Research in Developmental Disabilities 64 (2017) 47–55

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Research in Developmental Disabilities

Cognitive behavioural therapy and mindfulness based stress

reduction may be equally effective in reducing anxiety and
depression in adults with autism spectrum disorders
Bram B. Sizoo ∗ , Erik Kuiper
Center for Developmental Disorders, Dimence Institute for Mental Health, Nico Bolkesteinlaan 1, 7416 SB Deventer, The Netherlands

a r t i c l e i n f o a b s t r a c t

Article history: Anxiety and depression co-occur in 50–70% of adults with autism spectrum disorder (ASD)
Received 2 September 2016 but treatment methods for these comorbid problems have not been systematically studied.
Received in revised form 29 January 2017 Recently, two ASD-tailored protocols were published: mindfulness based stress reduction
Accepted 9 March 2017
(MBSR) and cognitive behavioural therapy (CBT). We wanted to investigate if both meth-
Number of reviews completed is 2 ods are equally effective in reducing anxiety and depression symptoms among adults with
ASD. 59 adults with ASD and anxiety or depression scores above 7 on the Hospital Anxiety
Keywords: and Depression Scale, gave informed consent to participate; 27 followed the CBT protocol,
Autism and 32 the MBSR treatment protocol. Anxiety and depression scores, autism symptoms,
Depression
rumination, and global mood were registered at the start, at the end of the 13-week treat-
Anxiety
ment period, and at 3-months follow-up. Irrational beliefs and mindful attention awareness
CBT
Mindfulness were used as process measures during treatment and at follow-up. Results indicate that
Therapy both MBSR and CBT are associated with a reduction in anxiety and depressive symptoms
among adults with ASD, with a sustained effect at follow-up, but without a main effect
for treatment group. A similar pattern was seen for the reduction of autistic symptoms,
rumination and the improvement in global mood. There are some indications that MBSR
may be preferred over CBT with respect to the treatment effect on anxiety when the scores
on measures of irrational beliefs or positive global mood at baseline are high. Mindfulness
and cognitive behavioral therapies are both promising treatment methods for reducing
comorbid anxiety and depression in adults with ASD.
© 2017 Elsevier Ltd. All rights reserved.

What this paper adds

The number of adults diagnosed with an autism spectrum disorder (ASD) is still increasing, yet there is still hardly any
empirical evidence on how best to treat conditions that frequently accompany ASD, like anxiety and depression. In addition,
there is a controversy and confusion over which treatment methods should be used, which may hamper access to proper
care. This paper focusses on whether mindfulness based stress reduction or cognitive behavioural therapy is the preferred
intervention for dealing with anxiety and depression in autism. We show that, in fact, both methods may work equally well.
There are some indications that when targeting anxiety, mindfulness may be preferred over cognitive behavioral therapy

∗ Corresponding author.
E-mail addresses: b.sizoo@dimence.nl (B.B. Sizoo), e.kuiper@dimence.nl (E. Kuiper).

http://dx.doi.org/10.1016/j.ridd.2017.03.004
0891-4222/© 2017 Elsevier Ltd. All rights reserved.
48 B.B. Sizoo, E. Kuiper / Research in Developmental Disabilities 64 (2017) 47–55

if an individual shows high scores on the questionnaire measuring irrational beliefs or when the positive global mood at
baseline is high.

