Acceptance and Commitment Therapy as an Early Intervention Approach to Support High Functioning Autistic Girls

Addressing the Unique Mental Health Needs of Autistic Girls Through Early, Values-Based Intervention

Image provided courtesy of Charlie Hammond on Unsplash

Abstract

Young autistic girls, particularly those considered high functioning, face increased risk for mood disorders such as anxiety and depression, suicidal ideation, and self-harming behaviors. A growing body of research suggests that these outcomes are linked to social coping mechanisms such as masking and camouflaging — strategies used to hide autistic traits and conform to neurotypical norms during social interactions. Overreliance on these strategies contributes to heightened risks of autistic burnout, fatigue, and shutdown. This paper summarises current research on the vulnerabilities and coping mechanisms of autistic girls with a view to Acceptance and Commitment Therapy (ACT) being a potentially effective early intervention approach to support this cohort.

Introduction

Autism Spectrum Disorder (ASD) presents differently across sexes, with girls often exhibiting subtler behavioral traits than boys. Diagnostic frameworks have historically been based on male-presenting autism, which contributes to the under-identification of autistic girls (Lai et al., 2015). Despite having comparable levels of autistic traits, many girls go undiagnosed or are misdiagnosed with mood, anxiety, or personality disorders due to their ability to mask symptoms and present socially appropriate behaviors (Lai et al., 2015; Green et al., 2019).

In developing compensatory social strategies such as rehearsed social scripts or mimicking neurotypical peers, this cohort can mask core emotional and interpersonal difficulties (Dean et al., 2017). These strategies can delay diagnosis whilst continuing to contribute to internal stress, emotional burnout, and psychiatric complications (Green et al., 2019). As a result, autistic girls, especially those with high cognitive ability, are at elevated risk for emotional dysregulation, psychiatric comorbidities, and suicide (Attwood, 2021). Additionally, high-functioning autistic girls may be initially misdiagnosed with disorders such as OCD, eating disorders, or PTSD (Green et al., 2019), resulting in treatments that may address symptoms without recognizing the underlying autistic traits.

A critical step in supporting the mental health of girls with ASD, particularly those considered high functioning, may lie in tailored interventions such as Acceptance and Commitment Therapy, which address their specific social and emotional vulnerabilities.

Autism in girls v boys and the challenge of diagnosis

Autism spectrum disorder (ASD) is identified in girls at a considerably lower rate than in boys, with research traditionally reporting approximately a 4:1 male to female ratio (Fombonne, 2009). These findings however have been challenged on the basis that autistic traits may be less perceptible in females due to coping mechanisms which ‘camouflage’ these traits, with previous diagnostic practices not accommodating for these differences (Kirkovski et al. 2013; Lai et al. 2016).

This conclusion questions the formerly held idea that girls are at reduced risk for developing ASD, based on the finding of lower prevalence rates among females resulting from differences in presentation and diagnosis between boys and girls.

To complicate this issue further, however, a meta-analysis by Chellow, Barbaro, and Freeman (2022) found more similarities than differences between boys and girls under the age of 6 in the expression of autistic behaviors. These findings indicate that factors, such as age of diagnosis and intellectual functioning, can lead to varying results in the differences between autism in boys and girls.

Whilst the cause of inconsistencies across the sex/gender literature is complex — with research ongoing — discernible behavioral differences between boys and girls with autism have been identified in areas of social behaviors, executive function, and restricted and repetitive behaviors. A large-scale neurobehavioral study by Supekar et al. (2021) analyzed data from over 1,000 children and adolescents (aged 6–17), finding that autism manifests differently across sex/gender, not just in severity but in the type and quality of traits — especially in social-emotional regulation.

This finding and related research (Hull et al. 2020, Dean et al. 2017) support the identification of categories where the presentation of autism differs between girls and boys, such as social communication (autistic girls are more likely to have an advanced vocabulary than autistic boys and are more likely to imitate their parents when compared to males’ imitation behavior), masking; (girls tend to mask their autistic symptoms more than boys), and social motivation; girls with ASD also tend to have higher social motivation and are often more observant of social dynamics than boys (Tierney et al., 2016).

