Experiences of Autism Acceptance and Mental Health in Autistic Adults
Experiences of Autism Acceptance and Mental Health in Autistic Adults
Eilidh Cage 0
Jessica Di Monaco 0
Victoria Newell 0
0 Department of Psychology, Royal Holloway, University of London , Egham Hill, Egham, Surrey TW20 0EX , UK
Mental health difficulties are highly prevalent in individuals on the autism spectrum. The current study examined how experiences and perceptions of autism acceptance could impact on the mental health of autistic adults. 111 adults on the autism spectrum completed an online survey examining their experiences of autism acceptance, along with symptoms of depression, anxiety and stress. Regression analyses showed that autism acceptance from external sources and personal acceptance significantly predicted depression. Acceptance from others also significantly predicted stress but acceptance did not predict anxiety. Further analyses suggested that experiences of “camouflaging” could relate to higher rates of depression. The current study highlights the importance of considering how autism acceptance could contribute to mental health in autism.
Autism acceptance; Mental health; Masking; Camouflaging
Autism is a lifelong neurodevelopmental condition which
affects the way individuals process the world; autistic1
individuals show differences in their social
communication, social interactions, sensory sensitivities, along with
restricted and repetitive interests and behaviours (APA
2013). The prevalence of comorbid mental health
conditions in autism is strikingly high. For example,
Eaves and Ho
found that 77% of young autistic adults in their
sample had additional mental health diagnoses, including
anxiety, depression and bipolar disorder. Other studies suggest
that the prevalence of depression in autistic individuals is
(Stewart et al. 2006)
. Anxiety is also frequently
found to be higher in the autistic population than within the
(Gillott and Standen 2007)
alongside a higher prevalence of social anxiety disorder
and White 2015)
. Difficulties with mental health are
consequently thought to contribute to a poorer quality of life in
Given this high prevalence of mental health difficulties, it
is vital to understand why those on the autism spectrum are
at a higher risk. There are a number of possible factors that
could contribute to this prevalence. The current study adopts
the “social model approach” as a means of explaining mental
health comorbidity in autism. The social model claims that
factors external to the individual cause disabling features
—for example, an employer’s attitudes
or lack of understanding of autism could prevent autistic
individuals from finding employment, rather than
difficulties an individual may experience as a result of autism itself.
When applying the social model to mental health in autism,
one factor—and the focus of the current study—that could
impact on mental health is an individual’s experiences and
perceptions of autism acceptance. Other factors which may
affect mental health in autism may include sensory
(Green and Ben-Sasson 2010)
and intolerance of
(Maisel et al. 2016)
. The current study focused
1 We use identity-first language or “person on the autism spectrum”
to fit with the language preferences of the autism community in the
(Kenny et al. 2016)
and the participants in the current study.
on autism acceptance as it has been little explored as a risk
factor for mental health issues in autistic adults.
Autism acceptance can be defined as an individual feeling
accepted or appreciated as an autistic person, with autism
positively recognised and accepted by others and the self as
an integral part of that individual. Autism acceptance from
others could be important for autistic individuals’ mental
health for a number of reasons. Within the mental health
literature, perceived stigma from others is thought to
contribute negatively to the mental health of stigmatised groups
(Mak et al. 2007)
. In terms of stigma against autistic people,
Sasson et al. (2017
) found that non-autistic individuals tend
to make rapid unfavourable judgements about those on the
autism spectrum. In their study, neurotypical participants
rated pictures or videos without knowing that some of the
people in the videos were on the autism spectrum.
