Is social camouflaging associated with anxiety and depression in autistic adults?

Recent advances in biomimetic nanodelivery systems for the treatment of depression

Depression and cognitive disorders remain major challenges in healthcare, with conventional treatments often facing limitations such as slow onset, side effects, and poor drug delivery to the brain. Biomimetic nanodelivery systems, including nanozymes, cell membrane-based systems, and exosomes, have emerged as promising solutions to these issues. These systems leverage natural biological processes to enhance drug targeting, improve bioavailability, and regulate complex biological pathways. Nanoenzymes, with their catalytic properties, offer antioxidant and anti-inflammatory benefits, while cell membranes and exosomes provide efficient targeting and immune evasion. However, challenges remain, including the immaturity of large-scale production techniques, stability concerns, and incomplete understanding of their mechanisms of action. Moreover, the long-term safety, pharmacokinetics, and toxicity of these systems require further investigation. Despite these obstacles, the potential of biomimetic nanodelivery systems to revolutionize depression treatment is significant. Future research should focus on optimizing their preparation, improving drug targeting and release, and ensuring clinical safety. Multidisciplinary collaboration will be essential for advancing these systems from the laboratory to clinical practice, offering new therapeutic avenues for depression and other neurological disorders.

Gender and family-role portrayals of autism in British newspapers: An intersectional corpus-based study

A recent large-scale study on the portrayal of autism in British newspapers revealed a deficit-based coverage, which concentrated on children and boys in particular, typically represented from the mothers' perspective. This follow-up study refines these representations, considering how they differ by gender and family role. We analysed 2998 text samples, which discussed autism in the context of four combinations of gender and family roles, namely, BOY, GIRL, FATHER and MOTHER. These samples included sources with different publication dates, reporting style and political orientation. Autism representations remained negative regardless of gender and family role. Over time, stories about autistic girls started to emerge, identifying them as a distinct group explicitly compared to autistic boys. Newspapers, especially broadsheets, associated girls with diagnostic difficulties, camouflaging and sometimes gender dysphoria - discussed particularly for those assigned female at birth. The child's autism was more often attributed to maternal than paternal behaviours or lifestyle. Autistic mothers were mentioned more often than fathers and were portrayed negatively. We conclude that newspapers portray female autism as less significant than male autism and, in addition, place mothers under more ethical scrutiny than fathers. These disparities reflect both historical biases in autism research and gender and family-role stereotypes.

Adults on the autism spectrum differ from neurotypical peers when self-generating but not passively-experiencing somatosensation: a high-density electrophysiological (EEG) mapping and virtual reality study

Little is known about how different features of tactile inputs affect somatosensory perception in autism. In this study we combined high-density electroencephalography (EEG) and virtual reality (VR) to assess how the volition and pattern consistency of somatosensory stimulation influenced the electrophysiological responses in neurotypical (n = 30) and autistic (n = 30) adults. Specifically, we compared N1 and P300 amplitudes when vibrotactile stimulation were actively triggered by self-motion (Active) versus passively triggered by target-motion (Passive). We also measured the mismatch negativity (MMN) to assess how deviations in the pattern of stimulus duration affected the electrophysiological responses. We observed comparable responses regardless of pattern deviation in the MMN time window between groups, but different patterns of amplitude in this time frame based on whether the stimulation was Active or Passive. In the autism group we observed smaller N1 amplitudes in response to Passive, but not Active, vibrations as compared to the control group. Conversely, there were overall larger magnitude P300 amplitudes in the autism group, but comparable levels of Passive-to-Active attenuation between groups. Overall, the autism cohort demonstrated variation from the neurotypical cohort with respect to the volition of the stimuli, but there were comparable results between groups in response to pattern deviation. These findings suggest that there are subtle differences in how adults with and without autism handle self-generated and externally-generated somatosensory sensations.

Self-reported masking in sexual minority and heterosexual autistic adults

Masking can include suppressing or concealing certain behaviors to appear "non-autistic" and is one response to the excess social stressors of being a neurominority in a neurotypical-majority society. It is important to understand how persons who are multiply marginalized (e.g. an autistic person assigned female sex at birth who is bisexual), who experience multiple layers of excess social stressors, may face additional pressures to conceal their authentic selves. Autistic persons may be more likely than neurotypical persons to identify with a sexual minority orientation, such as asexual, bisexual, gay or pansexual. To advance our understanding of how marginalized identities may be associated with masking, we examined self-reported masking using the Camouflaging Autistic Traits Questionnaire in a sample of autistic adults (N = 462). After matching participants for assigned sex at birth and age, and after controlling for these effects in modeling, we found that sexual minority autistic adults reported significantly higher levels of masking relative to heterosexual autistic adults. We situate these findings within literatures on masking, minority stress, and stigma.Lay AbstractMasking can include hiding certain behaviors to appear "non-autistic." Masking is one response to the stress of being autistic in a non-autistic world. Being autistic is only one part of someone's identity, though. Other parts of a person's identity include things like a person's sexual orientation. Autistic people are more likely than non-autistic people to have a sexual orientation other than heterosexual, like asexual, bisexual, gay, or pansexual. People who are both autistic and a sexual minority may experience social stress because of different pressures from society. These different pressures may mean sexual minority autistic adults feel pressured to social camouflage more than heterosexual autistic adults. Thus, we compared masking in sexual minority autistic and heterosexual autistic adults. In the statistical models, we controlled for two other factors that may impact masking: sex assigned at birth and age. We found that sexual minority autistic adults reported significantly higher levels of masking relative to heterosexual autistic adults. We discuss how these findings fit within previous research on masking and minority stress.

The differential diagnosis of autism spectrum disorder in adults

INTRODUCTION

Diagnosing autism spectrum disorder (ASD) in adults is challenging due to its heterogeneity and symptom overlap with other conditions. Making an accurate diagnosis can be difficult and overwhelming but is vital for proper accommodations and interventions while avoiding unproductive or harmful treatments.

AREAS COVERED

The authors have based their review on a comprehensive literature search using PubMed, PsycINFO, and Google Scholar to identify relevant recommendations, diagnostic tools, and common differential diagnoses for adults with ASD. A clinical framework is provided based on the DSM-5 criteria, starting with an evaluation of childhood symptom onset and persistent manifestations of the core criteria - social and communication impairment, along with restricted, repetitive behaviors. Conditions with overlapping presentations, including personality disorders, anxiety, depression, obsessive-compulsive disorder, attention-deficit/hyperactivity disorder, and schizophrenia, are discussed, as well as challenges in differentiating these from ASD.

EXPERT OPINION

Many factors complicate diagnosing ASD in adults - such as skewed public perception or misinformation spread on social media. Existing tools frequently miss subtle or atypical presentations, particularly in underdiagnosed groups like women and older adults. Promising advances in machine learning and artificial intelligence will hopefully improve diagnostic precision in the future. Up-to-date clinician training and large-scale research remain paramount for refining adult ASD diagnosis.

Longitudinal Relationships Between Depressive Attributional Style and Internalizing Symptoms in an Autism-Enriched Sample of Incoming College Students

Background

Anxiety and depression are among the most common psychiatric conditions reported in first-year college students. Autistic adults are estimated to face double the rate of anxiety and depression compared with non-autistic peers, influencing quality of life, social success, and academic performance. One potential avenue to understand and address internalizing symptoms in autistic adults beginning their college careers is depressive attributional style, a biased causal explanatory style in which negative life events are attributed to internal, stable, and global causes. The current study evaluates the relationship between depressive attributional style and symptoms of anxiety and depression across the first semester of college, as moderated by autistic traits. We also explore baseline depressive attributional style across additional marginalized aspects of identity based on race/ethnicity, gender, and sexual orientation, and examine potential interaction effects of autistic traits on these relationships.

Methods

Undergraduate students were recruited from four northeastern universities. Our sample (n = 144) includes 47 participants who self-identified or reported a formal autism diagnosis, and 97 non-autistic participants. Participants completed baseline and endpoint questionnaires, as well as a 2-minute biweekly survey, tracking changes in sadness, anhedonia, and anxiety throughout their first semester.

Results

Longitudinal analyses demonstrate that elevated depressive attributional style at baseline predicted biweekly anxiety, sadness, and anhedonia symptoms across the semester. This pattern extended across (was not moderated by) levels of autistic traits, however, participants who reported higher autistic traits endorsed a significantly greater depressive attributional style at baseline, and greater anxiety, sadness, and anhedonia throughout the semester. The relationship between autistic traits and depressive attributional style was strongest for participants with a nonheterosexual orientation.

Conclusion

This study underscores the autistic community-identified need for mental health research, with attention to intersecting identities, and suggests depressive attributional style for further investigation as a potential treatment target.

Abstract

In the first year of college, many students face challenges with anxiety and depression. Autistic students report even higher mental health concerns than non-autistic students. One way to understand why this happens is by looking at how college students explain negative events in their lives. Autistic students may have a more depressive attributional style, in which they see themselves as a cause of negative events and believe that bad things will persist. This outlook is known to contribute to anxiety and depression.

Abstract

We wanted to see how a depressive attributional style might relate to anxiety and depression over the first semester of college, and whether this is affected by autistic traits and stress. We also looked at how autistic traits influence the relationship between depressive attributional style and the marginalized aspects of identity based on race/ethnicity, gender, and sexual orientation.

