Suarez, V., Moon, E, & Najdowski, A. (2022). Systematic review of acceptance and commitment training components in the behavioral intervention of individuals with autism and developmental disorders. Behavior Analysis in Practice, 15(1), 126-140. https://doi.org/10.1007/s40617-021-00567-7

Reviewed by:
Kristina Mira, MEd, QBA, IBA and Kate McKenna, MEd, MSEd, MS, BCBA
Association for Science in Autism Treatment

Why research this topic?

Research Synopses - Psuchological, Educational and Therapeutic InterventionsAcceptance and Commitment Therapy (ACT) is a psychotherapeutic intervention used to help individuals change their relationship with negative thoughts and emotions to foster cognitive and behavioral improvements that help the individual lead a more values-driven lifestyle. More specifically, ACT is grounded in Relational Frame Theory (RFT), a behavior analytic account of how humans learn to relate events and concepts through language and context (Gross & Fox, 2009; Tarbox et al., 2020). ACT helps individuals to adjust relational frames that have become unhelpful and form new relations that are more adaptive.

The overall goal of ACT is to increase psychological flexibility to improve an individual’s quality of life (Tarbox et al., 2020; Suarez et al., 2022). It involves training the individual to engage in alternative behaviors in the presence of previously aversive situations.

ACT methods are based on activities and thought exercises from six domains that promote the cultivation of psychological flexibility. These domains together make up the ‘ACT Hexaflex’ (Suarez et al., 2022) and include:

      • Present moment awareness: teaches mindfulness (e.g., breathing exercises, meditation) and skills related to noticing what is happening in the current moment rather than getting stuck thinking about past or future worries.
      • Values identification: teaches individuals to identify and reiterate their personal values—what things are truly important to them.
      • Committed action: teaches individuals to identify specific behaviors and plan actions that are in alignment with, or bring them closer to, their stated values.
      • Self-as-context: teaches individuals to become more flexible about their identity and let go of negative self-labels that hinder values-directed actions.
      • Defusion: teaches individuals to step back from their thoughts and observe them in different ways, rather than become stuck in maladaptive thought patterns.
      • Acceptance: teaches individuals to use coping skills to face, accept and feel all emotions – even the uncomfortable ones.

Although ACT is a psychotherapeutic approach, its components have been translated for use in non-psychotherapeutic settings. When implemented in these other contexts, these methods are referred to as Acceptance and Commitment Training (ACTr). ACTr has recently gained attention within the field of applied behavior analysis (ABA), as several of the hexaflex domains contain behavioral components and therefore, individuals have argued that the methods can be in alignment with the scope of practice of behavior analysts and the seven dimensions of ABA (Tarbox et al., 2020; Suarez et al., 2022; Denegri & Catrone, 2025; Wilson, 2025). Currently, there is a lack of scientific evidence and research exploring the efficacy of ACTr within ABA contexts (Cihon et al., 2022; Wilson, 2025) however, researchers are beginning to explore this area in more depth. For example, Suarez and colleagues conducted a literature review of single-case research designs that investigated the efficacy of ACT components across different contexts. Specifically, the researchers examined several studies to examine the behavioral effects of different ACTr components with individuals with autism spectrum disorder (ASD) or developmental disorders (DD), their caregivers, and/or their staff.  This article will be reviewed below.

What did the researchers do?

The authors conducted a systematic review of the literature using the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines to search the PsycInfo database for relevant articles.

Articles were deemed admissible for the review if they met six pre-identified inclusion criteria: (a) article was published in an English peer-reviewed journal from any date up to May 2020, (b) the title or abstract of the study contained identified keywords used during the PRISMA search, (c) article used a single-case experimental design that incorporated manipulation of an independent variable, (d) article examined the impacts of one or more components of ACTraining on observable behavior, (e) article did not include other psychotherapeutic treatments, and (f) participants were either individual with ASD/DDs, their caregivers, or service providers.

Researchers used keywords, like ‘acceptance and commitment’ and ‘autism’, to conduct literature searches in PsycInfo to gather potential articles. Initial searches identified 1,426 articles. This was ultimately narrowed down to 29 articles (30 individual studies) after assessing each for inclusion criteria.

What did the researchers find?

Participants A total of 132 participants were recorded across all 30 studies, including caregivers, staff members, and individuals with ASD/DDs. Of the individuals with ASD/DDs, there were:

    • 46% adults
    • 24% adolescents
    • 30% children
Experimental Design A variety of systematic experimental designs were found in the literature.

    • Multiple-baseline experimental design – 83%
    • Other reported designs included changing-criterion design (7%), quasi experimental A-B design (3%), multielement design (3%), and multielement design within a multiple-baseline across participants design (3%).
Behaviors Chosen for Intervention Several overt behaviors were measured to determine effects of the intervention. Target behaviors differed across studies and participant type:

    • For individuals with ASD/DD’s: aggression, disruption, self-injury, noncompliance, and inflexible behaviors
    • For staff: engagement with clients, implementation of behavioral skills training, physical restraint use, staff injuries and medication administration
    • For caregivers: use of behavioral strategies by mothers

Some studies included additional measures of participant weight (3%) and cost-benefit analysis of the intervention (7%). 43% of the studies also included subjective measures through self-reports for private events.
Measurement Procedures Each of the 30 studies reported measuring overt behaviors with the following methods:

    • Rate (70%)
    • Interval recording (17%)
    • Percentage of opportunities (20%)
ACTraining Exercises Implemented The majority of the studies (73%) only included one ACT component, while 13% included two, 7% included three, 3% included five, and 3% included all six.

