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Cruz S, Zubizarreta SCP, Costa AD, Araújo R, Martinho J, Tubío-Fungueiriño M, Sampaio A, Cruz R, Carracedo A, Fernández-Prieto M. Is There a Bias Towards Males in the Diagnosis of Autism? A Systematic Review and Meta-Analysis. Neuropsychol Rev 2024:10.1007/s11065-023-09630-2. [PMID: 38285291 DOI: 10.1007/s11065-023-09630-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2023] [Accepted: 12/11/2023] [Indexed: 01/30/2024]
Abstract
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.
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Affiliation(s)
- Sara Cruz
- Psychology of Development Research Center, Lusiada University of Porto, Porto, Portugal.
- Department of Psychology, School of Philosophy, Psychology & Language Sciences, University of Edinburgh, Edinburgh, UK.
| | - Sabela Conde-Pumpido Zubizarreta
- Genomics and Bioinformatics Group, Center for Research in Molecular Medicine and Chronic Diseases (CiMUS), University of Santiago de Compostela (USC), Santiago de Compostela, Spain
| | - Ana Daniela Costa
- Psychological Neuroscience Laboratory (PNL), Research Center in Psychology (CIPsi), School of Psychology, University of Minho, Braga, Portugal
| | - Rita Araújo
- Psychological Neuroscience Laboratory (PNL), Research Center in Psychology (CIPsi), School of Psychology, University of Minho, Braga, Portugal
| | | | - María Tubío-Fungueiriño
- Genomics and Bioinformatics Group, Center for Research in Molecular Medicine and Chronic Diseases (CiMUS), University of Santiago de Compostela (USC), Santiago de Compostela, Spain
- Fundación Instituto de Investigación Sanitaria de Santiago de Compostela (FIDIS), Santiago de Compostela, Spain
- Genetics Group, GC05, Instituto de Investigación Sanitaria de Santiago (IDIS), Santiago de Compostela, Spain
- Grupo de Medicina Xenómica, U-711, Centro de Investigación en Red de Enfermedades Raras (CIBERER), University of Santiago de Compostela (USC), Santiago de Compostela, Spain
| | - Adriana Sampaio
- Psychological Neuroscience Laboratory (PNL), Research Center in Psychology (CIPsi), School of Psychology, University of Minho, Braga, Portugal
| | - Raquel Cruz
- Genomics and Bioinformatics Group, Center for Research in Molecular Medicine and Chronic Diseases (CiMUS), University of Santiago de Compostela (USC), Santiago de Compostela, Spain
- Grupo de Medicina Xenómica, U-711, Centro de Investigación en Red de Enfermedades Raras (CIBERER), University of Santiago de Compostela (USC), Santiago de Compostela, Spain
| | - Angel Carracedo
- Genomics and Bioinformatics Group, Center for Research in Molecular Medicine and Chronic Diseases (CiMUS), University of Santiago de Compostela (USC), Santiago de Compostela, Spain
- Genetics Group, GC05, Instituto de Investigación Sanitaria de Santiago (IDIS), Santiago de Compostela, Spain
- Grupo de Medicina Xenómica, U-711, Centro de Investigación en Red de Enfermedades Raras (CIBERER), University of Santiago de Compostela (USC), Santiago de Compostela, Spain
- Fundación Pública Galega de Medicina Xenómica, Servicio Galego de Saúde (SERGAS), Santiago de Compostela, Spain
| | - Montse Fernández-Prieto
- Genomics and Bioinformatics Group, Center for Research in Molecular Medicine and Chronic Diseases (CiMUS), University of Santiago de Compostela (USC), Santiago de Compostela, Spain
- Fundación Instituto de Investigación Sanitaria de Santiago de Compostela (FIDIS), Santiago de Compostela, Spain
- Genetics Group, GC05, Instituto de Investigación Sanitaria de Santiago (IDIS), Santiago de Compostela, Spain
- Grupo de Medicina Xenómica, U-711, Centro de Investigación en Red de Enfermedades Raras (CIBERER), University of Santiago de Compostela (USC), Santiago de Compostela, Spain
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Zhuang S, Tan DW, Reddrop S, Dean L, Maybery M, Magiati I. Psychosocial factors associated with camouflaging in autistic people and its relationship with mental health and well-being: A mixed methods systematic review. Clin Psychol Rev 2023; 105:102335. [PMID: 37741059 DOI: 10.1016/j.cpr.2023.102335] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2022] [Revised: 08/20/2023] [Accepted: 09/05/2023] [Indexed: 09/25/2023]
Abstract
Camouflaging involves hiding one's autistic characteristics in social situations. This mixed methods systematic review synthesized research on psychosocial factors associated with camouflaging and its relationship with mental well-being. Six databases were searched. The 58 included studies (40 qualitative, 13 quantitative, five mixed methods), encompassed 4808 autistic and 1780 non-autistic participants, and predominantly featured White, female, and late-diagnosed autistic adults with likely at least average intellectual and/or verbal abilities. Following a convergent integrated approach, quantitative data were transformed and synthesized with qualitative data for thematic synthesis. We identified three themes on psychosocial correlates of camouflaging: (1) social norms and pressures of a largely non-autistic world, (2) social acceptance and rejection, and (3) self-esteem and identity; and four themes on psychosocial consequences of camouflaging for well-being: (1) a pragmatic way of exerting individual agency and control; (2) overlooked, under-supported, and burnt out; (3) impact on social relationships; and (4) low self-esteem and identity confusion. Camouflaging emerges as primarily a socially motivated response linked to adverse psychosocial outcomes. A whole society approach towards acceptance and support for autistic individuals to express their authentic selves is needed. Future studies examining psychosocial influences on camouflaging should include participants who more broadly represent the autistic population.
