph>SD</emph> = 12.48, <emph>t</emph> = 4.35, <emph>p</emph> < 0.001) and follow-up (<emph>M</emph> = 19.62, <emph>SD</emph> = 14.09, <emph>t</emph> = 3.26, <emph>p</emph> = 0.007) according to SCAS total (raw) score (see Table 3). Paired sample <emph>t</emph>-tests also showed that social skills significantly improved pre- (<emph>M</emph> = 75.40, <emph>SD</emph> = 11.91) to post-treatment (<emph>M</emph> = 80.73, <emph>SD</emph> = 12.84, <emph>t</emph> = −3.14, <emph>p</emph> = 0.007) as measured by SSIS social skills standard score; however, differences in social skills were not statistically significant at pre-treatment and 1-month follow-up (<emph>M</emph> = 78.29, <emph>SD</emph> = 11.93, <emph>t</emph> = −1.35, <emph>p</emph> = 0.20).</p> <hd id="AN0180988100-21">Discussion</hd> <p>This study examined the feasibility and preliminary efficacy of a BA treatment for depression symptoms in autistic adolescents (i.e. BA-A) without intellectual disability in a single-arm/open trial. The results provide evidence to support feasibility of BA-A participation for adolescents with autism and their caregivers, as well as feasibility of BA-A implementation for clinicians. These preliminary findings indicate that BA-A may improve depression symptoms in youth on the autism spectrum and suggest that an RCT of the intervention is warranted to test its efficacy using a more rigorous study design.</p> <p>As hypothesized, BA-A was feasible for autistic adolescents without intellectual disability, caregivers, and clinicians. The majority of participants (>80%) completed all therapy sessions. Retention was comparable or superior to other trials of behavioral interventions for autistic youth ([<reflink idref="bib36" id="ref97">36</reflink>], [<reflink idref="bib37" id="ref98">37</reflink>]; [<reflink idref="bib54" id="ref99">54</reflink>]). In addition, clinician adherence to treatment session components (i.e. treatment fidelity/integrity) was high, and well above the generally accepted level of fidelity (i.e. ⩾80%; [<reflink idref="bib6" id="ref100">6</reflink>]).</p> <p>Also aligned with hypotheses, depression symptoms in autistic adolescents decreased pre- to post-BA-A according to multiple informants (i.e. self, caregiver, and independent evaluator), and treatment gains were maintained at 1-month follow-up. This may be because BA-A was developed for and to meet the needs of youth on the autism spectrum and prioritizes behavior change. BA-A is concrete and structured. Metaphors and other abstract concepts were intentionally excluded from BA-A treatment materials, and more concrete explanations of thoughts and feelings were incorporated into the intervention as some young people with autism have difficulty with metacognition and abstract (e.g. emotion-related) processes ([<reflink idref="bib7" id="ref101">7</reflink>]; [<reflink idref="bib16" id="ref102">16</reflink>]). In addition, youth with autism often benefit from structure and routine ([<reflink idref="bib44" id="ref103">44</reflink>]), and BA-A was designed to meet these needs. The therapy protocol is manualized, includes an adolescent handbook, and the sessions and out-of-session homework follow a consistent structure. Furthermore, BA-A focuses most heavily on behavior change with the goal of increasing engagement in activities that are important to the individual (i.e. aligned with personal values) and/or result in pleasure, and decreasing engagement in activities that sustain depressed and low mood. It may be that BA as a construct (i.e. an increase in actions that yield positive outcomes for the individual; [<reflink idref="bib30" id="ref104">30</reflink>]) is the critical component of more comprehensive depression interventions (e.g. CBT; [<reflink idref="bib22" id="ref105">22</reflink>]; [<reflink idref="bib35" id="ref106">35</reflink>]). Studies of depression treatments in neurotypical individuals have indicated that BA is a potential mechanism of action (i.e. basis or reason for treatment effect; [<reflink idref="bib31" id="ref107">31</reflink>]; [<reflink idref="bib58" id="ref108">58</reflink>]). Future research should investigate BA as a potential mechanism of change in depression symptoms pre- to post-BA-A. Investigations of biomarkers of treatment response, such as reward responsivity ([<reflink idref="bib42" id="ref109">42</reflink>]), would also further the field.</p> <p>In addition, social skills in youth on the autism spectrum improved following BA-A. Although social skills were a secondary outcome of interest, social skills were directly targeted in BA-A through social skills training (e.g. instruction in initiating and maintaining conversations). As results from other studies have indicated an association between social skills and depression symptoms in autistic youth ([<reflink idref="bib47" id="ref110">47</reflink>]; [<reflink idref="bib67" id="ref111">67</reflink>]), social skills training may be an important component of a depression intervention for this group. For some autistic youth, an increase in social activation, which is a component of behavioral activation and includes engagement in values-aligned social activities and meaningful relationships ([<reflink idref="bib59" id="ref112">59</reflink>]) may be critical to improvement in depression symptoms. Future depression treatment studies with autistic youth should investigate the possible associations between increased engagement in social activities and feelings of social connectedness (i.e. inclusion, belonging), in addition to overall social skills, and improved depression symptoms. Future studies should also examine autistic youth perspectives of their social engagement, values, and goals, as this study only examined parent-reported social skills (rather than youth-reported social quality and connectedness). In this study, social skills improved from baseline to immediately following BA-A as hypothesized. Nonetheless, contrary to hypotheses, gains in social skills were not sustained at one-month follow-up, suggesting a greater emphasis on maintenance of learned social skills may be needed in BA-A. Future refinements and improvements to the intervention should take this into consideration.