474121

2013
AUT0010.1177/1362361312474121AutismMazurek

Article
Autism

Loneliness, friendship, and well-being in 2014, Vol. 18(3) 223­–232

© The Author(s) 2013
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DOI: 10.1177/1362361312474121
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Micah O Mazurek

Abstract
This study examined the relations among loneliness, friendship, and emotional functioning in adults (N = 108) with
autism spectrum disorders. Participants completed self-report measures of symptoms of autism spectrum disorders,
loneliness, number and nature of friendships, depression, anxiety, life satisfaction, and self-esteem. The results indicated
that loneliness was associated with increased depression and anxiety and decreased life satisfaction and self-esteem, even
after controlling for symptoms of autism spectrum disorders. In addition, greater quantity and quality of friendships were
associated with decreased loneliness among adults with autism spectrum disorders. Multivariate models indicated that
friendship did not moderate the relationship between loneliness and well-being; however, number of friends provided
unique independent effects in predicting self-esteem, depression, and anxiety above and beyond the effects of loneliness.
This was the first study to examine the relations among these aspects of social and emotional functioning in adults with
autism spectrum disorders, and the results indicate that this topic warrants further clinical and research attention.

Keywords
adults, anxiety, autism spectrum disorders, depression, friendship, loneliness

Introduction
Individuals with autism spectrum disorders (ASDs) experi-
ence significant difficulties in social functioning, including
deficits in core social abilities and problems establishing
and maintaining peer relationships (American Psychiatric
Association, 2000). These social and interpersonal prob-
lems generally persist and sometimes worsen in adulthood,
contributing to functional impairment (Seltzer et al., 2004).
Despite the steady increase in ASD prevalence (Centers for
Disease Control and Prevention, 2012), few studies have
focused on the experiences of adults with ASDs.
Existing research indicates that adults with ASDs face
many challenges in terms of occupational success, inde-
pendent living, and relationship formation (Billstedt et al.,
2005; Eaves and Ho, 2008; Howlin et al., 2004). In previ-
ous studies, only a small percentage of adults with ASDs
were reported to have friendships or romantic relationships
(Billstedt et al., 2011; Engstrom et al., 2003; Howlin et al.,
2004). There is also evidence that increased awareness of
social deficits is associated with both depression and anx-
iety among individuals with ASDs (Mazurek and Kanne,
2010; Sterling et al., 2008). Rates of depressive symp-
toms increase with age among individuals with ASDs
(Ghaziuddin et al., 2002; Sterling et al., 2008), and adults
with ASDs are at significantly greater risk of mood and
anxiety disorders than are individuals in the general popu-
lation (Gillott and Standen, 2007; Mazefsky et al., 2008;
Moseley et al., 2011). Thus, identifying factors that may be
associated with social and emotional functioning for adults
with ASDs is highly important.
Loneliness
There is considerable evidence that loneliness and social
support have a strong influence on overall well-being in the
general population. However, this has yet to be examined
among adults with ASDs. Contrary to historical assump-
tions, individuals with ASDs do not always prefer social
isolation. They often want to develop relationships but face
University of Missouri, USA
Corresponding author:
Micah O Mazurek, Department of Health Psychology, Thompson
Center for Autism and Neurodevelopmental Disorders, University of
Missouri, 205 Portland Street, Columbia, MO 65211, USA.
Email: mazurekm@missouri.edu