Abstract

We gave surveys to college students about their attributional style and experiences with depression and anxiety. Participants completed several surveys both before and after their first semester at college. They also completed a brief survey two times per week during the semester.

Abstract

We found that a depressive attributional style at baseline (presemester) was related to depression and anxiety symptoms across the semester. Participants with higher levels of autistic traits reported a more depressive attributional style and greater depression and anxiety during the semester. Individuals with higher autistic traits who identify as LGBTQIA+ were more likely than heterosexual individuals with high autistic traits to have a more depressive attributional style.

Abstract

This study helps us understand that a depressive attributional style might be related to anxiety and depression in both autistic and non-autistic students. In addition, a depressive attributional style may be more common in autistic individuals. These findings could mean that helping people develop a more adaptive thinking about negative events could help prevent or treat anxiety and depression in college students.

Abstract

Because we wanted our study to be accessible for autistic students without a formal diagnosis, we were unable to look at how the social identity of being autistic related to anxiety and depression throughout the semester.

Abstract

These findings give us first evidence that a depressive attributional style appears to be related to anxiety and depression in autistic students. This suggests that interventions designed to address the depressive attributional style in non-autistic individuals could potentially benefit autistic individuals as well, which may support access to mental health treatment for the autistic community.

A qualitative exploration of the experience of autistic females in Hong Kong

There are fewer females than males diagnosed with autism, but autistic females are said to be under-identified and underrepresented in the existing diagnostic and service systems. The gender discrepancy may potentially be attributed to the lack of accurate understanding of autistic females and their needs. Emerging research has begun to document the experiences of autistic women in Western countries, but their experience in Eastern cultures is almost unknown. This study aimed to investigate the lived experience of autistic women in Hong Kong. Thirteen formally diagnosed or self-diagnosed autistic women completed semi-structured interviews, discussing how they identified with autism, their diagnostic experience, and their understanding of autism. Results based on thematic analysis revealed Hong Kong autistic women commonly experienced emotional problems and encountered autistic models on the way they came to identify with autism, despite often being dismissed by families and professionals. They found an autism diagnosis or identity meaningful to their self-understanding. Societal misunderstanding toward autism had a great impact on their self-identity as an autistic female. Findings can inform improved services for autistic women in Hong Kong and provide insights to enhance understanding of autism in Chinese culture.Lay abstractThere are more males than females with autism. One of the reasons can be that we do not understand autistic females well. Some research in Western cultures has begun to document the lived experience of autistic females, but no such studies are conducted with Chinese autistic females. This study explored the first-person experience of living with autism in Hong Kong autistic women. We conducted qualitative interviews with 13 women with a formal diagnosis of autism or self-diagnosed as autistic. We used semi-structured interviews to discuss how they came to recognize or identify with autism, their diagnostic experience, and their understanding of autistic females. We summarized several broad themes that depicted their experience. Participants recognized autism in themselves when seeing other autistic people. They indicated mental health challenges that led them to seek help from professionals, who might sometimes reject their concerns about autism. Participants found it meaningful to have an autism diagnosis or identity, but other people's judgment would affect their self-understanding. Participants also described themselves different from the stereotypes of autism, not the same as autistic males, and were perceived by others as not autistic enough. Our findings suggested autistic women in Hong Kong faced challenges in identity development and support services. There is a need to increase awareness and knowledge about autism in professionals and the public. Understanding how unique cultural factors that influence the identity of autistic women or individuals in Chinese cultures is important to promote their well-being.

The 12-item self-report Questionnaire for Difficulty in Social Communication as a simultaneous prescreening of autism spectrum and social anxiety

Aim

Young patients with social communication difficulties are often diagnosed with autism spectrum disorder (ASD), social communication disorder (SCD), or social anxiety disorder (SAD). This study aimed to develop a questionnaire, especially focusing on the prescreening of SAD complicated by ASD/SCD.

Methods

The 12-item self-report Questionnaire for Difficulty in Social Communication (DISC-12) was developed and analyzed using exploratory factor analysis in 94 patients with ASD/SCD (35 with SAD, 59 without). An additional 17 patients with only SAD were included. Convergent validity was assessed via correlations with the Autism Spectrum Quotient (AQ) and Liebowitz Social Anxiety Scale (LSAS). DISC-12 scores and demographics were compared across ASD/SCD, ASD/SCD + SAD, and SAD groups. Receiver operating characteristic (ROC) analysis of DISC-12 subscales distinguished autistic traits from social anxiety.

Results

Factor analysis revealed a three-factor model for the DISC-12, comprising nonassertiveness, poor empathy, and interpersonal hypersensitivity. DISC-12 showed significant correlations with the AQ (r = 0.412, p < 0.001) and LSAS (r = 0.429, p < 0.001). Patients with ASD/SCD had higher Poor Empathy scores, while SAD patients had higher Interpersonal Hypersensitivity scores than the other groups. ROC analysis indicated that Poor Empathy and Interpersonal Hypersensitivity subscale scores effectively differentiated ASD/SCD from patients with SAD and vice versa.

Conclusion

DISC-12 is a rapid and effective prescreening tool for identifying both ASD and social anxiety, particularly in young patients with self-reported difficulties in social communication.

Exploring the construct validity of the Camouflaging Autistic Traits Questionnaire: A factor analytic study

'Camouflaging' is a set of strategies used by autistic people to hide or compensate for their autistic characteristics to fit into predominantly non-autistic social environments. Many researchers have used the Camouflaging Autistic Traits Questionnaire (CAT-Q) to measure camouflaging. However, there have been questions about the construct validity of the CAT-Q as a measurement of camouflaging. The present study examined the extent to which CAT-Q items were distinguishable from other theoretically and empirically related measures of social anxiety, fear of negative evaluation and autistic social traits. Autistic adults (N = 308) completed the CAT-Q and social anxiety, fear of negative evaluation and autistic social traits measures. The small-to-large positive associations between camouflaging and social anxiety, fear of negative evaluation and autistic social traits (r = 0.14-0.65) were not indicative of collinearity. Three exploratory factor analyses, in which CAT-Q items were factor-analysed together with social anxiety, fear of negative evaluation and autistic social traits items respectively, showed that CAT-Q items generally loaded onto different factors from social anxiety, fear of negative evaluation and autistic social traits items, with the exception of the CAT-Q Assimilation subscale items, which cross-loaded mostly with autistic social traits items. Overall, the CAT-Q items were positively associated with, but also differentiated from, most social anxiety, fear of negative evaluation and autistic social traits items, providing support for the measure's construct validity.Lay abstractAutistic people describe having to mask or 'camouflage' their autistic selves to fit into certain social settings. Many researchers have used the CAT-Q to measure the extent to which autistic people engage in camouflaging. However, some researchers have questioned whether the CAT-Q measures camouflaging or whether it measures other related experiences and behaviours associated with social anxiety, fear of being negatively judged or social autistic traits. In our study, we analysed the CAT-Q to check whether it is indeed similar to or different from these related experiences. To do this, we asked 308 autistic adults to complete the CAT-Q and questionnaires about social anxiety, fear of being negatively judged and autistic social features. Then, we put all the CAT-Q items together with the items from each of the other measures in three separate analyses (called factor analyses) to see how the items would group together. These analyses showed us whether camouflaging behaviours are distinguishable and different from, or cluster together with, these other experiences. We found that most of CAT-Q items grouped together separately from the other measures' items, suggesting that camouflaging differs from these other related experiences. Only some items from one of the CAT-Q subscales clustered together with some social anxiety and autistic items, suggesting these may need to be teased out better in the future. Generally, our findings show that we can use the CAT-Q to measure camouflaging behaviours among autistic people.

Is There a Bias Towards Males in the Diagnosis of Autism? A Systematic Review and Meta-Analysis

Autism is more frequently diagnosed in males, with evidence suggesting that females are more likely to be misdiagnosed or underdiagnosed. Possibly, the male/female ratio imbalance relates to phenotypic and camouflaging differences between genders. Here, we performed a comprehensive approach to phenotypic and camouflaging research in autism addressed in two studies. First (Study 1 - Phenotypic Differences in Autism), we conducted a systematic review and meta-analysis of gender differences in autism phenotype. The electronic datasets Pubmed, Scopus, Web of Science, and PsychInfo were searched. We included 67 articles that compared females and males in autism core symptoms, and in cognitive, socioemotional, and behavioural phenotypes. Autistic males exhibited more severe symptoms and social interaction difficulties on standard clinical measures than females, who, in turn, exhibited more cognitive and behavioural difficulties. Considering the hypothesis of camouflaging possibly underlying these differences, we then conducted a meta-analysis of gender differences in camouflaging (Study 2 - Camouflaging Differences in Autism). The same datasets as the first study were searched. Ten studies were included. Females used more compensation and masking camouflage strategies than males. The results support the argument of a bias in clinical procedures towards males and the importance of considering a 'female autism phenotype'-potentially involving camouflaging-in the diagnostic process.