1. Introduction

Autism spectrum disorders (ASD) are often accompanied by comorbid conditions like anxiety and depression (Croen,
Zerbo, & Qian, 2015; Hofvander, Delorme, & Chaste, 2009; Joshi, Wozniak, & Petty, 2013; Roy, Prox-Vagedes, & Ohlmeier,
2015), which may aggravate the degree of ASD related impairment, leading to more communication problems, social iso-
lation, irritability, self-harm, stereotyped and obsessive behaviour, and sleep disturbance (Perry, Marston, & Hinder, 2001;
Roy et al., 2015). Recognising depression and anxiety in individuals with ASD is a challenge as these comorbid conditions
can present in an atypical manner (Mazzone, Ruta, & Reale, 2012).
There is a lack of evidence for the efficacy of methods that address the accompanying symptoms in adults with ASD.
Among others, authors of British (NICE clinical guideline 142, 2013) and Dutch guidelines (Kan et al., 2014), have recently
called for further research on treatment methods for comorbid conditions in adults with ASD (Bishop-Fitzpatrick, Minshew, &
Eack, 2013), as comorbidity has mainly been studied in children. More than 70% of children with ASD are reported to have one
comorbid disorder, while 41% have more than one comorbid disorder (Matson and Nebel-Schwalm, 2007; Simonoff, Pickles,
& Charman, 2008). The occurrence of anxiety and depression in children seems to increase with age (Gadow, DeVincent,
& Pomeroy, 2004; Gillott and Standen, 2007; Weisbrot, Gadow, & DeVincent, 2005; White, Oswald, & Ollendick, 2009).
Lugnegård (2011) reported that in their study 70% of adults with Asperger’s syndrome reported at least one depressive
episode, while 50% reported an anxiety disorder (Lugnegård, Hallerbäck, & Gillberg, 2011). Others report that depression
occurs in 38–53% of adults with ASD (Hofvander et al., 2009; Matson and Nebel-Schwalm, 2007). In addition to the anxiety
and depressive conditions mentioned here, other conditions such as intellectual impairment, ADHD, tic-disorders, psychotic
and obsessive-compulsive disorders, as well as addiction co-occur in adults with ASD (Ghaziuddin, Weidmer-Mikhail, &
Ghaziuddin, 1998; Hofvander et al., 2009).
In individuals with ASD, anxiety is associated with an intuitive lack of understanding of the social context, with executive
function problems, and limited theory of mind skills (Hobson, 2002; Ozsivadjian and Knott, 2011). Similarly to anxiety, it
has consistently been reported that depressive symptoms occur in the course of ASD (Rutter, 1970). In a clinical account of
Asperger’s syndrome, Wing (1981, p118) reported the presence of: “clinically diagnosable anxiety and varying degrees of
depression. . . especially in late adolescence and adult life, which seem to be related to the painful awareness of handicap and
difference from other people” (Wing, 1981). Later in life, anxiety and depressive symptoms may result from accumulated
negative experiences through problematic social interactions associated with ASD. It is challenging to recognize comorbid
psychiatric conditions in people with ASD because the symptoms of these comorbid conditions can be masked by those typical
to ASD (Mazzone et al., 2012). Depressive symptoms can manifest as aggressive behaviour, increased agitation, increased or
decreased compulsive behaviour, sleep problems or a deterioration in functioning (Stewart, Barnard, & Pearson, 2006), and
a relationship between depression and suicide has also been shown in adults with ASD (Cassidy et al., 2014). In addition,
people with ASD show a tendency to ruminate, which can sustain anxiety and depression (McLaughlin and Nolen-Hoeksema,
2011; Nolen-Hoeksema, 2000).
Cognitive Behavioural Therapy (CBT) is an effective treatment method for anxiety and depressive disorders (James, Soler,
& Weatherall, 2005). It has been shown that people with ASD report negative cognitions that are related to their anxiety
symptomatology (Ozsivadjian, Hibberd, & Hollocks, 2014). Parents report that CBT has a positive effect on anxiety symptoms
in children with ASD (Danial and Wood, 2013; Wood, Drahota, & Sze, 2009; Wood, Fujii, & Renno, 2011), but there are also
indications that this applies to anxiety and depression in adults with ASD (Cardaciotto and Herbert, 2004; Weiss and Lunsky,
2010). It was found that CBT had a positive effect on depressive symptoms, but not on anxiety (McGillivray and Evert, 2014).
In a study exploring the effects of CBT on obsessive-compulsive symptoms comorbid to ASD, using a sample of 46 adolescents
and adults, a significant improvement compared to the treatment as usual (TAU) was found (Russell, Jassi, & Fullana, 2013).
In a recent meta-analysis of CBT used to treat people with ASD and comorbid affective disorders, a small to medium effect
size was reported, but there was a considerable heterogeneity in age, intervention type, and study design in the studies
analysed (Weston, Hodgekins, & Langdon, 2016).
Mindfulness Based Therapy (MBT) appears to be effective for various physical and psychological complaints. It is described
as the conscious awareness that arises by focusing attention on elements in the environment as they are, in the actual
moment, and without judgement (Kabat-Zinn, 2005). The ability to be mindful is trained in MBT by using several attention
exercises (like sitting, lying down, walking meditation as well as yoga), in addition to homework exercises. There are indi-
cations that MBT is effective for adults with anxiety and depressive symptoms, but also for people with other psychiatric or
somatic diagnoses (Hofmann, Sawyer, & Witt, 2010). Mindfulness-Based Stress Reduction (MBSR) and Mindfulness Based
Cognitive Therapy (MBCT) are two well-known forms of mindfulness therapy. MBCT combines cognitive therapy with mind-
fulness meditation. MBSR however, is less cognitively oriented, and was originally applied as a treatment for chronic medical
complaints, reducing suffering and improving well-being and health (Segal, Williams, & Teasdale, 2002). It has been reported
that adults with ASD show fewer symptoms of depression and negative affect, and decreased rumination after completing
MBSR therapy compared to before the therapy (Spek, van Ham, & van Lieshout, 2010; Spek, van Ham, & Nyklicek, 2013).
Spek and colleagues argue that MBSR suits adults with ASD better than MBCT because MBSR does not contain cognitive
elements and is therefore less trying for adults with ASD. In addition, MBSR avoids a direct confrontation with emotions,
 B.B. Sizoo, E. Kuiper / Research in Developmental Disabilities 64 (2017) 47–55 49

