Effects of Cognitive Behavioral Therapy in Autistic Adults: A Systematic Review and Meta-Analysis of Randomized Controlled Trials

Abstract

Background:

Autism is a neurodevelopmental disability characterized by differences in communication, social interaction, and behavior. Cognitive behavioral therapy (CBT) is a promising intervention for autistic people, yet research mainly focuses on children.

Objective:

To assess the effects of CBT in autistic adults.

Methods:

We performed a systematic review. We conducted searches in PubMed/MEDLINE, Embase, Cochrane Central Register of Controlled Trials, and ClinicalTrials.gov. We included randomized controlled trials (RCTs) evaluating CBT in autistic adults (≥16 years). We performed study selection, data extraction, and risk of bias assessment in duplicate. We conducted meta-analyses using random-effects models. We determined the certainty of evidence using the Grading of Recommendations, Assessment, Development, and Evaluation methodology.

Results:

We included 10 RCTs (n = 537). Most RCTs had small sample sizes and a high risk of bias, and most meta-analyses showed heterogeneity. For alexithymia, CBT probably caused an important reduction (1 RCT; MD: −5.30 points; 95% confidence intervals: –10.87 to + 0.27; moderate certainty of the evidence) at less than 6 months post-treatment. Regarding other outcomes at less than 6 months, CBT may reduce depression and anxiety and improve quality of life; however, it may have little to no effect on social anxiety, functioning, obsessive-compulsive symptoms, mental health symptom severity, and all-cause discontinuation. For autistic traits, CBT may lead to an increase in scores. The evidence for these latter outcomes remains very uncertain (very low certainty of the evidence).

Conclusion:

CBT showed very uncertain effects across most outcomes in autistic adults. CBT probably reduced alexithymia at less than 6 months post-treatment. These findings are limited by methodological issues in the included RCTs, such as small sample sizes and high risk of bias. Overall, evidence on the effect of CBT in autistic adults remains limited, highlighting the need for more rigorous research to inform clinical practice.

Community Brief

Why is this an important issue?

Existing research on the effectiveness of cognitive behavioral therapy (CBT) in autism has predominantly focused on pediatric populations, leaving a critical gap in understanding its effects in adults. No previous systematic review has reported specific results on the effects of CBT in autistic adults.

What is the purpose of the study?

The purpose was to conduct a systematic review to evaluate the effects of CBT specifically in autistic adults. In addition, we assessed the certainty of the evidence using the Grading of Recommendations, Assessment, Development, and Evaluation methodology.

What did the authors do to review the literature?

We developed a systematic search strategy combining the terms “Autism,” “Cognitive Behavioral Therapy,” “Adult,” and their respective synonyms. We applied this strategy to the PubMed/MEDLINE, Embase, and Cochrane Central Register of Controlled Trials (CENTRAL) databases.

What studies did the authors find?

We selected a total of 11 articles, corresponding to 10 randomized controlled trials (RCTs). Five of these were conducted in the United Kingdom, two in Sweden, and the remaining three in the United States, Japan, and South Korea. The total sample size was 537 autistic people; the mean age ranged from 19.7 to 45.7 years, and the proportion of male participants ranged from 38.1% to 90%.

In summary, what did those studies show?

In summary, CBT probably results in an important reduction in alexithymia at <6 months of follow-up (moderate-certainty evidence). For all other outcomes, such as depression, anxiety, social anxiety, obsessive-compulsive symptoms, functioning, quality of life, mental health symptom severity, autistic traits, and all-cause discontinuation, the certainty of the evidence was very low. The available data suggest that CBT may reduce depression and anxiety and may improve quality of life, while it may have little to no effect on the remaining outcomes. Most RCTs had small sample sizes and a high risk of bias.

What are the remaining gaps in the literature?

The effect of CBT remains unclear for symptoms such as depression, anxiety, social anxiety, severity of mental health symptoms, obsessive-compulsive symptoms, functioning, autistic traits, all-cause discontinuation, and quality of life due to the very low certainty of the available evidence.

Based on this review, what do the authors recommend?

More robust and methodologically rigorous RCTs are needed to better understand the role of CBT in this population and to inform clinical practice.

Keywords

autism cognitive behavioral therapy systematic review

Introduction

Autism is a neurodevelopmental disability characterized by differences in communication and social interaction, as well as restricted, repetitive patterns of behavior, interests, or activities.¹ According to the Global Burden of Disease Study 2019, approximately 4.3 million disability-adjusted life years were attributed to autism worldwide, reflecting a 38.7% increase since 1990.² This rising prevalence highlights the growing need for timely diagnosis, individualized support, and accessible evidence-based interventions aimed at improving participation, autonomy, educational attainment, and quality of life among autistic people.¹

Autistic adults commonly experience persistent anxiety and depressive symptoms,^3–4 differences in emotion regulation^5,6 and social functioning,⁷ and reduced quality of life.⁸ Many also report differences in daily living skills, self-direction, employment participation, and maintaining social relationships.^9,10 Additional features such as alexithymia (defined as differences in identifying and describing one’s own emotions and an externally oriented thinking style⁵), sensory processing differences, and differences in executive functioning may further affect social participation, occupational functioning, and subjective well-being.^3,4,11 These emotional and functional challenges highlight the need for effective psychological interventions tailored to the specific needs of autistic adults.

Cognitive behavioral therapy (CBT) is a structured, time-limited, and goal-oriented psychological intervention grounded in the cognitive model, which posits that emotions and behaviors are influenced by individuals’ interpretations of internal and external events.¹² CBT focuses on identifying and modifying maladaptive thoughts, beliefs, and behaviors through collaborative empiricism, combining cognitive and behavioral techniques such as cognitive restructuring, behavioral activation, exposure, problem-solving, and skills training.¹² Its underlying philosophy emphasizes the active role of the individual in understanding and modifying cognitive and behavioral patterns that contribute to emotional distress and functional impact.

In the general adult population, CBT is widely used as a first-line intervention for anxiety disorders, depression, stress-related conditions, and differences in emotion regulation and has consistently demonstrated beneficial effects on mental health symptom severity, functioning, and quality of life.^13–15 Given the high prevalence of anxiety, depressive symptoms, social functioning difficulties, and reduced quality of life among autistic adults, CBT has emerged as a potentially relevant intervention for addressing these outcomes in this population.¹⁵

While substantial evidence supports the effectiveness of CBT in autistic children and adolescents, the evidence base for autistic adults remains limited and fragmented.^16–18 Previous reviews have primarily focused on pediatric populations or have combined data across age groups, limiting the ability to draw conclusions regarding the effectiveness of CBT specifically in autistic adults.¹⁹ Consequently, there is uncertainty regarding the magnitude and certainty of CBT’s effects on mental health, functioning, and quality of life in this population.

Therefore, a comprehensive synthesis of the available evidence focusing exclusively on autistic adults is needed to inform clinical decision-making and guide service provision.

To address this gap, we conducted a systematic review and meta-analysis to evaluate the effects of CBT specifically in autistic adults. In addition, this SR assessed the certainty of evidence using the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) methodology.^20,21

Methods

Design and eligibility criteria

We conducted a systematic review following the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) 2020 guidelines²² (Supplementary Data S1) to evaluate the effects of CBT in autistic adults. The study protocol was registered in PROSPERO (CRD42024568715).