Understanding Camouflaging, Stigma, and Mental Health for Autistic People in Japan

Background

Camouflaging refers to behaviors in which autistic individuals mask their autistic characteristics and "pass" as non-autistic people. It is postulated that camouflaging is a response to stigma, and preliminary evidence supports this hypothesis. However, research on this topic outside of Western countries is limited. This study replicated and extended previous work in the West that examined the relationships between camouflaging, stigma, and mental health of autistic adults, with a Japanese sample.

Methods

Two-hundred eighty-seven autistic people living in Japan (146 men, 120 women, 14 nonbinary, 5 other gender identities, 2 preferred not to say; mean age = 37.5 years, standard deviation = 9.8 years) completed an online survey on camouflaging, perceived stigma, coping strategies for stigma, mental well-being, generalized anxiety, social anxiety, and depression. We used hierarchical multiple regression analyses to investigate the relationships between camouflaging and stigma and coping strategies for stigma. Mediation analyses were also employed to examine whether camouflaging mediated the relationships between stigma and autistic people's mental health.

Results

Replicating previous work, we found that higher camouflaging was associated with higher perceived stigma. Both coping strategies of hiding/denying and valuing/embracing stigmatized characteristics were positively related to camouflaging. Camouflaging mediated the association of stigma with depression, generalized anxiety, and social anxiety (but not well-being).

Conclusions

Our findings support the hypothesis that camouflaging is closely related to autism-related stigma and can influence the impact of stigma on mental health. More work around social outreach and addressing autism-related stigma would be beneficial to reduce the negative role of camouflaging.

CARE Model of Treatment for stuttering: Theory, assumptions, and preliminary findings

The purpose of this article is to present a theory of therapy for stuttering, its related assumptions, and findings from associated empirical studies. Specifically, we propose the Blank Center CARE™ Model of Treatment (CT) for stuttering, which differs from the current, widely employed fluency model of treatment (FT). The CT reflects the authors' belief in the need to move away from fluency-focused or seemingly ableist treatments (i.e., any approach that attempts to correct, cure, or fix a disabling condition) for stuttering. The authors propose a shift toward a theory of treatment that addresses whole-person wellness and considers the treatment of stuttering from outside the framework of fluency shaping and stuttering modification. In support of such considerations, this article provides preliminary findings from both non-clinical and clinical studies of using the CT for children and adults. Although preliminary, these findings appear to lend empirical support to the authors' belief that the treatment of stuttering needs to change. In essence, a change in the zeitgeist regarding the treatment of stuttering may contribute to an associated paradigm shift from FT to CT in the management of stuttering in children and adults.

Anxiety Disorders in Autistic People: A Narrative Review

Anxiety is the most common co-occurring mental health condition across the lifespan for autistic people. The authors summarize the extant research on prevalence, correlates and predictors, measurement, and treatment of anxiety disorders in autistic people, which has rapidly expanded in the past decade. In addition to addressing gaps within each of these areas, the authors propose that there is a need for future work to center autistic perspectives, employ longitudinal designs, and expand the focus to include autistic adults and those with co-occurring intellectual disability.

Understanding Mechanisms that Maintain Social Anxiety Disorder in Autistic Individuals Through the Clark and Wells (1995) Model and Beyond: A Systematic Review

Given the high co-occurrence of social anxiety in autism, no reviews to date have explored how cognitive and behavioural mechanisms identified to maintain social anxiety in non-autistic individuals may operate in autistic individuals. This systematic review evaluated: (1) empirical evidence underlying the Clark and Wells (1995) Cognitive Model of Social Anxiety in autistic individuals; (2) how vulnerability factors identified from autism literature (beyond core autistic traits) may be associated with social anxiety beyond the cognitive model. Published peer-reviewed English articles until 27th November 2023 were retrieved from PubMed, EMBASE, Ovid MEDLINE and PsycINFO. Quality appraisal and risk of bias were assessed using The Standard Quality Assessment Criteria for Evaluating Primary Research papers from a Variety of Fields tool. 47 articles met full inclusion criteria and included autistic individuals (with clinical diagnosis), a measure of social anxiety, and a mechanism outlined by either (or both) research questions. The majority of the 3340 participants across studies were male without intellectual disability, White/Caucasian, with 7 studies reporting an average age above 30 years old. Most studies used only self-report measures that may have inflated associations observed between social anxiety and mechanisms. All studies employed cross-sectional design, and no causality inferences could be drawn. Methodological issues around potential construct overlaps between social anxiety and autistic traits are highlighted. Overall, there is evidence in support of the as reported by Clark and Well (in: Heimberg (eds), A cognitive model of social phobia, The Guilford Press, 1995) model, as greater fear of negative evaluation from others, use of safety behaviours and somatic symptoms, and peer victimisation were associated with greater social anxiety. The review contributes evidence in support of autism specific contextual, predisposing/antecedent and maintenance factors of social anxiety beyond the original Clark and Well (in: Heimberg (eds), A cognitive model of social phobia, The Guilford Press, 1995) model. Given the potential for considerable heterogeneity for each highlighted process at an individual level across autistic individuals, clinicians can broaden formulation conversations with autistic clients to understand how autism related factors may influence the development and maintenance of social anxiety symptoms when applying and adapting the Clark and Well (in: Heimberg (eds), A cognitive model of social phobia, The Guilford Press, 1995) model.

Camouflaging, internalized stigma, and mental health in the general population

BACKGROUND

Camouflaging, the strategies that some autistic people use to hide their differences, has been hypothesized to trigger mental health ramifications. Camouflaging might reflect ubiquitous impression management experiences that are not unique to autistic people and similarly impact the mental health of non-autistic people.

AIMS

We first examined whether individuals in the general population camouflage and manage impressions while experiencing mental health repercussions, and how gender and neurodivergent traits modified these associations. We then assessed how camouflaging and impression management arose from internalized stigma, and their inter-relationships in shaping mental health outcomes.

METHODS

Data were collected from 972 adults from a representative U.S. general population sample, with measures pertaining to camouflaging, impression management, mental health, internalized stigma, and neurodivergent traits. Multivariate hierarchical regression and moderated mediation analyses were used to address the two research aims.

RESULTS

Both camouflaging and self-presentation (a key component of impression management) were associated with mental health presentations in the general population, which overlapped with those previously reported in autistic people. These associations were more pronounced in women compared with men and were of different directions for individuals with higher autistic traits versus higher ADHD traits. Internalized stigma might be a key stressor that could elicit camouflaging and impression management through social anxiety, which in turn might lead to adverse mental health outcomes.

CONCLUSIONS

These findings advance the conceptual clarity and clinical relevance of camouflaging and impression management across social and neurodiverse groups in the general population. The ramifications of camouflaging and impression management underscore the need to alleviate internalized stigma for better mental health across human groups.

Validation of the camouflaging autistic traits questionnaire short form (CATQ-SF)

BACKGROUND

Camouflaging of autistic traits involves hiding or compensating for autistic characteristics, often due to stigma or a desire to fit in with others. This behaviour has been associated with mental health issues in autistic individuals. The 2 5-item Camouflaging Autistic Traits Questionnaire (CAT-Q) is the most commonly used self-report measure of camouflaging. In this study, a 9-item short form version was developed for use in clinical and research settings.

AIMS

To construct and psychometrically validate a brief self-report measure of camouflaging.

METHOD

The Camouflaging Autistic Traits Questionnaire - Short Form (CATQ-SF) was developed and its factor structure and psychometric properties were evaluated in two studies. Study 1 used a large, online sample of autistic and non-autistic adults (N = 832) to evaluate the factor structure, psychometric properties, and measurement invariance of the CATQ-SF. Study 2 used an independent sample of autistic and non-autistic adults (N = 80) to test Study 1's findings.

RESULTS

In Study 1, evidence for a three-factor structure was observed, with good internal consistency (combined autistic & non-autistic α = 0.84). In addition, the instrument demonstrated measurement invariance, and reliably predicted higher levels of autistic traits. In Study 2, the 3-factor structure was replicated, and good internal consistency was again observed (combined autistic and non-autistic α = 0.89). In both studies, psychometric properties were of similar or higher validity compared to the full-form CAT-Q.

CONCLUSIONS

The CATQ-SF can be used by clinicians and researchers to measure camouflaging in autistic and non-autistic adults quickly and reliably.

A qualitative interview study on quality of life and ageing experiences of autistic adults

Quality of life across the lifespan has been established as a key research priority by the autism community. Still relatively little is known about the quality of life and ageing experiences of older autistic adults. Most studies to date have used generic measures of quality of life which may not accurately capture the experiences of autistic people. The aim of this qualitative study was to understand how autistic adults experience and define quality of life as they age. We conducted semi-structured interviews with 16 autistic adults aged 40+ from the UK and Luxembourg. Using reflexive thematic analysis, we identified five themes that contribute to quality of life: (1) Diagnosis is pivotal, (2) Connection with others, (3) Autonomy over space and time, (4) 'Paperwork of life', (5) Vulnerability. This study identifies autism-specific aspects of quality of life and highlights ways in which ageing and autism intersect and impact quality of life.

Impact of developmental language disorders on mental health and well-being across the lifespan: a qualitative study including the perspectives of UK adults with DLD and Australian speech-language therapists

OBJECTIVE

This study aims to explore the educational, occupational and socioemotional experiences of people with developmental language disorder (DLD) across the lifespan to gain insight into risk and protective factors for mental health.