and the techniques are easier to learn (Spek et al., 2010). In a recent systematic review of 6 studies, Cachia et al. (2016)
showed that mindfulness training reduced anxiety, depression and rumination, whilst increasing positive affect in adults
with high-functioning ASD (Cachia, Anderson, & Moore, 2016).
There is some discussion in clinical practice as to whether anxiety and depressive symptoms in adults with ASD should
be treated with CBT or with MBSR. Advocates of CBT argue that people with ASD are used to rationalizing their experiences,
and are therefore more inclined to follow the rationale of CBT (Weiss and Lunsky, 2010). Conversely, proponents of MBSR
claim that a mindfulness technique is preferential because it avoids the cognitive effort that is required in CBT, and that it is
this cognitive effort that is likely to be impaired in the presence of comorbid anxiety and depressive symptoms (Spek et al.,
2013). As yet, evidence as to the comparative effectiveness of CBT and MBSR is lacking.
Two protocols were recently published in the Netherlands that were specifically designed for adults with ASD (Schuurman,
2010; Spek, 2010). Both protocols were adapted to better explain aspects of autism and were reviewed in close collaboration
with adults who had been diagnosed with ASD. The main changes involved text clarification such as avoiding metaphors,
as some people with ASD are inclined to literal interpretations. In both protocols the instructions were made as clear as
possible and extra attention was paid to homework planning, bearing in mind issues with potential executive functioning
problems. In addition, repetition was introduced and a slower pace was set. One protocol covers CBT (Schuurman, 2010),
and the other protocol describes MBSR therapy (Spek et al., 2010). Both methods are used in the treatment of anxiety and
depressive symptoms in adults with ASD. The MBSR protocol has been shown to be effective (Kiep, Spek, & Hoeben, 2014;
Spek et al., 2013), but no research has yet been conducted on the CBT protocol.
In this study we sought to compare CBT with MBSR with respect to anxiety and depression in adults with ASD. It was
hypothesized that there would be no significant difference between CBT and MBSR in the associated reduction of anxiety
and depressive symptoms, or in the reduction of negative affect or the increase in positive affect. Given the close relationship
between manifest autistic symptoms and co-occurring anxiety and depression, it was also hypothesized that there would
be no significant difference between MBSR and CBT in the associated reduction of autistic symptoms and rumination. In
addition, it was expected that dysfunctional cognitions would be reduced by CBT but not by MBSR, and that the degree of
mindful attention awareness would increase with MBSR therapy but not with CBT.