High-functioning autism v Low-functioning autism

The focus of this paper is on girls with high-functioning autism, acknowledging that this is not a formal diagnosis within the Diagnostic and Statistical Manual of Mental Disorders (DSM-5). Rather, this term is used to describe autistic individuals who can function relatively independently but may still exhibit autistic traits and experience challenges in specific areas. This also recognizes that individuals with high-functioning autism can lead full lives and thrive with appropriate support, even with strong cognitive and language skills; individuals may still face challenges in social situations and with sensory processing.

The characteristic challenges faced by these individuals include, but are not limited to, communication and social interaction where individuals may struggle with reciprocal conversation, understanding social cues, making eye contact, and interpreting nonverbal communication (Baron-Cohen, S., Tager-Flusberg, H., & Lombardo, M. V., 2013), repetitive behaviors and interests where individuals may have intense interests in specific topics, engage in repetitive actions, and prefer routines and predictability. (South, M., Ozonoff, S., & McMahon, W. M.,2005), and challenges with sensory sensitivities, where some individuals may be overly sensitive to sensory input, while others may have muted reactions (Tomchek, S. D., & Dunn, W., 2007). Table 1 below summarises gender differences in autistic characteristics between boys and girls across functioning levels.

Table 1. Gender differences in autistic characteristics between boys and girls across functioning levels. Table created by the author based on findings by Attwood, T. (2021), Mandy, W., Chilvers, R., Chowdhury, U., Salter, G., Seigal, A., & Skuse, D. (2012), Dean, M., Harwood, R., & Kasari, C. (2017), Lai, M. C., Lombardo, M. V., Auyeung, B., Chakrabarti, B., & Baron-Cohen, S. (2015),

Camouflaging and Masking Behaviors

A key coping mechanism among autistic girls is camouflaging or ‘masking’ — efforts to suppress or compensate for autistic traits to blend into neurotypical social environments (Hull et al., 2020). Table 2 below presents common masking behaviors observed in autistic girls during social interaction. Research by Tierney, Burns, and Kilbey (2016) highlights that while autistic girls are motivated to form friendships, they increasingly resort to strategies such as masking and imitation during adolescence, often at the expense of their mental well-being. Sedgewick et al. (2016) found that girls frequently express a desire “to be normal,” using social copying and mimicry to gain peer acceptance.

Table 2. Common masking behaviours in autistic girls and young women. Table created by the author based on findings by Attwood, T. (2021), Hull, L., Mandy, W., Lai, M.-C., Baron-Cohen, S., Allison, C., Smith, P., & Petrides, K. V. (2019), Dean, M., Harwood, R., & Kasari, C. (2017).

The Cost of Camouflaging

Camouflaging and masking behaviors are often employed by autistic girls to ‘fit in’ during social interaction or avoid social exclusion. However, the resulting, longer-term psychological costs can be problematic and harmful. Regular masking is associated with difficulties around sense of identity, emotional exhaustion, and autistic burnout — a state of extreme mental, emotional, and physical fatigue resulting from chronic life stress and the suppression of authentic self-expression (Raymaker et al., 2020). Autistic burnout may be made even worse by the challenges of navigating neurotypical social norms without appropriate and targeted support.

When masking becomes a habitual coping strategy, it can constrict access to essential social connections and reinforce feelings of isolation and inadequacy. Autistic individuals who mask often feel isolated and disconnected from others. Since they aren’t showing their authentic self, even friends or colleagues only know the ‘mask’, preventing truly fulfilling connections.

Masking may also increase risks associated with issues of personal boundaries and possible exploitation, as by ignoring their own comfort to please others, an autistic person might ‘go along’ with situations that feel wrong or unsafe. This can make them more vulnerable to abuse or manipulation; for example, overriding their instincts and personal boundaries to avoid conflict might put them at risk in unhealthy relationships.

Hull et al. (2020) found that autistic females report significantly higher rates of masking than their male counterparts, which in turn correlated with increased levels of anxiety, depression, and stress. This aligns with findings by Dean et al. (2017), who demonstrated that despite superficially typical social behavior, autistic girls reported more internalised distress and loneliness than boys. These camouflaging behaviors not only obscure the clinical picture — social camouflage can prevent access to appropriate diagnosis and support, leading to internalized distress, confusion about identity, and persistent feelings of failure or isolation- but also increase the likelihood of mental health crises, including suicidal ideation.