Findings showed that the autistic people were rated as less
likeable, less attractive and that the participant would be less
likely to engage with them socially, suggesting that societal
acceptance may be poor. Moreover, when interviewed about
their experiences of acceptance from society, adults on the
autism spectrum reported that a lack of public
understanding was contributing to their experiences of social isolation
(Griffith et al. 2012)
. Studies examining autism
acceptance additionally indicate that although non-autistic
people are aware of autism
(Dillenburger et al. 2013, 2015)
misunderstandings and misconceptions are common
nonetheless, such as believing that changing an autistic child’s
diet can lessen symptoms, or that autism can be outgrown
(Tipton and Blacher 2014). Further, unconscious biases
towards autism can still be prevailingly negative even in
those who work regularly with autistic children
In terms of acceptance from closer social networks,
having the opportunity to engage with others who are
likeminded and to develop one’s sense of belonging is thought
to be important to the well-being of autistic adults
(Milton and Sims 2016)
. Indeed, sense of belonging is argued
to be vital to the well being of all individuals, irrespective
(Baumeister and Leary 1995)
. Research has also
suggested that previous experience of contact with autistic
individuals is associated with greater autism acceptance in
(Gardiner and Iarocci 2014)
with a family member on the autism spectrum tend to be
more accepting and open towards autism
(Nevill and White
. Longitudinal studies have also shown that autistic
individuals believe supportive family and friends help them
to develop greater feelings of self-worth
. Equally, parents of autistic children who
demonstrate higher acceptance of their child’s autism have been
found to have fewer mental health problems
(Weiss et al.
. Additionally, in a study where loneliness was
positively correlated with anxiety and depression, individuals on
the autism spectrum who reported having more friends
experienced fewer feelings of loneliness, as well as fewer anxious
and depressive symptoms
. As such, it may
be that feeling accepted by others could act as a protective
factor against mental health problems.
Personal acceptance is also an important variable within
mental health—for example, unconditional self-acceptance
in non-clinical samples has been shown to negatively
correlate with anxiety
(Chamberlain and Haaga 2001)
(Flett et al. 2003)
. Many autistic people want to
be accepted for being “who they are” and take pride in being
neurodivergent, a term (alongside neurodiversity) used to
describe differences in the way people think, with diversity
in the brain an important and celebrated part of human
(Cage et al. 2016a; Humphrey and Lewis 2008; Hurlbutt
and Chalmers 2002; Jaarsma and Welin 2012; Robertson
. Therefore, the current study also considered personal
acceptance of being on the autism spectrum. Kapp et al.
(2013) noted that those who self-identified more strongly
with the concept of neurodiversity tended to view autism
itself more positively. Recent research has also indicated that
identifying positively with an autistic identity mediates the
relationship between self-esteem and mental health
difficulties, suggesting that personal acceptance of autism as part of
one’s identity could protect against depression and anxiety
(Cooper et al. 2017)
. Despite this, many autistic
individuals frequently report “masking” or “camouflaging”—that is,
they may use strategies to camouflage the fact they are on
the autism spectrum in order to “fit in” to the non-autistic
(Dean et al. 2016; Hull et al. 2017)
one’s identity as an autistic person could have a subsequent
impact on experiences of acceptance, if one is not “out” as
being on the autism spectrum.
To the best of our knowledge, no research has directly
examined autistic adults’ perceptions and experiences of
autism acceptance and their relation to mental health
difficulties. It is not known how autism acceptance from both
self and others relates to mental health outcomes for autistic
adults. The current research thus aimed to test the
relationship between perceived autism acceptance and mental health
(specifically, depression, anxiety and stress) in a sample of
autistic adults. We hypothesised those autistic adults who
experienced less autism acceptance would show greater
prevalence of the symptoms of depression, anxiety and
Autistic adults over the age of 18 were recruited via a
range of means; these included sharing a link to the online
survey on social media or through autism organisations
and groups in the UK. A link to the survey was provided
for individuals wishing to participate. Groups and
organisations were initially contacted with an explanation of the
study via email, and were invited to participate and share
the survey. Adverts were also placed on the websites of
Research Autism and Autism West Midlands. Participants
who completed the whole survey were entered into a prize
draw to win a £50 voucher.
A total of 111 individuals completed the survey,
although 9 of these participants did not complete all of the
demographic questions. 54 participants reported that they
had a diagnosis of an autism spectrum condition (49%)
and 73 participants reported a diagnosis of Asperger’s
Syndrome (66%) - with overlap due to some participants
selecting both options—which could reflect the current
categorisation of Asperger’s Syndrome and autism under
the umbrella category of “autism spectrum disorder” in the
DSM-5 (APA 2013). Two participants reported a diagnosis
of pervasive developmental disorder not otherwise
specified. Further, 11 participants reported that they did not
currently have a formal diagnosis of autism. These
participants were not included in the regression analyses, since
we controlled for age of diagnosis. However, we decided
to include these individuals in other analyses since
removing their responses did not alter any of the other results.