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224
barriers in developing relationships due to social compe-
tence difficulties (Bauminger et al., 2003; Causton-
Theoharis et al., 2009). Thus, loneliness appears to be a
clinically important consideration for this population.
Loneliness is generally understood to reflect a negative
emotional state arising from a perception of unfulfilled
social needs (Peplau and Perlman, 1982; Russell et al.,
1984). By contrast, social isolation is an objective measure
of social contact, and does not imply subjective appraisal
(either positive or negative). In fact, solitude may be per-
ceived positively by some individuals, while loneliness
may be experienced by others even in the presence of
objective social relationships (Heinrich and Gullone, 2006).
As such, loneliness and social isolation are related, yet con-
ceptually distinct.
A need for social connection has long been considered a
fundamental aspect of the human experience. As argued by
Baumeister and Leary (1995), this basic drive is believed to
underlie a range of other psychological processes, and to
represent a universal human motivation. Likewise, a lack of
belonging is associated with a range of negative psychoso-
cial effects, ranging from physical health to psychological
well-being. Among individuals in the general population,
loneliness has been consistently linked with negative emo-
tional outcomes, including decreased self-esteem (Davis
et al., 1992; Schultz and Moore, 1988), reduced satisfaction
with life and perceived meaning (Goodwin et al., 2001;
Stillman et al., 2009), increased depression (Cacioppo et al.,
2006b; Wei et al., 2005), and increased anxiety (Cacioppo
et al., 2006a).
Loneliness in individuals with ASDs
There has been an increasing emphasis on understanding
the potential impact of social difficulties on emotional
functioning among individuals with ASDs. However, the
vast majority of this research has been conducted among
children. Across most studies, children with ASDs have
reported greater loneliness than typically developing chil-
dren, including both social and emotional aspects of loneli-
ness (Bauminger et al., 2003, 2004; Bauminger and Kasari,
2000; Lasgaard et al., 2010; Locke et al., 2010). Children
with ASDs also experience high rates of loneliness despite
the fact that their understanding of the affective compo-
nents of the construct may be less complete than that of
their typically developing peers (Bauminger et al., 2003).
There is also evidence that loneliness is associated with
negative emotional outcomes for children with ASDs. For
example, in previous studies of children with ASDs, loneli-
ness has been associated with decreased feelings of self-
worth (Bauminger et al., 2004) and increased social anxiety
(White and Roberson-Nay, 2009).
In contrast, studies have yet begun to explore the expe-
rience of loneliness among adults with ASD diagnoses.
However, some studies have used general population
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Autism 18(3)
samples to examine the relations between characteristics of
the broader autism phenotype and social-emotional func-
tioning. Jobe and White (2007) found that autism traits
among young adults in the general population were associ-
ated with increased self-reported loneliness. Pollmann et al.
(2010) also used a nonclinical population to examine the
associations between autism traits and relationship satisfac-
tion within romantic relationships. The results indicated
that higher autism traits were associated with decreased
self-reported relationship satisfaction among men, but
loneliness was not specifically assessed.
Friendship in individuals with ASDs
Individuals with ASDs are at risk of difficulties forming
and maintaining friendships, which may place them at
greater risk of experiencing loneliness. Previous studies
have found that children with ASDs have fewer friends
than typically developing children (Bauminger and
Shulman, 2003; Koning and Magill-Evans, 2001), and that
their friendships are characterized by shorter duration and
less frequent get-togethers (Bauminger and Shulman,
2003). Furthermore, there is evidence that peer engage-
ment appears to decline over the course of childhood for
children with ASDs (Rotheram-Fuller et al., 2010).
Rowley et al. (2012) found that only 34% of children with
ASDs were reported by parents to have at least one good
friend, as compared to 71% of children with other special
educational needs and 93% of typically developing chil-
dren. Locke et al. (2010) also found that adolescents with
ASDs reported poorer quality friendships than typically
developing peers, particularly with regard to companion-
ship and helpfulness.
Relatively fewer studies have examined the role of
friendship in the lives of older adolescents and adults with
ASDs. Orsmond et al. (2004) examined the social experi-
ences of a large sample of adolescents and adults with
ASDs who were living with parents. Only 8.1% of the
sample had at least one close reciprocal friendship, and
20.9% had at least one relationship with a peer that
involved some shared activities. However, almost half the
sample had no peer relationships at all. In addition, few of
the participants socialized weekly with either friends
(20.9%) or people from work or school (13%). More
recently, Shattuck et al. (2011) examined social participa-
tion among adolescents (ages 13–17 years) with ASDs
using data from the National Longitudinal Transition
Study-2 (NLTS2). They found that 43% of adolescents
with ASDs never got together with friends outside of
school or organized activities. Similarly, over half the