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Affiliation(s)
- Sici Zhuang
- School of Psychological Science, The University of Western Australia, Australia.
| | - Diana Weiting Tan
- School of Psychological Science, The University of Western Australia, Australia; Macquarie School of Education, Macquarie University, Australia
| | | | - Lydia Dean
- Autistic Consultant, Western Australia, Australia
| | - Murray Maybery
- School of Psychological Science, The University of Western Australia, Australia
| | - Iliana Magiati
- School of Psychological Science, The University of Western Australia, Australia
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3
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Simcoe SM, Gilmour J, Garnett MS, Attwood T, Donovan C, Kelly AB. Are there gender-based variations in the presentation of Autism amongst female and male children? J Autism Dev Disord 2023; 53:3627-3635. [PMID: 35829944 PMCID: PMC10465371 DOI: 10.1007/s10803-022-05552-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/23/2022] [Indexed: 11/29/2022]
Abstract
The Questionnaire for Autism Spectrum Conditions (Q-ASC; Attwood, Garnett & Rynkiewicz, 2011) is one of the few screening instruments that includes items designed to assess female-specific ASD-Level 1 traits. This study examined the ability of a modified version of the Q-ASC (Q-ASC-M; Ormond et al., 2018) to differentiate children with and without ASD-Level 1. Participants included 111 parents of autistic children and 212 parents of neurotypical children (5-12 years). Results suggested that the gendered behaviour, sensory sensitivity, compliant behaviours, imagination, and imitation subscales differentiated autistic females from neurotypical females. Compared to autistic males, autistic females had higher scores on gendered behaviour, sensory sensitivity, social masking, and imitation. Results are discussed in relation to early detection of autistic female children.
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Affiliation(s)
- Sarah Mae Simcoe
- School of Applied Psychology, Griffith University, Mt Gravatt, Brisbane, Australia
| | - John Gilmour
- Institute of Social Science Research, University of Queensland, St Lucia, Brisbane, Australia
| | | | - Tony Attwood
- School of Applied Psychology, Griffith University, Mt Gravatt, Brisbane, Australia
- Attwood and Garnett Events, Brisbane, Australia
| | - Caroline Donovan
- School of Applied Psychology, Griffith University, Mt Gravatt, Brisbane, Australia
| | - Adrian B Kelly
- School of Psychology and Counselling, Queensland University of Technology, Kelvin Grove, Brisbane, Australia
- Centre for Child Health and Well-being, Mental Health and Resilience Theme, Queensland University of Technology, Kelvin Grove, Child Adversity, Brisbane, Australia
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Lundin Remnélius K, Bölte S. Camouflaging in Autism: Age Effects and Cross-Cultural Validation of the Camouflaging Autistic Traits Questionnaire (CAT-Q). J Autism Dev Disord 2023:10.1007/s10803-023-05909-8. [PMID: 36757540 DOI: 10.1007/s10803-023-05909-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/18/2023] [Indexed: 02/10/2023]
Abstract
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.