Further, 84% self-reported additional mental health
diagnoses or developmental conditions. This included
depression (n = 57), anxiety (n = 62), social anxiety (n = 35),
attention deficit hyperactivity disorder (n = 18), obsessive
compulsive disorder (n = 18), post-traumatic stress
disorder (n = 9), bipolar disorder (n = 7) and Tourette’s
syndrome (n = 4).
Data collection took place from June 2016 to October
2016. The median time to complete the survey was 12 min.
All participants gave full informed consent to
participation and all responses were recorded anonymously. Ethical
approval for this study was obtained through Royal
Holloway, University of London.
Participants were asked a number of demographic
questions to establish the nature of the sample. The mean age of
participants at the time of the survey was 36.4 (SD = 12.0),
with a range from 18 to 72 years old. Mean age of
diagnosis was 31.4 (SD = 14.0), ranging from 4 to 69 years old.
Information on gender identity, sexual identity, employment,
education and ethnicity is shown in Table 1. Demographic
information demonstrated that the current sample mostly
consisted of female, heterosexual, well-educated White
British participants. Although women were not specifically
targeted, the survey attracted substantially more autistic women
than men. This could be due to women being more likely
to complete surveys
(Sax et al. 2003)
or the topic being of
particular interest to women.
*Numbers may not add up to 100% due to rounding
**Participants reported a range of other gender identities such as a
gender, non-binary or genderfluid
***Participants reported a range of other sexual identities such as
asexual, pansexual and demi-sexual
Before the study commenced, the proposal for this research
was reviewed by several autistic adults, to ensure that the
research was in line with the priorities of the autism
community—since all too often, autistic individuals are not involved
in the research process itself
(Pellicano et al. 2014)
Feedback was positive and their advice was taken on board in
ensuring question wording within the survey was clear and
Participants completed the survey online using the
Qualtrics survey platform. Online survey methods were utilised
in this research as this method is an efficient way to examine
the suggested hypothesis. After giving consent, participants
were asked for their preference of person-first (“person with
autism”) or identity-first (“autistic person”) language, as
there is debate around the use of these terms
(Kenny et al.
. Results showed that 62% of our sample preferred
identity-first language. Selection of preferred term meant
that all of the survey questions reflected the individual’s
preference where appropriate. Following this, participants
first reported their diagnoses and age of autism diagnosis,
followed by questions concerning experiences of acceptance,
then the Depression, Anxiety and Stress Scale (DASS-21),
and finally demographic questions.
Autism Acceptance Questions
To the best of our knowledge, there is no pre-existing
measure designed to measure autistic individuals’ perceptions of
autism acceptance. The current study aimed to quantify their
perceptions of autism acceptance. First, participants were
asked whether they felt that society (specified as the
general public, made up of people who did not personally know
them) generally accepted them, with “yes”, “no”,
“sometimes” and “prefer not to say” as response options. These
response options were used to obtain a categorical response
for acceptance. Second, they were asked to rate the
statement “over the past week, I have felt accepted by society as
an autistic person/person with autism”, on a 5-point scale
from “strongly agree” to “strongly disagree”. These response
options were used to fit with the standardised 5-point scale
used elsewhere in the survey (e.g. the DASS-21). Finally,
to assess perceptions of autism acceptance from
different sources, participants were also asked to report “how
accepted by society do you feel as an autistic person”, “how
accepted by your family and friends do you feel as an autistic
person”, and “how much have you personally accepted
yourself as an autistic person” on a scale from zero (“not at all”)
to ten (“completely”). Validation of these items is discussed
in the “Results” section.
Further, open textboxes were used to obtain qualitative
responses, such that participants could “tell us more about
[their] experiences of acceptance or non-acceptance”.