2. Methods

2.1. Participants and procedure

Between January and December 2014, 59 participants diagnosed with ASD were recruited in the outpatient department
of Dimence Mental Health, which provides psychiatric care for adults of normal to high intelligence. The sample included
38 male and 21 female participants with a mean age of 37.4 years (SD 10.2). The DSM-IV diagnosis of ASD had been estab-
lished earlier by experienced clinicians according to national guidelines, using multiple sources of information to establish
a diagnosis of ASD such as diagnostic interviews with patients and relatives, semi-structured clinical interviews based on
the autism diagnostic interview revised (ADI-R) (Lord, Rutter, Le Couteur, 1994), a DSM-IV checklist, and all available infor-
mation from school- and child psychiatric services concerning childhood development. Absence of intellectual impairment
was based on clinical impressions in the course of the initial diagnostic assessment, and where there was doubt, an addi-
tional assessment using the Wechsler Adult Intelligence Scale (WAIS IV) was conducted. Adults with ASD were eligible to
participate in the study if they were considered able to do their exercises and homework on a daily basis. The exclusion
criteria were; intellectual impairment, prior experience with mindfulness or CBT treatment, inability to participate in a
group, current psychotic or panic symptoms, and current substance use disorder.
Approval for the study was obtained from the local medical and ethical committee prior to the start of the project. Experi-
enced therapists were trained in either MBSR or CBT techniques described in the protocols for adults with ASD (Schuurman,
2010; Spek, 2010). The MBSR and the CBT groups consisted of 9–11 participants each, and a series of 3 consecutive groups for
each method was planned. Potential participants were approached by their own therapists who explained the procedures
and asked for informed consent. Subsequently participants were asked to complete the Hospital Anxiety and Depression
Scale checklist (HADS) (Spinhoven et al., 1997). If a score on either the anxiety or depression scale was clinically significant
(7 or more), inclusion in the study could proceed. In each series, the first 9 participants were sequentially assigned to the
CBT group, and the following 9 participants to the MBSR group. The groups were not matched in this sequential assignment
procedure. Participants assigned to the CBT or MBSR groups were offered the opportunity to follow the alternative treatment
upon completion of the study protocol. No one made use of this option. Each participant was assigned a number to allow
for coded data collection. The therapists remained in possession of the name-number keys. It was not feasible to include
a treatment as usual (TAU) group into the study, due to the limited number of eligible participants. There was also the
practical problem of motivating patients with anxiety or depression to complete questionnaires over a period of 6 months,
focusing on the two interventions that they were not participating in. In the training rooms, the participants completed
questionnaires such as the HADS, Global Mood Scale (GMS) (Denollet, 1993), Social Responsiveness Scale for Adults (SRS-A)
(Noens, De la Marche, & Scholte, 2012), and the Rumination Reflection Questionnaire(RRQ) (Trapnell and Campbell, 1999),
in the first and the last (13th) session. Three months after completing the training session these questionnaires were again
completed during a re-capitulation session. In addition to the main series of questionnaires, the Irrational Beliefs Inventory
50 B.B. Sizoo, E. Kuiper / Research in Developmental Disabilities 64 (2017) 47–55

(IBI) (Koopmans, Sanderman, & Timmerman, 1994)and the Mindfulness Attention Awareness Scale (MAAS) (Schroevers,
Nyklicek, & Topman, 2008) were administered as process measures in sessions 1, 4, 8, 13, and at 3 months follow-up.

2.2. Outcome measures

The HADS (Zigmond and Snaith, 1983) is a self-report questionnaire consisting of 14 items; 7 relating to depressive
symptoms (HADS-D), and 7 to anxiety symptoms (HADS-A). The questionnaire has been validated in a Dutch patient popu-
lation, which showed that the test-retest reliability and the internal consistency were good (Spinhoven et al., 1997). To our
knowledge there is no validation data specifically for adults with ASD, but the HADS is used routinely in clinical practice
for this patient population. The Dutch version of the GMS measures the degree of subjective impairment. This instrument
consists of 10 items, and gives an indication of the positive (GMS-P) and negative (GMS-N) affect resulting from general
health and psychological problems. Both positive and negative scales have got a high internal consistency and the GMS
is reported to have good reliability and validity (Denollet, 1993). This measure has previously been used in an adult ASD
population (Kiep et al., 2014). The SRS-A is a 64-item self-report questionnaire that is routinely used to measure autistic
symptoms in adults and is considered to have a good internal consistency in the adult ASD population (Noens et al., 2012).
The RRQ is used to measure the degree of rumination, and contains a subscale “rumination” with 12 items. Rumination is the
repeated occurrence of self-related and negative thoughts (Trapnell and Campbell, 1999). Answers are scored on a 5-point
Likert scale. This measure has also previously been used in an adult ASD population (Kiep et al., 2014).