DESIGN

Qualitative analysis of focus groups and written submissions. Data were combined and analysed using Braun and Clarke's reflexive thematic analysis approach within a critical realist framework.

SETTING

Southeast England and Western Australia.

PARTICIPANTS

Six adults with DLD from England and five speech-language therapists from Western Australia participated in focus groups and/or contributed written responses to the research team.

RESULTS

We developed four themes: 'perspectives on diagnosis and living with an invisible disability' explores participants' perspectives on diagnosis, the difficulty getting a diagnosis and perceptions of DLD as widely misunderstood; 'school struggles and self-esteem from past to present' details school experiences and their impact on mental health; 'DLD across the lifespan' explores DLD in adulthood with a focus on workplace difficulties, emotional well-being and mental health; 'A sense of belonging: communication, connection and support' provides a lived experience account into the social participation difficulties of adults with DLD and the importance of social support.

CONCLUSIONS AND IMPLICATIONS

Adults with DLD may experience poor self-esteem, anxiety and depression. These mental health concerns may result from (a) exhaustion due to masking/compensating for neurodevelopmental differences, (b) loneliness and/or disempowerment due to difficulties with social interaction and (c) adverse experiences such as bullying, discrimination and a lack of appropriate accommodation at school and in the workplace. A lack of awareness and support for people with DLD from health, education and employment providers was also seen as a contributing factor to poor mental health. Diagnosis may serve a protective function for mental health via self-understanding, self-esteem and self-advocacy.

Does Camouflaging Cause Reduced Quality of Life? A Co-Twin Control Study

Camouflaging has been proposed to have a detrimental effect on quality of life, yet previous research has not accounted sufficiently for potential confounding by genetic and shared environmental factors. The current study utilized a co-twin control design providing stringent control for a range of confounders to investigate the hypothesis that camouflaging autistic traits has a negative impact on quality of life. The sample included 140 individual twins from 42 monozygotic (MZ) and 28 dizygotic (DZ) twin-pairs, enriched for participants with neurodevelopmental conditions including 22 autistic participants. All twins provided self-reports of camouflaging and quality of life. Autistic participants and specifically autistic females displayed increased camouflaging behaviors compared to non-autistic participants. Across the sample, higher levels of camouflaging were associated with reduced quality of life, surviving adjustment for confounding effects of autistic traits, ADHD, sex, and age. Within DZ- as well as MZ-pairs, which provide the highest level of control for unmeasured confounders, twins who camouflaged more reported lower quality of life compared to their co-twins, consistent with a causal influence of camouflaging on quality of life. Our results strengthen previous claims purporting camouflaging behaviors as a risk factor for reduced quality of life.

A systematic review of social camouflaging in autistic adults and youth: Implications and theory

Social camouflaging (SC) is a set of behaviors used by autistic people to assimilate with their social environment. Using SC behaviours may put autistic people at risk for poor mental health outcomes. Following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, the goal of this systematic review was to investigate the development of SC and inform theory in this area by outlining the predictors, phenotype, and consequences of SC. This review fills a gap in existing literature by integrating quantitative and qualitative methodologies, including all gender identities/age groups of autistic individuals, incorporating a large scope of associated factors with SC, and expanding on theory/implications. Papers were sourced using Medline, PsycInfo, and ERIC. Results indicate that self-protection and desire for social connection motivate SC. Camouflaging behaviors include compensation, masking, and assimilation. Female individuals were found to be more likely to SC. Additionally, this review yielded novel insights including contextual factors of SC, interpersonal relational and identity-related consequences of SC, and possible bidirectional associations between SC and mental health, cognition, and age of diagnosis. Autistic youth and adults have similar SC motivations, outward expression of SC behavior, and experience similar consequences post-camouflaging. Further empirical exploration is needed to investigate the directionality between predictors and consequences of SC, and possible mitigating factors such as social stigma and gender identity.

The associations between self-rated autistic traits, social camouflaging, and mental health outcomes in Taiwanese anime, comics and games (ACG) doujin creators: an exploratory study

BACKGROUND

Doujin (どうじん) is a Japanese term referring to a circle where people share the same interests, usually something that belongs to the Anime, Comics, and Games (ACG) subculture. Individuals who belong to it and create related works, known as ACG doujin creators, are usually described as socially awkward and at potential risk of isolation. In such a context, they may theoretically exhibit higher autistic traits and manifest camouflaging tendencies, which may consequently be associated with their mental health. Nonetheless, the impact of autistic traits and camouflaging on mental health in this subculture remains significantly underexplored.

METHODS

We recruited 183 Taiwanese ACG doujin creators (age ranges from 18 to 41, 146 female and 37 male) via social networking platforms. Participants completed Chinese online surveys assessing socio-demographic information, doujin activities, past psychiatric history, the 35-item Version of Autism-Spectrum Quotient (AQ-35), Chinese version Camouflaging Autistic Traits Questionnaire (CAT-Q-Ch), the General Anxiety Disorder-7 (GAD-7), and the Patient Health Questionnaire-9 (PHQ-9). Linear regression analysis was employed to examine the associations between the aforementioned scales.

RESULTS

Our findings revealed that among ACG doujin creators, descriptively higher level of AQ-35 and CAT-Q-Ch than previous studies were found. Moreover, we observed a positive association between camouflaging behaviours and most AQ-35 subscales, with the exception of the mindreading subscale. Additionally, we identified that both camouflaging and autistic traits were significantly linked to higher PHQ-9 and GAD-7 scores.

CONCLUSIONS

Through this study, we gained insight into the distinctive characteristics of autistic traits, camouflaging behaviours, and mental health among Taiwanese ACG doujin creators, as the associations between the factors mentioned above are divergent compared to previous research. This topic demonstrated that camouflaging is also associated with adverse mental health in a subculture group.

Exploring the association between social camouflaging and self- versus caregiver-report discrepancies in anxiety and depressive symptoms in autistic and non-autistic socially anxious adolescents

LAY ABSTRACT

Social camouflaging or masking refers to strategies autistic individuals adopt to hide their autism persona when trying to fit in. It is unclear whether camouflaging is only applicable to social differences unique to autism, or more generally to any types of social difference, such as experiences of mental health difficulties. We asked 43 autistic and 39 non-autistic adolescents (aged 14-19 years, all of whom showed similarly high levels of social anxiety) and their primary caregivers to complete questionnaires about their mental health (anxiety and depression) and autistic traits, and adolescents self-reported camouflaging behaviours. We wondered if camouflaging may be used to hide mental health difficulties reported by young people and affect caregiver report on symptom severity. We found that adolescents who self-reported greater levels of autistic traits, anxiety and depression symptoms compared with their caregivers reported greater camouflaging. Adolescents who agreed on having high levels of autistic traits and anxiety symptoms with their caregivers reported greater camouflaging behaviours. We discuss how having high levels of autistic traits and anxiety may increase adolescents' camouflaging behaviours to hide social differences, which may contribute towards poor mental health outcomes. We think it is important to talk with adolescents about how camouflaging social and mental health difference can have negative impacts for mental health as well as possible positive social gains.

Double-Edged Effects of Social Strategies on the Well-Being of Autistic People: Impact of Self-Perceived Effort and Efficacy

BACKGROUND/OBJECTIVES

Autistic people employ various social strategies to form and maintain interpersonal relationships in their daily environments. These strategies can help autistic people with social interactions (leading to self-perceived efficacy of using social strategies), but can also lead to cognitive fatigue (self-perceived effort of using social strategies). However, previous studies have focused primarily on self-perceived effort, overlooking the self-perceived efficacy of using social strategies, and the balance between self-perceived effort and efficacy. To address this gap, this study examined the impact of autistic people's use of social strategies on their well-being, focusing on self-perceived effort, self-perceived efficacy, and their interaction effect.

METHODS

An online survey was conducted among self-reported autistic people in Japan aged 18-65 years, using a modified Compensation Checklist. Data from 104 self-reported autistic participants were analyzed using linear regression.

RESULTS

High self-perceived effort in using social strategies was negatively associated with well-being, whereas high self-perceived efficacy was positively associated with well-being. The interaction effect between effort and efficacy was not significant. These results were supported even when loneliness was used as an index of social well-being. Additionally, the number of strategies used by an autistic person was positively associated with well-being.

CONCLUSIONS

This study highlights the double-edged effect of autistic people using social strategies, and that using a broader repertoire of social strategies may improve the well-being of autistic people. These findings call for a nuanced approach by researchers and clinicians considering both the positive and negative aspects of using social strategies.

Why Are Autistic People More Likely to Experience Suicidal Thoughts? Applying the Integrated Motivational-Volitional Model with Autistic Adults

Background

Autistic people are at considerably greater risk of suicidality than non-autistic people, and the reasons behind this are not fully understood. Current suicide theories may be useful to help further our understanding of the mechanisms behind autistic suicidality. We aimed to test the key predictors of suicidal ideation-defeat and entrapment-as described in the integrated motivational-volitional (IMV) model of suicide behavior, in an autistic group. We also looked to extend the IMV model by including autism-related constructs of camouflaging and intolerance of uncertainty (IU).