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Affiliation(s)
- Karl Lundin Remnélius
- Center of Neurodevelopmental Disorders (KIND), Centre for Psychiatry Research, Department of Women's and Children's Health, Karolinska Institutet & Stockholm Health Care Services, Region Stockholm, Gävlegatan 22B, 113 30, Stockholm, Sweden.
| | - Sven Bölte
- Center of Neurodevelopmental Disorders (KIND), Centre for Psychiatry Research, Department of Women's and Children's Health, Karolinska Institutet & Stockholm Health Care Services, Region Stockholm, Gävlegatan 22B, 113 30, Stockholm, Sweden.,Child and Adolescent Psychiatry, Stockholm Health Care Services, Region Stockholm, Stockholm, Sweden.,Curtin Autism Research Group, Curtin School of Allied Health, Curtin University, Perth, WA, Australia
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Dell'Osso L, Cremone IM, Chiarantini I, Arone A, Massimetti G, Carmassi C, Carpita B. Autistic traits and camouflaging behaviors: a cross-sectional investigation in a University student population. CNS Spectr 2022; 27:740-6. [PMID: 34505557 DOI: 10.1017/S1092852921000808] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
BACKGROUND Increasing research is stressing the importance of identifying autistic traits (ATs) in clinical and general populations. University students may be a group at higher risk for the presence of ATs. Recently, specific attention has been paid to camouflaging strategies used by subjects in the autism spectrum in order to cope with the social environment. The aim of this work was to evaluate the prevalence of ATs and camouflaging behaviors in a population of University students. METHODS Subjects were requested to anonymously fill out through an online form the Adult Autism Subthreshold Spectrum and the Camouflaging AT Questionnaire. RESULTS ATs were more represented among males and among students of specific fields of study. Camouflaging behaviors were significantly more frequent among subjects with more severe autism spectrum symptoms, without differences depending from sex. CONCLUSIONS Our study confirms the strong association between ATs and camouflaging behaviors and the relationship between ATs, sex, and specific fields of study.
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Dell'Osso L, Cremone IM, Muti D, Massimetti G, Lorenzi P, Carmassi C, Carpita B. Validation of the Italian version of the Camouflaging Autistic Traits Questionnaire (CAT-Q) in a University population. Compr Psychiatry 2022; 114:152295. [PMID: 35042086 DOI: 10.1016/j.comppsych.2022.152295] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/30/2021] [Revised: 12/13/2021] [Accepted: 12/30/2021] [Indexed: 01/14/2023] Open
Abstract
The Camouflaging Autistic Traits Questionnaire (CAT-Q) is an instrument recently developed and validated in English for measuring social camouflaging. While increasing research is focusing on camouflaging behaviours often used for masking autistic traits in social contexts, the CAT-Q remains the only self-report instrument in this field. We aimed to validate the Italian version of the CAT-Q, further testing its validity and reliability in a large Italian University population (N = 2439). We employed the Adult Autism Subthreshold Spectrum (AdAS Spectrum) for assessing autism spectrum conditions. The CAT-Q demonstrated excellent internal consistency and test-retest reliability, as well as strong correlations with the AdAS Spectrum. Our results confirm that the CAT-Q is a valuable instrument for evaluating social camouflaging.
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Affiliation(s)
- Liliana Dell'Osso
- Department of clinical and experimental medicine, University of Pisa, Italy
| | - Ivan Mirko Cremone
- Department of clinical and experimental medicine, University of Pisa, Italy
| | - Dario Muti
- Department of clinical and experimental medicine, University of Pisa, Italy
| | | | - Primo Lorenzi
- Department of clinical and experimental medicine, University of Pisa, Italy
| | - Claudia Carmassi
- Department of clinical and experimental medicine, University of Pisa, Italy
| | - Barbara Carpita
- Department of clinical and experimental medicine, University of Pisa, Italy.
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Abstract
Some autistic people employ strategies and behaviours to cope with the everyday social world, thereby 'camouflaging' their autistic differences and difficulties. This review aimed to systematically appraise and synthesise the current evidence base pertaining to autistic camouflaging. Following a systematic search of eight databases, 29 studies quantifying camouflaging in children and adults with autism diagnoses or high levels of autistic traits were reviewed. The multiple methods used to measure camouflaging broadly fell under two different approaches: internal-external discrepancy or self-report. These approaches appear to relate to two distinct but potentially connected elements of camouflaging: observable behavioural presentations and self-perceived camouflaging efforts. While significant variation was noted across individual study findings, much of the existing literature supported three preliminary findings about the nature of autistic camouflaging: (1) adults with more self-reported autistic traits report greater engagement in camouflaging; (2) sex and gender differences exist in camouflaging; and (3) higher self-reported camouflaging is associated with worse mental health outcomes. However, the research base was limited regarding participant characterisation and representativeness, which suggests that conclusions cannot be applied to the autistic community as a whole. We propose priorities for future research in refining the current understanding of camouflaging and improving measurement methods.