</p> <p>Furthermore, anxiety symptoms in adolescents on the autism spectrum decreased from pre-treatment to post-treatment and follow-up as predicted. This may be because anxiety and depression have overlapping features; both are associated with negative affect and cognitive biases ([<reflink idref="bib15" id="ref113">15</reflink>]). In addition, BA increases approach and decreases avoidance behaviors ([<reflink idref="bib13" id="ref114">13</reflink>]), and escape/avoidance maintains and exacerbates anxiety ([<reflink idref="bib5" id="ref115">5</reflink>]; [<reflink idref="bib14" id="ref116">14</reflink>]; [<reflink idref="bib49" id="ref117">49</reflink>]). Although BA-A was not developed to treat anxiety symptoms and findings are preliminary due to the pilot nature of this trial, results indicate that the intervention may improve anxiety, as well as depression.</p> <p>Although the findings of the pilot study are promising and indicate feasibility and preliminary efficacy of the intervention, there are several important limitations that should be noted. First, the pilot trial had a relatively small sample that was predominantly composed of White, cisgender male adolescents with average to above average cognitive ability. The small, non-diverse sample impacted the types of analyses that could be conducted and may limit generalizability of the results. As such, follow-up investigations should recruit a larger sample that is more diverse in terms of gender identity, race, and ethnicity. In addition, future research should investigate whether the intervention may be appropriate for autistic adolescents with intellectual disability. Second, the investigation was a single-arm study. Given the lack of a control group, it is not possible to determine whether participants would have improved over time without participating in BA-A or if scores were affected by social desirability and/or placebo effect. To address these limitations, a large-scale RCT of the intervention with a control condition is needed. In addition, an RCT would allow for mediation analyses to examine a mechanism of action, such as BA as a construct. Third, the intervention was not delivered to all participants in the same format; some participants received the intervention in person and some via telehealth. Factors that may have impacted participant treatment modality included client/family preferences and logistics (e.g. transportation time and costs, access to telecommunications equipment (e.g. webcam), and quality of network connection; [<reflink idref="bib1" id="ref118">1</reflink>]; [<reflink idref="bib46" id="ref119">46</reflink>]). Although prior research has found that psychotherapy targeting depressive symptoms via telehealth is as effective as in person delivery ([<reflink idref="bib1" id="ref120">1</reflink>]; [<reflink idref="bib10" id="ref121">10</reflink>]; [<reflink idref="bib46" id="ref122">46</reflink>]), and results in this study were similar for the treatment modalities (see Supplementary Appendix B), potential differences in delivery across the two treatment formats and benefits and drawbacks of in person versus telehealth for autistic adolescents should be explored in future research. In addition, while the findings of the current study provide evidence to support the feasibility and preliminary efficacy of the intervention, it is also necessary to examine acceptability and appropriateness of the intervention. Furthermore, autistic young people were not involved in the development of BA-A. As such, BA-A would benefit from iterative refinement based on feedback from autistic youth and other vested community members (e.g. caregivers) to maximize future dissemination and implementation, and to ensure autistic perspectives and preferences are incorporated into the manualized protocol.</p> <hd id="AN0180988100-22">Supplemental Material</hd> <p>Graph: Supplemental material, sj-docx-1-aut-10.1177_13623613241252470 for Feasibility and preliminary efficacy of behavioral activation for treatment of depression in autistic adolescents by Michelle Menezes, Christina Burroughs, Jessica Pappagianopoulos, Eleonora Sadikova, Emily Fuhrmann, Genevieve Bohac, Robert Cross, Lauren Witte, Gabrielle Brinkmann, Rachel Lemley, Denis G Sukhodolsky and Micah O Mazurek in Autism</p> <hd id="AN0180988100-23">Supplemental Material</hd> <p>Graph: Supplemental material, sj-docx-2-aut-10.1177_13623613241252470 for Feasibility and preliminary efficacy of behavioral activation for treatment of depression in autistic adolescents by Michelle Menezes, Christina Burroughs, Jessica Pappagianopoulos, Eleonora Sadikova, Emily Fuhrmann, Genevieve Bohac, Robert Cross, Lauren Witte, Gabrielle Brinkmann, Rachel Lemley, Denis G Sukhodolsky and Micah O Mazurek in Autism</p> <ref id="AN0180988100-24"> <title> References </title> <blist> <bibl id="bib1" idref="ref59" type="bt">1</bibl> <bibtext> Acierno R., Gros D. F., Ruggiero K. J., Hernandez-Tejada M. A., Knapp R. G., Lejuez C. W... Tuerk P. W. (2016). Behavioral activation and therapeutic exposure for posttraumatic stress disorder: A noninferiority trial of treatment delivered in person versus home-based telehealth. Depression and Anxiety, 33(5), 415–423.