Methods

We recruited 374 autistic adults from the community (female 42.5%; 18-63 years of age), who completed a cross-sectional online survey between August 2020 and January 2021. We collected data on lifetime suicidality, depression symptoms, defeat, entrapment, camouflaging, and IU.

Results

We found that entrapment significantly mediated the relationship between defeat and suicidal ideation. Camouflaging and IU were not found to moderate this pathway but were found to be significantly associated with suicidal ideation.

Conclusions

We found that entrapment mediates the relationship between defeat and suicidality in autistic adults. This is consistent with the predictions in the motivational phase of the IMV model of suicidal behavior, suggesting that this model is useful for understanding autistic suicidality. We did not find evidence that camouflaging and IU act as moderators within the mediated model. Nevertheless, there is some evidence that camouflaging and IU are worthwhile constructs to be aware of for future work researching autistic suicidality.

An Examination of Perceived Stress and Emotion Regulation Challenges as Mediators of Associations Between Camouflaging and Internalizing Symptomatology

Background

Camouflaging involves the masking of autism traits, potentially creating an outer impression of "non-autisticness." Although associations of camouflaging with anxiety and depression in autistic adults are widely reported, factors that mediate these associations are unclear. We examined two potential mediators of the association between camouflaging and anxiety/depression: perceived stress and emotion regulation (ER) challenges.

Methods

Seven hundred eighty-seven autistic adults (18.2-78.2 years) recruited through Simons Powering Autism Research (SPARK) Research Match completed questionnaires, including the Camouflaging Autistic Traits Questionnaire (CAT-Q), and measures of autistic traits, depressive and anxious symptomatology, perceived stress, and ER challenges. Four moderated mediation models were tested. In all models the independent variable was CAT-Q total score, and the moderator variable was sex designated at birth. The dependent variable was depressive or anxious symptomatology, and the mediator variable was perceived stress or ER challenges.

Results

We found that more camouflaging, increased ER challenges, and higher levels of perceived stress were associated with greater depressive and anxious symptomatology. We also found that perceived stress and ER challenges significantly mediated the associations between camouflaging and both depression and anxiety. In the model with perceived stress and anxiety, sex moderated the mediation, with females showing a stronger mediation. There was no significant moderation in any of the other models.

Conclusion

We contextualize the findings within the broader literature on camouflaging as a response to stigma and other facets of minority stress. We discuss how the results of this study support the idea that the day-to-day stress of living in a neurotypical world, the cognitively demanding nature of camouflaging, and the constraints that camouflaging place on autistic people's behaviors in social contexts (e.g., contributing to suppressing ER strategies such as stimming), create a cycle that contributes to elevated rates of anxiety and depression in autistic people.

Examining the Relations Between Social Competence, Autistic Traits, Anxiety and Depression in Autistic and Non-Autistic Children

The current study examined whether social competence and autistic traits are related to anxiety and depression in autistic and non-autistic children. Parents of 340 children aged 6 to 12 years old, including 186 autistic and 154 non-autistic children completed the Autism Spectrum Quotient (AQ) to assess their child's autistic traits, the Multidimensional Social Competence Scale (MSCS) to assess their child's social competence, and the Behaviour Assessment Scale for Children 2 (BASC-2) to assess their child's internalizing symptoms of depression and anxiety, and children were administered the Wechsler Abbreviated Scale of Intelligence, Second Edition (WASI-II) to assess their intellectual abilities. Hierarchical multiple regression analyses were conducted to investigate the relations between social competence, autistic traits, anxiety, and depression. Social competence was related to anxiety and depression symptoms in autistic children, but only depression symptoms in non-autistic children, above and beyond the effects of autistic traits, IQ and age. Autistic children were also reported to experience more severe anxiety and depression symptoms, and more autistic traits were related to higher levels of anxiety and depression in both groups. These findings suggest that social competence and internalizing symptoms are intricately connected in autistic children and need to be jointly considered in both assessment and intervention. The social implications are discussed with an emphasis on acceptance of diverse social styles as a viable avenue to reduce children's internalizing symptoms.

Satisfaction with social connectedness is associated with depression and anxiety symptoms in neurodiverse first-semester college students

LAY ABSTRACT

How satisfied people feel with their social connections and support is related to mental health outcomes for many different types of people. People may feel less socially connected at some times in their life-like when they start college. Feeling disconnected from others could lead to depression or anxiety. The transition to college may be especially difficult for autistic students as they are more likely to have difficulties adjusting socially. In our study, we asked 263 college students to answer questions about their emotions and social satisfaction twice per week during their first semester of college. We found that students who reported being less satisfied with their social connectedness (either at the beginning or throughout the semester) tended to express more symptoms of depression and anxiety. This relationship between social satisfaction and anxiety was even stronger for people who had a strong desire for social interaction (i.e. were more socially motivated). Students with more autistic traits tended to report more mood concerns, and they also reported being less satisfied with friendships at the beginning of the semester. This information may help to support ongoing efforts to better address mental health in autistic college students by encouraging efforts to improve social satisfaction.

Spontaneous instrumental approach-avoidance learning in social contexts in autism

BACKGROUND

Individuals with Autism Spectrum Condition (ASC) are characterized by atypicalities in social interactions, compared to Typically Developing individuals (TD). The social motivation theory posits that these difficulties stem from diminished anticipation, reception, and/or learning from social rewards. Although learning from socioemotional outcomes is core to the theory, studies to date have been sparse and inconsistent. This possibly arises from a combination of theoretical, methodological and sample-related issues. Here, we assessed participants' ability to develop a spontaneous preference for actions that lead to desirable socioemotional outcomes (approaching/avoiding of happy/angry individuals, respectively), in an ecologically valid social scenario. We expected that learning abilities would be impaired in ASC individuals, particularly in response to affiliative social feedback.

METHOD

We ran an online social reinforcement learning task, on two large online cohorts with (n = 274) and without (n = 290) ASC, matched for gender, age and education. Participants had to indicate where they would sit in a waiting room. Each seat was associated with different probabilities of approaching/avoiding emotional individuals. Importantly, the task was implicit, as participants were not instructed to learn, and emotional expressions were never mentioned. We applied both categorical analyses contrasting the ASC and TD groups and dimensional factor analysis on affective questionnaires.

RESULTS

Contrary to our hypothesis, participants showed spontaneous learning from socioemotional outcomes, regardless of their diagnostic group. Yet, when accounting for dimensional variations in autistic traits, as well as depression and anxiety, two main findings emerged among females who failed to develop explicit learning strategies: (1) autism severity in ASC correlated with reduced learning to approach happy individuals; (2) anxiety-depression severity across both ASC and TD participants correlated with reduced learning to approach/avoid happy/angry individuals, respectively.

CONCLUSIONS

Implicit spontaneous learning from socioemotional outcomes is not generally impaired in autism but may be specifically associated with autism severity in females with ASC, when they do not have an explicit strategy for adapting to their social environment. Clinical diagnosis and intervention ought to take into account individual differences in their full complexity, including the presence of co-morbid anxiety and depression, when dealing with social atypicalities in autism.

Sex Differences and Parent-Teacher Discrepancies in Reports of Autism Traits: Evidence for Camouflaging in a School Setting

The purpose of this study was to examine sex differences and informant discrepancies in parent- and teacher-reports of autism traits. Data were drawn from the Simons Simplex Collection to create a sex-matched sample of autistic youth (N = 388; 4-17 years). Included participants had both parent and teacher reports of autistic traits from the Social Responsiveness Scale (SRS). Within each sex group, parent and teacher raw SRS scores were compared. Scores within each informant group (parent/teacher) was assessed for sex differences. Predictors of parent-teacher discrepancies were examined. Despite no sex differences in parent-reported autistic traits, teachers reported males as having more autistic traits compared to females. Parents of females reported significantly more autistic traits than teachers across multiple domains. Being older and female were significant predictors of increased parent-teacher discrepancy for multiple domains. These results suggest discrepancies between the observed autistic traits for females at home and school and builds on the growing body of literature highlighting potential camouflaging across development in autistic youth: parent-teacher discrepancies may reflect ways that autistic females are overlooked by teachers due to conscious changes in behavior or gender-based expectations of female characteristics. Discussion of discrepancies on an individual basis may therefore alleviate potential long-term consequences of camouflaging.

Examining an integrated path model of psychological and sociocultural predictors of camouflaging in autistic adults

LAY ABSTRACT

Many autistic people use strategies known as 'camouflaging' to change how noticeable their autistic traits are in social situations. Previous research suggests that camouflaging is largely motivated by psychological and social factors. However, most studies so far have only looked at a few psychosocial factors related to camouflaging. In this study, we explored a model that included several individual psychological factors (such as fear of being negatively judged, self-esteem and autistic identity) and broader social and cultural factors (such as perceived stigma, negative life events, cultural emphasis on conformity and desire to fit in or stand out). We surveyed 225 autistic adults aged 18-77 years online. Our findings showed that several sociocultural factors were indirectly linked to camouflaging through individual psychological factors. Fear of being negatively judged emerged as a strong predictor of camouflaging. Specifically, autistic adults who perceived greater stigma, felt greater pressure to conform, had a lesser desire to stand out and a greater desire to fit in tended to experience a greater fear of being negatively judged and reported more camouflaging. In addition, those who experienced more negative life events were more likely to engage in camouflaging. Our study identifies key psychological and social factors as potential targets for social change. Our findings emphasise that our societies need to shift away from stigmatising attitudes towards accepting and including autistic people, which could reduce the pressure on autistic individuals to camouflage in social situations.