We included published randomized controlled trials (RCTs) evaluating CBT interventions in autistic adults (≥16 years old) diagnosed as autistic at any stage of life (adulthood, childhood, or adolescence) using any diagnostic criteria. The intervention was CBT-based psychotherapy, defined for this review as any structured psychotherapeutic program explicitly grounded in CBT theoretical frameworks and incorporating at least one core CBT component (e.g., cognitive restructuring, behavioral activation, exposure-based strategies, problem-solving training, or skills training),¹² delivered either as a standalone intervention or as part of multicomponent psychosocial programs. The comparator group included autistic people not receiving CBT, such as those on a waitlist, receiving usual care, or undergoing minimal psychological support. The outcomes of interest were patient-centered and clinical, with a focus on mental health-related measures.

We excluded conference abstracts, protocols in the implementation phase, reviews, editorials, or duplicate publications. No restrictions were applied regarding language, publication date, sample size, or follow-up duration.

Information sources and search strategy

We systematically searched PubMed/MEDLINE, Embase, and the Cochrane Central Register of Controlled Trials (CENTRAL) from inception. The last search was conducted on February 20, 2024. We grouped the key terms into three categories: “Autism,” “Cognitive Behavioral Therapy,” and “Adult.” The complete search strategy is detailed in Supplementary Data S2. In addition, we searched for relevant studies in ClinicalTrials.gov and manually reviewed the reference lists of included articles and previous systematic reviews^19,23–26 to identify potentially eligible studies.

Selection process

We imported search results into Rayyan^® (Qatar Computing Research Institute, Doha, Qatar), where we manually verified and eliminated duplicates. Two independent groups assessed the eligibility of studies. Group 1 (G.V.-J., A.M.-F., C.H.C.-P.) and Group 2 (J.P.-C. and A.V.S.M.) independently reviewed titles and abstracts of the articles and selected those potentially eligible two authors per group (A.V.S.M. and C.H.C.-P., A.M.-F. and A.B.-C., and G.V.-J., and J.P.-C.) independently conducted full text reviws. Discrepancies were resolved by consensus.

Data extraction

Randomly assigned pairs of authors (G.V.-J., A.M.-F., C.H.C.-P., J.P.C., A.V.S.M.) extracted data, working independently. We developed a standardized data extraction form in a Microsoft Excel sheet to ensure consistency across all data collected. Each pair cross-checked the extracted data for accuracy. In cases of discrepancies, a third author (A.B.-C.) was consulted. We extracted the following information: first author, year of publication, country, study design, sample size, population characteristics (including age, sex, mean intelligence quotient [IQ], comorbidities, inclusion and exclusion criteria, number of randomized participants, and pre-study treatments), follow-up duration, study setting, funding source, total study duration, intervention details (name, frequency and number of sessions, content, individual or group format, delivery mode, and type of facilitator), and characteristics of the control group. In addition, we recorded the outcomes assessed, including the specific time points at which they were measured.

Outcomes of interest

Our protocol specified the evaluation of the following primary outcomes: quality of life (overall well-being across physical, psychological, and social domains); mental health symptoms, including depression, general anxiety, social anxiety (fear of social situations due to possible negative evaluation), alexithymia (difficulty identifying and expressing emotions), and obsessive-compulsive symptoms (intrusive thoughts and repetitive behaviors); functioning (ability to manage daily activities and social roles); and mental health symptom severity (intensity of non-autism-related symptoms such as depression, anxiety, and related emotional difficulties). Additional protocol-specified outcomes included autistic traits (behaviors typically associated with autism) and dropout rates (participants who did not complete the intervention or control for any reason). We reported these outcomes according to the assessment scales used in each study and the follow-up time points evaluated (post-randomization or post-treatment).

Risk of bias assessment

Two authors (J.P.-C. and A.V.S.M.) independently assessed the risk of bias using the Risk of Bias (RoB) tool,²⁷ which evaluates seven domains: sequence generation, allocation concealment, blinding of participants and personnel, blinding of outcome assessment, incomplete outcome data, selective outcome reporting, and other sources of bias.

We defined other sources of bias according to the Cochrane RoB guidance and included potential conflicts of interest, funding bias, baseline imbalances, and deviations from the study protocol not captured in the other domains.²⁷ We judged each domain as low risk of bias, high risk of bias, or unclear risk of bias. We resolved discrepancies by discussion with a third reviewer (A.B.C.) until we reached consensus.

For domains that may vary by outcome (blinding of outcome assessment and incomplete outcome data), we performed at the outcome level and summarized them descriptively at the study level in Supplementary Data S3.

Statistical analyses

We conducted meta-analyses using Review Manager (RevMan) Web version 7.4.0. applying a random-effects model with the inverse variance method. For continuous outcomes, we used mean differences (MDs) or standardized mean differences (SMDs) with 95% confidence intervals (CIs) depending on the homogeneity of the measurement instruments. We used MDs when all studies reporting a given outcome employed the same measurement scale, allowing interpretation in the original units. We used SMDs when studies used different measurement instruments for the same outcome to ensure comparability across studies. For dichotomous outcomes, we reported relative risks (RRs) with 95% CIs.

We used intention-to-treat (ITT) results when available, as ITT preserves the benefits of randomization and reduces bias.²⁸ When ITT data were not available, we used per-protocol results. We analyzed post-treatment values, defined as outcomes measured after the intervention period, and grouped outcomes by short-term (<6 months) and long-term (≥6 months) follow-up. When multiple measures of an outcome were reported, we prioritized longer follow-up, global scores, and the most clinically appropriate instruments within each follow-up category.

We did not perform planned subgroup analyses based on the format of CBT or comorbidities (e.g., anxiety) due to the limited number of studies per subgroup and intervention heterogeneity. We did not assess publication bias, as no meta-analysis included 10 or more studies, the minimum required to reliably evaluate small-study effects.

We provide further details in Supplementary Data S4.

Certainty of evidence assessment

We assessed the certainty of the evidence using the GRADE methodology.^20,21 We evaluated all outcomes by consensus among the authors and classified them as high, moderate, low, or very low certainty, based on the standard GRADE domains: risk of bias, imprecision, inconsistency, and indirectness. We applied a partially contextualized approach, using a single threshold for decision-making, the minimal important difference (MID), for each outcome.

To distinguish between trivial and important effects, we used the following MIDs, expressed as the number of cases per 100 patients: ±0.2 SD for SMDs, according to Cohen proposal²⁹; ±2.06 points on the Autism Spectrum Quotient (AQ; range: 0–50 points) for autistic traits; and ±2.04 points on the 20-item Toronto Alexithymia Scale (TAS-20; range: 20–100 points) for alexithymia. We derived these thresholds by translating 0.2 SMD (a small effect) into the original scale units due to the absence of predefined MIDs.²⁹ For all-cause discontinuation, we used a threshold of ± 10 events per 100 patients, based on RCT data reporting dropout rates around 17% in CBT arms³⁰ and broader evidence showing rates between 16% and 26% in adult mental health populations.³¹ We selected this value as a clinically meaningful cutoff, established by consensus and supported by relevant literature.

We provide a detailed description of the certainty of evidence assessment in Supplementary Data S5. We used GRADEpro software to generate the Summary of Findings (SoF) table. In addition, we grouped RCTs according to two follow-up periods.

Results

Study selection

In our systematic search, we identified 363 articles. Following the removal of duplicates, 239 records underwent title and abstract screening, resulting in 29 articles being assessed in full text. In addition, we evaluated four articles from other sources in full text. Ultimately, 11 publications corresponding to 10 RCTs met our inclusion criteria. Russell 2019/2020 was reported in two publications: a health technology assessment report³² and a journal article.³³ All others included RCTs^30,34–41 were reported in a single publication each. We did not identify any further studies through reference searches of the included publications (Fig. 1). We provide details on excluded studies and reasons for exclusion during the full-text review in Supplementary Data S6.

