Psychological Interventions for Autistic Adolescentswith Co-Occurring Anxiety and Depression: Considerations Linked to Autism Social Identity and Masking.

Adolescence marks a time of increased vulnerability to developing mental health difficulties. Recent literature has pointed towards both risk and protective factors that contribute to the development and maintenance of co-occurring mental health difficulties amongst autistic adolescents. For example, autistic individuals may mask their autistic traits to fit in with neurotypical peers, but prolonged masking may negatively influence the development of one's autistic identity and increase vulnerability to developing mental health difficulties. In this commentary, we focus our efforts on highlighting how 1) autistic identity and 2) masking behaviours may be considered within a holistic and person-centred formulation to guide treatment for mental health difficulties in autistic adolescents. In current clinical practice, mental health practitioners may not explicitly enquire about potential construct overlap between these autism related factors and other cognitive and behavioural factors that perpetuate mental health difficulties. We propose a series of assessment questions that clinical professionals may use when developing a shared understanding with autistic adolescents of how they perceive the relationship between autism and co-occurring mental health difficulties. Our goal is to support clinical professionals to consider ways of integrating advances in autistic identity and masking literature in autism to inform the assessment and formulation of co-occurring mental health difficulties when supporting autistic children and young people. Community Brief Why is this topic important? It is now well established that autistic people are at disproportionate risk for having co-occurring mental health conditions, but there is limited high-quality research on mental health interventions for this group. Much research has aimed to adapt mental health interventions developed based on psychological models that do not account for the features of autism. For example, psychological models emphasizing on how one's thinking and behavioral patterns maintain mental health difficulties may fail to contextualize them as autistic individuals' responses to living in a predominantly neurotypical environment. There appears to be a disconnect between emerging topics such as autistic identity (one's personal and social identity in relation to being autistic) and masking (suppression of one's autistic traits in order to "fit in" with non-autistic peers), which can either increase risk/vulnerability to developing mental health difficulties or buffer against emotional and social distress, and clinical assessment and practice when supporting autistic individuals to navigate mental health interventions. What is the purpose of this article? This article focuses on highlighting how the interaction between (1) autistic identity and (2) masking behaviors should be carefully considered when clinicians examine interactions between autistic traits and co-occurring mental health difficulties, leading to more person-centered treatments and shared understanding. In current clinical practice, mental health practitioners may not explicitly inquire about the relationship between one's autistic experiences and other cognitive and behavioral factors that perpetuate mental health difficulties. What personal or professional perspectives do the authors bring to this topic? We are a group of clinical psychologists working with autistic children, young people, and adults in the United Kingdom. We have also conducted research into the areas of masking and autistic identity. What is already known about this topic? We know from research that prolonged and persistent social masking and having a negative autistic identity can increase an autistic individual's vulnerability to experiencing autistic burnout, as well as experiencing negative mental health outcomes over time. However, to the best of our knowledge, incorporation of masking and autistic identity into routine assessment and formulation to understand autistic individuals' experiences of mental health difficulties is very inconsistent in clinical practice. What do the authors recommend? We propose a series of assessment questions that clinical professionals may use when developing a shared understanding with autistic individuals of how they perceive the relationship between autism and co-occurring mental health difficulties. Our goal is to support clinical professionals to consider ways of integrating advances in autistic identity and masking literature to inform the assessment and formulation of co-occurring mental health difficulties when supporting autistic individuals, starting in childhood and adolescence. How will these recommendations help neurodivergent adults now or in the future? We hope this recommendation will contribute toward how clinicians can work together with autistic individuals to ensure formulation of mental health difficulties incorporates their personal understanding of and relationship with autism. Through identifying links between autism and maintenance factors incorporated within psychological models of anxiety and depression, we hope that interventions can be better adapted to acknowledge and account for autistic individuals' experiences in a more person-centered way.