The clinical characteristics of autistic women with restrictive eating disorders

BACKGROUND

Autistic women are at high risk of developing restrictive eating disorders (REDs), such as anorexia nervosa.

AIMS

This study provides an overview of the clinical characteristics of autistic women with REDs to (i) enhance understanding of increased risk, and (ii) support the identification of autistic women in eating disorder services.

METHOD

We compared self-reported autistic and disordered eating characteristics of: autistic participants with REDs (Autism + REDs; n = 57); autistic participants without REDs (Autism; n = 69); and women with REDs who are not autistic (REDs; n = 80). We also included a group of women with high autistic traits (HATs) and REDs, but no formal autism diagnosis (HATs + REDs; n = 38).

RESULTS

Autism + REDs participants scored similarly to Autism participants in terms of autistic characteristics and to REDs participants in terms of experiencing traditional disordered eating symptoms. Autism + REDs participants were distinguished from both groups by having more restricted and repetitive behaviours and autism-specific eating behaviours related to sensory processing, flexibility and social differences. HATs + REDs participants showed a similar pattern of scores to Autism + REDs participants, and both also presented with high levels of co-occurring mental health difficulties, particularly social anxiety.

CONCLUSION

The presentation of autistic women with REDs is complex, including both traditional disordered eating symptoms and autism-related needs, as well as high levels of co-occurring mental health difficulties. In eating disorder services, the REDs presentation of autistic women and those with HATs should be formulated with reference to autism-specific eating behaviours and co-occurring difficulties. Treatment adaptations should be offered to accommodate autistic characteristics and related needs.

Camouflaging in Autistic Adults is Modulated by Autistic and Neurotypical Characteristics of Interaction Partners

Many autistic people reportedly engage in camouflaging to navigate everyday social interactions; however, the function of this behavior remains largely unknown. We hypothesized that autistic people camouflage more toward neurotypical others than toward autistic others, employing it as a strategy to "fit in" within the neurotypical-majority community. This study aimed to empirically investigate this hypothesis for the first time. Autistic and neurotypical participants took part in a web-based survey. Data from 48 autistic and 137 neurotypical participants were analyzed. Camouflaging toward autistic and neurotypical others was separately measured using the modified Camouflaging Autistic Traits Questionnaire (CAT-Q). For each CAT-Q item, a sentence describing a hypothetical interaction partner with autistic or neurotypical characteristics was added, creating respective sentence conditions. The interaction effect of the participants' characteristics and sentence conditions was analyzed using a multilevel regression analysis, accounting for differing individual baselines. The analysis revealed an interaction effect between participants' characteristics and sentence conditions. The autistic group showed significantly more camouflaging in the autistic sentence condition than in the neurotypical sentence condition. Conversely, the neurotypical group did not differ significantly in camouflaging levels in the sentence conditions. Contrary to our hypothesis, autistic people demonstrated more camouflaging toward autistic others than toward neurotypical others. This finding questions the assumption that autistic people camouflage to assimilate into a neurotypical-majority society. Instead, it could be conceptualized as a more general social strategy used by autistic people aiming to improve their relationships with others.

Correlates of Quality of Life in Autistic Individuals

Background

Quality of life is an important outcome to autistic individuals. However, the correlates of quality of life in this population are not well known. The purpose of this project was to investigate the extent to which employment, depression, anxiety, and social participation were associated with quality of life in autistic individuals. We also explored potential associations between emotion dysregulation and quality of life.

Method

Baseline data from two randomized control trials were used for analysis. A total of 125 autistic adolescents and adults aged 16-45 (M = 25.40) participated. Linear regression models were constructed to investigate whether employment, depression, anxiety, and social participation were associated with five domains of quality of life: overall, physical health, psychological, social relationships, and environment. Additional linear regression models explored whether emotion dysregulation was associated with the same quality of life domains.

Results

Surprisingly, employment was not significantly associated with any quality of life domain. Greater depression severity was significantly associated with poorer quality of life across all domains. Greater social participation was associated with better quality of life, but only for individuals with lower anxiety. More severe dysphoria was associated with poorer overall quality of life and the psychological and physical health domains.

Conclusions

Results suggest that mental health and emotion dysregulation are important predictors of quality of life for autistic people. They also suggest that anxiety symptoms may attenuate the beneficial effects of social participation. This study provides insight into the unique experiences of autistic individuals and highlights potential unmet need.

Herpertz S, Fuchs T. Emotion recognition in autism spectrum condition during the COVID-19 pandemic

LAY ABSTRACT

In the COVID-19 pandemic, wearing face masks became mandatory to prevent the spread of the virus. However, they restrict the ability to recognize emotions to the upper part of the face. Since individuals with autism spectrum condition often tend to look at the lower half of the face, they may be particularly restricted in emotion recognition by people wearing masks, since they are now forced to look at the upper half of the face. The current study compared the recognition of facially expressed emotions between individuals with and without autism spectrum condition. Each photo was shown in three types, once uncovered, once with face mask, and once with sunglasses. Our results revealed a reduction in accuracy of individuals with autism spectrum condition at recognizing emotions in all three stimulus types and exhibited more difficulties distinguishing anger, fear, pride, and embarrassment. During the emotion recognition task, there was no difference in which facial areas the groups looked at. We did not find evidence that the disadvantages of individuals with autism spectrum condition in emotion recognition were due to looking at different areas of the face.

Exploring the mediating effect of camouflaging and the moderating effect of autistic identity on the relationship between autistic traits and mental wellbeing

Mental health difficulties are prevalent among autistic adults. Camouflaging (behaving differently to fit in) may be a mechanism by which autistic traits and mental health difficulties relate to each other, but little research has considered the role of different facets of camouflaging. Additionally, autistic identity might buffer against camouflaging and mental health difficulties. This research aims to explore the mediating effects of camouflaging behaviours on the relationship between autistic traits and both positive and negative mental wellbeing, as well as how autistic identity might moderate the relationship between autistic traits and camouflaging, and also mental health. Data were available for 627 autistic adults, recruited through volunteer databases and social media. Participants completed measures of autistic traits, anxiety, depression, positive wellbeing, camouflaging behaviours (compensating for difficulties, masking, and assimilating/putting on an act) and autistic identity. Mediation and moderated mediation models were tested, applying 95% bootstrapped CIs (10,000 resamples) and including age, gender and diagnosis as covariates. There were no significant direct effects between autistic traits and mental wellbeing. Assimilation was a significant mediator of all mental wellbeing measures, and compensation was a significant mediator of positive wellbeing only. Autistic identity was not a significant moderator. Assimilation and compensation should be considered when offering psychological interventions to support mental wellbeing of autistic people. Additional research into external drivers of camouflaging (e.g. stigma) and mechanisms by which camouflaging impacts mental wellbeing, such as autonomy, authenticity, skill mastery and community, may identify other areas of support. Concurrently, societal change is necessary to reduce the need to camouflage.

It is More Anxiousness than Role-playing: Social Camouflaging Conceptualization Among Adults on the Autism Spectrum Compared to Persons with Social Anxiety Disorder

PURPOSE

Autistic individuals consider social camouflaging, e.g., masking autistic traits or social skills compensation, as exhausting and effortful, often leading to diminished well-being or burnout, as well as adaptive for satisfying social interactions. Developing camouflaging may result in isolation, social avoidance, increased self-stigmatization, and misdiagnosis, including social anxiety disorder. The study's objective was to explore and conceptualize social camouflaging, with a particular focus on social anxiety symptoms, autistic burnout, and public stigma, among autistic individuals, with two comparative samples: with social anxiety disorder (SAD) and dual diagnoses (SAD + ASD).

METHODS

254 individuals participated in the study (including 186 females, 148 with ASD diagnosis). CAT-Q, AQ-10, AASPIRE's Autistic Burnout Scale, LSAS-SR, The Perceived Public Stigma Scale were used.

RESULTS

The findings suggest differences in the interrelation dynamics between the samples studied, with autistic burnout and social anxiety symptoms of essential significance in camouflaging strategies, and autistic traits being of secondary importance. Structural equation models showed that the proposed conceptualization, with camouflaging and autistic burnout as the outcome variables, exhibited acceptable fit, implying that this strategy is costly and may result in exhaustion.

CONCLUSION

The total score of camouflaging did not differ between the groups studied, suggesting that a tendency to camouflage is rather transdiagnostic, deriving from anxiousness and negative self-perception, not being autistic per se.