Specific ACT components used across the studies included:

    • Present moment awareness (90%)
    • Committed actions (23%)
    • ·Values identification (17%)
    • Defusion (17%)
    • Acceptance (7%)
    • Self-as-context (3%)
Individuals Implementing the ACTraining 25 studies reported information regarding who implemented the ACT components:

    • Professionals in the field (80%)
    • Parents (16%)
    • Individual with DD (4%)
Intervention Format Different studies implemented ACT training in different formats:

    • Individual training sessions (60%)
    • Group training sessions (23%)
    • Pyramidal training format (17%)
    • Telehealth components (7%) (all of which were used within the pyramidal formats)
Intensity/Length of ACTr Intervention Of the 30 studies, 27 (90%) indicated the duration of training sessions:

    • 1 hour or less (56%)
    • 2 to 4 hours (26%)
    • 5 to 8 hours (4%)
    • 1 day (15%)

97% of the studies reported the total number of training sessions implemented:

    • 1 session (17%)
    • 2 to 5 sessions (24%)
    • 6 to 9 sessions (28%)
    • 10-13 sessions (24%)
    • 14 or more sessions (7%)

The majority of studies reported a total duration of the intervention to be 1-5 consecutive days.
Outcomes Outcomes reported across the studies indicated the following levels of effectiveness of the training results:

    • Below minimally effective results (23%)
    • Minimally effective results (33%)
    • Moderately effective results (17%)
    • Highly effective results (27%)
Maintenance and Generalization Only 4 studies (13%) assessed for generalization. Researchers identified that generalization was successful in 75% of these studies.

19 studies (47%) included maintenance assessments, of which all reported that results maintained successfully following intervention.
Social Validity Only 37% of the studies reported social validity measures. Of these, 55% were in the format of surveys and 45% were conducted via interviews. Although specific details were not provided, in each of the 11 studies, measures supported some aspect of social validity. It is not clear if each study specifically assessed participant views of all three pillars of social validity (i.e., goals, procedures, and outcomes).
Technological Description of Procedures Results of the analysis indicated that 87% of the studies included procedural descriptions that were technological and replicable.
IOA and Treatment Fidelity Of the studies that reported mean IOA data, 79% were over 90% agreement. 13% of the studies indicated IOA between 80% – 90%.

Treatment fidelity data was collected in 33% of the studies, with ranges of mean fidelity from 90% – 100%.

What are the strengths of the study?

Systematic reviews of the literature are beneficial because the body of current research can be gathered and investigated across a variety of parameters and variables. The examination of these studies seems to indicate that positive results can be achieved in the absence of all six hexaflex components. Further component analysis with individuals on the autism spectrum is needed to determine the interplay of hexaflex components and participant characteristics. Additionally, this analysis revealed gaps in the research that is currently available about ACTr. Findings can be used to guide future research.

What are the limitations of the study?

There are some limitations of this study that should be noted. In the examination of elements of the studies, a measurement of treatment fidelity, the accuracy of implementation of ACTr as intended, was missing. Additionally, there was no evaluation of data trends for individual participants. The review examined single-subject studies only. No group-design research articles were included, which limits the generalizability of the results.

What do the results mean?

This literature review evaluated 30 peer-reviewed studies that implemented at least one component of ACTr with individuals with ASD/DDs and found that 33% reported minimally effective results, 17% reported moderately effective results and 27% reported highly effective results. The majority of the 30 studies (73%) included only one component of ACTr, with 90% of the studies incorporating present moment awareness. Also, of the studies that included generalization and maintenance measurements, the majority reported that results were upheld across time or other novel contexts.

So, how can we interpret these results for applied purposes? Based on the findings reported in the studies reviewed in this article, it is evident that ACTr may be somewhat effective for individuals with ASD/DDs as well as their teachers and caregivers, with intervention effects maintaining and generalizing to different situations. Additionally, not all six components of the hexaflex are necessary to achieve these results. This finding has useful clinical significance revealing that ACTr can still be implemented with some, and even only one, of the hexaflex components. Most of the studies reviewed in this article incorporated only present moment awareness, also known as mindfulness, suggesting that this component could be important in producing positive treatment outcomes. Social validity also appears to be high in each of the 11 studies that measured it, suggesting that the methods involved in ACTr are generally acceptable by clients and stakeholders. Despite these positive outcomes, further research is needed to solidify the utility of ACTr on the individual level for those with ASD/DDs, and in what specific contexts. A final needed area of investigation is the identification of the specific components, or combination, which are necessary for effective and meaningful outcomes.

References

Cihon, J., Schlinger, H., Ferguson, J., Leaf, J., & Milne, C. (2022). Is ACTraining behavior analytic? A review of Tarbox et al. (2020). Behavior Analysis in Practice, 18(1), 29-33.

Denegri, S., & Catrone, R. (2025). Using acceptance and commitment training and behavior skills training to enhance therapist pairing skills. Behavioral Interventions, 40, e70050.

Gross, A., & Fox, E. (2009). Relational frame theory: An overview of the controversy. The Analysis of Verbal Behavior, 25, 87-98.

Tarbox, J., Szabo, T. G., & Aclan, M. (2020). Acceptance and commitment training within the scope of practice of applied behavior analysis. Behavior Analysis in Practice, 1-22.

Suarez, V., Moon, E, & Najdowski, A. (2022). Systematic review of acceptance and commitment training components in the behavioral intervention of individuals with autism and developmental disorders. Behavior Analysis in Practice, 15(1), 126-140.

Wilson, A. (2025). Introduction to the special section: Spotlight on acceptance and commitment training. Behavior Analysis in Practice, 18, 14-16.

Reference for this article:

Mira, K., & McKenna, K. (2025). Research Synopsis: Systematic review of acceptance and commitment training components in the behavioral intervention of individuals with autism and developmental disorders. Science in Autism Treatment, 22(12).

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