Acceptance and Commitment Therapy (ACT)

Acceptance and Commitment Therapy (ACT) is a relatively recent behavioral therapy that integrates mindfulness, behavioral change strategies, and values-based action to promote psychological flexibility — the ability to remain present and committed to meaningful actions despite difficult thoughts and emotions (Hayes et al., 1999). Unlike traditional cognitive-behavioral approaches that aim to change the content of distressing thoughts, ACT encourages individuals to accept their internal experiences while committing to behaviors aligned with personal values (Hayes, Strosahl, & Wilson, 2012).

Research supports ACT’s effectiveness across a wide range of psychological conditions including anxiety, depression, chronic pain, and substance use (A-Tjak et al., 2015). Its emphasis on psychological flexibility, emotional regulation, and values-based living makes it particularly effective for populations dealing with chronic or stigmatized experiences, and supports the development of interpersonal and social skills. ACT is not symptom-focused but aims to enhance quality of life by fostering a meaningful, values-consistent life. As such, it is increasingly used in diverse settings, including schools, workplaces, and medical environments (Hayes et al., 2012).

ACT enhances interpersonal skills and communication by fostering psychological flexibility and emotional regulation through the development of six core processes: acceptance, cognitive defusion, being present, self-as-context, values, and committed action (Hayes et al., 2012). These six components are referred to within ACT as the Hexaflex, which is illustrated in diagram 1 below. These six processes are interrelated and work together to help individuals relate to their thoughts and emotions in a non-judgmental way and respond more effectively to internal struggles rather than avoid or suppress them (Harris, 2009).

Figure 1. Hexaflex model representing the six components of Acceptance and Commitment Therapy (Hayes et al, 2012)

One of the primary ways ACT supports communication is through its emphasis on mindfulness and present-moment awareness. By encouraging individuals to be fully engaged in the here and now, ACT helps them attend more carefully to verbal and nonverbal cues in social interactions (Harris, 2019). This leads to greater attunement to others’ needs and responses, improving mutual understanding and empathy.

ACT also promotes acceptance of uncomfortable internal experiences, such as anxiety or social discomfort, without avoidance. This is particularly useful in interpersonal situations where individuals may feel vulnerable or fear judgment. Instead of withdrawing or reacting defensively, ACT encourages individuals to notice these feelings without letting them dictate behavior, thereby fostering more open and authentic communication (Zhang et al., 2018).

By using cognitive defusion techniques, clients learn to observe thoughts without attaching literal truth or power to them, reducing their impact on behavior. Cognitive defusion techniques help reduce the impact of unhelpful thoughts — such as “I’m not good at talking to people” or “They’ll think I’m boring” — that often interfere with social confidence. Through defusion, these thoughts are seen as mental events rather than facts, allowing individuals to engage more freely and assertively in conversations (Hayes et al., 2012).

Values clarification is another key element that directly enhances interpersonal functioning. ACT helps individuals identify the kinds of relationships they want and the qualities they value in communication — such as honesty, kindness, or collaboration — and supports actions that align with those values. This leads to more consistent, value-driven interactions and deeper connections (Luoma et al., 2007).

ACT as a Pathway for Early Mental Health Support for Autism

Research supports the effectiveness of Acceptance and Commitment Therapy in improving interpersonal relationships, demonstrating that ACT-based interventions can reduce interpersonal problems, increase emotional expressiveness, and improve social functioning across diverse populations, including those with social anxiety, depression, or autism spectrum conditions (O’Connor et al., 2021; Masuda et al., 2014).

More recent research has shown promising results for ACT with adult autistic populations. Pahnke et al. (2023) conducted a randomized controlled trial of a 14-week ACT intervention (NeuroACT) for autistic adults and found significant improvements in quality of life and reductions in depression and anxiety. Similarly, Pahnke et al. (2014) evaluated a six-week ACT-based skills training group for high-functioning autistic adolescents and young adults, with participants showing reduced stress and improved emotional regulation. Although gender-specific outcomes were not reported, the findings suggest ACT can enhance resilience and emotional coping in autistic youth.

