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Journal of Autism and Developmental Disorders volume

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Autism spectrum disorders, Autistic people -- Behavior modification, Cognitive-behavioral therapy, Community mental health services, Attitude (Psychology)


Cognitive–behavioral therapy (CBT) can improve anxiety and depression in autistic adults, but few autistic adults receive this treatment. We examined factors that may influence clinicians’ use of CBT with autistic adults. One hundred clinicians completed an online survey. Clinicians reported stronger intentions (p = .001), more favorable attitudes (p < .001), greater normative pressure (p < .001), and higher self-efficacy (p < .001) to start CBT with non-autistic adults than with autistic adults. The only significant predictor of intentions to begin CBT with clients with anxiety or depression was clinicians’ attitudes (p < .001), with more favorable attitudes predicting stronger intentions. These findings are valuable for designing effective, tailored implementation strategies to increase clinicians’ adoption of CBT for autistic adults.

Autistic adults have high rates of anxiety and depression (Buck et al. 2014; Croen et al. 2015), and often do not receive quality mental healthcare for these or other co-occurring conditions (Maddox et al. 2019; Roux et al. 2015; Shattuck et al. 2011). Developing strategies to address co-occurring psychiatric conditions is a high research priority for stakeholders in the autistic community (Frazier et al. 2018; Pellicano et al. 2014). Recent research suggests that cognitive–behavioral therapy (CBT) is effective at treating anxiety and depression in autistic adults (Spain et al. 2015), but many autistic adults do not receive CBT (Roux et al. 2015). This study examined factors that may influence community mental health clinicians’ use of CBT with autistic adults with co-occurring anxiety or depression. Identifying factors that influence clinicians’ use of CBT is crucial for developing mental health services and clinician training programs for autistic adults. The current study focuses on CBT because (1) CBT is a well-established evidence-based treatment for anxiety and depression among adults in the general population, making it the “current gold standard of psychotherapy” (David et al. 2018, p. 1), and (2) CBT is the most studied and supported psychosocial treatment for anxiety and depression in autistic adults (Weiss and Lunsky 2010; White et al. 2018).

Few studies have examined reasons why mental health clinicians who work with—or could work with—autistic adults may or may not use CBT with this population. Cooper et al. (2018) surveyed 50 therapists in the UK about their experiences adapting CBT for autistic clients (of any age) and their confidence working with this population. An important study limitation is that the survey respondents were recruited through a training workshop about adapting CBT for autistic people. In this self-selected sample, 64% of therapists had not received prior training on working with autistic clients. On average, they reported feeling moderately confident about using their core therapeutic skills with autistic people (i.e., being empathetic, developing a therapeutic relationship, and gathering information from an autistic client to understand his or her difficulties), and reported less confidence in using other key skills, such as identifying effective therapeutic approaches for autistic clients and using their knowledge of mental health treatments to help autistic clients. However, this study did not test which factors influence the therapists’ intention to use CBT or actual use of CBT with their autistic clients.

How can we increase clinicians’ use of CBT with autistic adult clients who present with anxiety or depression? To explore this question, we applied the theory of planned behavior (TPB; Ajzen 1991), a leading causal model of behavior change. The TPB posits that an individual’s attitudes, perceived norms, and/or self-efficacy influence intentions to perform a behavior, and that intentions predict behavior, under circumstances that permit the individual to act (Fig. 1). While the TPB has been used to predict and understand many health-related behaviors (Armitage and Conner 2001), it has only recently been applied to the implementation of evidence-based practices for autistic children in community settings (Fishman et al. 2018, 2019; Ingersoll et al. 2018). For example, Fishman and colleagues (2018) found that autism support classroom teachers’ intentions to use visual schedules with their students strongly predicted their subsequent use of this evidence-based practice. These findings highlight the value of measuring intentions to use specific practices.

Fig. 1

The proximal determinants of intention and behavior, as defined by the theory of planned behavior (Ajzen 1991)

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The present study is the first to assess TPB constructs in the context of community mental health clinicians providing CBT to autistic adults with co-occurring anxiety or depression. Specifically, we measured community mental health clinicians’ intention, or motivation, to start CBT with their autistic adult clients with co-occurring anxiety or depression, and four potential determinants of this intention (described below): attitudes, descriptive norms, injunctive norms, and self-efficacy towards starting CBT with autistic adults with co-occurring anxiety or depression. To determine whether these associations were specific to working with autistic adults, we also asked about clinicians’ intentions and potential determinants of intentions to start CBT with non-autistic adult clients with anxiety or depression. For the current study, intention to start CBT is a more appropriate outcome than the actual use of CBT with autistic adults because many community mental health clinicians have few to no autistic clients on their caseload and lack training in autism (Maddox et al. 2019). In the TPB, intentions are the most proximal determinant of behavior (Fishbein and Ajzen 2010). Thus, understanding clinicians’ intentions to use a specific evidence-based practice can directly inform future efforts to change clinician behavior and address barriers to treatment access (Fishman et al. 2018; Moullin et al. 2018).

In this study, attitudes refer to the clinicians’ perceptions of the advantages and disadvantages of starting CBT with their adult clients with co-occurring anxiety or depression. Normative pressure refers to the clinicians’ perceptions of what others like them do (descriptive norms) and what others expect them to do (injunctive norms) when offering anxiety or depression treatment to an adult client. Self-efficacy (also called perceived behavioral control) refers to the clinicians’ sense of agency to start CBT with an adult client. One advantage of considering these factors is that they are malleable and could be targeted with tailored implementation strategies to improve implementation of evidence-based practice (Fishman et al. 2019). However, it is important to note that these factors are only a small subset of possible barriers to clinicians delivering CBT to autistic adults. For example, we do not examine financial or funding issues, agency leadership engagement, implementation climate, organizational policies, or characteristics of the clients (Damschroder et al. 2009). The current study represents a first step in better understanding the research-to-practice gap related to mental health services for autistic adults.


This is a post-peer-review, pre-copyedit version of an article published in Journal of Autism and Developmental Disorders. The final authenticated version is available online at:



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