Content analysis was subsequently conducted on these qualitative
responses. Here, responses were first screened for common
themes by two independent coders (JDM and VN) who
familiarised themselves separately with the data. Categories were
then agreed upon, discrepancies resolved and all responses
were grouped into the categories by the two coders
independently. Inter-rater reliability was calculated using the ReCal
and is reported in the “Results”
Depression, Anxiety and Stress Scale (DASS‑21)
(Lovibond and Lovibond 1995)
is a self-report
scale used to measure depression, anxiety and stress. This
measure consists of 21 items and is a short version of the full
42 item DASS. We used the short version as it is shown to
have as good reliability and validity as the long version
(Cronbach’s alpha 0.94, 0.87 and 0.91 for the depression, anxiety
and stress subscales respectively, Antony et al. 1998; Ng et al.
, along with good construct validity (Henry and
Crawford 2005). The DASS-21 has also previously been used with
(Maddox and White 2015)
. Participants were
asked to rate 21 statements and to judge whether they could be
applied to their life over the past week, on a scale from one to
four (1 = did not apply to me at all; 2 = applied to me some of
the time; 3 = applied to me a considerable degree; 4 = applied
to me very much or most of the time). The 21 items could be
divided into 7 items each for depression, anxiety and stress
scales. A total score for each scale (depression, anxiety and
stress) was computed and multiplied by two (maximum
possible score for each scale = 42). Internal consistency in the
current sample showed high consistency for the depression
(Cronbach’s alpha = 0.919) and stress (Cronbach’s alpha = 0.842)
scales, while the anxiety scale had acceptable consistency
(Cronbach’s alpha = 0.790). These estimates are similar to
previous research using the DASS with autistic adults
0.861 and 0.805 for depression, stress and anxiety subscales
respectively, Maddox and White 2015)
This cross-sectional study had a correlational design. The
outcome variable was mental health (depression, anxiety or
stress score on the DASS) and the main predictor variables of
interest were perceptions of autism acceptance.
When asked whether they felt society, in general, accepted
them as an autistic person, 7% of participants said “yes”,
43% said “no” and 48% said “sometimes” (2% preferred
not to say). Participants were also asked to rate the
statement “over the past week, I have felt accepted by society
as an autistic person/person with autism”; 24.3% strongly
agreed or agreed, 34% neither agreed nor disagreed, and
41.4% disagreed or strongly disagreed with this statement.
The validity of the three items examining autism
acceptance from society, family and friends, and personal
acceptance of autism diagnosis was assessed. As shown in Table 2,
perceived acceptance from society and family and friends
correlated significantly with ratings of acceptance from
society over the past week. Personal acceptance did not correlate
with this item or perceived societal acceptance, but did
correlate with family and friend acceptance (r = .21, p = .027).
The three items assessing autism acceptance from the
three sources were then assessed using principal
component analysis (PCA) to test whether the items were
measuring one overall construct of perceived acceptance,
or if they were measuring acceptance from three
separate sources. The KMO statistic was acceptable (0.528),
individual item KMO values were above 0.74, and
Bartlett’s test of sphericity was significant (χ2 (3) = 33.66,
p < .001), indicating that PCA was appropriate with the
current sample size
. The analysis extracted
one component (eigenvalue 1.57) explaining 52.46% of
total variance. The factor loadings of the three items onto
this component indicated that perceived acceptance from
society (factor loading = 0.801) and family and friends
(0.848) loaded significantly onto one component.
However, personal acceptance did not load significantly onto
the component (factor loading = 0.462; according to
(2002, as cited in Field 2013)
only loadings greater than 0.512 for a sample size of 100
are statistically significant). Further, when testing for
reliability using Cronbach’s alpha, removal of the personal
*This item was scored according to how much the participant agreed that they had felt accepted by society
as an autistic person over the past week on a 5-point scale from “strongly agree” (1) to “strongly disagree”
(5). All other items were rated on a scale from “0” (not at all) to “10” (completely)
acceptance item increased Cronbach’s alpha from 0.51
to a more acceptable value of 0.64. Given these results,
the two items considering societal acceptance and family
and friend acceptance were combined into a measure of
“external sources of acceptance”, and that personal autism
acceptance was considered as a separate construct.
Mean ratings of perceived acceptance, on a scale from
zero (“not at all”) to ten (“completely”) from external
sources (society, family and friends) and personal
acceptance are shown in Table 3, showing that personal autism
acceptance was greater than perceived acceptance from
external sources, t(110) = 7.93, p < .001, 2-tailed, d = 0.76.
