Refining and Testing a Behavioral Activation Treatment for Depression in Autistic Adolescents

Autistic youth are at far higher risk for depression than their neurotypical peers, and depression symptoms have significant negative impacts on functioning and quality of life of autistic young people. Despite great need, there are currently no evidence-based interventions for depression in autistic youth. Informed by my reviews on depression in autistic individuals, I developed and piloted a manualized behavioral activation (BA) treatment for depression in autistic adolescents in a single-arm or open trial (n = 15), supported by funding from American Psychological Foundation. Notably, autistic youth depression symptoms significantly improved pre-treatment to post-treatment and 1-month follow-up. To further the aforementioned pilot work, this study will iteratively refine our previously developed BA treatment based on comprehensive feedback from vested community members and test the refined intervention in an initial randomized controlled trial (RCT) versus an enhanced treatment as usual (TAU) control condition; we will conduct this research project in partnership with a community advisory board comprised of autistic youth, caregivers of autistic youth, and autistic-serving mental health providers to ensure the treatment protocol is aligned with community needs and values. To refine BA treatment, we will seek feedback on previously developed BA manual/materials through a series of focus groups (3 groups comprised of caregivers, 3 groups comprised of providers) and individual interviews with autistic youth (12-17 years old) with depression. Following each round of individual interviews/focus groups, we will refine BA manual/materials (iterative revision). Subsequently, we will evaluate effects of refined BA intervention in an RCT versus enhanced TAU control condition; 60 autistic adolescents (12-17 years old) with clinically significant depression symptoms will be randomized. We will compare change in depression symptoms from pre- treatment to post-treatment and 1-month follow-up across groups. We will additionally examine change in engagement in enjoyable and values-aligned activities (or construct of BA) as a mechanism of action of reduction of depression after BA relative to TAU. We hypothesize that autistic youth in the manualized BA condition will exhibit greater depression symptom reduction than autistic youth in enhanced TAU, and increased enjoyable/values-aligned activities will mediate treatment response. Furthermore, we will investigate feasibility and acceptability of refined BA treatment. We will examine BA treatment session attendance, and we predict that ≥80% of participants randomized to BA will attend all sessions. Adolescents and caregivers will complete post-treatment acceptability/satisfaction surveys and qualitative interviews; and we hypothesize that manualized BA intervention will be rated as feasible, acceptable, and useful. The proposed research project, in addition to the proposed training plan, will logically connect my previous research experience to a future R01 submission of a fully-powered multisite RCT of manualized BA treatment and provide critical skills required for my transition to research independence in the field of community-engaged autism clinical trial research. Project Number: 1K23MH138758-01A1 | Fiscal Year: 2026 | NIH Institute/Center: National Institute of Mental Health (NIMH) | Principal Investigator: Michelle Menezes | Institution: STATE UNIVERSITY NEW YORK STONY BROOK, STONY BROOK, NY | Award Amount: $195,046 | Activity Code: K23 | Study Section: Effectiveness of Mental Health Interventions Study Section[EMHI] View on NIH RePORTER: https://reporter.nih.gov/project-details/11229450