sample never received phone calls from friends or were
invited to social activities by friends. In addition, findings
revealed that these indicators of social participation were
significantly lower than among adolescents with other
types of disabilities.
Mazurek
Friendship as a protective factor
Given that individuals with ASDs may be at risk of experi-
encing loneliness, and that loneliness is associated with
negative emotional outcomes, identifying factors that may
serve a protective function is important. Close friendship
may represent a potential buffer against negative effects of
social difficulties on well-being among adults with ASDs. In
fact, there is a precedent for this in previous research among
both typically developing children and those with ASDs.
Among typically developing children, having at least one
good friend is associated with greater well-being even after
controlling for overall social success in the larger peer group
(Bukowski et al., 1994; Hodges et al., 1999; Linsey, 2002).
Parker and Asher (1993) found that children who had a close
friend experienced less loneliness than those without a close
friend, even when they were not accepted by the larger peer
group. In addition, greater friendship quality was associated
with decreased loneliness, even after controlling for social
acceptance. More recent research has shown that both quan-
tity and quality of children’s friendships provide unique
contributions to emotional functioning, including loneliness
and depression (Nangle et al., 2003).
Among children and adolescents with ASDs, friendship
and social support also appear to influence perceived lone-
liness. For example, Bauminger et al. (2004) found that
children with ASDs who reported higher quality friend-
ships also reported less loneliness and greater overall self-
worth. In a more recent study, Whitehouse et al. (2009)
found that adolescents with Asperger’s syndrome (AS)
reported significantly poorer quality friendships, and lower
scores on a measure of friendship motivation as compared
to typically developing adolescents. In addition, the adoles-
cents with AS also reported higher levels of loneliness and
depression than did typically developing adolescents.
Friendship quality was negatively associated with loneli-
ness in both groups, but was not significantly associated
with depressive symptoms in either group. Similarly,
Lasgaard et al. (2010) found that self-reported loneliness
among adolescent boys with ASDs was negatively corre-
lated with perceived social support from classmates,
friends, and parents.
There is also some evidence that friendship may offer
additional protective benefits for children with ASDs. For
example, having at least one reciprocal friendship in ele-
mentary school was found to be associated with greater
peer acceptance among children with ASDs (Rotheram-
Fuller et al., 2010). However, the associations between
friendship and emotional functioning have been somewhat
mixed in other previous studies. For example, Mazurek and
Kanne (2010) found that children and adolescents with
ASDs who had friendships that were limited in reciprocity
had greater anxiety and depression than either those with
good quality friendship or those with no friends. However,
Kelly et al. (2008) found that peer relationship quality was
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225
not significantly associated with anxiety and depression in
a sample of children with ASDs.
Current study
In summary, there have been no previous studies of the
associations among loneliness, friendship, and well-being
in adults with ASDs. This knowledge would provide impor-
tant information about whether friendship relationships
may serve an emotionally protective role for adults with
ASDs. Thus, based on previous research, the following
hypotheses were proposed: (1) loneliness will be associated
with decreased well-being among adults with ASDs, (2)
friendship will be associated with decreased loneliness
among adults with ASDs, and (3) friendship will moderate
the relationship between loneliness and well-being among
adults with ASDs.
Methods
Participants
The sample for this study included 108 adults with ASDs
ranging in age from 18 to 62 years (M = 32.4 years, stand-
ard deviation (SD) = 12.5 years), who were recruited with
the assistance of a national open enrollment ASD registry,
the Interactive Autism Network (IAN) Research Database
at Kennedy Krieger Institute, and Johns Hopkins Medicine,
Baltimore, Maryland. Participants were recruited by email
and completed all measures online using a web-based for-
mat. Participants were provided with a US$15 gift card for
participation in the study, and recruitment continued until
the target sample size was achieved. Eligibility require-
ments included age range (18 years of age or above), ability
to complete measures independently, and a previous pro-
fessional diagnosis of ASDs, including autism or autistic
disorder (29.6%), AS (63.9%), or pervasive developmental
disorder, not otherwise specified (NOS) (6.5%). The major-
ity of the sample was male (52.8%) and Caucasian (88.0%).
Additional sample characteristics are presented in Table 1.
Measures
Participants completed a demographic and history form
designed for this study. Information included age, race,
diagnostic information, relationship status, employment,
living arrangements, and specific information about friend-
ship, as described below.
ASD symptoms
Symptoms of ASDs were assessed using the Autism
Spectrum Quotient–Short (AQ-Short) (Hoekstra et al.,
2011), an abbreviated 28-item version of the original
50-item self-report questionnaire, the AQ (Baron-Cohen
226 Autism 18(3)