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Affiliation(s)
- Julia Cook
- Research Department of Clinical, Educational, & Health Psychology, University College London, UK.
| | - Laura Hull
- Research Department of Clinical, Educational, & Health Psychology, University College London, UK
| | - Laura Crane
- Centre for Research in Autism and Education (CRAE), UCL Institute of Education, University College London, UK
| | - William Mandy
- Research Department of Clinical, Educational, & Health Psychology, University College London, UK
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Belcher HL, Morein-Zamir S, Mandy W, Ford RM. Camouflaging Intent, First Impressions, and Age of ASC Diagnosis in Autistic Men and Women. J Autism Dev Disord 2021; 52:3413-3426. [PMID: 34342806 PMCID: PMC9296412 DOI: 10.1007/s10803-021-05221-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/26/2021] [Indexed: 12/26/2022]
Abstract
Camouflaging of autistic traits may make autism harder to diagnose. The current study evaluated the relations between camouflaging intent, first impressions, and age of autism diagnosis. Participants comprised autistic and non-autistic adults (n = 80, 50% female) who completed the Camouflaging of Autistic Traits Questionnaire. They were later video-recorded having a conversation with a person unaware of their diagnostic status. Ten-second clips from half these videos were later shown to 127 non-autistic peers, who rated their first impressions of each participant. Results showed that autistic participants were rated more poorly on first impressions, males were rated less favourably than females, and male raters were particularly harsh in their evaluations of autistic males. Camouflaging intent did not predict first impressions but better first impressions were linked with a later age of diagnosis.
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Affiliation(s)
- Hannah L Belcher
- School of Psychology and Sport Science, Anglia Ruskin University, East Road, Cambridge, CB1 1PT, UK. .,IOPPN, King's College London, 16 Crespigny Park, Camberwell, London, SE5 8AB, UK.
| | - Sharon Morein-Zamir
- School of Psychology and Sport Science, Anglia Ruskin University, East Road, Cambridge, CB1 1PT, UK
| | - Will Mandy
- University College London, 1-19 Torrington Place, Bloomsbury, London, WC1E 7HB, UK
| | - Ruth M Ford
- School of Psychology and Sport Science, Anglia Ruskin University, East Road, Cambridge, CB1 1PT, UK
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Abstract
This study investigated sex/gender differences in camouflaging with children and adolescents (N = 84) with and without an autism diagnosis/increased levels of autistic traits using two conceptualisations/operationalisations of camouflaging. A significant group-by-gender interaction using ANCOVA, with the covariate of verbal IQ, reflected similar levels of social reciprocity in autistic and neurotypical females, whereas autistic males had lower reciprocity than neurotypical males. Autistic females also had higher reciprocity than autistic males, despite similar levels of autistic traits (behavioural camouflaging). Additionally, autistic males and females had similar theory of mind skills, despite females having increased reciprocity (compensatory camouflaging). These findings provide evidence of increased camouflaging in autistic females, which may contribute to delay in the recognition of difficulties and provision of support.
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Affiliation(s)
- Henry Wood-Downie
- Centre for Innovation in Mental Health - Developmental Lab, School of Psychology, University of Southampton, Highfield, Southampton, S017 1BJ, UK. .,Centre for Research in Inclusion, Southampton Education School, University of Southampton, Building 32, Southampton, SO17 1BJ, UK. .,West Sussex Educational Psychology Service, West Sussex County Council, 3rd Floor County Hall North, Chart Way, Horsham, RH12 1XH, UK.
| | - Bonnie Wong
- Centre for Innovation in Mental Health - Developmental Lab, School of Psychology, University of Southampton, Highfield, Southampton, S017 1BJ, UK.,East Sussex Educational Psychology Service, East Sussex County Council, Ocean House, 87-89 London Road, St Leonards-On-Sea, TN37 6DH, UK
| | - Hanna Kovshoff
- Centre for Innovation in Mental Health - Developmental Lab, School of Psychology, University of Southampton, Highfield, Southampton, S017 1BJ, UK
| | - William Mandy
- Research Department of Clinical, Educational & Health Psychology, University College London, London, UK
| | - Laura Hull
- Research Department of Clinical, Educational & Health Psychology, University College London, London, UK
| | - Julie A Hadwin
- Centre for Innovation in Mental Health - Developmental Lab, School of Psychology, University of Southampton, Highfield, Southampton, S017 1BJ, UK.,School of Education, Eden Building, Liverpool Hope University, Liverpool, L16 9JD, UK
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Perry E, Mandy W, Hull L, Cage E. Understanding Camouflaging as a Response to Autism-Related Stigma: A Social Identity Theory Approach. J Autism Dev Disord 2021. [PMID: 33788076 DOI: 10.1007/s10803-021-04987-w] [Citation(s) in RCA: 61] [Impact Index Per Article: 20.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/22/2021] [Indexed: 11/17/2022]
Abstract
Camouflaging refers to strategies used by autistic people to mask or hide social difficulties. The current study draws on Social Identity Theory to examine the relationship between camouflaging and autism-related stigma, testing the hypothesis that camouflaging represents an individualistic strategy in response to stigma. Two hundred and twenty-three autistic adults completed an online survey measuring perceived autism-related stigma, individualistic and collective strategies, camouflaging and mental wellbeing. Results indicated that higher camouflaging was positively associated with autism-related stigma and both individualistic and collective strategy use. Autism-related stigma was associated with lower wellbeing however this relationship was not mediated by camouflaging. These findings demonstrate how stigma contributes to camouflaging and highlight the complexities of navigating autistic identity while still camouflaging.