2.3. Process measures

Both process measures, MAAS and IBI, were administered to each treatment group to explore how specific the changes in
mindful awareness and irrational beliefs were for the MBSR and the CBT group respectively. Both measures have been used in
adult ASD populations in other studies. The 15-item self-report MAAS measures the frequency of daily mindful experiences,
and the questions are scored according to 6 answer categories (1 = almost always; 6 = almost never), where a high average
score indicates more mindfulness (Brown and Ryan, 2003). The internal consistency in the Dutch and American studies is
good with Cronbach’s alpha ranging from 0.81 to 0.87 (Schroevers et al., 2008). The IBI measures the degree of irrational
cognitions, and consists of 50-item self-report items, across five subscales (Worrying, Rigidity, Need for Approval, Problem
Avoidance and Emotional Irresponsibility). The items are scored on a 5-point Likert scale. (1 = strongly disagree, 5 = strongly
agree). A high total score reflects higher irrationality. The reported internal consistency is 0.83 (Koopmans et al., 1994).

2.4. Treatment procedure

The protocol for Cognitive Behavioural Therapy (CBT) in adults with ASD covers 13 weekly 90-min sessions (Schuurman,
2010). The CBT protocol focuses on dealing with autism and associated co-morbidity. The sessions have a fixed structure
and are described in detail in the protocol. The CBT program and the homework assignments are explained during the first
session. The participants document a personalised problem definition. In week 2 the target is the improvement of planning
and execution of tasks. This is done by focusing on ways to complete homework assignments. The third week deals with
information processing styles and the interaction between thoughts, feelings, and behaviour. In week 4 the focus is on
emotions and the necessity of having a safe space. Week 5 deals with negative and positive thoughts. Week 6 is about
recognizing and dealing with stress. In week 7 a short relaxation exercise is practiced and dysfunctional cognitions are
discussed. In week 8 participants learn to use an advanced relaxation method, and are introduced to the cognitive model
of CBT. In week 9 participants learn to challenge thoughts. Week 10 looks at ways to deal with frustration, disappointment,
and rumination. In week 11 the interaction with others is discussed and in week 12 the participants are asked to address
general problems. Finally, week 13 covers future plans and overcoming obstacles, as well as an end evaluation.
The protocol for Mindfulness-Based Stress Reduction (MBSR) in adults with ASD consists of 13 weekly, 90-min sessions.
The participants are informed about the training in the first week, during which the first series of questionnaires are com-
pleted by each participant. The actual training starts in the second week with a mindful eating exercise and a body scan.
Week 3 consists of further practicing the body scan and discussing home practice, followed by a 5-min mindful breathing
meditation. In week 4 the physical reactions to stress are discussed and the exercises conducted at home are reviewed.
During this session, the participants are also taught a mindful walking exercise, followed by a 5-min breathing exercise.
Week 5 consists of a 5-min breathing exercise after discussing home exercises. It is followed by an introduction to mindful
movement. In week 6 a sitting meditation is practiced with an emphasis on breathing and bodily sensations. After a 5-min
breathing exercise home practice is once again reviewed. This is followed by a listening meditation. In week 7 exercises that
have been taught in the preceding weeks are recapitulated and queries can be answered. This session ends with planning
home exercises and a mindful movement exercise. In week 8 a sitting meditation is practiced, after which home exercises
are discussed followed by a five-minute breathing exercise. This session ends with a short movement exercise. Week 9 sees a
sitting meditation with the emphasis on breathing and bodily sensations. Explanation is given about persistent thoughts and
their relationship to autism. A meditation exercise follows focussing on observing thoughts from a detached perspective. In
week 10 a sitting meditation is practiced focused on breathing and bodily sensations. After breathing exercises and mindful
observation of thoughts, home practice is discussed. In week 11 a sitting meditation is practiced followed by a movement
 B.B. Sizoo, E. Kuiper / Research in Developmental Disabilities 64 (2017) 47–55 51

exercise. The body scan is performed after which homework is discussed. In week 12 the body scan and sitting meditation
are once again practiced followed by a movement exercise. Finally, in week 13 participants discuss which exercises appealed
most and reflect on how the meditation exercises can help reduce stress in everyday situations.
Treatment integrity for both interventions was addressed by four unannounced visits to treatment sessions by two
senior therapists who were both trained in the intervention methods. This was decided because the majority of participants
strongly objected to the alternative method of recording each session for supervision purposes. After each of the eight visits,
the delivery of the treatment was judged to be in accordance with the protocols.