FIG. 1.

Flow diagram of study inclusion.

Studies characteristics

A is presented in Table 1 presents a summary of the characteristics of the included RCTs. Supplementary Data S7 provides detailed demographic information for each study. We included ten RCTs. Of these, 5 RCTs were conducted in the United Kingdom,^32–37 2 RCTs in Sweden,^30,39 and the other 3 RCTs^38,40,41 were conducted in different countries (United States, Japan, and Korea). The total sample size was 537 patients (range: from 30 to 84), the mean age ranged from 19.7 to 45.7 years, and the prevalence of males ranged from 38.1% to 90%.

Table 1.

Study Characteristics

Author (year)	Country	Population	Sample size	Intervention	Comparator	Follow-up total period	Funding
Capriola (2021)⁴⁰	USA	Autistic people (aged 16–25 years) and IQ ≥ 80 (mean age: 19.7 years, males: 75%)	32	STEPS: 12–16 weekly CBT-based sessions (∼60 min); transition support for students with ASD; includes outings, online family modules, and remote check-ins.	Transition as usual (TAU; i.e., waitlist control group)	4 months	The National Institute of Mental Health
Gaigg (2020)³⁴	UK	Autistic adults (mean age: I: 40.3 years, C: 45.7 years, mean IQ: I: 116.7, C: 117.6, males: 79.6%)	54	CBT Self-help (Serenity): 6–8-week online individual program; 8 sections with illustrated slides and exercises based on transdiagnostic CBT to understand and manage anxiety.	Waitlist	6 months	A Medical Research Council CASE studentship awarded to Dermot Bowler. Internal resources at City, University of London
Hesselmark (2014)³⁰	Sweden	Autistic adults with intelligence within the normal range (mean age: I: 31.9 years, C: 31.8 years, males: 54.8%) attending an outpatient tertiary psychiatric clinic	75	CBT Course Group: 36 weekly in-person group sessions (3h); ASD-adapted CBT with psychoeducation, mindfulness, and limited DBT techniques; led by trained mental health professionals.	Recreational activity: 36 weekly in-person group sessions (3h); participant-chosen activities to foster social interaction; no therapeutic techniques; in-person, led by experienced staff	36 weeks and 57 months post-treatment	L.J. Boëthius’ Foundation, The Swedish National Board of Health and Welfare, Swedish Research Council
Kuroda (2022)⁴¹	Japan	Autistic adults (mean age: I: 32.7 years, C: 29.6 years, mean IQ: I: 110.2 and C: 104.9, males: 68.3%) in the University of Tokyo Hospital and the National Institute of Mental Health in Tokyo	60	Group CBT: 8 weekly in-person sessions (∼100 min); focused on psychoeducation about ASD and emotion regulation; delivered by two therapists.	Waitlist	16 weeks	The National Center of Neurology and Psychiatry and Grants-in-Aid
Langdon (2016)³⁵	UK	Autistic adults (described in the original study as having Asperger syndrome and “high-functioning” autism) with anxiety disorders (mean age: 35.9 years, males: 52%, mean IQ: 105.5) attending community-based settings	52	3 individual CBT sessions + 21 weekly group sessions (1 h, 24 weeks); included psychoeducation, cognitive restructuring, anxiety management, exposure, and social skills training.	Waitlist	52 weeks	The National Institute for Health Research
Rodgers (2023)³⁷	UK	Autistic adults who are experiencing clinically significant anxiety (mean age: I: 39.5 years; C: 33.1 years, males: 64.7%) attending their home or a local NHS clinic	34	PAT-A©: Up to 12 weekly individual sessions (≥1 h); adapted CBT with modules on emotions (UaDE), mindfulness, uncertainty (CUES‐A©), social anxiety, phobias (VRE), and situational anxiety.	Current Clinical Services Plus: usual care (medication ± referral), plus two individual psychoeducational sessions (50–60 min) based on UaDE, focused on emotions and basic coping strategies	12 months	The United Kingdom autism research charity Autistica
Russell (2013)³⁶	UK	Autistic people aged between 14 and 65 years, with verbal IQ >70, and comorbid OCD (mean age: I: 28.6 years C: 25.2 years, males: 76.1%)	46	Standard CBT for OCD (ERP-based); up to 20 individual in-person sessions (∼1 h), typically weekly (some 2–3/week); duration varied; delivered by clinical psychologists.	Anxiety management: up to 20 individual sessions (∼1 h), typically weekly (some 2–3/week), psychoeducational modules; not a standardized therapy, used as control for therapist contact and anxiety support	12 months	The Marie Curie fellowship from the European Union
Russell (2019 and 2020)^32,33	UK	Autistic adults (⩾18 years old) with current depression (mean age: I: 35.3 years, C: 40.2 years, males: 73.9%) at New Castle and Bristol Clinics	70	Guided Self-Help: 6–10 individual sessions (30–45 min; initial planning up to 90 min); low-intensity CBT with behavioral activation for depression, adapted for ASD; delivered by assistant psychologists; in-person start, final sessions by phone/email.	Treatment as usual: standard NHS care (including no treatment, GP support, IAPT referral, secondary care, or antidepressants); up to 20 in-person sessions (∼1 h), depending on individual care pathway	24 weeks	NIHR Health Technology Assessment programme and NIHR Bristol Biomedical Research Centre
Westerberg (2023)³⁹	Sweden	Autistic people without intellectual disability aged 16-64 years and with normal IQ. (mean age: 32.6 years, males: 38.1%) at the University Health Care Research Center	84	Internet-based CBT (MILAS): 18 weekly text modules; self-guided with therapist feedback + biweekly online group discussions; focused on ASD knowledge, behavior, social skills, mental health, and daily strategies.	Self-guided reading of 2 ASD-related books over 18 weeks; individual, online, no strategies or exercises required	70 weeks	The Region Örebro Län, Sweden
Yang (2023)³⁸	South Korea	Autistic people aged 15–35 years (mean age: 20.9 years, males: 90%, mean IQ: 94.9)	30	App-based CBT (HARU ASD): daily self-guided sessions (10–15 min each, 48 sessions in total); included psychoeducation, behavioral activation, relaxation, cognitive restructuring, and problem-solving.	Waitlist	66 days	The Ministry of Trade, Industry & Energy of South Korea

C, control group; CBT, cognitive behavioral therapy; CUES-A, Coping with Uncertainty in Everyday Situations; DBT, dialectical behavior therapy; ERP, exposure and response prevention; GP, general practitioner; I, intervention group; IAPT, increasing access to psychological therapies; IQ, intelligence quotient; NIHR, National Institute for Health Research; NHS, National Health Service; OCD, obsessive-compulsive disorder; PAT-A©, Personalised Anxiety Treatment–Autism; STEPS, The Stepped Transition in Education Program for Students with autism; UaDE, Understanding and Describing Emotions; UK, United Kingdom; USA, United States of America; VRE, Immersive Virtual Reality Environment–Delivered Graded Exposure Treatment.

Four RCTs^30,35,36,41 employed CBT through only in-person sessions, while three of them^34,38,39 utilized virtual methods (one as a mobile application, one as an online course, and another as an online treatment program). In addition, three RCTs^32,33,37,40 combined in-person and virtual components, with the virtual component consisting of follow-up through phone calls, emails, or chat platforms. In three RCTs, the intervention application was self-administered,^34,38,39 while in the others a trained mental health professional administered the intervention. In all RCTs, the frequency of CBT sessions was weekly, while in only one study³⁴ it was on demand because it was a virtual course.