As a non-pathologizing, therapeutic model to support greater psychological flexibility, ACT therefore appears well-suited to address the mental health challenges of high-functioning autistic girls. By helping these individuals develop greater psychological flexibility — the capacity to accept difficult thoughts and emotions while engaging in meaningful behavior (Hayes et al., 1999) — the six components of the model may be effective in helping this cohort relate to their thoughts and emotions in a non-judgmental way and respond more effectively to internal struggles — rather than avoid or suppress them.

As an important adjunct, ACT may also extend support to parents and caregivers of children with ASD. Corti et al. (2018) evaluated an ACT-based parent-training intervention and found that parents of autistic children reported decreased stress and increased psychological flexibility, underlining the therapy’s systemic impact.

Future Directions

Given the unique psychological stressors and potential negative outcomes faced by high-functioning autistic girls as outlined in this paper, ACT may offer the potential to provide an effective, gender-sensitive early intervention support option. Its emphasis on developing psychological flexibility may provide an effective tool for countering the problems posed and reinforced by chronic masking and camouflaging. Additionally, ACT’s core processes — such as defusion from distressing thoughts and clarifying values — may help this group build a more authentic sense of self and reduce dependency on socially exhausting coping strategies.

Based on the key issues discussed in this paper, it is proposed that a pilot program be considered to address and evaluate the potential benefits of an ACT-based intervention in a sample of high-functioning autistic girls aged 7–12 years. A pilot program of this nature would ideally involve the child, their parent or caregiver, and the clinician, with the parent/caregiver's involvement, collaboration, and overall understanding of the program being paramount to the success of the intervention. Additionally, it would be advisable for the clinician to have undertaken training that includes a strong understanding of differences in autistic behavior and presentations, as well as the nuances of masking and camouflaging behavior (Tierney et al., 2016).

In terms of practical application, ACT principles can be adapted for use with a wide range of ages, from children as young as 5 years old to adults. While the approach was originally developed for an adult population, ACT interventions have subsequently been adapted and applied to younger populations, including adolescents and children. More recently, Dr. Tamar Black (an educational and developmental psychologist based in Victoria, Australia) has developed ACT resources specifically tailored to children: ACT for Treating Children (New Harbinger, 2022) and The ACT Workbook for Kids (New Harbinger, 2024). ACT for Treating Children teaches therapists how to use ACT in individual therapy with children ages 5–12. This resource is written in simple, user-friendly, and child-friendly language and employs the ACT Kidflex: a simplified version of the ACT Hexaflex (discussed above). The ACT Workbook for Kids complements this book by providing a range of activities grounded in evidence-based ACT to help children cope with worry, sadness, and anger, with the expectation that children can undertake them either independently or with a parent, counselor, or clinician.

To maximize the efficacy and effectiveness of such a program, the ACT-based intervention would also need to be developed to reflect the lived realities of autistic girls, which may include using concrete language, relatable examples, and visual supports. If feasible, group-based interventions may also help to address the isolation and loneliness frequently reported by this group and to assist in practicing the components of ACT in a safe, interpersonal environment (Dean et al., 2017; Sedgewick et al., 2016).

Conclusion

High-functioning autistic girls face a complex interplay of strengths and vulnerabilities that are often overlooked in traditional diagnostic and therapeutic frameworks. Their ability to mask or camouflage autistic traits can delay recognition, obscure needs, and exacerbate risks for anxiety, depression, burnout, and suicidal ideation. While these coping strategies may provide short-term social inclusion, the long-term psychological toll — loss of authenticity, emotional exhaustion, and identity confusion — can be profound.

Acceptance and Commitment Therapy (ACT) may offer a promising, early intervention approach for this cohort. By fostering psychological flexibility, ACT supports autistic girls in acknowledging and accepting difficult internal experiences without resorting to avoidance, while encouraging actions that align with their personal values. This non-pathologizing approach addresses the unique mental health challenges posed by chronic masking, enabling individuals to build resilience, strengthen self-identity, and engage in more authentic social connections. ACT’s six core processes — acceptance, cognitive defusion, present-moment awareness, self-as-context, values, and committed action — provide a structured yet adaptable framework for developing emotional regulation, self-advocacy, and interpersonal skills.