2.5. Statistical analysis

Patient characteristics in the different groups were compared using ANOVA and nonparametric Chi squared tests. The
scores of the HADS, GMS, SRS-A and RRQ questionnaires were analysed with a one-way repeated measures ANOVA procedure
for both intervention groups (CBT and MBSR) at three time points; at the start (T1), upon completion of the 13-week training
(T2), and at the 3-month follow-up (T3). For the MAAS and IBI process measures, five set-points in time were used in repeated
measures analysis; at the start (T1), after 1 month (T1a), after 2 months (T1b), upon completion of the 13-week training
(T2), and at the 3-month follow-up (T3).
The treatment effect on depression (d-dep) and anxiety (d-anx) were defined as the anxiety or depression score at baseline
(T1) minus the score at completion of the treatment (T2). To determine if it is possible to predict at baseline which type
of treatment is most effective in reducing anxiety (d-anx) or depression (d-dep) symptoms, regression analyses were used
for the CBT and the MBSR groups separately, using the T1 scores for the process measures (MAAS, IBI), and the outcome
measures (GMS, SRS-A, and RRQ), and age and sex as independent variables, with d-anx and d-dep as independent variables,
in separate forward regression models.
Computations were made using IBM©SPSS©version20 software, using two-tailed analyses with alpha set at 0.05.

3. Results

The mean age was 35.1 (SD = 9.22) in the CBT group (N = 27, 70% male), and 39.4 (SD = 10.81) in the MBSR group (N = 32, 59%
male). Age and gender did not differ significantly in between both groups. The HADS, GMS, SRS-A, RRQ, IBI and MAAS scores
were normally distributed. T-tests showed that there was no statistically significant difference at baseline (T1) between the
treatment groups for the variables HADS-A, HADS-D, SRS-A, RRQ, GMS, MAAS, and IBI (Table 1).
There was a significant main effect on anxiety and depression scores (HADS-A, HADS-D) for time, but not for treatment
group, and no interaction effects. Post-hoc analysis showed that anxiety and depression scores at T2 and T3 were significantly
lower than at T1 (p < 0.05). There were significant main effects on positive and negative general mood scores (GMS-P, GMS-N)
for time, but not for treatment group, and no interaction effects. Post-hoc analysis showed that positive general mood scores
at T2 and T3 were significantly higher than at T1 (p < 0.05), whereas the negative general mood scores at T2 and T3 were
significantly lower than at T1 (p < 0.05). The autism symptom scores (SRS-A) and rumination scores (RRQ) declined over
time as a significant main effect, but without a main effect for treatment group, and no interaction effects. Again, post-hoc
analysis showed that autism symptoms and rumination scores at T2 and T3 were significantly lower than at T1 (p < 0.05).
The irrational beliefs and mindfulness process measures were collected at five set-point in time. A significant main effect
for time was seen on the IBI scores, but not for treatment group. The interaction effect was statistically significant. Post-hoc
analysis for both interventions separately showed that IBI scores in the CBT group were significantly greater at T2 and T3
compared to T1, T1a and T1b (p < 0.05). Post hoc analysis for the MBSR group showed no significant differences between the
time points. The mindfulness process measure (MAAS) did not show any significant main effects for time or intervention
group.
The regression analyses with treatment effect on anxiety (d-anx) as dependent variable yielded significant models for
both CBT (adjR2 = 0.216, F(1,19) = 6.513, p < 0.05) and for MBSR (adjR2 = 0.187, F(1,23) = 6.538, p < 0.05). The IBI score predicted
a negative treatment effect on anxiety in the CBT group (b = −0.47, t = −2.557, p < 0.05), whereas the GMS-P score predicted
a positive treatment effect on anxiety in the MBSR group (b = 0.505, t = 2.552, p < 0.05). No other statistically significant
predictors were found for the treatment effect on anxiety. For the treatment effect on depression, no predictive variables
were found.

4. Discussion

The study set out to compare the effect of mindfulness based stress reduction (MBSR) and cognitive behavioural therapy
(CBT) on anxiety and depression in adults with ASD, because although both the cognitive and the mindfulness approach have
been shown to be effective (Cachia et al., 2016; Weston et al., 2016) it is unknown if one is to be preferred over the other. As
was hypothesized, CBT and MBSR in this study sample appear to be associated with equal effects on anxiety and depressive
symptoms, as well as on global mood, rumination and autistic symptoms. The positive effects on the scores observed in both
therapies were sustained at the 3-month follow-up. However, without a treatment as usual group (TAU) it is not possible to
attribute the positive effects only to the treatment interventions. The results do tally however, with earlier studies reporting
positive effects of MBSR and CBT. In this study there is no evidence for recommending one treatment method over the other.
 52
Table 1
Scores (mean and standard deviation) for adults with autism spectrum disorder (ASD) in two treatment groups.