What You Are Hiding Could Be Hurting You: Autistic Masking in Relation to Mental Health, Interpersonal Trauma, Authenticity, and Self-Esteem

Background

Autistic masking refers to some autistic individuals' tendency to hide, suppress, or camouflage their autistic traits, autistic identity, or autism diagnosis. Autistic masking also may include unconscious or conscious attempts to mimic the behavioral, cognitive, or sensory styles of nonautistic neurotypical people and to suppress natural forms of autistic behavior, cognition, and reactions to sensory experiences. Since autistic people are a stigmatized minority in many neurotypical dominated societies, passing as nonautistic through autistic masking may be an attempt to avoid autism stigma and a reaction to previous interpersonal trauma. Increased autistic masking behaviors are associated with reports of increased depression, anxiety, burnout, and exhaustion in autistic people, and thus, exploring the roots and impact of autistic masking is an important mental health topic.

Methods

This study investigated the relationships between autistic masking and depression, anxiety, gender identity, sexual orientation, interpersonal trauma, self-esteem, authenticity, and autistic community involvement. Participants were autistic adults (n = 342) recruited through autistic social media groups.

Results

This study found that higher self-reported autistic masking behaviors were associated with higher reports of past interpersonal trauma, greater anxiety and depression symptoms, lower self-esteem, lower authenticity, and lower participation within the autistic community. Autistic masking was not associated with gender identity or sexual orientation.

Conclusions

The results of this study highlight the relationship between autistic masking and past interpersonal trauma, finding that autistic masking behavior is associated with mental health, self-esteem, and authenticity risks for autistic adults. We call into question the teaching of autistic masking strategies in therapies and education programs for autistic people based on the negative associations with autistic masking presented in this study and other research in this field.

Reliability and validity of the Japanese version of the camouflaging autistic traits questionnaire

This study investigated the factor structure and determined the reliability and validity of the Camouflaging Autistic Traits Questionnaire-Japanese version (CAT-Q-J) among 204 autistic and 410 non-autistic people. Since a confirmatory factor analysis revealed no factor validity of the CAT-Q-J for both autistic and non-autistic adults, an exploratory factor analysis was conducted to ensure the psychometric properties matched those of the original scale as much as possible. The results showed the CAT-Q-J comprised three subscales, a four-item compensation subscale, a five-item masking scale, and a five-item assimilation subscale. The overall CAT-Q-J and all three subscales showed sufficient internal consistency and moderate-to-good and stable test-retest reliability in both the autistic and non-autistic samples. Convergent validity was also supported by the correlations found with measures of autistic traits, well-being, anxiety, and depression. Different from the original CAT-Q, compensation/masking for the autistic sample was not correlated with mental health or autistic traits. The reliability and the validity of the overall CAT-Q-J were confirmed; however, caution should be exercised when interpreting its subscales.

A meta-ethnography of autistic people's experiences of social camouflaging and its relationship with mental health

LAY ABSTRACT

Some autistic people describe trying to hide autistic behaviour and seem more neurotypical. Researchers called this 'social camouflaging' and have linked it with mental health difficulties. We used a step-by-step approach to identify research where autistic people talk about social camouflaging to explore the relationship between camouflaging and poor mental health. Thirteen studies were combined. The results describe how society negatively impacts autistic people's mental health, and camouflaging is a way to try and cope with this. Many autistic people find their camouflaging strategies have accidental negative consequences which also affect their mental health. Strategies which seemed 'successful' involved a lot of self-monitoring, were very mentally demanding or were very habitual and seemed to have more of an effect on mental health. This might be important for clinicians who support autistic people with mental health difficulties.

Relations Between Social Camouflaging, Life Satisfaction, and Depression Among Polish Women with ADHD

BACKGROUND

This study investigated the relationship between social camouflaging, life satisfaction, and depression symptoms in Polish women with ADHD. It aimed to fill a research gap in understanding ADHD manifestations in women, particularly focusing on social camouflaging-a concept known in autism, referring to strategies used to mask symptoms in social interactions.

METHODS

A total of 329 women with ADHD took part in an online survey. The survey measured ADHD symptoms using the ADHD Self Report Scale (ASRS-vI.I), life satisfaction with the Satisfaction With Life Scale (SWLS), and depressive symptoms using the Patient Health Questionnaire-9 (PHQ-9). Additionally, a novel set of questions, inspired by the Camouflaging Autistic Traits Questionnaire (CAT-Q) but tailored for ADHD, was utilized to assess social camouflaging.

RESULTS

Results indicated a significant negative association between social camouflaging and life satisfaction and a positive correlation with depressive symptoms, even after controlling for demographic variables. Additionally, factors like being in a relationship and having a positive subjective financial situation correlated with higher well-being.

LIMITATIONS

Reliance on self-report measures, the cross-sectional design, and participants' self-reported ADHD diagnosis are the main limitations of the study.

CONCLUSION

The research underscores the importance of social camouflaging in understanding ADHD in women, suggesting that efforts to mask symptoms and meet societal expectations may link to lower life satisfaction and increased depressive symptoms. These findings advocate for continued research into these dynamics to develop more effective support for women with ADHD.

Brief Report: Self-Reported Medication Use in Individuals Diagnosed with Autism Spectrum Disorder in Adulthood: A U.S. Clinic Sample from 2012 to 2022

PURPOSE

As the understanding of autism spectrum disorder (ASD) across the lifespan has increased, so has the number of individuals being identified with ASD for the first time in adulthood. Understanding co-occurring psychiatric conditions in this subset of the ASD population is a growing focus of research; however, little is known about the rate at which psychiatric medications are prescribed to adults with a first-time diagnosis of ASD. The purpose of this study was to examine self-reported medication use in persons diagnosed with ASD in adulthood in a clinic sample (2012-2022) in the United States.

METHODS

The present study was a retrospective record review. Participants (n = 281) were drawn from an outpatient clinic specializing in the diagnosis of ASD in adults. Participants self-reported previous and current psychiatric medication prescription using a medication checklist.

RESULTS

Approximately 50% of participants self-reported being prescribed at least one psychiatric medication at the time of their initial evaluation appointment. The most commonly prescribed psychiatric medications were antidepressants (23.8%), followed by stimulants (16.7%).

CONCLUSION

Similar to individuals diagnosed with ASD in childhood, those identified with ASD for the first time in adulthood are prescribed psychiatric medication at a much higher rate than their same-age non-autistic peers. These results can inform future research and practice for improving outcomes for autistic adults, particularly those who were undiagnosed for much of their lives.

Investigating the Structure of the CESD-R and DASS-21 Across Adults with Low and High Levels of Autistic Traits

The current study examined factorial invariance of the Center for Epidemiologic Studies Depression Scale-Revised (CESD-R) and the Depression Anxiety Stress Scales-21 (DASS-21) using a convenience sample of 434 adults surveyed though Amazon Mechanical Turk. Participants were sorted into two groups based on their score on the Autism-Spectrum Quotient. Results indicated that the CESD-R did not demonstrate configural invariance. The DASS-21 demonstrated evidence of scalar invariance, indicating cross-group equality in factor loadings and factor intercepts. Findings suggest that the DASS-21 measures symptoms of depression, anxiety, and stress consistently across individuals with high and low levels of ASD-related traits, whereas the CESD-R may not be valid when assessing symptoms of depression in those with a high level of ASD-related traits.

Camouflaging in Autism: Age Effects and Cross-Cultural Validation of the Camouflaging Autistic Traits Questionnaire (CAT-Q)

Given that camouflaging has been suggested to contribute to delayed diagnosis and mental health problems among autistic people, validated measures of the construct are needed. This study describes the psychometric evaluation of the Swedish adaptation of the self-reported Camouflaging Autistic Traits Questionnaire (CAT-Q) in autistic (n = 100) and general population (n = 539) samples aged 10 to 83 years. Analyses indicated good-to-excellent internal consistency and test-retest reliability. Construct validity was supported by autistic participants scoring higher than non-autistic, and autistic females scoring higher than autistic males on the measure. Also as expected, camouflaging was associated with theoretically linked traits, including autistic behaviors and depressive symptoms. On the other hand, the factor structure of the original CAT-Q did not provide a good fit in the Swedish data set, and validity issues were found, particularly in children younger than 15 years, warranting further investigation of the construct validity of the scale. Different age trajectories were observed, where camouflaging behaviors decreased during adulthood in non-autistic people but remained at an elevated level among autistic people.

Dropping the mask: It takes two

LAY ABSTRACT

In some situations, autistic people feel pressure to change their social behaviour by camouflaging. In other situations, autistic people feel they don't need to change their social behaviour. Instead, they feel they can socialise in ways that feel authentic or true to themselves. Past research has tended to focus on autistic people's experiences of camouflaging rather than their experiences of authenticity. In this study, we asked autistic people what it is like for them when they can socialise in ways that feel authentic or true to themselves. Autistic people described authentic-feeling socialising as more free, spontaneous and open than camouflaging. In supportive environments, this kind of socialising had more positive and less negative consequences than camouflaging. Autistic people felt that having self-awareness and acceptance of their own social needs and being around autistic and nonautistic people who were accepting and understanding helped them to socialise in authentic-feeling ways. Autistic people also spoke about communication behaviours they felt nonautistic people should use to help overcome misunderstandings and create autism-friendly social environments. These findings suggest it is helpful for autistic people to have access to supportive and accepting social environments in which they feel able to socialise in ways that feel authentic to them. In creating such social environments, it is important to focus on nonautistic people's knowledge and attitude towards autistic people and also their ability to use helpful communication behaviours.