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Jedrzejewska A, Dewey J. Camouflaging in Autistic and Non-autistic Adolescents in the Modern Context of Social Media. J Autism Dev Disord 2021. [PMID: 33748903 DOI: 10.1007/s10803-021-04953-6] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/25/2021] [Indexed: 10/21/2022]
Abstract
Camouflaging is described as a set of strategies used to prevent others from noticing one's social difficulties. Research indicates heightened levels of camouflaging behaviours in the adult autistic population. To extend understanding of camouflaging in adolescents, this mixed-methods study explored camouflaging behaviours in offline and online contexts with 40 autistic and 158 non-autistic adolescents. At the quantitative phase, participants completed measures of camouflaging behaviours (online vs offline) and measures of social media use. Following this, six autistic adolescents participated in semi-structured interviews. Findings indicate that in the offline context, autistic adolescents camouflage more than non-autistic adolescents. Online, autistic participants camouflage less than they do offline, and females camouflage more than males. Implications for research and theory are discussed.
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Bernardin CJ, Mason E, Lewis T, Kanne S. "You Must Become a Chameleon to Survive": Adolescent Experiences of Camouflaging. J Autism Dev Disord 2021; 51:4422-35. [PMID: 33590426 DOI: 10.1007/s10803-021-04912-1] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/01/2021] [Indexed: 01/14/2023]
Abstract
Camouflaging includes strategies used by individuals to mask or hide autistic traits. Research has shown that both autistic and neurotypical individuals engage in camouflaging and that there may be sex differences in the reasons for camouflaging in autistic adults. The purpose of this qualitative study was to extend previous research on the lived experience of camouflaging through exploring camouflaging motivations and consequences in autistic and neurotypical adolescents through both questionnaires (n = 132) and semi-structured interviews (n = 19). Results revealed trends in camouflaging motivations and consequences by diagnosis and sex, as well as by sex within the autistic group. These findings further inform our understanding of camouflaging and why it may be reported as particularly detrimental for autistic females.
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Hull L, Levy L, Lai MC, Petrides KV, Baron-Cohen S, Allison C, Smith P, Mandy W. Is social camouflaging associated with anxiety and depression in autistic adults? Mol Autism 2021; 12:13. [PMID: 33593423 PMCID: PMC7885456 DOI: 10.1186/s13229-021-00421-1] [Citation(s) in RCA: 67] [Impact Index Per Article: 22.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2020] [Accepted: 02/03/2021] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND There is inconsistent evidence for a clear pattern of association between 'camouflaging' (strategies used to mask and/or compensate for autism characteristics during social interactions) and mental health. METHODS This study explored the relationship between self-reported camouflaging and generalised anxiety, depression, and social anxiety in a large sample of autistic adults and, for the first time, explored the moderating effect of gender, in an online survey. RESULTS Overall, camouflaging was associated with greater symptoms of generalised anxiety, depression, and social anxiety, although only to a small extent beyond the contribution of autistic traits and age. Camouflaging more strongly predicted generalised and social anxiety than depression. No interaction between camouflaging and gender was found. LIMITATIONS These results cannot be generalised to autistic people with intellectual disability, or autistic children and young people. The sample did not include sufficient numbers of non-binary people to run separate analyses; therefore, it is possible that camouflaging impacts mental health differently in this population. CONCLUSIONS The findings suggest that camouflaging is a risk factor for mental health problems in autistic adults without intellectual disability, regardless of gender. We also identified levels of camouflaging at which risk of mental health problems is highest, suggesting clinicians should be particularly aware of mental health problems in those who score at or above these levels.
