Adolescence can be a challenging time for anyone, but for Autistic teens, the journey can come with unique emotional, social, and sensory hurdles. Depression is more common among Autistic youth than their neurotypical peers, often going undiagnosed or misunderstood. Research shows Autistic adolescents are at a higher risk for depression due in part to social isolation, sensory overload, bullying, and feeling misunderstood in school and community settings (Simonoff et al., 2008; Jackson et al., 2018; Kirby et al., 2023). Depression may manifest differently in Autistic youth—through withdrawal, increased repetitive behaviors, changes in appetite, sleep disturbances, or a loss of interest in previously enjoyed activities. These signs are often misattributed to Autism rather than recognized as co-occurring mental health concerns. Recent meta-analyses have confirmed psychiatric comorbidities such as anxiety, ADHD, depression, and sleep disorders are more prevalent in Autistic individuals than in the general population (Hossain et al., 2020; Lai et al., 2019; Lugo-Marín et al., 2019). Studies report between 70% and 92% of Autistic individuals experience at least one co-occurring psychiatric condition (Brookman-Frazee et al., 2018; Simonoff et al., 2008), with these challenges persisting from early childhood (Muratori et al., 2019) through young adulthood (Jackson et al., 2018). Mental health difficulties are associated with poorer health outcomes (Ahmedani & Hock, 2012) and reduced quality of life (Mason et al., 2019), including an increased risk of suicidality (Kirby et al., 2023).
Depression can disrupt daily routines, severely limit an Autistic adolescent’s ability to participate in meaningful activities, and negatively impact the development of a positive self-identity. Participation and identity formation are critical developmental tasks during adolescence. Resilience—defined as adaptive functioning in the face of adversity—is critical to Autistic youth managing these challenges. However, many Autistic individuals struggle to access mental health services, in part because providers often lack the training and confidence to support them effectively (Dreiling et al., 2022). Mandy (2022) describes the autism mental health paradox: a high likelihood of developing mental health problems but a low likelihood of receiving effective help. A neurodivergence-informed, holistic approach is needed—one that considers the interplay of biological, psychological, and social factors (Lai, 2023). Occupational therapy can play a vital role in supporting Autistic adolescents by fostering resilience through participation, identity formation, and emotional regulation. OT offers a powerful, practical, and individualized approach to help youth navigate the complexities of adolescence and thrive.
The Role of Occupational Therapy
Depression often leads teens to disengage from daily routines, hobbies, and social activities—further isolating them and diminishing their sense of purpose. OTs help Autistic adolescents re-engage with meaningful occupations by identifying and adapting activities that bring joy, foster self-determination, and support social connection. Interventions might include modifying hobbies to align with sensory preferences, building predictable routines to reduce feelings of being overwhelmed, and facilitating participation in low-pressure, interest-based environments. Participation in meaningful activities not only improves mood but also cultivates a sense of accomplishment and belonging—essential ingredients in resilience (Nielsen et al., 2020).
Within OT, occupation is both the means and the end of intervention. “Doing” is a powerful agent of change, and Autistic individuals often experience deep emotional connections to their occupations (Dallman, 2024). Research shows occupation is intricately linked to identity, belonging, and future aspirations (Hansson, 2022). By helping adolescents explore their strengths, preferences, and values through occupation, OTs support the development of a resilient and positive self-concept. Autistic teens may struggle with self-esteem—often due to pressures to mask their Autistic traits or conform to neurotypical norms. OT practitioners create safe, affirming spaces where Autistic identity is celebrated and self-expression is encouraged through creative or sensory-motor-based activities. These approaches promote self-advocacy, self-understanding, and authentic identity formation (McCauley et al., 2019; Román-Oyola, 2018).
Emotional regulation is another critical area where OT can make a meaningful impact. Depression can impair a teen’s ability to manage strong emotions, and Autistic adolescents may face additional challenges with affective contact and sensory processing (Dallman, 2024). OTs teach and practice self-regulation strategies tailored to the individual’s needs, including sensory-based calming techniques (e.g., weighted blankets, movement breaks), visual supports for recognizing emotions, and structured routines that embed co-regulation strategies with caregivers. Evidence supports the use of cognitive and occupation-based interventions such as the Alert Program and Social Stories to enhance self-regulation in natural contexts (Pfeiffer, 2018; Kuypers, 2011).