Autism Severity and its Relationship to Disability

Autism severity is currently defined and measured based exclusively on the severity levels of the two core symptom domains: social-communication and restricted or repetitive patterns of behaviors and interests. Autistic individuals, however, are often diagnosed with other medical, developmental, and psychological co-occurring conditions. These additional challenges such as intellectual disability, limited expressive and/or receptive language, and anxiety disorders, can have a tremendous impact on the day-to-day lives of autistic individuals, for both their adaptive functioning as well as their sense of wellbeing. Furthermore, the initial presentation of core symptoms and their likelihood of changing over time are influenced by the presence of such co-occurring conditions. In order to truly understand how a person's autism impacts their life, both core symptoms as well as other challenges should be considered. This approach was recently taken by The Lancet Commission on the future of care and clinical research in autism, which proposed the term "profound autism" for a subgroup of individuals presenting with high core symptom severity, co-occurring intellectual disability, and little or no language, who require extensive long-term care. Considering other individual factors such as daily living skills, specific support needs and environmental resources would also enhance the evaluation of disability in autistic individuals. As currently employed in the assessment of intellectual disability, a multidimensional approach to autism could provide a more comprehensive system for classification of impairment. At present, however, there is no formal way to designate the combined effect of these different aspects of autism on a person's life. A comprehensive outlook that acknowledges impairments, capabilities, co-occurring conditions, and environmental factors would be useful for identifying subgroups of individuals as well as for determining individual needs and strengths in clinical assessments. Lay Summary: The severity of a person's autism is currently defined based on the severity of their core autism symptoms: impaired social-communication and the presence of restricted or repetitive patterns of behaviors and interests. But autistic people often face additional challenges such as intellectual disability, epilepsy, and anxiety disorder, that considerably impact their everyday life, wellbeing, and the need for support. A more complete view of autism severity, one that includes core symptoms as well as additional challenges, could help identify meaningful sub-groups of autistic individuals and could be useful in clinical care. Appeared originally in Autism Res 2023; 16:685-696.

Perspectives of autistic adolescent girls and women on the determinants of their mental health and social and emotional well-being: A systematic review and thematic synthesis of lived experience

LAY ABSTRACT

Difficulties with mental health and low levels of well-being are more common among autistic girls and women than non-autistic people, but we do not fully understand why. Research does not focus enough on what autistic girls and women could tell us about this. This review aims to summarise the studies where autistic girls and women explain things that affect their mental health and well-being to help us understand how to prevent these difficulties from developing. Three research databases were searched to find possibly relevant studies. There were 877 studies found, which two researchers screened according to particular criteria. They found 52 studies that could be included in this review. One researcher evaluated the quality of these studies and extracted the key information from them. This review summarises the views of 973 autistic girls and women aged between 13 and 70+. The findings from the 52 studies were analysed, and we found many factors that affect the mental health and well-being of autistic girls and women. These factors fall into two categories: (1) difficulties living in a world not designed for autistic people and (2) the impact of stigma due to being autistic.

Meaningful Social Inclusion and Mental Well-Being Among Autistic Adolescents and Emerging Adults: Protocol for a Community-Based Mixed Methods Study

BACKGROUND

In the United States, autistic people face high rates of co-occurring mental illnesses and premature death due to self-harm, which are indicators of threats to mental well-being. Social inclusion may enhance mental well-being and resilience among autistic people. According to Simplican and colleague's (2015) model of social inclusion for people with intellectual and developmental disabilities, social inclusion is an interaction between community participation and interpersonal relationships. There is limited research on social inclusion that includes the integration of interpersonal relationships and community participation among autistic people or the impact of social inclusion on the well-being of autistic people. Additionally, little evidence exists regarding how autistic people prefer to be included in the community or form interpersonal relationships.

OBJECTIVE

The long-term objective of this project is to improve social inclusion factors to support the mental well-being of autistic people. This protocol describes a community-based, mixed methods pilot study to develop a definition of meaningful social inclusion for autistic people and to understand the relationship between meaningful social inclusion and mental well-being among autistic adolescents and emerging adults.

METHODS

The project uses a community-based, sequential mixed methods design with a formative phase (Phase 1) that informs a survey phase (Phase 2) and concludes with a process evaluation of the community engagement process (Phase 3). During Phase 1, we will recruit 10 community partners (autistic adults and stakeholders) and conduct sharing sessions to cocreate a definition of meaningful social inclusion and a survey of meaningful social inclusion and well-being. During Phase 2, we will recruit 200 participants (100 autistic adolescents and emerging adults and 100 caregivers) to complete the survey. We will examine whether meaningful social inclusion predicts well-being given sociodemographic factors using ordered logistic regression, with well-being categorized as low, medium, and high. During Phase 3, the community partners from Phase 1 will complete a survey on their experiences with the project.

RESULTS

Ethics approval was obtained for this project in March 2023. We have recruited community partners and started the Phase 1 focus groups as of September 2023. Phase 2 and Phase 3 have not yet started. We expect to complete this study by March 2025.

CONCLUSIONS

Using a community-based, mixed methods approach, we intended to develop a definition of meaningful social inclusion for autistic people and understand the role meaningful social inclusion plays in the well-being of autistic people.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

PRR1-10.2196/52658.

Understanding the relationship between social camouflaging in autism and safety behaviours in social anxiety in autistic and non-autistic adolescents

BACKGROUND

Social camouflaging (hereafter camouflaging) in autism includes factors such as masking and compensating for one's neurodevelopmental differences, and to assimilate or 'fit in' with non-autistic peers. Efforts to hide one's authentic self and autism traits (masking) resemble impression management (IM) in safety behaviours identified in Clark and Wells' (1995) cognitive model of social anxiety (SA). This study explores the relationship between camouflaging in autism and safety behaviours in SA among autistic and non-autistic adolescents.

METHODS

One hundred fifteen adolescents (14-19 years) with (n = 61; 36 female) and without (n = 54; 37 female) a clinical diagnosis of autism matched on age and SA symptom severity were recruited from clinics, schools and online. Adolescents completed online measures including autism traits, SA symptoms, camouflaging behaviours, SA-related safety behaviours and SA-related negative cognitions. Partial and bivariate Pearson's correlations and structural equation modelling were used to understand the relationship between camouflaging, safety behaviours, autism traits and SA in both groups. Exploratory factor analysis assessed item-level factor cross-loadings between camouflaging and safety behaviours.

RESULTS

Across both groups, masking and IM were significantly associated with SA symptom severity, not autism traits, via SA-related social cognitions. Exploratory factor analysis indicated construct overlap across masking, assimilation, IM and avoidance behaviours and identified factors analogous to self-focused attention, social avoidance and mental rehearsal identified in the Clark and Wells' (1995) model of SA.

CONCLUSIONS

This is the first study using group-matched design to identify that masking (factor in social camouflaging) and IM both relate to SA in autistic and non-autistic adolescents. Assessment and formulation of construct overlap between masking and IM may inform psychoeducation and adaptation of SA treatment for autistic adolescents.

Does camouflaging predict age at autism diagnosis? A comparison of autistic men and women

It is frequently reported that females are likely to receive an autism diagnosis at a later age than their male counterparts, despite similar levels of autistic traits. It has been suggested that this delay in diagnosis may in part reflect the propensity of females, more than males, to engage in camouflaging behaviors that reduce the appearance of autism-related traits. This article presents two studies which examined the relationship between gender/sex, camouflaging, and age at diagnosis in two samples of (cis-gender) autistic adults. Study 1 included data from three online samples including 242 autistic men and 570 autistic women aged 18-75 years. Study 2 included data from a longitudinal population-based sample including 24 autistic men and 35 autistic women aged 20-24 years. Camouflaging was measured with the self-report Camouflaging Autistic Traits Questionnaire (CAT-Q). Overall, the results showed that, on average, females were diagnosed later than males. There was a stronger relationship between camouflaging and age at autism diagnosis (AaD) for females, compared with males. Within sample one, there was a significant camouflaging-by-sex interaction; high-camouflaging females had a later AaD. The role of autistic traits and changes in attitudes towards female autism and camouflaging need further exploration. These findings highlight the need for greater clinician and key stakeholder awareness and understanding of camouflaging behavior, particularly for females, during the diagnostic process.

Special considerations for assessing and caring for autism in girls and women

PURPOSE OF REVIEW

As the specificities of autistic women are increasingly recognized, this review aims to highlight emerging areas of research. These areas primarily focus on measurement bias of diagnostic tools, the physical and mental health of autistic women, and the unique aspects of the lives of autistic women, both personally and professionally across all life stages.

RECENT FINDINGS

Conventional diagnostic tools struggle to capture the specificities of autism in females, but more sensitive instruments like the GQ-ASC (Girls' Questionnaire for Autism Spectrum Conditions), later also referred to as Q-ASC (Questionnaire for Autism Spectrum Conditions) in the scientific literature, show better performances. Autistic women face particular challenges, including an increased risk of physical and mental health problems throughout their lives as women (puberty, motherhood, menopause). Autistic women also encounter specific difficulties in their employment that require greater consideration.

SUMMARY

The findings of this review identify research areas that need to be developed to better understand and support autistic girls and women and to enhance clinical practice for them.