Depression, Anxiety and Stress Scale
The mean for the DASS depression score was 17.8
(SD = 12.7), with scores ranging from 0 to 42. The mean
for DASS anxiety score was 12.9, (SD = 9.14), ranging
from 0 to 40. Finally, the mean DASS stress score was
22.3 (SD = 9.96), ranging from 0 to 42. These scores are
similar to those reported in
Maddox and White (2015)
study with autistic adults (although they did not multiply
the results by two), but are significantly higher than the
means reported in the non-autistic population (for
Henry and Crawford (2005)
report the means from
depression (5.66), anxiety (3.76) and stress (9.46) scores
in 1794 non-autistic, non-clinical participants).
Age of diagnosis
Considering the relationships between acceptance and
mental health, Spearman’s correlational analyses showed
that societal acceptance over the past week correlated
significantly with DASS depression scores (ρ (107) = 0.288,
p = .002) and DASS stress scores (ρ (109) = 0.281, p = .003);
but there was no significant correlation with DASS anxiety
scores (ρ (106) = 0.096, p = .32).
Further regression analyses were conducted to test
whether acceptance from external sources or personal
acceptance could predict mental health symptoms. Three
separate hierarchical regressions with depression, anxiety
and stress as the outcome variables were conducted.
Blockwise entry was used to analyse the data; age, age of
diagnosis, gender and the other DASS scales (since the scales were
highly correlated with one another, Table 4) were entered
into the first step for each model. In the second step, the two
types of acceptance (external sources and personal) were
entered. Several participants (n = 27) were not included in
the final analyses as they had missing data for one or more
of the variables. Correlations between the three DASS scales
and predictor variables are shown in Table 4.
First, depression was considered as the outcome variable;
the first step explained 34.6% of the variance in depression
scores, and adding the acceptance variables as predictors in
step two could explain 52.1% of the variance, a significant
change (p < .001). The final model was also a significant fit
to the data (F (7, 83) = 11.80, p < .001). This final model
shows that age of diagnosis, anxiety, external acceptance and
personal acceptance could significantly predict depression
scores (Table 5).
Figure 1 demonstrates the relationship between
depression, external acceptance and personal
acceptance—indicating that there was a relationship between depression and
autism acceptance such that greater levels of depression
were associated with less perceived acceptance from
external sources and less personal acceptance.
Next, stress was entered as the outcome variable. The first
step explained 54% of the variance in depression scores, and
adding the acceptance variables in step two explained 57%
of the variance, a non-significant change (p= .11). The final
model was a significant fit to the data, F (7, 83)= 14.32,
p < .001. This final model shows that anxiety and external
acceptance significantly predicted stress scores (Table 6).
With increasing stress scores, participants perceived less
autism acceptance from external sources (Fig. 2).
Finally, anxiety was tested as the outcome variable; here
the first step explained 52% of the variance in depression
scores, and adding the acceptance variables in step two
explained 54% of the variance, a non-significant change
(p = .21). The final model was a significant fit to the data,
F (7, 83) = 12.61, p < .001. This final model shows that age
of diagnosis, depression and stress scores significantly
predicted anxiety scores (Table 7).
Content Analysis of Qualitative Results
63 participants gave qualitative responses when asked
to provide further information on their experiences of
B unstandardised beta coefficient, SE B standard error, β standardised
autism acceptance. Content analysis was used to examine
and categorise these responses, with four broad themes
agreed upon: positive acceptance experiences, negative
acceptance experiences, consequences of
acceptance/nonacceptance, and an “other” category. Within these themes,
21 sub-categories were agreed. The categories are shown
below in Table 8. Inter-rater reliability was assessed using
kappa coefficients, demonstrating that 12 categories had
almost perfect agreement, 7 had substantial agreement and
2 had moderate agreement (following the guidelines for
Landis and Koch (1977)
The categories with the most responses were
misunderstandings and misconceptions about autism, experiences of
masking/camouflaging, negative acceptance experiences
from society and from specific organisations, mental health
difficulties, and difficulties with social interactions. Example
quotes from each of these categories are shown in Table 9.