Regarding the comparator, six RCTs^{32–35,38,40,41} used a waitlist or treatment as usual control, while four RCTs^30,36,37,39 compared the intervention with minimal psychological support. Supplementary Data S8 presents the scales used to assess each outcome.

Risk of bias

Overall, most studies were rated as having a high risk of bias according to the RoB 1.0 tool. Although the majority showed a low risk of bias for allocation concealment, 4 out of 10 RCTs had an unclear risk for sequence generation. We judged all studies to have a high risk of bias for blinding of participants and personnel. Regarding the blinding of outcome assessors, we assessed 3 out of 10 RCTs as high risk, and another 3 as unclear. For incomplete outcome data, 7 out of 10 RCTs presented a high risk of bias. We identified selective outcome reporting as high risk in 2 out of 10 RCTs.

Finally, in the domain of other sources of bias, we rated 5 out of 10 RCTs as high risk due to no information on washout period,³⁵ COVID-19 affecting follow-up,³⁷ baseline imbalance in residential and financial status,^32,33 baseline differences in anxiety and depression levels and underpowered sample,³⁰ and self-selection leading to unmatched baseline characteristics.³⁴ We rated one RCT⁴⁰ as unclear (Supplementary Data S3). These judgments describe overall study-level methodological characteristics.

Outcomes and certainty of the evidence

The Summary of Findings (SoF) table is available in Table 2.

Table 2.

Summary of Findings Table for the Effects of CBT in Autistic Adults

Outcomes(follow-up)	Number and type of studies	InterventionCBT	ControlNon-CBT	Relative effect(95% CI)	Absolute difference(95% CI)	Certainty of the evidence (GRADE)	Interpretation
Depression (<6 months)	8 RCT (n = 387)	N: 202	N: 185	—	SMD: −0.23 SD (−0.47 to 0.00)	⨁◯◯◯ Very low^a,b,c	CBT may reduce depression at <6 months, but the evidence is very uncertain.
Depression (≥6 months)	1 RCT (n = 84)	N: 42	N: 42	—	SMD: −0.18 SD (−0.61 to +0.24)	⨁◯◯◯ Very low^a,d	CBT may have little to no effect on depression at ≥6 months, but the evidence is very uncertain.
Anxiety (<6 months)	7 RCT (n = 300)	N: 155	N: 145	—	SMD: −0.29 SD (−0.66 to +0.07)	⨁◯◯◯ Very low^a,b,c	CBT may reduce anxiety at <6 months, but the evidence is very uncertain.
Anxiety (≥6 months)	1 RCT (n = 84)	N: 42	N: 42	—	SMD: −0.04 SD (−0.46 to +0.39)	⨁◯◯◯ Very low^a,d	CBT may have little to no effect on anxiety at ≥6 months, but the evidence is very uncertain.
Obsessive-compulsive symptoms (<6 months)	3 RCT (n = 108)	N: 59	N: 49	—	SMD: −0.12 SD (−0.51 to +0.26)	⨁◯◯◯ Very low^a,c,e	CBT may have little to no effect on obsessive-compulsive symptoms at <6 months, but the evidence is very uncertain.
Functioning (<6 months)	4 RCT (n = 191)	N: 100	N: 91	—	SMD: +0.01 SD (-0.61 to +0.63)	⨁◯◯◯ Very low^a,c,e	CBT may have little to no effect on functioning at <6 months, but the evidence is very uncertain.
Quality of life (<6 months)	5 RCT (n = 272)	N: 145	N: 127	—	SMD: +0.37 SD (+0.12 to +0.62)	⨁◯◯◯ Very low^a,b,e	CBT may increase quality of life at <6 months, but the evidence is very uncertain.
Quality of life (≥6 months)	2 RCT (n = 143)	N: 74	N: 69	—	SMD: +0.27 SD (−0.06 to +0.60)	⨁◯◯◯ Very low^a,b	CBT may increase quality of life at ≥6 months, but the evidence is very uncertain.
Social anxiety (<6 months)	3 RCT (n = 106)	N: 54	N: 52	—	SMD: +0.17 SD (−0.31 to +0.65)	⨁◯◯◯ Very low^a,c,d	CBT may have little to no effect on social anxiety at <6 months, but the evidence is very uncertain.
Severity of mental health symptoms (<6 months)	2 RCT (n = 86)	N: 42	N: 44	—	SMD: −0.13 SD (−0.56 to +0.29)	⨁◯◯◯ Very low^a,b,e	CBT may have little to no effect on severity of mental health symptoms at <6 months, but the evidence is very uncertain.
Autistic traits (<6 months) Assessed with AQ (range: 0-50) Higher scores indicate greater levels	1 RCT (n = 45)	Mean: 30.96	Mean: 28.6	—	MD: +2.36 points (−2.91 to +7.63)	⨁◯◯◯ Very low^a,d	CBT may increase autistic traits at <6 months, but the evidence is very uncertain.
Alexithymia (<6 months) Assessed with TAS-20 (range: 20-100) Higher scores indicate greater levels	1 RCT (n = 60)	Mean: 62.1	Mean: 67.4	—	MD: −5.30 points (−10.87 to +0.27)	⨁⨁⨁◯ Moderate	CBT probably causes an important reduction in alexithymia at <6 months of follow-up.
All-cause discontinuation (during treatment period)	8 RCT (n = 451)	27/224 (12.1%)	32/227 (14.1%)	RR: 0.91 (0.47–1.79)	RD: −1.3 per 100 (−7.5 to +11.1)	⨁◯◯◯ Very low^a,b	CBT may have little to no effect on all-cause discontinuation during treatment period, but the evidence is very uncertain.

The following minimal important differences (MIDs) were considered: 0.2 SD for SMDs; 2.06 points on the AQ for autistic traits (range: 0–50 points); 2.04 points on the TAS-20 for alexithymia (range: 20–100 points); and 10 events per 100 people on all-cause discontinuation.

Explanations of certainty of evidence.

Two levels of certainty were downgraded for risk of bias because < 50% of the meta-analysis weight is composed of studies at low risk of bias.

One level of certainty was downgraded for imprecision because the 95% CI of the absolute effect crosses 1 MID.

Two levels of certainty were downgraded for inconsistency because <60% of the meta-analysis weight is composed of studies whose point estimates of the absolute effects (RD or MD) are on the same side of the MID as the overall estimate.

Two levels of certainty were downgraded for imprecision because the 95% CI of the absolute effect crosses 2 MID.

One level of certainty was downgraded for inconsistency because 60–80% of the meta-analysis weight is composed of studies whose point estimates of the absolute effects (RD or MD) are on the same side of the MID as the overall estimate.

AQ: Autism Spectrum Quotient, TAS-20: 20-item Toronto Alexithymia Scale, CI: confidence interval, MD: mean difference, RCT: randomized controlled trial, RR: risk ratio, RD: risk difference, SD: standard deviation, SMD: standardized mean difference.

Depression

Compared to the control group, CBT may reduce depression during post-treatment follow-up periods of less than 6 months (8 RCTs; SMD: −0.23 SD; 95% CI: −0.47 to 0.00; very low certainty). However, for follow-up periods of 6 months or longer, CBT may have little to no effect on depression (1 RCT; SMD: −0.18 SD; 95% CI: −0.61 to +0.24), and for both timeframes, the evidence is very uncertain (Fig. 2A).

