Each month at Ability Partners, our hard-working Occupational Therapists gather to present, analyse and discuss different journal articles. In April 2024, the group talked about strengths based practice for enhancing mental health for autistic people. 

They recently covered the following journal: 

Holmes, L., Goebel, R., Hollingue, C., Zhu, S., Zhang, H., Shan, W., … Rothman, E. (2023). Reductions in depression and anxiety among autistic adults participating in an intervention to promote healthy relationships. American Journal of Occupational Therapy, 77. 7702185070. 

Summary of Journal Article 

This journal article was sourced to support clinical practice when addressing the strength-based practices used to enhance mental health for autistic people. Details of the article are as follows; 

• Sample: fifty-five autistic adults aged 20 to 43 years old. 55% female, 17% male, 11% non-binary, 2% other  
• Objective: To determine the feasibility and preliminary effectiveness of the Healthy Relationships on the Autism Spectrum (HEARTS) intervention, a six-session, group-based psychoeducational intervention for the improvement of relationship health.  
• Treatment areas: Psychoeducational group-based intervention (healthy relationships on the autism spectrum) focusing on health relationships for autistic adults.  

What is autism? 

Autism spectrum disorder (ASD) is a lifelong neurodevelopmental disorder, meaning that it occurs early in development. It can occur with or without intellectual disability.  

The diagnostic criteria requires persistent deficits in social communication and interaction as well as restricted and repetitive patterns, behaviours, and activities.  

There are three levels of autism with level three resulting in the most severe deficits and requiring the most support.  

What is the Healthy Relationships on the Autism Spectrum (HEARTS) intervention? 

• Hearts is a psychoeducation-based group program.  
• Hearts was co-designed with autistic people and in this study co-delivered with autistic people.  
• Hearts is not a deficit-based remedial model. It encourages participants to think about how they would prefer to communicate and express their needs to others. Because of this, there is no focus on eye contact or small talk etc.  

Hearts involves 6 sessions of psychoeducation focusing on Rothman et. Al (2022):  

Healthy and unhealthy relationships  

• Abusive relationships  

• Warning signs of unhealthy relationships  
  
  Launching new relationships  

• Developing curiosity in other people  
• Active listening  
• Avoiding relationship pitfalls  
  
  Neurohealth for relationship health  

• Coping with relationship anxiety  
• Why eating, sleeping, exercising and relaxing are important for relationship health  
  
  Meeting new people  

• Reconnecting with old friends  
• Perspective taking and empathy 
• Handling jealousy  
• Disclosing autism to new friends  
• Progressing relationships  
  
  Setting and respecting boundaries  

• Setting boundaries  
• Respecting boundaries  
• Renegotiating boundaries  
• Apologising and accepting apologies  
  
  Ending relationships  

• Signs a relationship should end  
• Reasons it can be hard to end relationships 
• How to end relationships  
• Domestic violence and sexual assault hotlines  

Why is this an important topic for health professionals to consider? 

• In 2018 there were 205,200 autistic people living in Australia (ABS, 2018). 
• The prevalence rate of autism in Australia has increased overtime. As of 2018 1.3% of males and 0.4% of females had autism. 
• Autism is the biggest disability group on the NDIS making up 35% of participants (NDIS, 2023). 
• The NDIS estimates that the average autistic participant receives $32,800 in NDIS funding, resulting in a total cost of approximately 5.7 billion dollars (176,460×32,800) (National Disability Insurance Scheme (NDIS), 2019). 
• Autistic adults are four times more likely to experience depression as non-autistic adults (Hudson et al., 2019). 
• Data from NSW found that the leading cause of death for autistic people without intellectual disability aged between five and sixty-five is injury and poisoning- which included suicide (Hwang et al., 2019). Other studies have found suicide or self-harm to be over three times more likely in autistic adults when compared to non-autistic adults (Hand et al., 2019). Contrastingly, the top causes of death for non-autistic people in NSW in 2019 were neoplasms, circulatory diseases and injury and poisoning (Hwang et al., 2019). 
• Social isolation and loneliness has been linked to anxiety and depression in autistic people (Grace et al., 2022). 

Methodology Review:  

• Objective: to determine the feasibility and preliminary effectiveness of the Healthy Relationships on the Autism Spectrum (HEARTS) intervention, a six session, group-based psychoeducational intervention for the improvement of relationship health. 
• One group pre test post test design.  
• It was a non experimental design with no control so unfortunately any improvements in anxiety and depression can not be directly attributed to the intervention. 
• There was a financial incentive for participants, with participants receiving $20 for each class they attended, which may have helped with participant attrition.  
• Each intervention was delivered by a teaching team of two made up of one autistic and one nonautistic person.  
• Not all participants had a formal diagnosis of autism. 25% had a self-diagnosis of autism 
• Participants were required to have at least one social relationship that they wanted to improve on. 
• Used a linear mixed-effect model to analyse how depression and anxiety scores changed over time. 

How were research questions answered? 
1. Pretest survey before the first class 
2. Weekly depression and anxiety measures 
3. Post intervention survey at 6 weeks after the final class (12 weeks after baseline) 

The study reported using: 

• Promis depression short form (reported as a t scored out of 50) 
• Promis anxiety short form (reported as a t score out of 50) 
• Hostile automatic thoughts scale 
• Measures of adolescent relationship harassment and abuse 
• Coping with rejection and jealousy 
• Motivation to engage with others 
• Positive thinking scale  
• Predominate response questionnaire 
• Rejection sensitivity 
• State self-compassion scale 
• The UCLA loneliness scale 

The data analysis focused on:  

• Promis depression short form (reported as a t scored out of 50) 
• Promis anxiety short form (reported as a t score out of 50) 

Findings  

Attrition: 69 people consented to be engaged in the study. 55 people completed 4 or more sessions and were included in the study. Roughly a 20% attrition rate. 

Depression: On average depression t scored decreased by 1.39 points per week on the promise depression short form. A minimal importance difference is 3-4 points (Kroenke et al., 2020). So after three-four weeks it would have reached a minimally important change. 

Anxiety: on average anxiety t scores decreased by 0.99 per week on the promise anxiety short form. A minimal important difference for this scale is 4 (Kroenke et al. 2019). So after three-four weeks it would have reached a minimally important change. 

Other findings:  

• Individuals with an official diagnosis of depression had depression t scores that were on average 8.24 points higher. 
• They tried to use inferential statistics to break the results down by gender (Male, Female and Other). The results did show that cisgender men were less likely than other groups to show weekly improvements. All other breakdowns (cisgender women, others ect) did not show any statistically significant differences.  
• Higher anxiety t scores were significantly correlated with: 
• Tendency to have a fight, flight or freeze response to a stressful incident 
• Lower levels of positive thinking 
• Lower levels of self-compassion. 
• Higher depression t scores were significantly correlated with: 
• Tendency to have a fight, flight or freeze response to a stressful incident. 
• Reduced ability to cope with rejection and jealousy  
• Anxiety 

Conclusion 

There is preliminary support for the effectiveness of HEARTS on depression and anxiety. The results contribute to the evidence base to consider when designing supports for the development of relationships skills for autistic adults. 

If you or someone you know has autism and would like support developing healthy relationships, contact Ability Partners today or learn more about our Autism Teletherapy Service.