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Affiliation(s)
- Laura Hull
- Research Department of Clinical, Educational and Health Psychology, University College London, 1-19 Torrington Place, London, WC1E 7HB UK
| | - Lily Levy
- Research Department of Clinical, Educational and Health Psychology, University College London, 1-19 Torrington Place, London, WC1E 7HB UK
- Present Address: Homerton University Hospital NHS Foundation Trust, London, UK
| | - Meng-Chuan Lai
- Centre for Addiction and Mental Health and The Hospital for Sick Children, Department of Psychiatry, University of Toronto, Toronto, Canada
- Autism Research Centre, Department of Psychiatry, University of Cambridge, Cambridge, UK
- Department of Psychiatry, National Taiwan University Hospital and College of Medicine, Taipei, Taiwan
| | - K. V. Petrides
- London Psychometrics Laboratory, University College London, London, UK
| | - Simon Baron-Cohen
- Autism Research Centre, Department of Psychiatry, University of Cambridge, Cambridge, UK
| | - Carrie Allison
- Autism Research Centre, Department of Psychiatry, University of Cambridge, Cambridge, UK
| | - Paula Smith
- Autism Research Centre, Department of Psychiatry, University of Cambridge, Cambridge, UK
| | - Will Mandy
- Research Department of Clinical, Educational and Health Psychology, University College London, 1-19 Torrington Place, London, WC1E 7HB UK
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14
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Jorgenson C, Lewis T, Rose C, Kanne S. Social Camouflaging in Autistic and Neurotypical Adolescents: A Pilot Study of Differences by Sex and Diagnosis. J Autism Dev Disord 2021; 50:4344-4355. [PMID: 32270386 DOI: 10.1007/s10803-020-04491-7] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
Camouflaging is a process through which individuals mask autistic traits. Studies suggest autistic females may camouflage more than autistic males. However, research has focused on adults and includes few comparisons between autistic and neurotypical individuals. This study compared levels of camouflaging by sex and diagnosis in autistic and neurotypical adolescents. Females reported higher overall levels of camouflaging when not accounting for age. When accounting for age, an age by diagnosis interaction effect emerged. This possible effect of age on camouflaging has implications for understanding how camouflaging behaviors develop and warrants further exploration. Differences also emerged on behaviors labeled as masking and assimilation, subcomponents of camouflaging, with females appearing more similar to their neurotypical peers on behaviors related to social awareness.
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Affiliation(s)
- Courtney Jorgenson
- Department of Psychological Sciences, University of Missouri, 103 McAlester Hall, Columbia, MO, 65202, USA.
| | - Timothy Lewis
- Department of Special Education, University of Missouri, Columbia, USA
| | - Chad Rose
- Department of Special Education, University of Missouri, Columbia, USA
| | - Stephen Kanne
- Department of Health Psychology and Thompson Center for Autism and Neurodevelopmental Disorders, University of Missouri, Columbia, USA
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Chew L, Sun KL, Sun W, Wang Z, Rajadas J, Flores RE, Arnold E, Jo B, Fung LK. Association of serum allopregnanolone with restricted and repetitive behaviors in adult males with autism. Psychoneuroendocrinology 2021; 123:105039. [PMID: 33161257 PMCID: PMC8428554 DOI: 10.1016/j.psyneuen.2020.105039] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/06/2020] [Revised: 10/02/2020] [Accepted: 10/26/2020] [Indexed: 12/21/2022]
Abstract
Autism spectrum disorder (ASD) has been associated with imbalance between excitatory and inhibitory (E/I) neurotransmission systems, as well as with neuroinflammation. Sitting at the crossroads between E/I imbalance and neuroinflammation is a class of endogenous hormones known as neurosteroids. Current literature points to dysregulated steroid metabolism and atypical neurosteroid levels in ASD as early as in utero. However, due to the complexity of neurosteroid metabolomics, including possible sex differences, the impact of neurosteroids on ASD symptomatology remains unclear. In this study, we assessed neurosteroid levels and ASD symptom severity of 21 males with ASD and 20 full-scale-IQ-matched typically developing (TD) males, all aged 18-39. Using liquid chromatography-tandem mass spectrometry, concentrations of allopregnanolone, cortisol, dehydroepiandrosterone, progesterone, and testosterone were measured in saliva and serum. With the exception of cortisol's, all neurosteroids' concentrations were found to have ASD vs. TD group differences in distribution, where one group was normally distributed and the other non-normally distributed. Serum allopregnanolone levels in males with ASD were found to negatively correlate with clinician-rated measures of restricted and repetitive behavior measures (ADOS-2 RRB and ADI-R RRSB domain scores). Additionally, lower serum allopregnanolone levels were found to predict more negative camouflaging scores, which represent greater differences in self- and clinician-rated symptom severity, of both ASD symptomatology overall and repetitive behaviors in particular. Taken together, our findings demonstrate that in adult males with ASD, decreased serum allopregnanolone levels are associated with more severe restricted and repetitive behaviors and with less insight into the severity of these behaviors.