Table 1. Social and demographic characteristics.

Total sample (N = 108)

Residence
Live alone 19.4%
Live with parent(s) 38.0%
Live with partner, spouse, or roommate 28.7%
Other 13.9%
Employment
Full-time job 24.1%
Part-time job 25.0%
Not employed, student 24.1%
Not employed, not student 26.9%
Relationship status
Married 22.2%
In a romantic relationship 2.8%
Divorced/separated 6.5%
Single 58.3%
Friendship status
Has a close or best friend 60.2%
Does not have a close or best friend 39.8%
Sample with best friend (n = 64)
Frequency of visits with close friend
About once a day 10.8%
3–5 days per week 18.5%
1–2 days per week 18.5%
Every few weeks 27.7%
Less than once per month 24.6%
Frequency of phone contact with close friend
Several times per day 4.6%
About once a day 9.2%
3–5 days per week 13.8%
1–2 days per week 18.5%
Every few weeks 23.1%
Less than once per month 30.8%
Frequency of electronic communication with close friend
Several times per day 29.2%
About once a day 18.5%
3–5 days per week 16.9%
1–2 days per week 13.8%
Every few weeks 9.2%
Less than once per month 12.3%

et al., 2001). The AQ was originally developed to assess
symptoms of autism along a continuum, using a quantita-
tive approach. Items are rated on a 4-point scale, ranging
from definitely agree to definitely disagree. The AQ-Short
has demonstrated good psychometric properties, including
strong reliability and validity among general population
and clinical samples. The original scoring for the AQ uti-
lized a dichotomous approach for each item (with a possi-
ble range of scores of 0–50) (Baron-Cohen et al., 2001).
However, subsequent studies have utilized the full range of
responses in order to provide a more fine-grained differen-
tiation among scores in subsequent analysis (Austin, 2005;
Hoekstra et al., 2011). This study utilized this approach for
scoring the AQ-Short, resulting in a total score ranging
from 28 to 112, with higher scores indicating greater autism
traits. The Cronbach’s alpha coefficient of .85 in the current
sample indicated solid internal consistency.
Loneliness
Loneliness was assessed using the 8-item version of the
University of California, Los Angeles Loneliness Scale
(ULS-8) (Hays and DiMatteo, 1987). The ULS is one of the
most widely used measures of loneliness and has been used

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Mazurek 227

Table 2. Ms, SDs, and correlation coefficients (N = 108).

Variable M SD 1 2 3 4 5 6 7
AQ–Short 80.6 12.2
Loneliness 20.9 4.7 .30**
Depression 8.4 6.2 .09 .48**
Anxiety 7.4 5.4 .11 .34** .73**
Life satisfaction 18.8 8.1 –.23* −.46** −.40** −24*
Self–esteem 17.7 4.9 −.22* −.38** −.57** −.54** .54**
Number of friends 3.1 3.1 −.41** −.34** .03 .06 .17 −.01
URCS 5.1 1.2 −.23 −.29* −.001 −.05 .14 −.03 .24

AQ–Short: Autism Spectrum Quotient–Short; URCS: Unidimensional Relationship Closeness Scale; M: Mean; SD: standard deviation.
*p < .05; **p < .01; **p < .001.