Evidence from both general and autistic populations indicates ACT’s effectiveness in improving quality of life, reducing distress, and enhancing social functioning. When tailored to the lived realities of autistic girls — through concrete language, visual supports, relatable examples, and, where appropriate, group formats — it is feasible that ACT may have the potential to not only support the individual but also empower parents and caregivers as active participants in the intervention process.

Future work should focus on piloting and rigorously evaluating ACT-based programs for high-functioning autistic girls, particularly in late childhood when social pressures and masking behaviors intensify. By equipping this population with the tools to navigate social demands while remaining true to their authentic selves, ACT can serve as a preventive, strengths-based pathway that addresses immediate mental health needs and promotes long-term well-being.

References

Attwood, T. (2021). Understanding vulnerability in girls and young women with high-functioning autism spectrum disorder. Journal of Clinical Medicine, 10(1), 7.

A-Tjak, J. G. L., Davis, M. L., Morina, N., Powers, M. B., Smits, J. A. J., & Emmelkamp, P. M. G. (2015). A meta-analysis of the efficacy of acceptance and commitment therapy for clinically relevant mental and physical health problems. Psychotherapy and Psychosomatics, 84(1), 30–36.

Baron-Cohen, S., Tager-Flusberg, H., & Lombardo, M. V. (Eds.). (2013). Understanding other minds: Perspectives from developmental social neuroscience (3rd ed.). Oxford University Press.

Black, T. (2024). The ACT Workbook for Kids; Fun Activities to Help You Deal with Worry, Sadness and Anger using Acceptance and Commitment Therapy. 2nd edition. New Harbinger Publications.

Black, T. (2022). ACT for Treating Children — The Essential Guide to Acceptance Commitment Therapy for Kids. New Harbinger Publications.

Chellow, H., Barbaro, J., & Freeman, N. (2022). Examining similarities and differences in autism presentation in boys and girls aged 1–6 years: A systematic review. Journal of Autism and Developmental Disorders, 52(4), 1661–1685.

Corti, C., Spillmann, M., Lages, A., Meili, I., & Stoecklin, M. (2018). Acceptance and commitment therapy-oriented parent-training for parents of children with autism. Journal of Contextual Behavioral Science, 10, 1–8.

Dean, M., Harwood, R., & Kasari, C. (2017). The art of camouflage: Gender differences in the social behaviors of girls and boys with autism spectrum disorder. Autism, 21(6), 678–689.

Fombonne, E. (2009). Epidemiology of pervasive developmental disorders. Pediatric Research, 65(6), 591–598.

Green, R. M., Travers, A. M., Howe, Y., & McDougle, C. J. (2019). Women and autism spectrum disorder: Diagnosis and implications for treatment of adolescents and adults. Current Psychiatry Reports, 21(4), 22.

Harris, R. (2009). ACT made simple: An easy-to-read primer on acceptance and commitment therapy. New Harbinger Publications.

Harris, R. (2019). The happiness trap: How to stop struggling and start living (2nd ed.). Trumpeter.

Hayes, S. C., Strosahl, K. D., & Wilson, K. G. (2012). Acceptance and commitment therapy: The process and practice of mindful change (2nd ed.). Guilford Press.

Hayes, S. C., Strosahl, K. D., & Wilson, K. G. (1999). Acceptance and commitment therapy: An experiential approach to behavior change. Guilford Press.

Hull, L., Mandy, W., Lai, M.-C., Baron-Cohen, S., Allison, C., Smith, P., & Petrides, K. V. (2019). Development and validation of the Camouflaging Autistic Traits Questionnaire (CAT-Q). Journal of Autism and Developmental Disorders, 49(3), 819–833.

Hull, L., Petrides, K. V., & Mandy, W. (2020). The female autism phenotype and camouflaging: A narrative review. Review Journal of Autism and Developmental Disorders, 7(4), 306–317.