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Affiliation(s)
- Leila Chew
- Department of Psychiatry & Behavioral Sciences, Stanford University, California, USA; David Geffen School of Medicine, University of California at Los Angeles, California, USA
| | - Kevin L Sun
- Department of Psychiatry & Behavioral Sciences, Stanford University, California, USA
| | - Wenchao Sun
- Biomaterial and Advanced Drug Delivery Lab, Stanford University, California, USA
| | - Zhe Wang
- Biomaterial and Advanced Drug Delivery Lab, Stanford University, California, USA
| | - Jayakumar Rajadas
- Biomaterial and Advanced Drug Delivery Lab, Stanford University, California, USA
| | - Ryan E Flores
- Department of Psychiatry & Behavioral Sciences, Stanford University, California, USA; Keck School of Medicine, University of Southern California, Los Angeles, California, USA
| | - Emily Arnold
- Department of Psychiatry & Behavioral Sciences, Stanford University, California, USA
| | - Booil Jo
- Department of Psychiatry & Behavioral Sciences, Stanford University, California, USA
| | - Lawrence K Fung
- Department of Psychiatry & Behavioral Sciences, Stanford University, California, USA.
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16
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Cassidy SA, Gould K, Townsend E, Pelton M, Robertson AE, Rodgers J. Is Camouflaging Autistic Traits Associated with Suicidal Thoughts and Behaviours? Expanding the Interpersonal Psychological Theory of Suicide in an Undergraduate Student Sample. J Autism Dev Disord 2020; 50:3638-3648. [PMID: 31820344 PMCID: PMC7502035 DOI: 10.1007/s10803-019-04323-3] [Citation(s) in RCA: 76] [Impact Index Per Article: 19.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
The current study explored whether people who camouflage autistic traits are more likely to experience thwarted belongingness and suicidality, as predicted by the Interpersonal Psychological Theory of Suicide (IPTS). 160 undergraduate students (86.9% female, 18–23 years) completed a cross-sectional online survey from 8th February to 30th May 2019 including self-report measures of thwarted belongingness and perceived burdensomeness, autistic traits, depression, anxiety, camouflaging autistic traits, and lifetime suicidality. Results suggest that camouflaging autistic traits is associated with increased risk of experiencing thwarted belongingness and lifetime suicidality. It is important for suicide theories such as the IPTS to include variables relevant to the broader autism phenotype, to increase applicability of models to both autistic and non-autistic people.
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Affiliation(s)
- S A Cassidy
- School of Psychology, University of Nottingham, Nottingham, NG7 2RD, UK. .,Institute of Neuroscience, Newcastle University, Newcastle upon Tyne, UK.
| | - K Gould
- School of Psychology, University of Nottingham, Nottingham, NG7 2RD, UK
| | - E Townsend
- School of Psychology, University of Nottingham, Nottingham, NG7 2RD, UK
| | - M Pelton
- School of Psychological, Social and Behavioural Sciences, Coventry University, Coventry, UK.,Centre for Innovative Research Across the Lifespan, Coventry University, Coventry, UK
| | - A E Robertson
- School of Psychological, Social and Behavioural Sciences, Coventry University, Coventry, UK.,Centre for Innovative Research Across the Lifespan, Coventry University, Coventry, UK
| | - J Rodgers
- Institute of Neuroscience, Newcastle University, Newcastle upon Tyne, UK
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Livingston LA, Shah P, Milner V, Happé F. Quantifying compensatory strategies in adults with and without diagnosed autism. Mol Autism 2020; 11:15. [PMID: 32051011 PMCID: PMC7014718 DOI: 10.1186/s13229-019-0308-y] [Citation(s) in RCA: 49] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2019] [Accepted: 12/18/2019] [Indexed: 11/20/2022] Open
Abstract
Background There is growing recognition that some autistic people engage in ‘compensation’, showing few behavioural symptoms (e.g. neurotypical social skills), despite continuing to experience autism-related cognitive difficulties (e.g. difficulties in social cognition). One way this might be achieved is by individuals consciously employing ‘compensatory strategies’ during everyday social interaction. However, very little is currently known about the broad range of these strategies, their mechanisms and consequences for clinical presentation and diagnosis. Methods We aimed to measure compensatory strategies in autism for the first time. Using a novel checklist, we quantified self-reported social compensatory strategies in 117 adults (58 with autism, 59 without autism) and explored the relationships between compensation scores and autism diagnostic status, autistic traits, education level, sex and age at diagnosis. Results Higher compensation scores—representing a greater repertoire of compensatory strategies—were associated with having an autism diagnosis, more autistic traits and a higher education level. The link between autism diagnostic status and compensation scores was, however, explained by autistic traits and education level. Compensation scores were unrelated to sex or age at diagnosis. Limitations Our sample was self-selected and predominantly comprised of intellectually able females; therefore, our findings may not generalise to the wider autistic population. Conclusions Together, our findings suggest that many intellectually able adults, with and without a clinical diagnosis of autism, report using compensatory strategies to modify their social behaviour. We discuss the clinical utility of measuring self-reported compensation (e.g., using our checklist), with important implications for the accurate diagnosis and management of autism and related conditions.
