This systematic review synthesized evidence on mentalization- and Theory of Mind (ToM)-based interventions for autistic individuals and their caregivers across 19 eligible studies (549 total participants; 481 autistic individuals, 68 caregivers), with no restrictions on language or publication year.
Interventions generally improved ToM task performance and reflective functioning, with effect sizes ranging from small (d ≈ 0.20) to large (d > 1.0). However, gains were mostly limited to structured, proximal tasks (e.g., false-belief understanding) and showed limited, inconsistent generalization to real-world social functioning. Only 3 of 19 studies used mentalization-based approaches; no controlled trials demonstrated effectiveness for mentalization-based interventions over a control condition.
- High heterogeneity in study design, populations, outcome measures, and intervention types prevents firm conclusions about effectiveness. - MMAT quality appraisal reflects methodological rigor, not formal risk-of-bias assessment; many studies lacked full randomization or adequate control for confounders. - Most samples were predominantly male and high-functioning, limiting generalizability across the autism spectrum and to autistic girls/women.
Structured, skill-based ToM interventions show the most robust short-term evidence for children with ASD, but clinicians should not assume these gains will translate to everyday social functioning. Relational and mentalization-based approaches for adults and caregivers are promising but still need controlled trials before confident adoption.
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