</bibtext> </blist> <blist> <bibl id="bib2" idref="ref4" type="bt">2</bibl> <bibtext> American Psychiatric Association. (2022). Diagnostic and statistical manual of mental disorders (5th ed., text rev.).</bibtext> </blist> <blist> <bibl id="bib3" idref="ref48" type="bt">3</bibl> <bibtext> Bal V. H., Wilkinson E., Glascock V., Hastings R. P., Jahoda A. (2023). Mechanisms of change in behavioral activation: Adapting depression treatment for autistic people. Cognitive and Behavioral Practice, 30(4), 589–596.</bibtext> </blist> <blist> <bibl id="bib4" idref="ref62" type="bt">4</bibl> <bibtext> Becker J. L., Rogers E. C., Burrows B. (2017). Animal-assisted social skills training for children with autism spectrum disorders. Anthrozoös, 30(2), 307–326.</bibtext> </blist> <blist> <bibl id="bib5" idref="ref1" type="bt">5</bibl> <bibtext> Beckers T., Craske M. G. (2017). Avoidance and decision making in anxiety: An introduction to the special issue. Behaviour Research and Therapy, 96, 1–2.</bibtext> </blist> <blist> <bibl id="bib6" idref="ref70" type="bt">6</bibl> <bibtext> Borrelli B. (2011). The assessment, monitoring, and enhancement of treatment fidelity in public health clinical trials. Journal of Public Health Dentistry, 71, S52–S63.</bibtext> </blist> <blist> <bibl id="bib7" idref="ref25" type="bt">7</bibl> <bibtext> Carpenter K. L., Williams D. M. (2023). A meta-analysis and critical review of metacognitive accuracy in autism. Autism, 27(2), 512–525.</bibtext> </blist> <blist> <bibl id="bib8" idref="ref72" type="bt">8</bibl> <bibtext> Clarke C., Hill V., Charman T. (2017). School based cognitive behavioural therapy targeting anxiety in children with autistic spectrum disorder: A quasi-experimental randomised controlled trail incorporating a mixed methods approach. Journal of Autism and Developmental Disorders, 47, 3883–3895.</bibtext> </blist> <blist> <bibl id="bib9" idref="ref56" type="bt">9</bibl> <bibtext> Craig P., Dieppe P., Macintyre S., Michie S., Nazareth I., Petticrew M. (2008). Developing and evaluating complex interventions: The new medical research council guidance. British Medical Journal, 337, 979–983.</bibtext> </blist> <blist> <bibtext> Cuijpers P., Noma H., Karyotaki E., Cipriani A., Furukawa T. A. (2019). Effectiveness and acceptability of cognitive behavior therapy delivery formats in adults with depression: A network meta-analysis. JAMA Psychiatry, 76(7), 700–707.</bibtext> </blist> <blist> <bibtext> Cuijpers P., Van Straten A., Warmerdam L. (2007). Behavioral activation treatments of depression: A meta-analysis. Clinical Psychology Review, 27(3), 318–326.</bibtext> </blist> <blist> <bibtext> Czajkowski S. M., Powell L. H., Adler N., Naar-King S., Reynolds K. D., Hunter C. M... Epel E. (2015). From ideas to efficacy: The ORBIT model for developing behavioral treatments for chronic diseases. Health Psychology, 34(10), 971–982.</bibtext> </blist> <blist> <bibtext> Dimidjian S., Barrera M. Jr. Martell C., Muñoz R. F., Lewinsohn P. M. (2011). The origins and current status of behavioral activation treatments for depression. Annual Review of Clinical Psychology, 7, 1–38.</bibtext> </blist> <blist> <bibtext> Dymond S., Roche B. (2009). A contemporary behavior analysis of anxiety and avoidance. The Behavior Analyst, 32, 7–27.</bibtext> </blist> <blist> <bibtext> Eysenck M. W., Fajkowska M. (2018). Anxiety and depression: Toward overlapping and distinctive features. Cognition and Emotion, 32(7), 1391–1400.</bibtext> </blist> <blist> <bibtext> Grainger C., Williams D. M., Lind S. E. (2014). Metacognition, metamemory, and mindreading in high-functioning adults with autism spectrum disorder. Journal of Abnormal Psychology, 123(3), 650–659.</bibtext> </blist> <blist> <bibtext> Gresham F., Elliott S. N. (2008). Social Skills Improvement System Rating Scales. Pearson.</bibtext> </blist> <blist> <bibtext> Hirvikoski T., Mittendorfer-Rutz E., Boman M., Larsson H., Lichtenstein P., Bölte S. (2016). Premature mortality in autism spectrum disorder. The British Journal of Psychiatry, 208(3), 232–238.</bibtext> </blist> <blist> <bibtext> Horwood J., Cooper K., Harvey H., Davies L., Russell A. (2021). The experience of autistic adults accessing adapted cognitive behaviour therapy: ADEPT (Autism Depression Trial) qualitative evaluation. Research in Autism Spectrum Disorders, 86, 101802.</bibtext> </blist> <blist> <bibtext> Hotton M., Coles S. (2016). The effectiveness of social skills training groups for individuals with autism spectrum disorder. Review Journal of Autism and Developmental Disorders, 3, 68–81.</bibtext> </blist> <blist> <bibtext> Hudson C. C., Hall L., Harkness K. L. (2019). Prevalence of depressive disorders in individuals with autism spectrum disorder: A meta-analysis. Journal of Abnormal Child Psychology, 47, 165–175.