B.B. Sizoo, E. Kuiper / Research in Developmental Disabilities 64 (2017) 47–55

CBTa (N = 27) MBSR (N = 32) Main effect time, p, Main effect group, p,
partial eta sq. (2 ) partial eta sq. (2 )

T1b , e T1a T1b T2 T3 T1e T1a T1b T2 T3

HADS-Ac 13.6 (3.0) 10.9 (4.4) 10.5 (4.4) 12.1 (3.6) 9.5 (3.0) 9.4 (3.5) F(2) = 20.02, p = 0.000, F(1) = 1.577, p = 0.217,
2 = 0.351 2 = 0.041
HADS-D 9.9 (4.7) 6.9 (5.0) 7.2 (5.8) 9.4 (4.0) 7.3 (5.6) 6.5 (4.0) F(2) = 22.18, p = 0.000, F(1) = 0.023, p = 0.881,
2 = 0.375 2 = 0.001
GMS-P 11.4 (4.7) 14.1 (7.0) 13.9 (7.4) 12.8 (4.6) 14.2 (6.2) 16.0 (6.1) F(2) = 5.46, p = 0.006, F(1) = 0.529, p = 0.471,
2 = 0.123 2 = 0.013
GMS-N 20.6 (9.6) 16.9 (10.1) 14.3 (9.7) 18.0 (8.0) 15.2 (8.3) 13.9 (7.7) F(2) = 9.08, p = 0.000, F(1) = 0.410, p = 0.526,
2 = 0.1899 2 = 0.010
SRS-A 98.1 (24.7) 94.7 (29.4) 92.0 (30.7) 86.4 (24.6) 80.1 (20.0) 79.7 (23.7) F(2) = 4.41, p = 0.016, F(1) = 2.52, p = 0.121,
2 = 0.109 2 = 0.065
RRQ 34.9 (7.3) 32.4 (8.1) 33.0 (6.9) 35.2 (6.5) 31.5 (7.5) 31.2 (7.8) F(2) = 6.213, p = 0.003, F(1) = 0.161, p = 0.690,
2 = 0.138 2 = 0.004
IBI 126.0 129.1 129.7 143.0 140.7 137.4 139.7 141.1 142.1 142.7 F(4) = 6.848, p = 0.000, F(1) = 0.896, p = 0.351,
(18.6) (19.1) (29.3) (32.1) (25.7) (18.9) (18.2) (21.7) (19.3) (17.5) 2 = 0.176 2 = 0.027
MAASd 43.0 (12.1) 45.6 (12.8) 44.2 (15.5) 43.4 (14.0) 43.9 (51.4) 46.4 (10.0) 49.4 (12.2) 49.0 (11.0) 50.4 (10.4) 51.4 (10.7) F(4) = 1.34, p = 0.258, F(1) = 1.85, p = 0.182,
2 = 0.037 2 = 0.050
a
Treatment groups: CBT = cognitive behavioral therapy, MBSR = mindfulness based stress reduction.
b
T1 = at start, T1a = after 1 month, T1b = after 2 months, T2 = at end of treatment after 3 months, T3 = follow up 3 months after end of treatment.
c
Measures: HADS-A/D, Hospital anxiety and depression scale, GMS-P/N = global mood scale positive and negative affect, SRS-A = social responsiveness scale for adults, RRQ = rumination reflection questionnaire,
IBI = irrational beliefs scale, MAAS = mindfulness attention and awareness scale.
d
the interaction effect ((time x group) was significant (F(4) = 2.661, p < 0.05).
e
there were no statistically significant differences in the T1 scores between the CBT and the MBSR groups for all measures (i.e. t < 1.48, p > 0.14).
 B.B. Sizoo, E. Kuiper / Research in Developmental Disabilities 64 (2017) 47–55 53