A subset of participants spontaneously reported
experiences of “masking” or “camouflaging” the fact that they
were on the autism spectrum (n = 27). These qualitative
reports indicated a potential relationship between
experiences of camouflaging and mental health, with some
participants reporting how camouflaging had a detrimental effect
on their psychological wellbeing. Exploratory analyses were
thus conducted to examine the hypothesis that camouflaging
could have negative effects on mental health. A two
(camouflaging: yes or no)× three (DASS scale: depression, anxiety
or stress) mixed ANOVA was conducted on DASS scores,
to test whether camouflaging related to symptoms of mental
health. There was a main effect of DASS (F (2, 212)= 37.45,
p < .001, ηp2 =0.26), with planned contrasts using
Bonferroni showing that overall more depression was reported
than anxiety (p < .001), but significantly less depression
than stress (p = .037), as well as more stress than anxiety
(p < .001). There was no main effect of camouflaging (F
(1, 106) = 2.46, p = .12, ηp2 = 0.023). There was a
significant interaction between camouflaging and the DASS (F (2,
212) = 4.55, p = .012, ηp2 = 0.041). Planned contrasts using
t tests showed only significant differences in depression
between those who reported camouflaging and those who
did not (t (107) = − 0.256, p = .012, g = 0.56), with those who
spontaneously reported camouflaging also reporting higher
depression. Further exploratory analyses showed that when
asked how accepted over the past week they had felt, those
who reported camouflaging were more likely to disagree
that they had experienced acceptance (Likelihood ratio:
X2(2) = 6.68, p = .035). Finally, there was no significant
gender differences in spontaneous reports of camouflaging
(Likelihood ratio X2(2) = 0.60, p = .740).
The current study aimed to test the relationship between
autism acceptance and mental health (specifically,
depression, anxiety and stress) in autistic adults. We hypothesised
that autistic adults who experienced less acceptance would
show a greater prevalence of depression, anxiety and stress
symptoms. Findings showed that depression was predicted
by autism acceptance from external sources (society, family
and friends) and personal acceptance. Stress was predicted
only by acceptance from external sources. There was no
relationship between anxiety and autism acceptance.
The finding that depression was predicted by
acceptance from external sources makes sense if the importance
of supportive others is first considered. For example,
Hurlbutt and Chalmers (2002)
claim that families have a large
role in helping autistic individuals develop the skills needed
to become successful adults in society. Further, for adults
and adolescents with Asperger’s Syndrome,
argued that the care and support of family members who
accept an individual’s anxiety can protect against the
development of depression.
Lasgaard et al. (2010
) also noted that
perceived social support from family and peers was
negatively correlated with loneliness in autistic adolescents.
Feeling accepted by others as an autistic person could be a
protective factor against depression.
Further, we also found that greater personal autism
acceptance predicted lower depressive symptoms. Indeed, a
recent study by Cooper et al. (2017) showed that identifying
→ Mental health difficulties
→ Physical health difficulties
→ Feeling different and/or isolated
→ Need to educate more about autism
→ Difficulties with social interactions
→ Impact of late diagnosis
→ Unsure about acceptance
Misunderstandings and misconceptions 29 “People don’t seem to understand that autism affects every single aspect of who
I am as a person, and telling me there should be a cure is telling me I shouldn’t
exist... I can’t feel accepted by society until society understands that autistic
people sometimes need support, and there’s nothing wrong with that, but there is
something very wrong with wanting to change an autistic person into someone
“Because my responses are slightly different from neurotypical people I am
times regarded as mentally ill when I am not. I find this very frustrating.”
From society 13 “Generally I don’t think society accepts the traits that often go hand in hand with
autism though and I therefore am also very pessimistic about the integration of
people with autism into society.”
From specific organisations (e.g. work- 11 “Since being diagnosed I have found that, other than specific autism support
place, educational settings, etc.) services, mention of autism is met blankly or dismissed, even by those who have
remarked on my oddity. I have told my employers, and they acknowledge what I
have told them but don’t really understand what it means to me.”