FIG. 2.

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FIG. 2.

Meta-analysis of the effect of CBT versus non-CBT at <6 months and ≥6 months follow-up periods. Figure panels: (A) Depression, (B) anxiety, (C) obsessive-compulsive symptoms, (D) functioning, (E) quality of life, (F) social anxiety, (G) severity of mental health symptoms, and (H) all-cause discontinuation during treatment period. ^aCl calculated by the Wald-type method. ^bTau² calculated by the DerSimonian and Laird method. Risk of bias domains: A, random sequence generation (selection bias); B, a llocation concealment (selection bias); C, blinding of participants and personnel (performance bias); D, blinding of outcome assessment (detection bias); E, incomplete outcome data (attrition bias); F, selective reporting (reporting bias); G, other bias. CBT, cognitive behavioral therapy

Anxiety

Compared to the control group, CBT may reduce anxiety during post-treatment follow-up periods of less than 6 months (7 RCTs; SMD: −0.29 SD; 95% CI: −0.66 to + 0.07; very low certainty). In contrast, for follow-up periods of 6 months or longer, CBT may have little to no effect on anxiety (1 RCT; SMD: −0.04 SD; 95% CI: −0.46 to +0.39), and the evidence is very uncertain for these findings (Fig. 2B).

Obsessive-compulsive symptoms

Compared to the control group, CBT may have little to no effect on obsessive-compulsive symptoms for post-treatment follow-up periods of less than 6 months (3 RCTs; SMD: −0.12 SD; 95% CI: −0.51 to +0.26; very low certainty), but the evidence is very uncertain (Fig. 2C). No RCTs evaluated this outcome at 6 months or longer follow-up.

Functioning

Compared to the control group, CBT may have little to no effect on functioning during post-treatment follow-up periods of less than 6 months (4 RCTs; SMD: +0.01 SD; 95% CI: −0.61 to + 0.63; very low certainty) (Fig. 2D). No RCTs evaluated this outcome at 6 months or longer follow-up.

Quality of life

Compared to the control group, CBT may increase quality of life during post-treatment follow-up periods of less than 6 months (5 RCTs; SMD: +0.37 SD; 95% CI: +0.12 to + 0.62; very low certainty) and 6 months or longer (2 RCTs; SMD: +0.27 SD; 95% CI: −0.06 to + 0.60). However, the evidence is very uncertain for both periods (Fig. 2E).

Social anxiety

Compared to the control group, CBT may have little to no effect on social anxiety during post-treatment follow-up periods of less than 6 months (3 RCTs; SMD: +0.17 SD; 95% CI: −0.31 to + 0.65; very low certainty) (Fig. 2F). No RCTs evaluated this outcome at 6 months or longer follow-up.

Severity of mental health symptoms

Two studies^30,36 included in the meta-analysis reported mental health symptom severity using the Clinical Global Impression (CGI) or CGI-Severity (CGI-S) scales. These scales provide a global evaluation of overall clinical symptom severity based on the evaluator’s judgment, rather than assessing specific domains such as depression, anxiety, or social functioning.^30,36 Compared to the control group, CBT may have little to no effect on the severity of mental health symptoms for post-treatment follow-up periods of less than 6 months (2 RCTs; SMD: −0.13 SD; 95% CI: −0.56 to + 0.29; very low certainty) (Fig. 2G), but the evidence is very uncertain. No RCTs evaluated this outcome at 6 months or longer follow-up.

Autistic traits

Compared to the control group, CBT may increase autistic traits during post-treatment follow-up periods of less than 6 months (1 RCT; MD: +2.36 points; 95% CI: −2.91 to +7.63; very low certainty), though the evidence is very uncertain. No RCTs evaluated this outcome at 6 months or longer follow-up.

Alexithymia

Compared to the control group, CBT reduced alexithymia during post-treatment follow-up periods of less than 6 months (1 RCT; MD: −5.30 points; 95% CI: −10.87 to +0.27), though this difference was not statistically significant. Based on moderate-certainty evidence, CBT probably results in an important reduction in alexithymia. No RCTs evaluated this outcome at 6 months or longer follow-up.

All-cause discontinuation during treatment period

Compared to the control group, CBT may have little to no effect on all-cause discontinuation, but the evidence is very uncertain (8 RCT; RD: −1.3 per 100; 95% CI: −7.5 to + 11.1; very low certainty) (Fig. 2H).

Discussion

Summary of main results

We assessed 10 RCTs (n = 537) evaluating the effects of CBT in autistic adults. Most outcomes, including depression, anxiety, social anxiety, functioning, severity of mental health symptoms, all-cause dropouts, obsessive-compulsive symptoms, autistic traits, and quality of life, showed very low certainty evidence with no clear benefit or harm. Alexithymia was the only outcome showing a probable reduction, supported by moderate-certainty evidence, during post-treatment follow-up periods of less than 6 months. Most RCTs had small sample sizes and a high risk of bias, and their results were inconsistent. Overall, the findings are limited by the very low certainty of the evidence, preventing firm conclusions about the effects of CBT in this population.

Agreements and disagreements with other studies or reviews

We compiled the evidence about the effects of CBT in autistic adults. Compared to the extensive research conducted in children, there is a relative paucity of systematic reviews focusing on treatment options for autistic adults. As awareness and understanding of autism in adulthood continue to grow, it becomes increasingly important to clarify current therapeutic trends and to inform comprehensive, evidence-based management strategies for this population.

Our findings indicate that most RCTs focus on anxiety and depression as common mental health comorbidities of autism. The evidence on CBT’s effect on anxiety in autistic adults remains highly uncertain across both short-term (<6 months) and longer-term (≥6 months) follow-up periods. These findings are consistent with a prior systematic review²⁵ that included both children and adults but did not specify the timeframes used to assess clinical outcomes. Although adaptations of CBT for adults, such as CBT-Adapted Self-Directed and CBT-Non-Adapted Self-Directed, have been examined, their effects were not statistically significant.²⁵ In contrast, another systematic review¹⁹ reported improvements in anxiety following CBT. However, the magnitude of the effect may depend on the assessment method used, with clinician-rated measures typically yielding more robust results than self-reports.¹⁹

In our review, the evidence on CBT’s impact on social anxiety was also very uncertain, likely due to the small number of RCTs specifically addressing this outcome. This is consistent with findings from an uncontrolled clinical trial that tested an eight-week modified group CBT program targeting social anxiety and social functioning in autistic adolescents and young adults without intellectual disability (ages 16–38).⁴² That intervention, which included social skills training, exposure exercises, and behavioral experiments, led to significant improvements in social anxiety (p < 0.001), social motivation (p = 0.032), restricted interests and repetitive behaviors (p = 0.025), and mood symptoms including depression, anxiety, and stress (p < 0.05).⁴² Although the effect sizes were small, these results are aligned with the general trends observed in our review.

Regarding depression, the evidence on the effect of CBT in autistic adults remains highly uncertain. A previous systematic review²⁶ that included a non-randomized controlled study comparing CBT and mindfulness-based stress reduction (MBSR)⁴³ found positive effects on depressive and anxiety symptoms, as well as reductions in rumination and autistic traits. Similarly, Linden 2023²⁵ reported that adapted and non-adapted CBT formats might reduce depressive symptoms in autistic adults compared with no intervention, though the certainty of the evidence was low. Taken together, these discrepancies suggest that standard CBT protocols may not adequately address the full range of co-occurring and functional differences present in autistic adults. This highlights the potential relevance of multimodal and personalized intervention frameworks that integrate CBT with complementary therapeutic approaches as an important direction for future research.