The results for the MBSR group correspond to earlier research that used the same therapy protocol (Kiep et al., 2014;
Spek et al., 2013). The results for the CBT group tally with earlier studies on CBT for anxiety and depression in adults with
ASD, although these studies represent a wide range of different cognitive methods (Weston et al., 2016), but not the protocol
used in this study (Schuurman, 2010).
It is important that,based on these results, professionals in clinical practice apply MBSR and CBT to reduce anxiety,
depression and rumination, as these treatable comorbid conditions add to the functional impairment of adults with ASD
(McLaughlin and Nolen-Hoeksema, 2011; Mazzone et al., 2012; Ozsivadjian and Knott, 2011). The decrease of SRS-A scores,
as well as the anxiety and depression scores, indicates a reduction in autistic symptoms. This could point to a possible
bi-directional relationship between anxiety and the severity of autistic symptoms, as has been suggested by others (Ben-
Sasson et al., 2008; Sukhodolsky, Scahill, & Gadow, 2008; Wood and Gadow, 2010), which again emphasizes the importance
of treating anxiety and depression in individuals with ASD.
Unexpectedly, the process measure for CBT (IBI) showed that there was a significant increase, not a reduction, of irrational
beliefs in the CBT group upon completion of the treatment and at the 3-month follow-up as compared to the three earlier
measurements (T1, T1a, and T1b). To our knowledge this pattern has not been reported previously and is contrary to general
findings that symptom recovery is associated with a reduction in irrational beliefs. There is a possibility that the increase in
irrational beliefs despite the reduction in anxiety and depressive symptoms, may mean that individuals with ASD express
their thoughts and beliefs more freely when they feel less anxious or depressed. However, these thoughts and beliefs display
autistic reasoning, which may then appear to be irrational, resulting in a higher IBI score than when probed at baseline. In
other words, autistic (irrational) thoughts may not be so readily expressed when people with ASD experience anxiety. Also,
a high irrational beliefs score at baseline was shown to predict a negative treatment effect for anxiety. This relationship
was only found for anxiety and not for depression, and only in the CBT group. A possible explanation is that people with
ASD and high IBI scores may tend to hold on to their own beliefs in order to understand and structure the world around
them. CBT challenges these thoughts, which may provoke anxiety rather than reduce it. In contrast, MBSR doesn’t attempt to
alter thought patterns, but teaches people to accept them in a non-judgmental fashion. The results might therefore indicate
that MBSR therapy is more effective than CBT in reducing anxiety in adults with ASD when they also present with high IBI
scores at baseline. This is a very tentative assumption that must be treated with caution, given the modest strength of the
regression models, the restricted sample sizes, and the other methodological limitations.
In the MBSR group, a high GMS-P score at baseline was associated with a positive treatment effect on anxiety symptoms,
but not on depressive symptoms. We could not find a clear explanation for this association, which was not seen in the CBT
group.
Contrary to what was expected, the process measure for MBSR (MAAS) did not change during the treatment period and
at follow-up, both in the MBSR group and the CBT group. This would indicate that this questionnaire is either not sensitive
enough for people with ASD, or that mindful awareness is more or less stable in adults with ASD.
In summary, cognitive behavioural therapy and mindfulness based stress reduction may be equally effective in reducing
anxiety and depressive symptoms in adults with autism spectrum disorders, as well as in reducing autistic symptoms,
rumination and improving the global mood. There are some indications that the score on the positive global mood scale at
baseline may predict the treatment effect for anxiety symptoms in the MBSR group, while the score on the irrational beliefs
inventory inversely may predict treatment outcome for anxiety symptom in the CBT group. More research is recommended
with larger numbers and in a randomized controlled design.

4.1. Strengths and limitations

To our knowledge this is the first study that compares specific protocols for adults with ASD to treat comorbid anxiety
and depression, yet there are a number of limitations. The number of participants in both groups was modest, limiting the
generalizability of the results. It also prevented us from taking into account other factors that may influence anxiety and
depression levels, such as pharmacological treatment. This was to preserve statistical power. The study had to be carried out
during the high pressure of daily practice in specialized treatment teams for adults with ASD, and this prevented the inclusion
of a control group. It is therefore not possible to know whether it was the group experience that was the active ingredient
in both treatment groups. Also, sequential randomization was considered appropriate given the considerable strain that the
participants were already under, many having been traumatized by long and ineffective treatments before being diagnosed
with ASD. The lack of blinding is therefore also a limitation in this study. Although there were frequent meetings with the
therapists, to allow for reflection on the proceedings, logistics prevented us from verifying treatment integrity for each
session. In retrospect, the study would have benefitted from a comprehensive measure of treatment fidelity.

Acknowledgements

We are grateful to the participants for their time and effort in completing the questionnaires, as well as our committed
staff members who were involved in this project. We thank the Dimence Institute of mental health for the generous support
that made this study possible.
54 B.B. Sizoo, E. Kuiper / Research in Developmental Disabilities 64 (2017) 47–55

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