27 “I do not exhibit symptoms much or am able to mask/hide them almost
“I have to invest a lot of energy into “passing” as neurotypical”
“I feel that I have spent the majority of my life engaged in the search for
ance and therefore I can fake neurotypical behaviour pretty well.”
“I mask well so I am accepted but not as an autistic person.”
Mental health 8 “[Masking] is incredibly exhausting and stressful and has ultimately led to mental
and physical health problems.”
“As the years pass I suffer increasing anxiety for lack of even casual acceptance by
my species and, conversely, huge spikes of anxiety when someone actually does
‘see’ me. Invisibility has become my comfort zone as well as my prison.”
Difficulties with social interactions 8 “After a lifetime of observing people, trying to work out why I am different and so
isolated, it seems to me that my lack of comprehension of non-verbal
communication limits my interaction with NTs looking for expected responses and results
in them looking past me.”
with an autistic identity was positively associated with
self-esteem, mediating an association with depression and
anxiety. Cooper et al. (2017) suggest that autistic identity
could act as a protective factor against mental health
difficulties, which the current findings would support if personal
acceptance is considered to be related to identity. It could
be argued that the relationship between depression and
personal acceptance is mediated by self-esteem—with
acceptance serving to boost self-esteem and thus protect against
depression. The possible relationship with self-esteem may
also explain why only depression was associated with
personal acceptance, since feelings of self-worth are part of
depression but not anxiety or stress (APA 2013). Further, a
meta-analysis of whether self-esteem predicted depression
and anxiety in a non-autistic sample found the directional
effect of self-esteem on depression was stronger than the
effect of depression on self-esteem
(Sowislo and Orth 2013)
Future research considering acceptance should endeavour to
measure self-esteem and clarify its relationship with mental
health and autism acceptance.
We also found that stress was predicted by
external sources of autism acceptance. Arguably, it is
stressful to not be accepted by others. In the social psychology
literature, social support has been shown to protect against
(Haslam et al. 2005)
. For example, less stress is seen
in workplaces where others are more accepting and
supportive of whom an individual wants to be
(Lang and Lee
. However, autistic individuals may struggle to feel
accepted by various individuals - with research suggesting
that they experience less social support from others as well
as perceiving more stress
(Bishop-Fitzpatrick et al. 2017)
More research is needed to understand how autistic
individuals’ experiences of acceptance might contribute to levels
of stress, along with how external support might serve as
In this study, participants’ qualitative responses add an
additional dimension and further insight into their
experiences. These responses revealed many in the sample
“camouflaged”—in other words, they acted as though non-autistic
or “neurotypical”. Being able to pretend or act as
neurotypical fits with the idea that autistic individuals are capable of
reputation management, and supports evidence that autistic
individuals can present themselves in a specific light
et al. 2008; Cage et al. 2013, 2016a, b; Scheeren et al. 2010,
. Importantly, the current results indicate that this
effort may be detrimental to mental health, with those who
reported camouflaging also reporting higher symptoms of
depression and fewer experiences of acceptance in the past
week. Additionally, recent research has attempted to explain
gender differences in the diagnosis of autism as females are
suggested to be better at camouflaging than males
et al. 2016; Dean et al. 2016; Lai et al. 2017; Tierney et al.
. However, the current study did not find any gender
difference in spontaneous reports of camouflaging, with
men just as likely to report camouflaging as women. More
research is needed to further understand camouflaging and
its relationship to mental health in autism.
Interestingly, autism acceptance did not predict anxiety.
It could be the case that other non-social factors play more
of a role in anxiety in autism. For example, intolerance of
uncertainty is an important concept within anxiety
disorders regardless of autism
(Carleton et al. 2012)
, where being
unable to deal with the uncertain aggravates anxiety. In both
autistic children and adults, intolerance of uncertainty has
been shown to relate to anxiety
(Boulter et al. 2014;
Maisel et al. 2016)
. Another factor which is thought to play an
important role in anxiety in autism is sensory sensitivities
(Green and Ben-Sasson 2010). Interestingly,
and Pellicano (2016
) found that intolerance of uncertainty
and anxiety were related to autistic children’s sensory
sensitivities, suggesting that there could be a dynamic interplay
between different variables and mental health outcomes.