Our findings also suggest that the evidence for CBT’s effect on quality of life remains very uncertain. While the point estimates from the included trials appear numerically positive, the very low certainty means we cannot conclude that CBT truly improves quality of life. This contrasts with Schweizer 2024,²⁶ who emphasized that quality of life in autistic adults is closely linked to anxiety, depression, and the stress associated with “masking.” Reported improvements in that review may reflect CBT’s capacity to reduce emotional distress and enhance coping strategies. The limited availability of tailored interventions for this population underscores the importance of person-centered and communication-adapted approaches. Furthermore, the variability in quality-of-life scores across instruments highlights the need to assess multiple dimensions of well-being and to explore how CBT can be better adapted for autistic adults. In line with these concerns, our review reinforces the urgent need for high-quality trials to clarify the certainty of the evidence and guide effective adaptations.

Consistent with previous work by Elliott,²³ our study confirms that evidence supporting CBT efficacy in autistic adults is limited and of low certainty. This reflects broader concerns about the applicability of standard CBT protocols to this population, given common challenges such as cognitive rigidity, abstract thinking difficulties, and atypical anxiety responses. Nevertheless, Kose²⁴ suggested that CBT may be more effective when adapted using specific strategies such as parental involvement, visual supports, concrete metaphors, positive reinforcement, and structured instructions. These adaptations may better accommodate the cognitive and behavioral characteristics of autistic people.

Evidence regarding CBT’s effect on functioning was also inconclusive. While our findings show no clear improvement, Weston¹⁹ and Schweizer²⁶ reported improvements in social and emotional functioning in autistic people, particularly in social interaction, anxiety reduction, and adaptive skills development. These discrepancies suggest that CBT’s functional benefits may be more prominent in specific domains rather than in global functioning, underscoring the need for domain-specific outcome measures in future research. Anxiety may also act as a key mediator of functioning: both Weston¹⁹ and Schweizer²⁶ emphasized that reducing anxiety can improve social engagement and autonomy, which may explain CBT’s selective impact.

Our review also highlights nuanced findings regarding autistic traits and alexithymia. The increase in autistic trait scores postintervention may reflect greater self-awareness rather than symptom worsening, consistent with literature linking higher trait recognition to poorer quality of life, reduced coherence, and increased emotional distress.^44,45 Although CBT may not directly alter core autistic traits, high treatment satisfaction suggests that participants perceive benefits. CBT probably results in an improvement of emotional awareness (reduction of alexithymia) at less than 6 months post-treatment, supported by moderate-certainty evidence. This is consistent with previous studies suggesting CBT may enhance the ability to identify and describe feelings in autistic adults,^30–32 targeting a core feature in this population.^46–48

Taken together, these findings support the value of tailored CBT adaptations, potentially including psychoeducation or follow-up sessions, to promote emotional regulation and sustain improvements. Future studies should explore long-term outcomes and refinements to CBT that address both emotional and social-cognitive domains to optimize effectiveness in autistic adults.

Finally, our review found the evidence on all-cause treatment discontinuation to be very uncertain, limiting conclusions about acceptability and retention. This aligns with Elliott 2021²³, who reported high retention (87%) in both CBT and anxiety management groups in an RCT for OCD in autistic people, though certainty was low. Similarly, Weston 2016¹⁹ did not report dropout rates explicitly but noted methodological shortcomings such as limited reporting on engagement, poor handling of missing data, and inadequate monitoring of treatment fidelity.

Although current data are insufficient to draw firm conclusions, these issues highlight the importance of rigorous RCTs that assess acceptability, adherence, and retention as core outcomes, particularly in complex clinical populations.

Certainty of evidence

The certainty of the evidence was primarily affected by small sample sizes and heterogeneity in interventions, which introduced limitations in the reliability and generalizability of our findings. Many of the included RCTs had relatively few participants, reducing the statistical power to detect significant effects and increasing the potential for random variations to influence results. This limitation was further compounded by the variability in intervention formats, including differences in session length, frequency, and delivery methods (e.g., individual vs. group therapy, in-person vs. online, adapted vs. non-adapted CBT).

In addition, the use of diverse outcome measures across studies contributed to heterogeneity, making direct comparisons challenging. While SMDs were used to account for variations in measurement scales, residual differences in how symptoms were assessed and reported may have affected consistency across studies. The heterogeneity in interventions also reflects the broader challenge of adapting CBT for autistic adults, as individual needs vary widely based on cognitive abilities, mental health symptom severity, and comorbid conditions.

As a result, the certainty of evidence was downgraded due to concerns regarding imprecision and inconsistency. The limited number of large-scale, high-quality RCTs further underscores the need for future research with larger, well-powered RCTs that employ standardized intervention protocols and outcome assessments. Addressing these limitations will be essential for strengthening the evidence base and guiding more definitive clinical recommendations for CBT in autistic adults.

Implications for clinical practice

Our findings underscore the need to prioritize the development and evaluation of adapted CBT interventions for autistic adults. The current evidence, derived from 10 RCTs (n = 537), shows very low certainty and inconclusive effects across most outcomes, with very low certainty and no clear benefits for anxiety, depression, obsessive-compulsive symptoms, social anxiety, functioning, quality of life, or autistic traits.

Only alexithymia showed a potential reduction, based on moderate certainty of evidence from a single RCT. However, no other outcome showed clinically meaningful improvement, and the overall certainty of the evidence was compromised by small sample sizes, heterogeneity of interventions, and high risk of bias across studies.

Evidence on CBT, whether adapted or not, remains limited. In addition, the limited number of RCTs addressing outcomes highlights important and persistent evidence gaps.

To enhance clinical relevance, future CBT programs should be tailored to the specific cognitive, emotional, and sensory needs of autistic adults. This may involve structured sessions, visual supports, simplified language, and a focus on emotional awareness and regulation. Interventions of longer duration, inclusion of booster sessions, or implementation within stepped-care models could potentially optimize outcomes, though these strategies remain insufficiently evaluated.

Digital and self-guided CBT formats represent a promising alternative for people with limited access to traditional services. However, these modalities still require rigorous clinical validation before they can be recommended for widespread implementation.

Given the current uncertainty of effects, clinical decisions should be cautious and individualized. Future research should go beyond symptom reduction and emphasize functionally meaningful outcomes, such as autonomy, interpersonal functioning, occupational engagement, and overall quality of life. High-quality RCTs with adequate power, longer-term follow-up, and transparent reporting of intervention fidelity, acceptability, and adaptations are urgently needed to inform evidence-based care for autistic adults.

Limitations and strengths

Our systematic review has several strengths. One of the main advantages is its comprehensive approach to evaluating the effects of CBT. Unlike most studies that focus solely on anxiety as a symptom in autism, our review includes a broad range of research examining its impact on various clinical outcomes. This allows for a more comprehensive understanding of CBT’s effects on different emotional manifestations within autism, representing a significant advancement compared with previous studies with a narrower focus.

Another key strength is the specific focus on autistic adults, in contrast to the majority of available evidence, which primarily targets children. This distinction is important because developmental differences may influence therapeutic engagement, responsiveness, and outcomes.

Finally, the methodological rigor employed in our study is a critical strength. A systematic approach was used for literature review and data analysis, following PRISMA 2020 guidelines,²² which enhances the validity of the findings. Furthermore, clearly defined inclusion criteria were applied, and a risk of bias assessment of the included RCTs was conducted.