</bibtext> </blist> <blist> <bibtext> Jacobson N. S., Dobson K. S., Truax P. A., Addis M. E., Koerner K., Gollan J. K., Gortner E., Prince S. E. (1996). A component analysis of cognitive-behavioral treatment for depression. Journal of Consulting and Clinical Psychology, 64(2), 295–304.</bibtext> </blist> <blist> <bibtext> Kerns C. M., Kendall P. C., Zickgraf H., Franklin M. E., Miller J., Herrington J. (2015). Not to be overshadowed or overlooked: Functional impairments associated with comorbid anxiety disorders in youth with ASD. Behavior Therapy, 46(1), 29–39.</bibtext> </blist> <blist> <bibtext> Kovacs M. (2011). Children's depression inventory (2nd ed.). Multi-Health Systems.</bibtext> </blist> <blist> <bibtext> Kuhlthau K. A., McDonnell E., Coury D. L., Payakachat N., Macklin E. (2018). Associations of quality of life with health-related characteristics among children with autism. Autism, 22(7), 804–813.</bibtext> </blist> <blist> <bibtext> Lai M. C., Kassee C., Besney R., Bonato S., Hull L., Mandy W... Ameis S. H. (2019). Prevalence of co-occurring mental health diagnoses in the autism population: A systematic review and meta-analysis. The Lancet Psychiatry, 6(10), 819–829.</bibtext> </blist> <blist> <bibtext> Laugeson E. A., Frankel F. (2011). Social skills for teenagers with developmental and autism spectrum disorders: The PEERS treatment manual. Routledge.</bibtext> </blist> <blist> <bibtext> Loades M. E. (2015). Evidence-based practice in the face of complexity and comorbidity: A case study of an adolescent with Asperger's syndrome, anxiety, depression, and chronic pain. Journal of Child and Adolescent Psychiatric Nursing, 28(2), 73–83.</bibtext> </blist> <blist> <bibtext> Luxford S., Hadwin J. A., Kovshoff H. (2017). Evaluating the effectiveness of a school-based cognitive behavioural therapy intervention for anxiety in adolescents diagnosed with autism spectrum disorder. Journal of Autism and Developmental Disorders, 47, 3896–3908.</bibtext> </blist> <blist> <bibtext> Manos R. C., Kanter J. W., Busch A. M. (2010). A critical review of assessment strategies to measure the behavioral activation model of depression. Clinical Psychology Review, 30(5), 547–561.</bibtext> </blist> <blist> <bibtext> Martell C., Addis M., Dimidjian S. (2004). Finding the action in behavioral activation: The search for empirically supported interventions and mechanisms of change. In Hayes S. C., Follette V. M., Linehan M. M. (Eds.), Mindfulness and acceptance: Expanding the cognitive-behavioral tradition (pp. 152–167). The Guilford Press.</bibtext> </blist> <blist> <bibtext> Martin F., Oliver T. (2019). Behavioral activation for children and adolescents: A systematic review of progress and promise. European Child & Adolescent Psychiatry, 28(4), 427–441.</bibtext> </blist> <blist> <bibtext> Mayes S. D., Gorman A. A., Hillwig-Garcia J., Syed E. (2013). Suicide ideation and attempts in children with autism. Research in Autism Spectrum Disorders, 7(1), 109–119.</bibtext> </blist> <blist> <bibtext> Mazzone L., Postorino V., De Peppo L., Fatta L., Lucarelli V., Reale L... Vicari S. (2013). Mood symptoms in children and adolescents with autism spectrum disorders. Research in Developmental Disabilities, 34(11), 3699–3708.</bibtext> </blist> <blist> <bibtext> Mazzuchelli T., Kane R., Rees C. (2009). Behavioral activation treatments for depression in adults: A meta-analysis and review. Clinical Psychology: Science and Practice, 16(4), 383–411.</bibtext> </blist> <blist> <bibtext> McCrae C. S., Chan W. S., Curtis A. F., Deroche C. B., Munoz M., Takamatsu S... Mazurek M. O. (2020). Cognitive behavioral treatment of insomnia in school-aged children with autism spectrum disorder: A pilot feasibility study. Autism Research, 13(1), 167–176.</bibtext> </blist> <blist> <bibtext> McCrae C. S., Chan W. S., Curtis A. F., Nair N., Deroche C. B., Munoz M... Mazurek M. O. (2021). Telehealth cognitive behavioral therapy for insomnia in children with autism spectrum disorder: A pilot examining feasibility, satisfaction, and preliminary findings. Autism, 25(3), 667–680.</bibtext> </blist> <blist> <bibtext> McGillivray J. A., Evert H. T. (2014). Group cognitive behavioural therapy program shows potential in reducing symptoms of depression and stress among young people with ASD. Journal of Autism and Developmental Disorders, 44, 2041–2051.</bibtext> </blist> <blist> <bibtext> Menezes M., Harkins C., Robinson M. F., Mazurek M. O. (2020). Treatment of depression in individuals with autism spectrum disorder: A systematic review. Research in Autism Spectrum Disorders, 78, 101639.</bibtext> </blist> <blist> <bibtext> Menezes M., Robinson L., Sanchez M. J., Cook B. (2018). Depression in youth with autism spectrum disorders: A systematic review of studies published between 2012 and 2016. Review Journal of Autism and Developmental Disorders, 5, 370–389.</bibtext> </blist> <blist> <bibtext> Moree B. N., Davis T. E. III. (2010). Cognitive-behavioral therapy for anxiety in children diagnosed with autism spectrum disorders: Modification trends. Research in Autism Spectrum Disorders, 4(3), 346–354.</bibtext> </blist> <blist> <bibtext> Nagy G. A., Cernasov P., Pisoni A., Walsh E., Dichter G. S., Smoski M. J. (2020). Reward network modulation as a mechanism of change in behavioral activation. Behavior Modification, 44(2), 186–213.