A whole-person, strengths-based approach is central to OT practice. Rather than focusing solely on symptoms, OT considers the adolescent’s interests, values, sensory needs, and goals. This holistic perspective aligns with the bio-psycho-social model (Khatri & Baniya, 2022) and recognizes the profound impact of environmental factors on mental health (Lai, 2023; Mandy, 2022). Autistic individuals are often expected to function in environments not designed for their needs, which can exacerbate mental health challenges. The Person-Environment-Occupation (PEO) model used by OT practitioners helps others understand and address challenges experienced by the individual in the context of their daily lives. Taking this transactive approach of looking at how the match of the person’s capacities/interests with the desired/needed occupation and what the environmental demands/supports are can promote success by adapting tasks/environments to be accommodating, affirming, and empowering (Kirby et al., 2023).
Collaboration is crucial. OTs work closely with caregivers, educators, and other team members to ensure consistency across settings and to build shared understanding. A collaborative approach enhances the adolescent’s support network and reinforces strategies that promote resilience and well-being. Post-diagnostic supports that educate and empower Autistic individuals—especially those that are strengths-based—can prevent mental health problems and foster long-term resilience (Mandy, 2022).
Summary
Autistic adolescents face a heightened risk of depression, often stemming from social isolation, sensory challenges, bullying, and a lack of understanding in and/or of their environments. Depression in this population is frequently underdiagnosed or misinterpreted, leading to significant impacts on participation, identity development, and emotional regulation. Occupational therapy practitioners have an essential role in addressing these challenges by promoting resilience through meaningful engagement, identity affirmation, and emotional support.
Occupational therapists help Autistic teens re-engage with activities that foster enjoyment, agency, and social connection while also supporting the development of structured routines and self-regulation strategies. By focusing on strengths, preferences, and values, OT practitioners empower adolescents to build a positive self-concept and navigate the complexities of adolescence with greater confidence. Grounded in a holistic, neurodivergence-affirming approach, OT interventions consider the dynamic interaction between the individual, their environment, and their occupations. Through collaboration with families and educators, OTs create consistent, supportive systems that enhance well-being and promote long-term mental health.
Suzanne Rappaport, OTD, OTR/L, is the Program Coordinator & Assistant Professor at Downstate Health Sciences University. For more information, email suzanne.rappaport@downstate.edu.
References
Ahmedani, B. K., & Hock, R. M. (2012). Health care access and treatment for children with co-morbid autism and psychiatric conditions. Social Psychiatry and Psychiatric Epidemiology, 47(11), 1807–1814. https://doi.org/10.1007/s00127-012-0482-0
American Occupational Therapy Association. (2017). Mental health promotion, prevention, and intervention in occupational therapy practice. American Journal of Occupational Therapy, 71(Supplement 2), 7112410035. https://doi.org/10.5014/ajot.2017.716S03
Brookman-Frazee, L., Stadnick, N., Chlebowski, C., Baker-Ericzén, M., & Ganger, W. (2018). Characterizing psychiatric comorbidity in children with autism spectrum disorder receiving publicly funded mental health services. Autism, 22(8), 938–952. https://doi.org/10.1177/1362361317712650
Dallman, A. (2024). Affective contact in autism: A phenomenological study of the emotional experiences of autistic adults. American Journal of Occupational Therapy, 78(4), 7804205070. https://doi.org/10.5014/ajot.2024.050502
Dreiling, N. G., Cook, M. L., Lamarche, E., & Klinger, L. G. (2022). Mental health Project ECHO Autism: Increasing access to community mental health services for autistic individuals. Autism, 26(2), 434–445. https://doi.org/10.1177/13623613211028000
Hansson, S. O., Björklund Carlstedt, A., & Morville, A. L. (2022). Occupational identity in occupational therapy: A concept analysis. Scandinavian Journal of Occupational Therapy, 29(3), 198–209. https://doi.org/10.1080/11038128.2021.1948608
Hossain, M. M., Khan, N., Sultana, A., Ma, P., McKyer, L. J., Ahmed, H. U., & Purohit, N. (2020). Prevalence of comorbid psychiatric disorders among people with autism spectrum disorder: An umbrella review of systematic reviews and meta-analyses. Psychiatry Research, 287, 112922. https://doi.org/10.31124/advance.11497014.v1
Jackson, S. L. J., Hart, L., Brown, J. T., & Volkmar, F. R. (2018). Brief report: Self-reported academic, social, and mental health experiences of post-secondary students with autism spectrum disorder. Journal of Autism and Developmental Disorders, 48(3), 643–650. https://doi.org/10.1007/s10803-017-3315-x
Khatri, P. and Baniya, M. (2022). Importance of the Bio-psychosocial Model of Practice in Health Care Services.https://www.jkahs.org.np/jkahs/index.php/jkahs/article/view/635
Kirby, A. V., Morgan, L., & Hilton, C. (2023). Autism and mental health: The role of occupational therapy. American Journal of Occupational Therapy, 77(2), 7702170010. https://doi.org/10.5014/ajot.2023.050303
Kuypers, L. (2011). The zones of regulation: A curriculum designed to foster self-regulation and emotional control. Think Social Publishing.