Our study also has several limitations. The first is the small sample size in many of the RCTs included in the meta-analysis, which affects the robustness of the findings. Small samples can lead to less precise results and increased variability, reducing the reliability of observed effects and limiting the generalizability of CBT’s effects in autistic adults.

Another limitation was the insufficient number of consistent studies available to perform a meta-analysis for all clinical outcomes. Third, in most cases, it was not possible to meta-analyze the MDs (pre–post intervention). Therefore, post-treatment values were used instead. This approach may be more susceptible to baseline imbalances and could affect the accuracy of the estimated effect sizes.

Last, there was substantial variability in outcome measurement tools across studies. The use of different psychometric instruments to assess similar constructs limited comparability and highlighted the need for greater standardization. To address this heterogeneity, we used standardized effect size metrics, which facilitated a more accurate synthesis and interpretation of the results across studies.

Conclusion

This systematic review evaluates the effects of CBT across different clinical outcomes in autistic adults. For most outcomes, including depression, anxiety, social anxiety, mental health symptom severity, functioning, all-cause dropouts, obsessive-compulsive symptoms, autistic traits, and quality of life, the evidence was uncertain. Only for alexithymia, CBT probably causes an important reduction at less than 6 months post-treatment.

These findings are substantially limited by methodological shortcomings in the included RCTs, such as small sample sizes, high risk of bias, and inconsistency in results. In addition, the limited use of pre–post intervention comparisons and the reliance on post-treatment data further restrict the interpretability of effects.

In summary, although CBT is widely recommended for autistic children or adolescents, the current evidence in autistic adults remains insufficient to draw firm conclusions regarding its effects across most clinical outcomes. More robust and methodologically rigorous RCTs are needed to better understand the role of CBT in this population and inform clinical practice.

Authorship Confirmation Statement

J.P.-C., C.H.C.-P., G.V.-J., A.M.-F., A.V.S.M., and A.B.-C. participated in the conception and design of the study. J.P.-C., C.H.C.-P., G.V.-J., A.M.-F., A.V.S.M., and A.B.-C. acquired the data. All authors participated in the analysis and interpretation of data. All authors participated in drafting or revising the article.

Protocol Registration Number

PROSPERO CRD42024568715.

Footnotes

Author Disclosure Statement

The authors declare to have no conflicts of interest regarding this article.

Funding Information

This article was self-funded by the authors.

Supplemental Material

References

1. Lord

, Brugha

, Charman

, et al. Autism spectrum disorder. Nat Rev Dis Primers. 2020;6(1):5; doi: 10.1038/s41572-019-0138-4

2. Li

, Yang

, Chen

, et al. Global, regional and national burden of autism spectrum disorder from 1990 to 2019: Results from the Global Burden of Disease Study 2019. Epidemiol Psychiatr Sci. 2022;31:e33; doi: 10.1017/S2045796022000178

3. Gotham

, Brunwasser

, Lord

. Depressive and anxiety symptom trajectories from school age through young adulthood in samples with autism spectrum disorder and developmental delay. J Am Acad Child Adolesc Psychiatry. 2015;54(5):369–376.e3; doi: 10.1016/j.jaac.2015.02.005

4. Underwood

JFG

, DelPozo-Banos

, Frizzati

, et al. Neurological and psychiatric disorders among autistic adults: A population healthcare record study. Psychol Med. 2023;53(12):5663–5673; doi: 10.1017/S0033291722002884

5. Cai

, Richdale

, Uljarević

, Dissanayake

, Samson

. Emotion regulation in autism spectrum disorder: Where we are and where we need to go. Autism Res. 2018;11(7):962–978; doi: 10.1002/aur.1968

6. Dell’Osso

, Massoni

, Battaglini

, et al. Emotional dysregulation as a part of the autism spectrum continuum: A literature review from late childhood to adulthood. Front Psychiatry. 2023;14:1234518; doi: 10.3389/fpsyt.2023.1234518

7. Halder

, Bruyere

, Gower

. Understanding strengths and challenges of people with autism: Insights from parents and practitioners. Int J Dev Disabil. 2024;70(1):74–88; doi: 10.1080/20473869.2022.2058781

8. Lin

, Wu

, Chien

, Gau

SSF

. Quality of life and clinical correlates in cognitively-able autistic adults: A special focus on sensory characteristics and perceived parental support. J Formos Med Assoc. 2025;124(2):157–163; doi: 10.1016/j.jfma.2024.03.022

9. Orsmond

, Shattuck

, Cooper

, Sterzing

, Anderson

. Social participation among young adults with an autism spectrum disorder. J Autism Dev Disord. 2013;43(11):2710–2719; doi: 10.1007/s10803-013-1833-8

10.

10. Jamil

, Gragg

, DePape

. The broad autism phenotype: Implications for empathy and friendships in emerging adults. Pers Individ Difr. 2017;111:199–204; doi: 10.1016/j.paid.2017.02.020

11.

11. Kiep

, Spek

, Ceulemans

, Noens

. Sensory processing and executive functioning in autistic adults. J Autism Dev Disord. 2025;55(6):2075–2084; doi: 10.1007/s10803-023-06008-4

12.

12. Fenn

, Byrne

. The key principles of cognitive behavioural therapy. InnovAiT Educ Inspir Gen Pract. 2013;6(9):579–585; doi: 10.1177/1755738012471029

13.

13. Fordham

, Sugavanam

, Edwards

, et al. Cognitive–behavioural therapy for a variety of conditions: An overview of systematic reviews and panoramic meta-analysis. Health Technol Assess. 2021;25(9):1–378; doi: 10.3310/hta25090

14.

14. Hofmann

, Asnaani

, Vonk

IJJ

, Sawyer

, Fang

. The efficacy of cognitive behavioral therapy: A review of meta-analyses. Cognit Ther Res. 2012;36(5):427–440; doi: 10.1007/s10608-012-9476-1

15.

15. Spain

, Sin

, Chalder

, Murphy

, Happé

. Cognitive behaviour therapy for adults with autism spectrum disorders and psychiatric co-morbidity: A review. Res Autism Spectr Disord. 2015;9:151–162; doi: 10.1016/j.rasd.2014.10.019

16.

16. Wood

, Fujii

, Renno

, Van Dyke

. Impact of cognitive behavioral therapy on observed autism symptom severity during school recess: A preliminary randomized, controlled trial. J Autism Dev Disord. 2014;44(9):2264–2276; doi: 10.1007/s10803-014-2097-7

17.

17. Neil

, Koufis

, Anderson

. Cognitive Behavior Therapy for People with Autism Spectrum Disorder. In: Matson

, Sturmey

., eds. Handbook of Autism and Pervasive Developmental Disorder. Springer International Publishing: Cham, Switzerland; 2022:1301–1320; doi: 10.1007/978-3-030-88538-0_58

18.

18. You

, Gong

, Guo

, Ma

. Cognitive behavioural therapy to improve social skills in children and adolescents with autism spectrum disorder: A meta-analysis of randomised controlled trials. J Affect Disord. 2024;344:8–17; doi: 10.1016/j.jad.2023.10.008

19.

19. Weston

, Hodgekins

, Langdon

. Effectiveness of cognitive behavioural therapy with people who have autistic spectrum disorders: A systematic review and meta-analysis. Clin Psychol Rev. 2016;49:41–54; doi: 10.1016/j.cpr.2016.08.001

20.