</bibtext> </blist> <blist> <bibtext> Nauta M. H., Scholing A., Rapee R. M., Abbott M., Spence S. H., Waters A. (2004). A parent-report measure of children's anxiety: Psychometric properties and comparison with child-report in a clinic and normal sample. Behaviour Research and Therapy, 42(7), 813–839.</bibtext> </blist> <blist> <bibtext> O'Nions E., Happé F., Evers K., Boonen H., Noens I. (2018). How do parents manage irritability, challenging behaviour, non-compliance and anxiety in children with autism spectrum disorders? A meta-synthesis. Journal of Autism and Developmental Disorders, 48, 1272–1286.</bibtext> </blist> <blist> <bibtext> Onken L. S., Carroll K. M., Shoham V., Cuthbert B. N., Riddle M. (2014). Reenvisioning clinical science: Unifying the discipline to improve the public health. Clinical Psychological Science, 2(1), 22–34.</bibtext> </blist> <blist> <bibtext> Osenbach J. E., O'Brien K. M., Mishkind M., Smolenski D. J. (2013). Synchronous telehealth technologies in psychotherapy for depression: A meta-analysis. Depression and Anxiety, 30(11), 1058–1067.</bibtext> </blist> <blist> <bibtext> Pascoe M. I., Forbes K., de la Roche L., Derby B., Psaradellis E., Anagnostou E., Nicolson R., Georgiades S., Kelley E. (2023). Exploring the association between social skills struggles and social communication difficulties and depression in youth with autism spectrum disorder. Autism Research, 16, 2160–2171. https://doi.org/10.1002/aur.3015</bibtext> </blist> <blist> <bibtext> Pezzimenti F., Han G. T., Vasa R. A., Gotham K. (2019). Depression in youth with autism spectrum disorder. Child and Adolescent Psychiatric Clinics, 28(3), 397–409.</bibtext> </blist> <blist> <bibtext> Pittig A., Treanor M., LeBeau R. T., Craske M. G. (2018). The role of associative fear and avoidance learning in anxiety disorders: Gaps and directions for future research. Neuroscience & Biobehavioral Reviews, 88, 117–140.</bibtext> </blist> <blist> <bibtext> Poznanski E. O., Mokros H. B. (1996). Children's depression rating scale, revised. Western Psychological Services.</bibtext> </blist> <blist> <bibtext> Pugliese C. E., Anthony L. G., Strang J. F., Dudley K., Wallace G. L., Naiman D. Q., Kenworthy L. (2016). Longitudinal examination of adaptive behavior in autism spectrum disorders: Influence of executive function. Journal of Autism and Developmental Disorders, 46(2), 467–477.</bibtext> </blist> <blist> <bibtext> Pugliese C. E., Wallace G. L., Anthony L. G., Kenworthy L. (2020). Understanding executive function challenges in autism spectrum disorders. In White S. W., Maddox B. B., Mazefsky C. A. (Eds.), The Oxford handbook of autism and co-occurring psychiatric conditions (pp. 305–325). Oxford University Press.</bibtext> </blist> <blist> <bibtext> Richdale A. L., Baglin C. L. (2015). Self-report and caregiver-report of sleep and psychopathology in children with high-functioning autism spectrum disorder: A pilot study. Developmental Neurorehabilitation, 18(4), 272–279.</bibtext> </blist> <blist> <bibtext> Rozenblat S., Shimshoni Y., Lebowitz E. R., Perez M., Koller J. (2023). A pilot trial of SPACE (Supportive Parenting for Anxious Childhood Emotions) in autism. Child Psychiatry & Human Development. Advance online publication. https://doi.org/10.1007/s10578-023-01555-4</bibtext> </blist> <blist> <bibtext> Russell A., Gaunt D., Cooper K., Horwood J., Barton S., Ensum I., Ingham B., Parr J., Metcalfe C., Rai D., Kessler D., Wiles N. (2019). Guided self-help for depression in autistic adults: The ADEPT feasibility RCT. Health Technology Assessment (Winchester, England), 23(68), 1–94. https://doi.org/10.3310/hta23680</bibtext> </blist> <blist> <bibtext> Russell A., Gaunt D. M., Cooper K., Barton S., Horwood J., Kessler D... Wiles N. (2020). The feasibility of low-intensity psychological therapy for depression co-occurring with autism in adults: The Autism Depression Trial (ADEPT)–A pilot randomised controlled trial. Autism, 24(6), 1360–1372.</bibtext> </blist> <blist> <bibtext> Santomauro D., Sheffield J., Sofronoff K. (2016). Depression in adolescents with ASD: A pilot RCT of a group intervention. Journal of Autism and Developmental Disorders, 46, 572–588.</bibtext> </blist> <blist> <bibtext> Santos M. M., Ullman J., Leonard R. C., Puspitasari A. J., Cook J., Riemann B. C. (2019). Behavioral activation as a mechanism of change in residential treatment for mood problems: A growth curve model analysis. Behavior Therapy, 50(6), 1087–1097.</bibtext> </blist> <blist> <bibtext> Schwartzman J. M., Bonner H. R. (2023). Behavioral and social activation in autism and associations with youth depressive symptoms from youth and caregiver perspectives. Journal of Autism and Developmental Disorders. Advance online publication. https://doi.org/10.1007/s10803-023-06039-x</bibtext> </blist> <blist> <bibtext> Schwartzman J. M., Roth M. C., Paterson A. V., Jacobs A. X., Williams Z. J. (2023). Community-guided, autism-adapted group cognitive behavioral therapy for depression in autistic youth (CBT-DAY): Preliminary feasibility, acceptability, and efficacy. Autism. Advance online publication. https://doi.org/10.1177/13623613231213543</bibtext> </blist> <blist> <bibtext> Storch E. A., Sulkowski M. L., Nadeau J., Lewin A. B., Arnold E. B., Mutch P. J... Murphy T. K. (2013). The phenomenology and clinical correlates of suicidal thoughts and behaviors in youth with autism spectrum disorders. Journal of Autism and Developmental Disorders, 43, 2450–2459.