extensively in both the general population and clinical sam-
ples (Russell, 1996; Russell et al., 1980). The ULS-8 has
demonstrated strong reliability and validity in previous
studies (Hays and DiMatteo, 1987), and Cronbach’s alpha
in the current sample was .80. Items are rated on a 4-point
scale, ranging from never to always, with higher total
scores indicating greater loneliness.
Friendship
Friendship status was assessed using a questionnaire devel-
oped for this study. Participants responded to the following
questions: “How many friends do you have right now?”
and “Do you have a close or best friend (who is not a mem-
ber of your family)?” Participants who reported having a
close friend (n = 64), then responded to the following ques-
tions: “How often do you get together with your close
friend?” “How often do you talk on the phone with your
close friend?” and “How often do you use email, Facebook,
instant messaging, or texting to talk with your close friend?”
See Table 2 for response options.
Friendship quality was assessed using the Unidimensional
Relationship Closeness Scale (URCS), a recently developed
self-report measure of perceived closeness in personal rela-
tionships (Dibble et al., 2012). The URCS is a 12-item self-
report scale that assesses the relationship closeness between
two persons. Items are rated on a 7-point scale, ranging from
strongly disagree to strongly agree, with higher total scores
indicating greater degree of intimacy. As suggested by the
authors, item 6 was omitted from the scale for this study due
to poor discriminant validity, resulting in an 11-item scale.
In the development study, the URCS demonstrated very
good construct validity, convergent validity, and reliability
for both romantic and friendship relationships. Cronbach’s
alpha in the current sample was .88. Only participants who
reported having a close friend completed the URCS (n = 64)
in this study.
Well-being
Life satisfaction was assessed with the widely used 5-item
Satisfaction with Life Scale (SWLS) (Diener et al., 1985).
Items are rated on a 7-point scale, ranging from strongly
disagree to strongly agree with higher total scores indicat-
ing greater overall life satisfaction. The SWLS has been
used extensively in clinical and nonclinical population
samples, and demonstrates excellent construct validity and
test–retest reliability (Pavot and Diener, 1993), and
Cronbach’s alpha in the current sample was .89.
Self-esteem was assessed using the Rosenberg Self-
Esteem Scale (RSE) (Rosenberg, 1965), a 10-item self-
report measure assessing general self-concept. The RSE
represents the most widely used instrument designed to
assess self-esteem, and has shown strong psychometric
properties, including reliability, validity, and cross-cultural
equivalence (Corwyn, 2000; Schmitt and Allik, 2005) Items
are rated on a 4-point scale, ranging from strongly agree to
strongly disagree with higher total scores indicating greater
self-esteem. Cronbach’s alpha in the current sample was .80.
Depression and anxiety were assessed using the Patient
Health Questionnaire (PHQ) (Spitzer et al., 1999). The
PHQ contains separate modules designed for specific
symptom types, and was designed to be consistent with
Diagnostic and Statistical Manual of Mental Disorders cri-
teria for particular diagnoses (American Psychiatric
Association, 1994). For this study, the 9-item depression
and the 7-item generalized anxiety modules were used. All
items are rated on a 4-point scale ranging from not at all to
nearly every day, with total scores indicating greater symp-
tom severity. Both the depression and generalized anxiety
modules of the PHQ have demonstrated excellent validity,
sensitivity, and specificity (Kroenke et al., 2001, 2010;
Spitzer et al., 1999). Cronbach’s alpha in the current sam-
ple ranged from .86 for the depression scale to .88 for the
anxiety scale.
Data analyses
Descriptive statistics, including percentage, mean, standard
deviation, and range, were calculated to characterize the
sample. To test hypothesis 1, Pearson’s correlations were
computed to examine the bivariate relationships between
loneliness and each well-being variable (including life
satisfaction, self-esteem, depression, and anxiety). To test