More research is needed to examine a wide range of social
and non-social risk factors for mental health difficulties in
It is also worth considering how Theory of Mind
ability may impact on perceptions of autism acceptance. It is
hypothesised that autistic individuals have a difficultly with
understanding other’s perspectives
(Baron-Cohen et al.
, which could affect whether the individual can
accurately recognise how accepted they are by other people.
However, research has shown that autistic individuals can
theorise about other minds, and this ability is dependent on
, task demands
et al. 2013)
and whether automatic or conscious Theory of
Mind is being tested
(Senju et al. 2009)
. A recent study by
also demonstrated that
neurotypical family members tended to underestimate their
autistic family member’s perspective-taking ability. Arguably, it
is therefore important that autistic people’s ability to reflect
upon their experiences of autism acceptance is not
underestimated. Mixed methods, as used in the current study, are
a key way of validating and supporting autistic individuals’
The current study is not without its limitations. First,
online survey methods rely on self-report which may be
deemed unreliable. As a means of testing an initial
hypothesis, though, we believe that online survey methods are
effective in reaching a large sample, in a means that is
accessible to many autistic people. Second, the participants
in this study were predominantly female, which may limit
the generalisability of the findings. Despite this, gender was
not a significant predictor in any of the analyses. Further, the
experiences of autistic women have been overlooked
(Pellicano et al. 2014)
, thus the reports from the current study are
arguably of great value in helping enhance understanding of
the experiences of autistic women, even if those experiences
are not that different to men. Third, as well as autism, a
high proportion of participants reported additional diagnoses
which could suggest that the survey attracted autistic adults
who had already experienced or were currently experiencing
mental health difficulties, and the results may not be
applicable to those who experience lower incidences of mental
health problems. However, research shows that comorbid
mental health difficulties are highly prevalent in autism (e.g.
Eaves and Ho 2008), thus the current findings are relevant
to a large proportion of the autistic population. Finally, the
current sample also mainly consisted of well-educated
individuals who would not be representative of the whole autism
spectrum. More research is clearly needed to include a wider
variety of individuals on the autism spectrum. Based on the
current study’s limitations, future research should aim to
access a wide range of autistic people using both online and
offline surveys. Given the paucity of research into
experiences of autism acceptance and its relationship to mental
health, further in-depth qualitative research would also be
advantageous for enhancing our understanding of these
Nonetheless, we believe that this study offers novel
insight into the importance of autism acceptance for
autistic adults and their mental health. Future research should
further examine how mental health difficulties in autistic
individuals can be protected against by improving autism
acceptance. Interventions designed to improve family and/
or peer support should be tested, as well as those intended to
boost personal acceptance or self-esteem. For example, peer
mentoring has been examined in a Higher Education context
and been shown to have the potential to improve autistic
(Lucas and James 2017)
. We would
particularly advocate for interventions designed alongside
autistic people, with a focus on neurodiversity
(GillespieLynch et al. 2017). Wider societal acceptance should also
be strived for to reduce the need for autistic adults to
camouflage, and instead be accepted as they are. Overall, the
current study demonstrated relationships between experiences
of autism acceptance, depression and stress in a sample
of autistic adults. There is still a long way to go in
understanding and tackling the high prevalence of mental health
difficulties in autism, but we believe that the social model
approach is a useful and positive lens through which mental
health outcomes could be improved.
Acknowledgments Thank you to all of the participants who took
part in this research, and to the autistic adults who kindly reviewed
this research and offered invaluable feedback before it commenced.
This research received no specific grant from any funding agency in
the public, commercial, or not-for-profit sectors.
Author Contributions EC conceived of the study, participated in
its design and coordination, performed the statistical analysis and
drafted the manuscript; JM and VN participated in the design,
performed the measurement, assisted with the interpretation of the data
and helped to draft the manuscript. All authors read and approved the
Compliance with Ethical Standards
Conflict of interest The authors have no conflict of interest to
Open Access This article is distributed under the terms of the
Creative Commons Attribution 4.0 International License
(http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use,
distribution, and reproduction in any medium, provided you give
appropriate credit to the original author(s) and the source, provide a link to
the Creative Commons license, and indicate if changes were made.
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