</bibtext> </blist> <blist> <bibtext> Tindall L., Mikocka-Walus A., McMillan D., Wright B., Hewitt C., Gascoyne S. (2017). Is behavioural activation effective in the treatment of depression in young people? A systematic review and meta-analysis. Psychology and Psychotherapy: Theory, Research and Practice, 90(4), 770–796.</bibtext> </blist> <blist> <bibtext> Walters S., Loades M., Russell A. (2016). A systematic review of effective modifications to cognitive behavioural therapy for young people with autism spectrum disorders. Review Journal of Autism and Developmental Disorders, 3, 137–153.</bibtext> </blist> <blist> <bibtext> Wechsler D. (2011). Wechsler Abbreviated Scale of Intelligence (2nd ed.). Pearson.</bibtext> </blist> <blist> <bibtext> Wechsler D. (2014). Wechsler Intelligence Scale for Children (5th ed.). Pearson.</bibtext> </blist> <blist> <bibtext> Wichers R., Van der Wouw L., Brouwer M., Lok A., Bockting C. (2023). Psychotherapy for co-occurring symptoms of depression, anxiety and obsessive-compulsive disorder in children and adults with autism spectrum disorder: A systematic review and meta-analysis. Psychological Medicine, 53(1), 17–33.</bibtext> </blist> <blist> <bibtext> Wilkinson E., Rinaldi M. L., Christodulu K. V. (2023). Predicting self-esteem and depressive symptoms from social skills among youth referred for an autism evaluation. Child Psychiatry & Human Development. Advance online publication. https://doi.org/10.1007/s10578-023-01581-2</bibtext> </blist> </ref> <ref id="AN0180988100-25"> <title> Footnotes </title> <blist> <bibtext> The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.</bibtext> </blist> <blist> <bibtext> The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This project was supported by American Psychological Foundation Elizabeth Munsterberg Koppitz Child Psychology Graduate Student Fellowship to Michelle Menezes. Michelle Menezes was affiliated with the University of Virginia at the time of data collection.</bibtext> </blist> <blist> <bibtext> Michelle Menezes</bibtext> </blist> <blist> <bibtext>Graph</bibtext> </blist> <blist> <bibtext>https://orcid.org/0000-0003-0155-8367 Denis G Sukhodolsky</bibtext> </blist> <blist> <bibtext>Graph</bibtext> </blist> <blist> <bibtext>https://orcid.org/0000-0002-5401-792X Micah O Mazurek</bibtext> </blist> <blist> <bibtext>Graph https://orcid.org/0000-0001-7715-6538</bibtext> </blist> <blist> <bibtext> Supplemental material for this article is available online.</bibtext> </blist> <blist> <bibtext> Participants were asked their preferences for identification as an autistic adolescent, adolescent with autism, or adolescent on the autism spectrum (see Table 1). Due to variability in preferences, identification terms are used interchangeably to respect and acknowledge the differing preferences of participants.</bibtext> </blist> </ref> <aug> <p>By Michelle Menezes; Christina Burroughs; Jessica Pappagianopoulos; Eleonora Sadikova; Emily Fuhrmann; Genevieve Bohac; Robert Cross; Lauren Witte; Gabrielle Brinkmann; Rachel Lemley; Denis G Sukhodolsky and Micah O Mazurek</p> <p>Reported by Author; Author; Author; Author; Author; Author; Author; Author; Author; Author; Author; Author</p> </aug> <nolink nlid="nl1" bibid="bib26" firstref="ref2"></nolink> <nolink nlid="nl2" bibid="bib40" firstref="ref3"></nolink> <nolink nlid="nl3" bibid="bib21" firstref="ref5"></nolink> <nolink nlid="nl4" bibid="bib25" firstref="ref9"></nolink> <nolink nlid="nl5" bibid="bib53" firstref="ref11"></nolink> <nolink nlid="nl6" bibid="bib23" firstref="ref13"></nolink> <nolink nlid="nl7" bibid="bib33" firstref="ref14"></nolink> <nolink nlid="nl8" bibid="bib61" firstref="ref15"></nolink> <nolink nlid="nl9" bibid="bib18" firstref="ref17"></nolink> <nolink nlid="nl10" bibid="bib39" firstref="ref18"></nolink> <nolink nlid="nl11" bibid="bib66" firstref="ref19"></nolink> <nolink nlid="nl12" bibid="bib28" firstref="ref20"></nolink> <nolink nlid="nl13" bibid="bib38" firstref="ref21"></nolink> <nolink nlid="nl14" bibid="bib57" firstref="ref22"></nolink> <nolink nlid="nl15" bibid="bib16" firstref="ref26"></nolink> <nolink nlid="nl16" bibid="bib13" firstref="ref27"></nolink> <nolink nlid="nl17" bibid="bib60" firstref="ref28"></nolink> <nolink nlid="nl18" bibid="bib48" firstref="ref29"></nolink> <nolink nlid="nl19" bibid="bib59" firstref="ref30"></nolink> <nolink nlid="nl20" bibid="bib11" firstref="ref32"></nolink> <nolink nlid="nl21" bibid="bib22" firstref="ref38"></nolink> <nolink nlid="nl22" bibid="bib35" firstref="ref39"></nolink> <nolink nlid="nl23" bibid="bib32" firstref="ref40"></nolink> <nolink nlid="nl24" bibid="bib62" firstref="ref41"></nolink> <nolink nlid="nl25" bibid="bib51" firstref="ref44"></nolink> <nolink nlid="nl26" bibid="bib52" firstref="ref45"></nolink> <nolink nlid="nl27" bibid="bib55" firstref="ref46"></nolink> <nolink nlid="nl28" bibid="bib19" firstref="ref49"></nolink> <nolink nlid="nl29" bibid="bib56" firstref="ref50"></nolink> <nolink nlid="nl30" bibid="bib47" firstref="ref55"></nolink> <nolink nlid="nl31" bibid="bib12" firstref="ref57"></nolink> <nolink nlid="nl32" bibid="bib45" firstref="ref58"></nolink> <nolink nlid="nl33" bibid="bib24" firstref="ref66"></nolink> <nolink nlid="nl34" bibid="bib64" firstref="ref68"></nolink> <nolink nlid="nl35" bibid="bib20" firstref="ref75"></nolink> <nolink nlid="nl36" bibid="bib27" firstref="ref76"></nolink> <nolink nlid="nl37" bibid="bib41" firstref="ref78"></nolink> <nolink nlid="nl38" bibid="bib63" firstref="ref79"></nolink> <nolink nlid="nl39" bibid="bib65" firstref="ref82"></nolink> <nolink nlid="nl40" bibid="bib50" firstref="ref86"></nolink> <nolink nlid="nl41" bibid="bib34" firstref="ref90"></nolink> <nolink nlid="nl42" bibid="bib43" firstref="ref91"></nolink> <nolink nlid="nl43" bibid="bib29" firstref="ref95"></nolink> <nolink nlid="nl44" bibid="bib36" firstref="ref97"></nolink> <nolink nlid="nl45" bibid="bib37" firstref="ref98"></nolink> <nolink nlid="nl46" bibid="bib54" firstref="ref99"></nolink> <nolink nlid="nl47" bibid="bib44" firstref="ref103"></nolink> <nolink nlid="nl48" bibid="bib30" firstref="ref104"></nolink> <nolink nlid="nl49" bibid="bib31" firstref="ref107"></nolink> <nolink nlid="nl50" bibid="bib58" firstref="ref108"></nolink> <nolink nlid="nl51" bibid="bib42" firstref="ref109"></nolink> <nolink nlid="nl52" bibid="bib67" firstref="ref111"></nolink> <nolink nlid="nl53" bibid="bib15" firstref="ref113"></nolink> <nolink nlid="nl54" bibid="bib14" firstref="ref116"></nolink> <nolink nlid="nl55" bibid="bib49" firstref="ref117"></nolink> <nolink nlid="nl56" bibid="bib46" firstref="ref119"></nolink> <nolink nlid="nl57" bibid="bib10" firstref="ref121"></nolink>
Header DbId: eric
DbLabel: ERIC
An: EJ1449942
AccessLevel: 3
PubType: Academic Journal
PubTypeId: academicJournal
PreciseRelevancyScore: 0
IllustrationInfo
Items – Name: Title
  Label: Title
  Group: Ti
  Data: Feasibility and Preliminary Efficacy of Behavioral Activation for Treatment of Depression in Autistic Adolescents
– Name: Language
  Label: Language
  Group: Lang
  Data: English
– Name: Author
  Label: Authors
  Group: Au
  Data: <searchLink fieldCode="AR" term="%22Michelle+Menezes%22">Michelle Menezes</searchLink> (ORCID <externalLink term="https://orcid.org/0000-0003-0155-8367">0000-0003-0155-8367</externalLink>)<br /><searchLink fieldCode="AR" term="%22Christina+Burroughs%22">Christina Burroughs</searchLink><br /><searchLink fieldCode="AR" term="%22Jessica+Pappagianopoulos%22">Jessica Pappagianopoulos</searchLink><br /><searchLink fieldCode="AR" term="%22Eleonora+Sadikova%22">Eleonora Sadikova</searchLink><br /><searchLink fieldCode="AR" term="%22Emily+Fuhrmann%22">Emily Fuhrmann</searchLink><br /><searchLink fieldCode="AR" term="%22Genevieve+Bohac%22">Genevieve Bohac</searchLink><br /><searchLink fieldCode="AR" term="%22Robert+Cross%22">Robert Cross</searchLink><br /><searchLink fieldCode="AR" term="%22Lauren+Witte%22">Lauren Witte</searchLink><br /><searchLink fieldCode="AR" term="%22Gabrielle+Brinkmann%22">Gabrielle Brinkmann</searchLink><br /><searchLink fieldCode="AR" term="%22Rachel+Lemley%22">Rachel Lemley</searchLink><br /><searchLink fieldCode="AR" term="%22Denis+G%2E+Sukhodolsky%22">Denis G. Sukhodolsky</searchLink> (ORCID <externalLink term="https://orcid.org/0000-0002-5401-792X">0000-0002-5401-792X</externalLink>)<br /><searchLink fieldCode="AR" term="%22Micah+O%2E+Mazurek%22">Micah O. Mazurek</searchLink> (ORCID <externalLink term="https://orcid.org/0000-0001-7715-6538">0000-0001-7715-6538</externalLink>)
– Name: TitleSource
  Label: Source
  Group: Src
  Data: <searchLink fieldCode="SO" term="%22Autism%3A+The+International+Journal+of+Research+and+Practice%22"><i>Autism: The International Journal of Research and Practice</i></searchLink>. 2024 28(12):3021-3032.
– Name: Avail
  Label: Availability
  Group: Avail
  Data: SAGE Publications. 2455 Teller Road, Thousand Oaks, CA 91320. Tel: 800-818-7243; Tel: 805-499-9774; Fax: 800-583-2665; e-mail: journals@sagepub.com; Web site: https://sagepub.com
– Name: PeerReviewed
  Label: Peer Reviewed
  Group: SrcInfo
  Data: Y
– Name: Pages
  Label: Page Count
  Group: Src
  Data: 12
– Name: DatePubCY
  Label: Publication Date
  Group: Date
  Data: 2024
– Name: TypeDocument
  Label: Document Type
  Group: TypDoc
  Data: Journal Articles<br />Reports - Research
– Name: Subject
  Label: Descriptors
  Group: Su
  Data: <searchLink fieldCode="DE" term="%22Behavior+Modification%22">Behavior Modification</searchLink><br /><searchLink fieldCode="DE" term="%22Outcomes+of+Treatment%22">Outcomes of Treatment</searchLink><br /><searchLink fieldCode="DE" term="%22Depression+%28Psychology%29%22">Depression (Psychology)</searchLink><br /><searchLink fieldCode="DE" term="%22Autism+Spectrum+Disorders%22">Autism Spectrum Disorders</searchLink><br /><searchLink fieldCode="DE" term="%22Adolescents%22">Adolescents</searchLink><br /><searchLink fieldCode="DE" term="%22Intervention%22">Intervention</searchLink><br /><searchLink fieldCode="DE" term="%22Program+Evaluation%22">Program Evaluation</searchLink><br /><searchLink fieldCode="DE" term="%22Mental+Health%22">Mental Health</searchLink><br /><searchLink fieldCode="DE" term="%22Symptoms+%28Individual+Disorders%29%22">Symptoms (Individual Disorders)</searchLink><br /><searchLink fieldCode="DE" term="%22Anxiety%22">Anxiety</searchLink><br /><searchLink fieldCode="DE" term="%22Interpersonal+Competence%22">Interpersonal Competence</searchLink><br /><searchLink fieldCode="DE" term="%22Children%22">Children</searchLink><br /><searchLink fieldCode="DE" term="%22Child+Behavior%22">Child Behavior</searchLink>
– Name: SubjectThesaurus
  Label: Assessment and Survey Identifiers
  Group: Su