Lai, M. C., Kassee, C., Besney, R., Bonato, S., Hull, L., Mandy, W., Szatmari, P., & Ameis, S. H. (2019). Prevalence of co-occurring mental health diagnoses in the autism population: A systematic review and meta-analysis. The Lancet Psychiatry, 6(10), 819–829. https://doi.org/10.1016/S2215-0366(19)30289-5
Lai M. C. (2023). Mental health challenges faced by autistic people. Nature Human Behaviour, 7(10), 1620–1637. http://doi.org/10.1038/s41562-023-01718-2
Law, M., Cooper, B., Strong, S., Stewart, D., Rigby, P., & Letts, L. (1996). The Person–Environment–Occupation Model: A transactive approach to occupational performance. Canadian Journal of Occupational Therapy, 63, 9–23. https://doi.org/10.1177/000841749606300103
Lugo-Marín, J., Magán-Maganto, M., Rivero-Santana, A., Cuellar-Pompa, L., Alviani, M., Jenaro-Rio, C., Díez, E., & Canal-Bedia, R. (2019). Prevalence of psychiatric disorders in adults with autism spectrum disorder: A systematic review and meta-analysis. Research in Autism Spectrum Disorders, 59, 22–33. https://doi.org/10.1016/j.rasd.2018.12.004
Mandy W. (2022). Six ideas about how to address the autism mental health crisis. Autism: The International Journal of Research and Practice, 26(2), 289–292. https://doi.org/10.1177/13623613211067928
Mason, D., Mackintosh, J., McConachie, H., Rodgers, J., Finch, T., & Parr, J. R. (2019). Quality of life for older autistic people: The impact of mental health difficulties. Research in Autism Spectrum Disorders, 63, 13–22. https://doi.org/10.1016/j.rasd.2019.02.007
McCauley, J. B., Harris, M. A., Zajic, M. C., Swain-Lerro, L. E., Oswald, T., McIntyre, N., Trzesniewski, K., Mundy, P., & Solomon, M. (2019). Self-esteem, internalizing symptoms, and theory of mind in youth with autism spectrum disorder. Journal of Clinical Child & Adolescent Psychology, 48(3), 400–411. https://doi.org/10.1080/15374416.2017.1381912
Muratori, F., Turi, M., Prosperi, M., Narzisi, A., Valeri, G., Guerrera, S., Santocchi, E., Apicella, F., Lattarulo, C., Calderoni, S., & Vicari, S. (2019). Parental perspectives on psychiatric comorbidity in preschoolers with autism spectrum disorders receiving publicly funded mental health services. Frontiers in Psychiatry, 10, 107. https://doi.org/10.3389/fpsyt.2019.00107
Nielsen, K. T., la Cour, K., Christensen, J. R., Pilegaard, M. S., von Bülow, C., Brandt, Å., Peoples, H., Jonsson, H., & Wæhrens, E. E. (2020). Lessons learned about occupation-focused and occupation-based interventions: A synthesis using group concept mapping methodology. Scandinavian Journal of Occupational Therapy, 27(7), 481–492. https://doi.org/10.1080/11038128.2018.1561940
Pfeiffer, B., Clark, G. F., & Arbesman, M. (2018). Effectiveness of cognitive and occupation-based interventions for children with challenges in sensory processing and integration: A systematic review. American Journal of Occupational Therapy, 72(1), 7201190020p1–7201190020p9. https://doi.org/10.5014/ajot.2018.028233
Román-Oyola, R., Figueroa-Feliciano, V., Torres-Martínez, Y., Torres-Vélez, J., Encarnación-Pizarro, K., Fragoso-Pagán, S., & Torres-Colón, L. (2018). Play, playfulness, and self-efficacy: Parental experiences with children on the autism spectrum. Occupational Therapy International, 2018, 4636780. https://doi.org/10.1155/2018/4636780
Simonoff, E., Pickles, A., Charman, T., Chandler, S., Loucas, T., & Baird, G. (2008). Psychiatric disorders in children with autism spectrum disorders: Prevalence, comorbidity, and associated factors in a population-derived sample. Journal of the American Academy of Child and Adolescent Psychiatry, 47(8), 921–929. https://doi.org/10.1097/CHI.0b013e318179964f