20. Guyatt

, Oxman

, Akl

, et al. GRADE guidelines: 1. Introduction—GRADE evidence profiles and summary of findings tables. J Clin Epidemiol. 2011;64(4):383–394; doi: 10.1016/j.jclinepi.2010.04.026

21.

21. Guyatt

, Oxman

, Vist

, GRADE Working Group. et al.; GRADE: An emerging consensus on rating quality of evidence and strength of recommendations. BMJ. 2008;336(7650):924–926; doi: 10.1136/bmj.39489.470347.AD

22.

22. Page

, McKenzie

, Bossuyt

, et al. The PRISMA 2020 statement: An updated guideline for reporting systematic reviews. BMJ. 2021;372:n71; doi: 10.1136/bmj.n71

23.

23. Elliott

, Marshall

, Morley

, et al. Behavioural and cognitive behavioural therapy for Obsessive Compulsive Disorder (OCD) in individuals with Autism Spectrum Disorder (ASD). Cochrane Database Syst Rev. 2021;9(9):CD013173; doi: 10.1002/14651858.CD013173.pub2

24.

24. Kose

, Fox

, Storch

. Effectiveness of cognitive behavioral therapy for individuals with autism spectrum disorders and comorbid obsessive-compulsive disorder: A review of the research. J Dev Phys Disabil. 2018;30(1):69–87; doi: 10.1007/s10882-017-9559-8

25.

25. Linden

, Best

, Elise

, et al. Benefits and harms of interventions to improve anxiety, depression, and other mental health outcomes for autistic people: A systematic review and network meta-analysis of randomised controlled trials. Autism. 2023;27(1):7–30; doi: 10.1177/13623613221117931

26.

26. Schweizer

, Endres

, Dziobek

, Tebartz Van Elst

. Psychosocial therapeutic approaches for high-functioning autistic adults. Front Psychiatry. 2023;14:1265066; doi: 10.3389/fpsyt.2023.1265066

27.

27. Higgins

JPT

, Altman

, Gotzsche

, Cochrane Statistical Methods Group. et al.; The cochrane collaboration’s tool for assessing risk of bias in randomised trials. BMJ. 2011;343:d5928; doi: 10.1136/bmj.d5928

28.

28. Higgins

JPT

, Thomas

, Chandler

, et al. Cochrane Handbook for Systematic Reviews of Interventions. Cochrane. 2024.

29.

29. Cohen

. Statistical Power Analysis for the Behavioral Sciences. 2nd ed. Routledge; 2013.

30.

30. Hesselmark

, Plenty

, Bejerot

. Group cognitive behavioural therapy and group recreational activity for adults with autism spectrum disorders: A preliminary randomized controlled trial. Autism. 2014;18(6):672–683; doi: 10.1177/1362361313493681

31.

31. Fernandez

, Salem

, Swift

, Ramtahal

. Meta-analysis of dropout from cognitive behavioral therapy: Magnitude, timing, and moderators. J Consult Clin Psychol. 2015;83(6):1108–1122; doi: 10.1037/ccp0000044

32.

32. Russell

, Gaunt

, Cooper

, et al. Guided self-help for depression in autistic adults: The ADEPT feasibility RCT. Health Technol Assess. 2019;23(68):1–94; doi: 10.3310/hta23680

33.

33. Russell

, Gaunt

, Cooper

, et al. 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. 2020;24(6):1360–1372; doi: 10.1177/1362361319889272

34.

34. Gaigg

, Flaxman

, McLaven

, et al. Self-guided mindfulness and cognitive behavioural practices reduce anxiety in autistic adults: A pilot 8-month waitlist-controlled trial of widely available online tools. Autism. 2020;24(4):867–883; doi: 10.1177/1362361320909184

35.

35. Langdon

, Murphy

, Shepstone

, et al. The People with Asperger Syndrome and Anxiety Disorders (PAsSA) trial: A pilot multicentre, single-blind randomised trial of group cognitive–behavioural therapy. BJPsych Open. 2016;2(2):179–186; doi: 10.1192/bjpo.bp.115.002527

36.

36. Russell

, Jassi

, Fullana

, et al. Cognitive behavior therapy for comorbid obsessive-compulsive disorder in high-functioning autism spectrum disorders: A randomized controlled trial. Depress Anxiety. 2013;30(8):697–708; doi: 10.1002/da.22053

37.

37. Rodgers

, Brice

, Welsh

, et al. A pilot randomised control trial exploring the feasibility and acceptability of delivering a personalised modular psychological intervention for anxiety experienced by autistic adults: Personalised Anxiety Treatment-Autism (PAT-A). J Autism Dev Disord. 2024;54(11):4045–4060; doi: 10.1007/s10803-023-06112-5

38.

38. Yang

, Chung

. Pilot randomized control trial of an App-Based CBT program for reducing anxiety in individuals with ASD without intellectual disability. J Autism Dev Disord. 2023;53(4):1331–1346; doi: 10.1007/s10803-022-05617-9

39.

39. Westerberg

, Holländare

, Bejerot

. An internet-based behavioral intervention for adults with autism spectrum disorder—A randomized controlled trial and feasibility study. Internet Interv. 2023;34:100672; doi: 10.1016/j.invent.2023.100672

40.

40. Capriola-Hall

, Brewe

, Golt

, White

. Anxiety and depression reduction as distal outcomes of a college transition readiness program for adults with autism. J Autism Dev Disord. 2021;51(1):298–306; doi: 10.1007/s10803-020-04549-6

41.

41. Kuroda

, Kawakubo

, Kamio

, et al. Preliminary efficacy of cognitive-behavioral therapy on emotion regulation in adults with autism spectrum disorder: A pilot randomized waitlist-controlled study. PLoS One. 2022;17(11):e0277398; doi: 10.1371/journal.pone.0277398

42.

42. Bemmer

, Boulton

, Thomas

, et al. Modified CBT for social anxiety and social functioning in young adults with autism spectrum disorder. Mol Autism. 2021;12(1):11; doi: 10.1186/s13229-021-00418-w

43.

43. Sizoo

, Kuiper

. Cognitive behavioural therapy and mindfulness based stress reduction may be equally effective in reducing anxiety and depression in adults with autism spectrum disorders. Res Dev Disabil. 2017;64:47–55; doi: 10.1016/j.ridd.2017.03.004

44.

44. Mason

, McConachie

, Garland

, Petrou

, Rodgers

, Parr

. Predictors of quality of life for autistic adults. Autism Res. 2018;11(8):1138–1147; doi: 10.1002/aur.1965

45.

45. Helles

, Gillberg

, Billstedt

. Asperger syndrome in males over two decades: Quality of life in relation to diagnostic stability and psychiatric comorbidity. Autism. 2017;21(4):458–469; doi: 10.1177/1362361316650090

46.

46. Gordon

, Murin

, Baykaner

, et al. A randomised controlled trial of PEGASUS, a psychoeducational programme for young people with high‐functioning autism spectrum disorder. J Child Psychol Psychiatry. 2015;56(4):468–476; doi: 10.1111/jcpp.12304

47.

47. Smith

, Greenberg

, Mailick

. Adults with autism: Outcomes, family effects, and the multi-family group psychoeducation model. Curr Psychiatry Rep. 2012;14(6):732–738; doi: 10.1007/s11920-012-0328-1

48.

48. Bagby

, Taylor

, Parker

JDA

. The twenty-item Toronto Alexithymia scale—II. Convergent, discriminant, and concurrent validity. J Psychosom Res. 1994;38(1):33–40; doi: 10.1016/0022-3999(94)90006-x

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