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228
hypothesis 2, Pearson’s correlations were computed to
examine the relationship between loneliness and both num-
ber of friends, and friendship closeness (for those with a
best friend). One-way analysis of variance (ANOVA) was
conducted to examine differences in loneliness between
individuals with and without a close friend. Finally, to test
hypothesis 3, linear regression analyses were conducted to
examine the unique contributions of friendship and loneli-
ness as well as the interaction between the two in contribut-
ing to well-being. Separate analyses were conducted for
each dependent variable of interest, including life satisfac-
tion, self-esteem, depression, and anxiety.
Results
Initial one-way ANOVAs were conducted to test for poten-
tial differences in study variables with regard to gender,
race, employment, marital status, or residence. Groups did
not differ at the p < .05 level with regard to loneliness, anxi-
ety, depression, life satisfaction, self-esteem, number of
friends, or friendship quality. In addition, age was not sig-
nificantly correlated with any of these variables of interest.
Finally, Chi-square tests revealed no significant differences
in any of the demographic variables when comparing those
with and without a close friend.
Loneliness and well-being
As predicted, loneliness was significantly correlated with
all emotional functioning variables. Specifically, loneliness
was positively correlated with depression (r = .48, p < .001)
and anxiety (r = .34, p = .001), and negatively correlated
with both satisfaction with life (r = −.46, p < .001) and self-
esteem (r = −.38, p < .001).
Given that AQ was also correlated with loneliness and
with some dependent variables of interest (see Table 2), a
series of linear regression analyses were conducted to
determine whether loneliness contributed to the prediction
of these variables after controlling for AQ. Loneliness pro-
vided significant main effects in the models predicting
depression (β = .49, p < .001), anxiety (β = .32, p = .002),
satisfaction with life (β = −.42, p < .001), and self-esteem (β
= −.32, p = .001). In contrast, AQ did not contribute to the
prediction of well-being in any model. Thus, the results
indicate that loneliness contributes significantly to
increased depression and anxiety and decreased life satis-
faction and self-esteem, even after controlling for the
effects of ASD symptoms.
Friendship and loneliness
Consistent with the second hypothesis, one-way ANOVA
results revealed that adults with a close friend reported sig-
nificantly lower levels of loneliness (M = 20.1, SD = 4.8)
than those without a close friend (M = 22.2, SD = 4.2),
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Autism 18(3)
F(1, 102) = 5.2, p = .02. To determine whether friendship
contributed to decreased loneliness even after controlling
for the effects of ASD symptoms, a subsequent linear
regression analysis was conducted with loneliness as the
dependent variable, and close friend (dichotomous) and AQ
as independent variables. The results indicated that both
close friendship (β = −.22, p = .02) and AQ (β = .28, p =
.004) provided significant main effects in predicting
loneliness.
Also consistent with predictions from the second hypoth-
esis, number of friends was negatively correlated with lone-
liness (r = −.34, p = .001). Again, to determine whether
number of friends contributed to decreased loneliness even
after controlling for the effects of ASD symptoms, a linear
regression analysis was conducted with loneliness as the
dependent variable, and number of friends and AQ as inde-
pendent variables. The results indicated that number of
friends provided significant main effects (β = −.29, p =
.007), but that AQ was not a significant predictor.
Finally, for those who reported having a best friend, the
closeness of the friendship relationship was negatively
correlated with loneliness (r = −.29, p = .02). To deter-
mine whether relationship closeness contributed to
decreased loneliness after controlling for the effects of
ASD symptoms, a subsequent linear regression analysis
was conducted with loneliness as the dependent variable,
and friendship closeness and AQ as the independent vari-
ables. The results indicated that AQ (β = .26, p = .04) pro-
vided significant main effects in predicting loneliness,
and that friendship closeness approached significance
(β = −.23, p = .06).
Friendship, loneliness, and well-being
To examine the extent to which friendship moderates the
relationship between loneliness and well-being (after
controlling for ASD symptoms), a series of hierarchical
linear regression analyses were conducted with the well-
being variable as the outcome. Within each model, loneli-
ness, friendship, and AQ were entered as independent
variables in step 1, and the interaction between loneliness
and friendship was entered in step 2. Prior to analysis, the
dependent variables were mean centered, and the interac-
tion terms were computed using centered variables.
Interaction terms were not significant predictors in any
model; thus, interaction terms were dropped from all sub-
sequent models.
Results from these models are presented in Table 3. For
the models examining the contributions of having a best
friend to the prediction of well-being, loneliness provided
significant main effects in all models (ranging from p =
.001 to p < .001), while neither having a best friend nor AQ
score were significant predictors in any model (including
those predicting life satisfaction, self-esteem, depression,
or anxiety).
Mazurek 229

Table 3. Linear regression analyses: loneliness and friendship variables predicting well-being.

Independent variables Life satisfaction Self-esteem Depression Anxiety

Adjusted R2 β Adjusted R2 β Adjusted R2 β Adjusted R2 β

Model 1 .20 .12 .21 .087
Loneliness −.44*** −.33** .51*** .34**
Best friend (yes/no) −.11 −.02 .11 .11
AQ-Short −.11 −.12 −−.05 .16
Model 2 .20 .17 .26 .12
Loneliness −.42*** −.39*** .56*** .38***
Number of friends −.02 −.24* .22* .22*
AQ-Short −.14 −.22* .05 .09
Model 3 .26 .19 .31 .16
Loneliness −.50*** −.48*** .62*** .44**
Friendship closeness −.03 −.19 .16 .09
AQ-Short −.11 −.07 −.07 .07

AQ-Short: Autism Spectrum Quotient–Short.