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Affiliation(s)
- Lucy Anne Livingston
- Social, Genetic and Developmental Psychiatry Centre, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK. .,School of Psychology, Cardiff University, Cardiff, UK.
| | - Punit Shah
- Department of Psychology, University of Bath, Bath, UK
| | - Victoria Milner
- Social, Genetic and Developmental Psychiatry Centre, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
| | - Francesca Happé
- Social, Genetic and Developmental Psychiatry Centre, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
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18
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Schuck RK, Flores RE, Fung LK. Brief Report: Sex/Gender Differences in Symptomology and Camouflaging in Adults with Autism Spectrum Disorder. J Autism Dev Disord 2019; 49:2597-604. [PMID: 30945091 DOI: 10.1007/s10803-019-03998-y] [Citation(s) in RCA: 44] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Autism spectrum disorder (ASD) is more prevalent in males than females. Previous research indicates females camouflage ASD symptoms more than males, potentially contributing to the difference in prevalence. This study investigated sex/gender differences in behavioral phenotypes in 17 males and 11 females with ASD, as well camouflaging in ASD, in an attempt to partially replicate findings from Lai et al. (Autism 21(6):690-702, 2017). Overall ASD symptoms were measured by the autism spectrum quotient (AQ). Mean AQ in females with ASD was higher than males with ASD, with the difference approaching statistical significance. Camouflaging was found to be more common in females with ASD, and not associated to social phobia. Furthermore, camouflaging correlated negatively with emotional expressivity in females, but not males, with ASD. These findings strengthen previous findings regarding camouflaging being more common in females and add to the literature on how camouflaging may be different in females versus males.
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Abstract
Camouflaging entails 'masking' in or 'passing' social situations. Research suggests camouflaging behaviours are common in autistic people, and may negatively impact mental health. To enhance understanding of camouflaging, this study examined reasons, contexts and costs of camouflaging. 262 autistic people completed measures of camouflaging behaviours, camouflaging contexts (e.g. work vs. family), camouflaging reasons (e.g. to make friends) and mental health symptoms. Findings indicated a gender difference in reasons for camouflaging, with autistic women more likely to endorse "conventional" reasons (e.g. getting by in formal settings such as work). Both camouflaging highly across contexts and 'switching' between camouflaging in some contexts but not in others, related to poorer mental health. These findings have implications for understanding camouflaging in autistic adults.
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Affiliation(s)
- Eilidh Cage
- Department of Psychology, Royal Holloway, University of London, Egham Hill, Egham, TW20 0EX, Surrey, UK.
| | - Zoe Troxell-Whitman
- Department of Psychology, Royal Holloway, University of London, Egham Hill, Egham, TW20 0EX, Surrey, UK
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20
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Abstract
There currently exist no self-report measures of social camouflaging behaviours (strategies used to compensate for or mask autistic characteristics during social interactions). The Camouflaging Autistic Traits Questionnaire (CAT-Q) was developed from autistic adults' experiences of camouflaging, and was administered online to 354 autistic and 478 non-autistic adults. Exploratory factor analysis suggested three factors, comprising of 25 items in total. Good model fit was demonstrated through confirmatory factor analysis, with measurement invariance analyses demonstrating equivalent factor structures across gender and diagnostic group. Internal consistency (α = 0.94) and preliminary test-retest reliability (r = 0.77) were acceptable. Convergent validity was demonstrated through comparison with measures of autistic traits, wellbeing, anxiety, and depression. The present study provides robust psychometric support for the CAT-Q.
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Affiliation(s)
- Laura Hull
- Research Department of Clinical, Educational & Health Psychology, University College London, London, UK.
- Department of Psychology, University College London, 26 Bedford Way, London, WC1H 0AP, UK.
| | - William Mandy
- Research Department of Clinical, Educational & Health Psychology, University College London, London, UK
| | - Meng-Chuan Lai
- Child and Youth Mental Health Collaborative, