The Preliminary Efficacy of Emotion Regulation Skills Training for Autistic Young Adults: A Pilot Study

Abstract

Emotion regulation plays a central role in individuals’ mental health and psychosocial adjustment in life. As autistic youth transition into emerging adulthood, mental health conditions become more apparent due to systemic barriers such as mandatory service disconnection and few available adult services. Accordingly, adequate support and services for young adults on the autism spectrum need to be continued for a smooth transition. Research has found that better emotion regulation skills are associated with better mental health. The current study adapted dialectical behavior therapy emotion regulation skills training and implemented an 8-week group program, which is tailored for autistic young adults. The program is called Skills Improvement on Emotion Regulation for Adults (SIERA), which was modified using feedback from autistic individuals and stakeholders. SIERA was implemented in four groups (n = 19) of autistic young adults. A single-group, pre- and posttest comparison design was used. Autistic young adults who participated in SIERA presented an increase in adaptive emotion regulation skills and psychological flexibility and a decrease in emotion dysregulation. Results indicated that SIERA was an efficacious intervention for autistic young adults in terms of improving emotion regulation skills. Future research directions and implications are also provided.

Community Brief

Why was this program developed?

Emotion regulation is one of the areas in which many autistic individuals present their service needs. Particularly for the young adult population, there are limited resources for emotion regulation. The manualized emotion regulation skills training program was developed based on feedback from autistic individuals, parents, autism researchers, and practitioners to fill the gaps that autistic young adults experience.

What does the program do?

The current program focuses on learning adaptive emotion regulation skills. Specifically, the program teaches dialectical behavior therapy (DBT) emotion regulation skills in which individuals can learn and explore their emotions, increase emotional resilience, and decrease vulnerability. To that end, individuals can strengthen their emotional awareness, increase their emotion regulation skills, and improve their ability to manage difficult emotions.

How did the researchers evaluate the new program?

After developing the program, the researchers ran four intervention groups for 19 participants. To evaluate the program, the researchers collected participants’ psychological flexibility, DBT skills use, tendency to use emotion regulation skills, and emotional distress to compare the program’s efficacy upon completion. In addition, across the eight sessions, the researchers collected a weekly progress checklist before and after each session to monitor participants’ weekly growth.

What were the early findings?

All the participants completed the program (100%) with 99% fidelity. Upon completing the program, participants significantly improved adaptive emotion regulation skills and decreased emotion dysregulation.

What were the weaknesses of this project?

The current program was initially developed to implement with a face-to-face group. After the first group had been completed, face-to-face groups were not feasible due to the outbreak of COVID-19. Subsequently, the remaining groups were implemented in a synchronous online format. Although the study results showed no significant differences between the in-person and synchronous online groups, online group participants expressed Zoom fatigue, which the in-person group did not experience.

What are the next steps?

The next step of this intervention is recruiting more autistic young adult participants to increase the sample size. Then, the intervention will be replicated in various settings where diverse autistic adults are involved, such as community colleges, trade schools, community agencies, and state vocational rehabilitation services, to reflect the heterogeneity of autism.

How will this work help autistic adults now or in the future?

The current study results indicated that participants showed improvement in emotion regulation skills. This program can be helpful for autistic adults by providing opportunities to explore their emotions and learn healthy emotion regulation skills. Consequently, autistic individuals can manage their emotional distress and cope with their emotional challenges in constructive ways. Since the program is manualized, it would also benefit community settings.

Introduction

Emotion regulation refers to an individual’s ability to monitor and modulate one’s emotions as needed,¹ which is often considered within the framework of coping to meet an individual’s personal and social goals.² Ample research has found that emotion regulation is a critical part of life due to its impact on individuals’ social engagement, academic performance, and daily functioning. For instance, individuals with difficulty regulating emotions present more support in establishing and maintaining social relationships.³ Students with better emotion regulation skills are more likely to interact with teachers and peers as well as to present better academic performances.^4,5 Also, the frequent use of adaptive emotion regulation strategies positively impacts individuals’ daily affective experiences.^6,7

The clinical characteristics of autism spectrum disorder (ASD) illustrate the need for various support in an autistic individual’s life domains, including, but not limited to, employment, navigating disability services, academic performance, daily living skills, self-advocacy, and mental health.^8–12 As autistic individuals transition into emerging adulthood, mental health becomes more of a noticeable concern as school-based services (e.g., special instruction, occupational therapy, and speech therapy) are no longer provided once they have exited high school¹³; thus, individuals often feel as though they are “falling off a cliff” afterward. A growing body of research found that deficits in emotion regulation are related to mental health.^10,14–16 According to recent research,¹⁷ autistic individuals are more likely to experience mental health conditions than non-autistic peers. To be more specific, autistic individuals utilize mental health services nine times more than non-autistic individuals due to depression, anxiety, and other psychiatric conditions.¹⁸ Also, nearly 50% of autistic individuals have been prescribed psychiatric medications due to their mental health condition.¹⁹

Importance of emotion regulation for autistic young adults in mental health

Autistic young adults who have co-occurring mental health conditions may need additional support in life.²⁰ For instance, autistic young adults who experience mental health conditions present a greater risk for suicidality and self-injurious behaviors.^21,22 Autistic college students with co-occurring mental health conditions reported the need for interpersonal relationship support to avoid additional social isolation, loneliness, and social stigmatization.^23–25 Moreover, owing to the co-occurring mental health conditions, many autistic young adults experience emotional dysregulation that impacts their daily lives.^26,27 One research further found that autistic youth with accompanying anxiety symptoms showed various emotional dysregulation occurrences such as difficulties with emotional awareness, acceptance, and goal-directed behaviors.²⁸ Many of them also presented feelings of being overwhelmed and needed additional time to soothe elevated emotions.^10,29 The current little support for emotion regulation for autistic young adults leads to an increase in unintended hospitalizations, emergency room visits, and police contact,³⁰ which can be prevented with appropriate services in advance. Yet, access to mental health and emotion regulation services is still lacking for autistic young adults,^31–33 despite they may benefit from learning a greater variety of adaptive coping strategies to minimize the risk of poor mental well-being.^34,35

Dialectical behavior therapy in emotion regulation

Dialectical behavior therapy (DBT) is a comprehensive cognitive and behavioral theory that addresses both acceptance and changes that help individuals learn healthier ways to cope with their intense emotions.^36,37 DBT is typically delivered in a standard format consisting of individual therapy, skills training, a therapist consultation team, and as-needed phone coaching for 48 weeks.³⁶ During the yearlong (48-week) treatment, the skills training introduces the emotion regulation module twice for 7 weeks and is usually delivered in a group format. For each cycle, the emotion regulation module is provided weekly, and every single session lasts 2 and a half hours long.³⁶

A myriad of research provided the efficacy of DBT skills training, particularly in emotion regulation among various disability groups,³⁸ including, but not limited to, eating disorders,³⁹ depression,⁴⁰ and attention deficit hyperactivity disorder.⁴¹ Despite the efficacy of emotion regulation in various disability groups, to the authors’ knowledge, there are only two published studies that addressed emotion regulation for autistic young adults. One unpublished study of a modified DBT skills training reported improvement in autistic adolescents’ emotion dysregulation and social skills.⁴² Another study found a modified DBT emotion regulation group intervention increased cognitive reappraisal and further improved social interactions among autistic young adults.⁴³ This preliminary evidence implies that DBT skills training may be beneficial for supporting autistic people’s emotion regulation and bringing beneficial outcomes to their daily lives. To that end, the present research can add the possibility of strengthening autistic individuals’ emotion regulation by teaching them how to manage their emotions through the practice of adaptive emotion regulation skills in a small group setting.

To supplement the current deficiency in emotion regulation services for autistic young adults, we developed and implemented a program for autistic young adults as 90-minute, eight weekly sessions in a small group format. The program is called Skills Improvement on Emotion Regulation for Adults (SIERA), which was modified based on the DBT^® Skills Training Manual (2nd ed.).³⁶ In this article, we describe how SIERA is grounded in DBT skills training, the process of SIERA, lessons learned from our pilot study results, limitations, implications, and next steps.

Emerging Practice

Development of SIERA

Initially, SIERA was developed by creating the manual, adapted from Linehan’s DBT^® Skills Training Manual (2nd ed.),³⁶ with input from the second author’s research lab members, who are educators/researchers in higher education and previous rehabilitation counseling practitioners. After the initial manual development, a combination of focus groups and individual interviews was conducted with stakeholders (e.g., caregivers of autistic youth, a researcher, and practitioners) and autistic young adults for further manual revision. For the interviews, three autistic young adults, two parents of transition-age autistic youth, three practitioners, and one emotion regulation researcher reviewed the initial draft of the manual and provided suggestions to tailor SIERA to be more autistic user-friendly. The feedback from interviews allowed the first author to make additional minor modifications to the manual before the implementation. The detailed information is further reported in a separate publication.⁴⁴

Resultant modifications

The interviewees expected autistic young adults’ diverse learning styles and comprehension of the concepts of emotion regulation. Thus, they recommended adding more visual learning materials, using concrete language, applying various teaching strategies, and providing a module summary handout to help autistic young adults engage in the SIERA intervention. As a result of interviews with autistic young adults and stakeholders, the SIERA manual was further modified. We added supplementary visual learning materials, simplified figures in Linehan’s DBT skills training manual, deleted jargon, and explained abstract concepts in more concrete descriptions for participants’ understanding. In addition, particular contents (e.g., mindfulness, understanding and naming emotions, and Describe, Express, Assert, Reinforce, Mindfully ask, Appear confident, Negotiate) were added to and/or subtracted from each module for efficient skills learning.

Each session starts with 3 minutes of mindfulness practice with calming music. After the mindfulness practice, homework is reviewed while the main facilitator checks in with each participant as a group. Then, the main concept of the module is explained by the main facilitator in a lecture format with PowerPoint slides (psychoeducation). While the main concept is explained, participants can freely ask questions if the content is unclear. After the psychoeducation, a 10-minute break is provided, and participants are encouraged to stand up and move around. After the break, the group resumes, and the main concept for the session is reviewed one more time. Then, participants engage in hands-on activities (e.g., role play, simulation, and group discussion) on the topic they just learned. The session ends with explaining homework for the week to practice the learned skills on their own; participants complete a weekly progress checklist.

Description of SIERA

As previously mentioned, SIERA is a manualized emotion regulation intervention adapted from DBT skills training that emphasizes teaching individuals how to regulate emotional responses.⁴⁵ To be more specific, SIERA is designed to improve emotion regulation among autistic young adults by teaching adaptive emotion regulation skills based on the DBT^® Skills Training Manual (2nd ed.) with the supervision of the second author. After a series of focus group and individual interviews with autistic young adults and stakeholders, the first author made additional changes to the SIERA manual for autistic individual users.⁴⁴ The reading level of the SIERA manual is the sixth grade level. The SIERA program was delivered in a small group format, consisting of eight weekly sessions. Each session lasts 90 minutes, with a 10-minute break in the middle. Each group comprised three to six participants, and the same two facilitators (one main facilitator and one cofacilitator) led all the intervention groups. The SIERA modules covered the main content of emotion regulation postulated by Linehan’s manual on the goals and comprehension of emotion regulation, as well as the reduction of emotional vulnerability and distress and the increase of emotional resilience.³⁶ Accordingly, SIERA consists of (a) Introduction to Emotion Regulation, (b) Understanding and Naming Emotions I, (c) Understanding and Naming Emotions II, (d) Decreasing Emotional Suffering and Changing Unwanted Emotions, (e) Changing Unwanted Emotions I, (f) Changing Unwanted Emotions II, (g) Increasing Resiliency and Decreasing Emotional Vulnerability I, and (h) Increasing Resiliency and Decreasing Emotional Vulnerability II (refer to Table 1 for SIERA curriculum that includes each session content).

Table 1.

SIERA Curriculum

Session number	Constructs	Content
Week 1	Orientation; Goals and Guidelines; Wise Mind; Introduction to Emotion Regulation	Program overview; goal setting and creating group rules; wise mind practice; emotions; emotion regulation
Week 2	Understanding and Naming Emotions I (Fear, Sadness, and Anger)	Name one’s own emotions; observe one’s own emotions; describe one’s own emotions
Week 3	Understanding and Naming Emotions II (Fear, Sadness, and Anger)	Identify three functions of emotions; HALT; understand myths about emotions
Week 4	TIP skills; Check the Facts	Manage really difficult emotions with skills; check the facts of current emotions
Week 5	Opposite Action	Identify situations that can use “opposite action”; apply seven steps of using “opposite action”
Week 6	Problem Solving	Identify situations that can use “problem solving”; apply seven steps of using “problem solving”
Week 7	ABC skills	Build pleasant emotions (A skills); set up one’s own “mastery level (B skills); rehearse future emotional situations (C skills)
Week 8	PLEASE; DEAR MAN Skills	Take care of body and mind together; communicate one’s desire effectively

ABC, Accumulate positive, Build mastery, Cope ahead; DEAR MAN, Describe, Express, Assert, Reinforce, Mindfully ask, Appear confident, Negotiate; PLEASE, treat Physical illness, balance Eating, Avoid substances, Sleep well, regular Exercise; SIERA, Skills Improvement on Emotion Regulation for Adults; TIP, Tip the temperature, Intense exercise, Paced breathing.

Two of the same facilitators (one main facilitator and one cofacilitator) ran a total of four SIERA groups (n = 3, n = 5, n = 6, n = 5). Each group was run consecutively for 8 weeks from January 2020 to August 2020. The first group was run in a face-to-face format, whereas the remaining three groups were run in a synchronous online format due to the impact of COVID-19. Before the development of SIERA, both facilitators completed a 6-week intensive online DBT skills training provided by the Behavioral Tech Institute. The main facilitator was the first author of this article, who was a PhD student with 5 years of counseling experience in the mental health field. The main facilitator had mental health counseling and psychoeducation experiences with autistic adolescents, adults, and their families. The cofacilitator was the research assistant, who was a senior student in psychology major at the same institution. The cofacilitator also worked as a full-time behavior technician for autistic children at a local autism center.

Evaluation Method

Recruiting autistic young adults

Upon institutional review board (IRB) approval of Michigan State University, SIERA participants were recruited from disability support service centers at universities in the Midwest and East Coast regions, college-affiliated autism centers in the Midwest and East Coast regions, and community disability service organizations in the Midwest. An official invitation letter, a recruitment flyer, and an IRB approval letter were sent via email to request research collaboration. We recruited autistic young adults who need and want to learn about emotion regulation skills voluntarily. Participants contacted the first author via email, phone calls, and text messages to participate in the SIERA program. The inclusion criterion to participate in the study was young adults (aged 18–26) and/or college students who were diagnosed with ASD but with no coexisting intellectual disability. The exclusion criterion was autistic young adults (aged 18–26) who have coexisting severe psychiatric conditions, aggressive behaviors, and/or intellectual disability. A total of 19 participants were recruited. Participants were informed of the opportunity to obtain a $100 online gift card after the completion of the program.

Measures

Acceptance and Action Questionnaire-II

Acceptance and Action Questionnaire-II (AAQ-II)⁴⁶ is designed to measure subjective emotional ability such as psychological flexibility. The AAQ-II consists of seven items, using a 7-point Likert-type rating scale. The average mean score in a clinical population was 28.30 (standard deviation [SD] = 9.90), while in a nonclinical population, it was 18.51 (SD = 7.05). Scores above a range of 24–28 present individuals’ current clinically relevant distress, meaning they have greater psychological inflexibility. The mean Cronbach’s alpha of the AAQ-II was 0.84, ranging from 78 to 0.88.⁴⁶ In this current study, Cronbach’s alpha ranged from 0.82 (presurvey) to 0.88 (postsurvey).

DBT-Ways of Coping Checklist

DBT-Ways of Coping Checklist (DBT‐WCCL)⁴⁷ measures how individuals may have coped with stressful events. The DBT-WCCL has 59 items, using a 4-point Likert-type rating scale consisting of two subscales: the DBT Skills Use Subscales (DSS) and the Dysfunctional Coping Subscale (DCS). The DSS has demonstrated strong internal consistency, with Cronbach’s alpha ranging from 0.91 to 0.96, and the internal consistency of the DCS ranged from 0.87 to 0.93.⁴⁷ In the current study, the internal consistency for DSS was α = 0.91–0.92, and for DCS the range was α = 0.79–0.82.

Emotion Regulation Questionnaire

The Emotion Regulation Questionnaire (ERQ)⁴⁸ is designed to measure respondents’ tendency to regulate their emotions in two ways: (a) cognitive reappraisal and (b) expressive suppression. Cognitive reappraisal is a form of emotion regulation strategy that can change the way of thinking between emotion and the eliciting events.⁴⁹ Expressive suppression is defined as the attempt to hide or inhibit emotions and expressive behavior.⁴⁸ The ERQ consists of 10 items and uses a 7-point Likert-type rating scale. High scores on each subscale indicate individuals’ frequent use of the specific emotion regulation skill. The ERQ is Cronbach’s alpha, ranging from 0.75 to 0.82 in cognitive reappraisal and from 0.68 to 0.76 in expressive suppression.⁴⁸ The Cronbach’s alpha in the present study was α = 0.64–0.68 for cognitive reappraisal and α = 0.63–0.73 for expressive suppression.

Emotion Dysregulation Inventory—Reactivity Short Form and Dysphoria

Emotion Dysregulation Inventory—Reactivity Short Form and Dysphoria (EDI-13)⁵⁰ is a shorter version of the EDI that includes a total of 13 items (reactivity—7 items; dysphoria—6 items). The EDI-13 uses a 5-point Likert scale. High scores on each subscale indicate individuals’ tendency to present specific emotion dysregulation, but no clinical cutoff score exists. Cronbach’s alpha internal consistency was 0.92 for the reactivity and 0.90 for dysphoria.⁵⁰ In this current study, Cronbach’s alpha for reactivity was α = 0.79–0.82 and α = 0.93 for dysphoria.

Weekly progress checklist

The authors created the weekly progress checklist to track participants’ progress after completing each session during the 8 weeks of intervention.

The weekly progress checklist consists of five items that ask about each participant’s (a) session engagement, (b) content understanding, (c) practical utilization of learned skills, (d) mood before today’s session, and (e) mood after today’s session. The weekly progress checklist uses a 5-point Likert-type rating scale (1 = strongly disagree; 2 = disagree; 3 = neutral; 4 = agree; 5 = strongly agree).

Fidelity checklist

To maintain fidelity across the group, the authors created a fidelity checklist to retain the core contents of the intervention. The fidelity checklist consists of four areas: (a) structure and setting, (b) dialectical instruction, (c) experiential activity, and (d) intervention contents. The fidelity checklist was measured by the same cofacilitator throughout the entire research, using a 4-point Likert-type rating scale (NA = not applicable; 0 = did not implemented; 1 = partially implemented; 2 = implemented).

SIERA program satisfaction

To measure participants’ satisfaction with the program, the first author asked a few questions during the focus group interviews that reflected the program’s satisfaction and participants’ lived experiences with SIERA. The questions include: “How satisfied are you with SIERA on a scale of one (very dissatisfied) to five (very satisfied)?” and “Please share any feedback that you want to share.”

Data analysis

Data analyses were conducted using the Statistical Package for the Social Sciences version 25.0 (SPSS Statistics, IBM Corporation, NY, USA). Descriptive statistics were used to present the demographic characteristics of the study participants as well as means (M), SD, and effect sizes of the variables used in this current study. Hedges’ g (n < 20) was reported to indicate the effect sizes.⁵¹ The Bonferroni correction was not used in the current study because SIERA was a preliminary intervention study to evaluate the feasibility and efficacy for autistic young adults with a small sample size.

Results and Lessons Learned

A total of 19 autistic young adults completed SIERA (four groups; three to six participants per group). One participant who completed the program did not fill out the pre- and postintervention surveys, which resulted in a total sample of 18 participants who completed the entire packet of surveys. The mean age of participants was 21.9 years old (SD = 4.16), and the male and female ratio was 50% (n = 9) each. Of the 18 participants, 1 was Asian, 2 were Black, and 15 were White. Most were in college (n = 12; 61.1%), three were in high school/post-high school, and three were self-employed. All participants self-reported that they were diagnosed with ASD with a formal confirmation from a clinical psychologist, school psychologist, and/or medical doctor. See Table 2 for details on the demographics of the participants.

Table 2.

Demographic Characteristics of SIERA Participants

Demographic characteristics	Young adults withASD (n = 18)
Demographic characteristics	n	%
Gender
Female	9	50
Male	9	50
Race
Asian	5.6	1
Black	5.6	1
White	88.8	16
Occupation
High school and post high school	16.7	3
College student	61.1	11
Employed	22.2	4
Professional who diagnosed
Clinical psychologist	33.3	6
Medical doctor	38.9	7
Other (neuropsychologist)	11.1	2
Other (psychologist)	5.6	1
Other (preschool teacher assessment)	5.6	1
Other (don’t remember)	5.6	1
Comorbidity
No	38.9	7
ADHD	22.2	4
Anxiety/general anxiety disorder	16.7	3
Depression	27.8	5
Blind	5.6	1
Cerebral palsy	11.1	2
Developmental delays	5.6	1
Myopia	5.6	1
PTSD	11.1	2
Learning disability	5.6	1
Living arrangement
Living with family members	83.3	15
Own apartment	16.7	3

Participants reported one or more co-occurring conditions.

ADHD, attention-deficit/hyperactivity disorder; ASD, autism spectrum disorder; PTSD, post-traumatic stress disorder.

Comparability of SIERA face-to-face and online group delivery

The SIERA intervention was conducted from January 2020 to August 2020. Due to the impact of COVID-19, the delivery format of the SIERA intervention had to be changed from face-to-face (the first group) to synchronous online (the remaining three groups). To present the magnitude of the effect of two different group modalities, Hedge’s g is reported.⁵¹ Both groups presented small effect sizes in the majority of domains after completing the intervention, meaning the group difference is negligible (see Table 3 for the details).

Table 3.

Comparing Face-to-Face and Synchronous Online Groups

	Premeasure			Postmeasure
	Face to face (n = 3)	Synchronous online (n = 15)	g	Face to face (n = 3)	Synchronous online (n = 15)	g
AAQ-II	24.00 (14.42)	32.35 (5.45)	1.16	23.67 (9.02)	25.27 (8.10)	0.19
DBT-WCCL
DSS	1.40 (0.46)	1.57 (0.53)	0.33	1.72 (0.36)	2.03 (0.45)	0.70
DCS	1.22 (0.41)	1.60 (0.44)	0.87	1.25 (0.10)	1.58 (0.43)	0.82
ERQ
Cognitive reappraisal	3.94 (0.67)	3.99 (1.09)	0.05	4.93 (0.58)	4.97 (0.92)	0.05
Expressive suppression	4.11 (0.25)	4.17 (1.53)	0.04	3.64 (1.32)	3.62 (1.33)	0.02
	Face to face (n = 3)	Synchronous online (n = 10)	g	Face to face (n = 3)	Synchronous online (n = 10)	g
EDI-13
Reactivity	16.67 (4.73)	12.8 (4.94)	0.79	5.33 (1.53)	4.90 (3.35)	0.14
Dysphoria	6.00 (3.00)	4.33 (2.08)	0.73	4.33 (2.08)	4.70 (6.53)	0.06

Between-group effect sizes, Hedge’s g, indicate small >0.2, medium >0.5, and large >0.8.

AAQ-II, Acceptance and Action Questionnaire-II; DBT-WCCL, DBT-Ways of Coping Checklist; DCS, Dysfunctional Coping Scale; DSS, DBT Skills Use Scale; EDI-13, Emotion Dysregulation Inventory-13; ERQ, Emotion Regulation Questionnaire.

SIERA efficacy

The efficacy of SIERA intervention is demonstrated by the results of pre- and postmeasures of AAQ-II, DBT-WCCL, ERQ, and EDI-13; see Table 4 for more details.

Table 4.

SIERA Intervention Efficacy

n = 18	Baseline		Post-SIERA		Analysis
n = 18	M	SD	M	SD	t	g
AAQ-II	31.44	7.94	25.83	7.93	2.57	0.71
DBT-WCCL
DSS	1.57	0.50	2.00	0.45	−4.52	0.90
DCS	1.55	0.46	1.52	0.41	0.27	0.07
ERQ
Cognitive reappraisal	4.09	1.02	4.94	0.84	−3.30	0.91
Expressive suppression	4.18	1.36	3.68	1.26	1.86	0.38
EDI-13
Reactivity	13.69	4.99	5.00	2.97	7.59	2.12
Dysphoria	8.54	6.65	4.62	5.72	3.57	0.63

Within-group effect sizes, Hedge’s g, indicate small >0.2, medium >0.5, and large >0.8.

Acceptance and Action Questionnaire-II

SIERA participants presented a decrease in AAQ-II score (M = 31.44, SD = 7.94 to M = 25.83, SD = 7.93) after completion of the intervention, indicating an increase in psychological flexibility after the SIERA intervention. A medium effect size (g = 0.71)⁵¹ was also found in psychological flexibility.

DBT-Ways of Coping Checklist

The DBT-WCCL consists of two subscales: the DSS and the DCS. The DSS presents individuals’ positive skills by utilizing skills learned in the SIERA group, while the DCS presents individuals’ dysfunctional coping skills use. SIERA participants presented an increase in the DSS (M = 1.57, SD = 0.50 to M = 2.00, SD = 0.45) with a large effect size (g = 0.90).⁵¹ Also, SIERA participants showed a slight decrease in the DCS (M = 1.55, SD = 0.46 to M = 1.52, SD = 0.41), indicating a slight decrease in dysfunctional coping skills.

Emotion Regulation Questionnaire

The ERQ consists of two subscales: cognitive reappraisal and expressive suppression. SIERA participants presented a significant improvement in emotion regulation skills with a large effect size (g = 0.91).⁵¹ Upon completion of SIERA, participants showed an increase in the cognitive reappraisal score (M = 1.57, SD = 0.50 to M = 2.00, SD = 0.45) and a decrease in expressive suppression scores (M = 4.18, SD = 1.36 to M = 3.68, SD = 1.26).

Emotion Dysregulation Inventory—Reactivity Short Form and Dysphoria

The EDI-13 consists of two subscales: reactivity and dysphoria. Parents of SIERA participants reported their son/daughter demonstrated a decrease in reactivity (M = 13.69, SD = 4.99 to M = 5.00, SD = 2.97; g = 2.12) and dysphoria (M = 1.55, SD = 0.46 to M = 1.52, SD = 0.41; g = 0.63) with medium to large effect size.⁵¹

SIERA fidelity

The SIERA intervention was implemented with high fidelity, with a mean rating of 99% across four groups. The weekly progress checklist asked about participants’ engagement (Q1), understanding (Q2), practicality of the intervention (Q3), mood before the session (Q4), and mood after the session (Q5). The average scores of weekly progress were Q1 (M = 4.25, SD = 0.21), Q2 (M = 4.42, SD = 0.11), Q3 (M = 4.31, SD = 0.14), Q4 (M = 3.38, SD = 0.20), and Q5 (M = 4.30, SD = 0.16).

SIERA program satisfaction

The SIERA intervention asked questions about participants’ satisfaction and their overall feedback during the focus group interviews. For the SIERA intervention satisfaction, participants indicated their satisfaction between four/satisfied and five/very satisfied. Two participants rated the intervention as five and a half out of five, which implied they enjoyed the program very much. Regarding the intervention feedback, all participants described their pleasant experiences. Participants wanted to recommend the SIERA program for other autistic individuals to learn about emotion regulation based on their experience and the impact of learning in a group setting. They also appreciated the value of emotion regulation in their lives and the quality of the intervention. A participant from the first group said, “Well, I don’t really have any other friends who have ASD. But, if I had a friend with ASD, I feel like ‘yes, you should try this. It works.’” One participant from the second group mentioned, “This particular program has helped me come to get to know why I’m having certain emotions in certain situations and to be able to figure out, rather how to control my emotions in those situations, especially high-stress situations.” A participant from the third group said, “One specific thing that I think I learned that would be most helpful is I think more having sort of like a toolkit of different strategies. This is probably the most helpful thing I learned from the group.” One participant from the fourth group stated, “I just really like working with you guys … you weren’t like really cheap tricks. It is like we were all in this together. A lot more helpful. And more enjoyable.” Another participant from the fourth group also mentioned, “And I felt like it was a pretty good experience. Everyone got along. And sometimes relatable. And I feel good.”

Discussion

Having adaptive emotion regulation skills and psychological flexibility is especially pivotal for autistic individuals because these skills allow them to be more resilient in coping during stressful situations or transitions in their lives. The current study investigated the efficacy of SIERA for autistic young adults, and the participants who completed SIERA showed substantial improvement in psychological flexibility and adaptive emotion regulation skills, along with a decrease in emotion dysregulation. Acceptance refers to embracing one’s feelings and experiences without trying to control or judge them,⁵² which also implies having the ability to accept undesirable thoughts and feelings. Measuring acceptance as a direct outcome in emotion regulation intervention research is scarce, especially for autistic individuals. The SIERA participants showed increases in psychological flexibility, which reinforces autistic individuals’ adaptive emotion regulation skills. In addition, autistic young adults who completed the SIERA program presented improvements in their adaptive emotion regulation skills, such as DBT skills use. This is congruent with extant literature that individuals who underwent DBT skills training programs showed an increase in adaptive emotion regulation skills.^53–57 Additionally, the results of the SIERA program were aligned with the existing standalone DBT skills training literature^{42,53,58–60} that individuals in a standalone DBT skills training intervention demonstrated a decrease in emotion dysregulation by presenting fewer negative emotions (e.g., anger, depression, and anxiety) and less intense emotional reactions. Likewise, SIERA results contributed to the improvement of adaptive emotion regulation skills for autistic young adults and a decrease in emotion dysregulation.

Limitations

Due to the nature of the current research being a preliminary efficacy investigation of the program, results must be interpreted with caution and cannot be generalized for all autistic young adults. One significant limitation is the changes in the delivery format due to COVID-19. After completing the first face-to-face group, the intervention changed its delivery format to synchronous online using Zoom. Accordingly, study participants had no in-person socializing opportunities with other group members during the 10-minute break due to not sharing the same physical space while the session was conducted. Thus, future study needs to be considered to implement the program in the same format across all the groups. Also, future research needs to compare any potential differences between in-person and synchronous online formats if two modalities are used simultaneously. In addition, the use of self-report measures may lead to threats to validity. Compared with objective measures, individuals tend to report socially desirable responses and interpret questionnaires subjectively in self-report measures, which yields internal validity concerns.

Implications

Group-based intervention offers distinct benefits for autistic individuals, such as positive outcomes (e.g., improved target skills) and creating safe therapeutic spaces for skills learning.^61,62 As one of the few emotion regulation interventions for autistic young adults, the current research findings add to the support for offering a type of mental health service in terms of brief psychoeducation programs during the transition period for autistic individuals. This type of program is imperative because the transition to adulthood is a vulnerable time for many autistic young adults due to the limited adult services and discontinued services during and after high school.^13,63,64 Considering the clinical characteristics of autism that they may need additional support for unexpected new life changes, transitioning youth and autistic young adults may need more support to navigate new roles and identities as adults. Counseling practitioners can provide such services to transitioning age youth and autistic young adults to equip them with positive and effective coping strategies to better handle the challenges they face in different life domains.

Moreover, the results of this study inform practitioners of the importance of skills-based programs for autistic individuals. The SIERA intervention addressed building skills rather than focusing on deficits or pathology.⁶⁵ The preliminary evidence from the current study further implies the positive and strengths-based approach of services in maximizing service outcomes in autistic individuals rather than addressing the deficits and limitations. While most autism research has traditionally focused on individuals’ social skills learning, behavior modifications, and vocational outcomes,^66–69 little research has been conducted in emotion regulation. The preliminary results of SIERA proposed that such programs can further complement existing autism research, which can eventually contribute to providing holistic transition services that address psychosocial aspects of disability adjustment. Lastly, the results of this pilot study can expand the research on supporting autistic adults’ emotional regulation. While autistic people may require support, we acknowledge interventions should not aim to change the core of autistic people.

Next Steps

The current study tested the efficacy of a modified emotion regulation program, SIERA, for autistic young adults. In order to strengthen the research findings and test the effectiveness of this new program, the number of SIERA participants needs to be increased. Future randomized controlled trials can help translate this intervention research into practice so that more autistic individuals have access to emotion regulation programs for their mental health care. In addition, to make SIERA more available for more end users, practitioner training is required, including para practitioners, parents of autistic children, and autistic researchers and individuals. There is a lived experience educator who demonstrated neurodivergent workshops and advocacy.⁷⁰ Having autistic individuals as facilitators and involving community members in SIERA will improve this intervention further by addressing issues such as double empathy and neurodivergent communication. Thus, planning and disseminating SIERA training for practitioners and the autistic community needs to be considered. Furthermore, more diverse evaluation tools are needed. Autistic individuals experience and define constructs such as quality of life or mental health conditions differently from the general population.⁷⁰ Thus, administering measures that are normed for autistic individuals, along with observational/physiological measures, can strengthen the validity and/or internal consistency of the outcomes of SIERA. Finally, we also need to consider potential harms or side effects such as a possible increase in camouflaging (“masking” behaviors). Studies found that camouflaging leads to an increase in autistic individuals’ adverse mental health outcomes.^71,72 Camouflaging is one of the common strategies that autistic individuals utilize to overcome social situations.^71,73 Despite yielding exhaustion and a negative impact on their mental health, many autistic individuals present masking behaviors due to the lack of awareness and acceptance of autism in society. Understanding the possible influence of SIERA on the increase in camouflaging needs to be addressed during the intervention with participants.

Conclusion

Emotion regulation plays an essential part in transition for autistic young adults because, in the immediate term, emotion regulation enables young adults to control unwanted emotions and have more pleasant emotions. Subsequently, these lead to better performance in daily life/at work/school, enriching interpersonal relationships and overall well-being. However, existing emotion regulation intervention has less emphasis on autistic young adults despite increased service needs by stakeholders and autistic individuals. SIERA is unique in terms of its focus on adaptive emotion regulation skills learning and psychological flexibility. The current study participants who completed SIERA showed substantial improvement in acceptance and adaptive emotion regulation strategies as well as a decrease in emotion dysregulation, which indicated the efficacy of the emotion regulation intervention. Providing emotion regulation intervention for autistic young adults seems promising as part of transition services to enhance their daily functioning and overall quality of life.

Footnotes

Authorship Confirmation Statement

H.L.: Conceptualization, methodology, formal analysis, investigation, writing—original draft preparation, writing—reviewing and editing, visualization, and project administration. G.K.L.: Conceptualization, methodology, supervision, and writing—reviewing and editing.

Author Disclosure Statement

All authors declare that they have no conflicts of interest.

Funding Information

The authors received no financial support for the research, authorship, and/or publication of this article.

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