  Data: <searchLink fieldCode="SU" term="%22Childrens+Depression+Inventory%22">Childrens Depression Inventory</searchLink><br /><searchLink fieldCode="SU" term="%22Wechsler+Abbreviated+Scale+of+Intelligence%22">Wechsler Abbreviated Scale of Intelligence</searchLink><br /><searchLink fieldCode="SU" term="%22Social+Skills+Improvement+System+Rating+Scales%22">Social Skills Improvement System Rating Scales</searchLink>
– Name: DOI
  Label: DOI
  Group: ID
  Data: 10.1177/13623613241252470
– Name: ISSN
  Label: ISSN
  Group: ISSN
  Data: 1362-3613<br />1461-7005
– Name: Abstract
  Label: Abstract
  Group: Ab
  Data: Depression is common among autistic youth and is associated with worse quality of life in this group. Despite significant need for high-quality efficacious treatments, there has been very limited research on interventions for depression in autistic youth. This single-arm pilot study examined the feasibility and preliminary efficacy of a novel, behavior-based approach for treatment of depression symptoms in autistic adolescents without intellectual disability (i.e. Behavioral Activation for Autistic Adolescents, BA-A). BA-A is an individually delivered manualized 12-session treatment that utilizes established BA strategies and incorporates common mental health treatment adaptations for autistic young people. Of the 18 youth (11-16 years old) who enrolled, 15 completed all 12 treatment sessions, as well as pre-treatment, post-treatment, and follow-up assessment visits. Clinician treatment fidelity was quite high. Paired sample t-tests found that depression symptoms decreased pre- to post-BA-A according to multiple informants (i.e. self, caregiver, and independent evaluator), and treatment gains were maintained at 1-month follow-up. Paired sample t-tests also found that caregiver-reported anxiety symptoms and social skills improved pre-treatment to post-treatment. The results, although preliminary, indicate that BA-A may improve depression symptoms in autistic youth without intellectual disability. Furthermore, these promising findings suggest that a randomized controlled trial of BA-A is warranted.
– Name: AbstractInfo
  Label: Abstractor
  Group: Ab
  Data: As Provided
– Name: DateEntry
  Label: Entry Date
  Group: Date
  Data: 2024
– Name: AN
  Label: Accession Number
  Group: ID
  Data: EJ1449942
PLink https://search.ebscohost.com/login.aspx?direct=true&site=eds-live&db=eric&AN=EJ1449942
RecordInfo BibRecord:
  BibEntity:
    Identifiers:
      – Type: doi
        Value: 10.1177/13623613241252470
    Languages:
      – Text: English
    PhysicalDescription:
      Pagination:
        PageCount: 12
        StartPage: 3021
    Subjects:
      – SubjectFull: Behavior Modification
        Type: general
      – SubjectFull: Outcomes of Treatment
        Type: general
      – SubjectFull: Depression (Psychology)
        Type: general
      – SubjectFull: Autism Spectrum Disorders
        Type: general
      – SubjectFull: Adolescents
        Type: general
      – SubjectFull: Intervention
        Type: general
      – SubjectFull: Program Evaluation
        Type: general
      – SubjectFull: Mental Health
        Type: general
      – SubjectFull: Symptoms (Individual Disorders)
        Type: general
      – SubjectFull: Anxiety
        Type: general
      – SubjectFull: Interpersonal Competence
        Type: general
      – SubjectFull: Children
        Type: general
      – SubjectFull: Child Behavior
        Type: general
      – SubjectFull: Childrens Depression Inventory
        Type: general
      – SubjectFull: Wechsler Abbreviated Scale of Intelligence
        Type: general
      – SubjectFull: Social Skills Improvement System Rating Scales
        Type: general
    Titles:
      – TitleFull: Feasibility and Preliminary Efficacy of Behavioral Activation for Treatment of Depression in Autistic Adolescents
        Type: main
  BibRelationships:
    HasContributorRelationships:
      – PersonEntity:
          Name:
            NameFull: Michelle Menezes
      – PersonEntity:
          Name:
            NameFull: Christina Burroughs
      – PersonEntity:
          Name:
            NameFull: Jessica Pappagianopoulos
      – PersonEntity:
          Name:
            NameFull: Eleonora Sadikova
      – PersonEntity:
          Name:
            NameFull: Emily Fuhrmann
      – PersonEntity:
          Name:
            NameFull: Genevieve Bohac
      – PersonEntity:
          Name:
            NameFull: Robert Cross
      – PersonEntity:
          Name:
            NameFull: Lauren Witte
      – PersonEntity:
          Name:
            NameFull: Gabrielle Brinkmann
      – PersonEntity:
          Name:
            NameFull: Rachel Lemley
      – PersonEntity:
          Name:
            NameFull: Denis G. Sukhodolsky
      – PersonEntity:
          Name:
            NameFull: Micah O. Mazurek
    IsPartOfRelationships:
      – BibEntity:
          Dates:
            – D: 01
              M: 12
              Type: published
              Y: 2024
          Identifiers:
            – Type: issn-print
              Value: 1362-3613
            – Type: issn-electronic
              Value: 1461-7005
          Numbering:
            – Type: volume
              Value: 28
            – Type: issue
              Value: 12
          Titles:
            – TitleFull: Autism: The International Journal of Research and Practice
              Type: main
ResultId 1