Interaction terms (loneliness × friendship variable) were not significant predictors in any model, and were dropped from all subsequent models.
*p < .05; **p < .01; ***p < .001.

Similarly, in the models examining the contributions of
friendship closeness to the prediction of well-being, loneli-
ness provided significant main effects in all models (again
ranging from p = .001 to p < .001), while neither friendship
closeness nor AQ score were significant predictors in any
model (including those predicting life satisfaction, self-
esteem, depression, or anxiety).
Finally, in the models examining the contributions of
number of friends to the prediction of well-being, signifi-
cant main effects were observed for number of friends in
most models. While loneliness was the only significant
predictor of life satisfaction (p < .001), number of friends
provided additional significant effects in the models pre-
dicting self-esteem (p = .03), depression (p = .03), and
anxiety (p = .04), even after controlling for the effects of
ASD symptoms.
Discussion
This was the first study to examine the associations between
loneliness, friendship, and well-being among adults with
ASDs. A primary finding from this study is that loneliness
was significantly correlated with increased depression and
anxiety, and decreased life satisfaction and self-esteem.
The effect sizes ranged from medium to large, with the
strongest association existing between loneliness and
depression. These findings are consistent with a large body
of literature on loneliness in the general population
(Cacioppo et al., 2006a, 2006b; Davis et al., 1992), and
extend our knowledge about the social and emotional lives
of adults with ASDs. Contrary to the idea that individuals
with ASDs do not experience or are not affected by loneli-
ness, these results show that loneliness can be associated
with negative emotional experiences for adults with ASDs,
and is worthy of increased clinical and research attention.
Interestingly, the associations between loneliness and
emotional functioning remained significant even after con-
trolling for the effects of ASD symptoms. This finding
lends support to the idea that loneliness may be a secondary
consequence of social difficulties for individuals with
ASDs, and that these consequences may have emotional
repercussions above and beyond the effects of social
impairment. Adults with ASDs who desire social connec-
tion, but who perceive that those social needs are unful-
filled, may be particularly vulnerable to depressed mood
and a decreased sense of self-worth. These findings are
consistent with an emerging body of work examining the
associations between loneliness and emotional functioning
in children with ASDs (Bauminger et al., 2004; White and
Roberson-Nay, 2009), and indicate that the interplay
between social and emotional experiences is similar for
adults with ASDs. Alternatively, it is also possible that
underlying depression and anxiety may give rise to feelings
of loneliness and increased social isolation. Longitudinal
studies are needed to examine the relationships between
these constructs over time.
A second important finding from this study was that
friendship was associated with decreased loneliness for
adults with ASDs. This is highly consistent with findings
from studies of children and adolescents in the general pop-
ulation (Nangle et al., 2003; Parker and Asher, 1993), and
from studies of children and adolescents with ASDs
(Bauminger et al., 2004; Whitehouse et al., 2009). These
results indicate that different aspects of friendship, includ-
ing having a close friend, the strength of the friendship rela-
tionship, and the size of the friendship network are all
significantly related to loneliness in adults with ASDs.
Additionally, friendship (i.e. having a best friend and num-
ber of friends) was associated with decreased loneliness
even when controlling for the effects of ASD symptoms.