Kirkovski, M., Enticott, P. G., & Fitzgerald, P. B. (2013). A review of the role of female gender in autism spectrum disorders. Journal of Autism and Developmental Disorders, 43(11), 2584–2603.

Lai, M.-C., Lombardo, M. V., Auyeung, B., Chakrabarti, B., & Baron-Cohen, S. (2015). Sex/gender differences and autism: Setting the scene for future research. Journal of the American Academy of Child & Adolescent Psychiatry, 54(1), 11–24.

Lai, M.-C., Lombardo, M. V., & Baron-Cohen, S. (2016). Autism. The Lancet, 383(9920), 896–910. https://doi.org/10.1016/S0140-6736(13)61539-1

Luoma, J. B., Hayes, S. C., & Walser, R. D. (2007). Learning ACT: An acceptance and commitment therapy skills-training manual for therapists. New Harbinger Publications.

Masuda, A., Price, M., & Latzman, R. D. (2014). A meta-analytic review of the efficacy of acceptance and commitment therapy for clinically relevant mental and physical health problems. Journal of Contextual Behavioral Science, 3(1), 36–45.

O’Connor, M., Villatte, J. L., & Hayes, S. C. (2021). Using acceptance and commitment therapy to improve social functioning in people with autism spectrum disorder: A systematic review. Clinical Psychology Review, 84, 101973.

Pahnke, J., Hirvikoski, T., Bjureberg, J., Bölte, S., & Bölte, S. (2023). NeuroACT–an acceptance and commitment therapy intervention for autistic adults: A randomized controlled trial. Autism, 27(4), 1107–1120.

Pahnke, J., Lundgren, T., Hursti, T., & Hirvikoski, T. (2014). Outcomes of an acceptance and commitment therapy-based skills training group for students with high-functioning autism spectrum disorder: A quasi-experimental pilot study. Autism, 18(8), 953–964.

Raymaker, D. M., Teo, A. R., Steckler, N. A., Lentz, B., Schilling, C., Cross, E. I., … & Nicolaidis, C. (2020). “Having all of your internal resources exhausted beyond measure and being left with no clean-up crew”: Defining autistic burnout. Autism in Adulthood, 2(2), 132–143.

Sedgewick, F., Crane, L., Hill, V., & Pellicano, E. (2016). “I’m not just rude”: Autistic women and girls talk about their experiences of masking. Women and Girls with Autism Spectrum Disorder: Understanding Life Experiences from Early Childhood to Old Age, 49–62.

South, M., Ozonoff, S., & McMahon, W. M. (2005). Repetitive behavior profiles in Asperger syndrome and high-functioning autism. Journal of Autism and Developmental Disorders, 35(2), 145–158.

Supekar, K., Iuculano, T., Chen, L., & Menon, V. (2021). Sex differences in behavioral and brain functioning in autism spectrum disorder elucidated through multisite harmonized analysis. JAMA Psychiatry, 78(9), 1015–1025.

Tierney, S., Burns, J., & Kilbey, E. (2016). Looking behind the mask: Social coping strategies of girls on the autistic spectrum. Research in Autism Spectrum Disorders, 23, 73–83.

Tomchek, S. D., & Dunn, W. (2007). Sensory processing in children with and without autism: A comparative study using the short sensory profile. The American Journal of Occupational Therapy, 61(2), 190–200.

Zhang, C. Q., Leeming, E., Smith, P., Chung, P. K., Hagger, M. S., & Hayes, S. C. (2018). Acceptance and commitment therapy for health behavior change: A contextually-driven approach. Frontiers in Psychology, 8, 2350.

[1] Table based on findings by Attwood, T. (2021), Mandy, W., Chilvers, R., Chowdhury, U., Salter, G., Seigal, A., & Skuse, D. (2012), Dean, M., Harwood, R., & Kasari, C. (2017), Lai, M. C., Lombardo, M. V., Auyeung, B., Chakrabarti, B., & Baron-Cohen, S. (2015),

[2] Table 2 based on findings by Attwood, T. (2021), Hull, L., Mandy, W., Lai, M.-C., Baron-Cohen, S., Allison, C., Smith, P., & Petrides, K. V. (2019), Dean, M., Harwood, R., & Kasari, C. (2017).