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230
The third aim of the study was to examine the extent to
which friendship may moderate the effects of loneliness on
emotional functioning in adults with ASDs. Counter to
these predictions, the results did not show evidence of mod-
eration. Specifically, loneliness by friendship interaction
terms were not significant predictors in any of the regres-
sion models. Instead, loneliness appeared to account for the
largest amount of variance in all models, above and beyond
the effects of both ASD symptoms and friendship variables;
and this relationship did not differ as a function of friend-
ship status. This was the case for models examining self-
esteem, life satisfaction, depression, and anxiety. However,
further examination of these results reveals that the quan-
tity of friendships does appear to play an important role in
emotional functioning. In fact, the total number of friend-
ships provided significant main effects in predicting self-
esteem, depression, and anxiety, above and beyond the
effects of both loneliness and ASD symptoms. These find-
ings suggest that decreasing loneliness and increasing the
total social network may have a significant impact on over-
all well-being for adults with ASDs.
Limitations
This study was limited in several ways. First, the study uti-
lized a cross-sectional design. Therefore, issues of timing
or causality among these variables cannot be determined.
In future studies, longitudinal designs will be most inform-
ative in examining these issues as they unfold over time.
Longitudinal studies among both child and adult samples
would allow for a better understanding of potential causal
relationships among variables, as well as an examination of
developmental shifts in social and emotional functioning.
Findings from longitudinal studies in the general popula-
tion indicate that loneliness predicts increases in depression
over time, even after controlling for initial levels of depres-
sion and other psychosocial variables (Cacioppo et al.,
2006b). Although there has been some evidence of a recip-
rocal relationship between these variables over time
(Cacioppo et al., 2006b), a recent 5-year longitudinal study
found evidence that loneliness predicted changes in depres-
sive symptoms across time, while the reverse was not true
(Cacioppo et al., 2010). These issues require further study
among adults with ASDs to determine whether the relation-
ships between loneliness and emotional functioning are
unidirectional or bidirectional over time.
A second limitation of this study is that the sample may
not be representative of the larger population of adults with
ASDs. The gender ratio in the current sample, with nearly
equal numbers of males and females, was not comparable
to that of the broader ASD population, which is closer to a
4:1 male:female ratio (Fombonne, 2005). The reasons for
this are not clear, but may be an indication of potential sam-
pling bias. That is, females, or those who are more socially
interested, may have been more motivated to participate in
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Autism 18(3)
a study focused on social and emotional functioning.
Although there were no gender differences in any of the
social or emotional variables assessed, the potential for this
bias remains possible. Similarly, the percentage of individ-
uals in the current sample who reported having close friends
was much higher than has been reported in previous studies
(e.g. Orsmond et al., 2004; Shattuck et al., 2011). Again,
this may reflect participation bias, or it may reflect differ-
ences in methodology. For example, this study utilized self-
report of friendship number and quality, while previous
studies (e.g. Orsmond et al., 2004; Shattuck et al., 2011)
used parent-report for these constructs.
Finally, the participants were enrolled in a national
autism network, and may differ from the general ASD pop-
ulation in additional undetermined ways. Aside from AQ
scores and DSM-IV diagnostic categories, additional infor-
mation about participants’ ASD diagnoses was not availa-
ble. Specifically, information was not collected regarding
the professional qualifications of the clinicians who pro-
vided the diagnoses, nor about the diagnostic battery. A bet-
ter characterization of the participants, including objective
measures of ASD symptoms, cognitive functioning, and
adaptive skills would be informative in future research.
This study also relied on self-report for all measured
constructs. Because internalizing symptoms, self-esteem
and life satisfaction, are primarily subjective experiences,
self-report is typically preferred in general population stud-
ies of these constructs. However, previous studies have
suggested that individuals with ASD struggle with under-
standing and describing emotional experiences (Ben
Shalom et al., 2006; Losh and Capps, 2006). Future work in
this area may also benefit from the inclusion of multiple
reporters, including perceptions of friendship quality from
both members of the friendship dyad. This would allow for
a more nuanced understanding of the quality of dyadic
friendship relationships, and the extent to which concord-
ance or discordance in characterizing the relationship
relates to other social and emotional variables.
Conclusion
This study provides an important first look at the social and
emotional experiences of adults with ASDs. These findings
extend current knowledge in several important ways, and
highlight the clinical importance of loneliness. Significant
correlations were found between loneliness and a number
of negative emotional experiences, including increased
depression and anxiety, and reduced well-being. Given that
individuals with ASDs are already at increased risk of anxi-
ety and depression (Gillott and Standen, 2007; Mazefsky
et al., 2008; Moseley et al., 2011), loneliness may represent
an important mechanism in the developmental course of
internalizing problems through adolescence and adulthood.
A better understanding of the developmental course and
consequences of loneliness will be essential to inform our
Mazurek
understanding of social and emotional well-being in indi-
viduals with ASDs. Finally, strategies to reduce and prevent
loneliness in adults with ASDs appear to be important tar-
gets for future research and clinical practice.
Declaration of conflicting interest
The author declares that there is no conflict of interest.
Funding
This work was supported by the University of Missouri School of
Health Professions Catalyst Award.
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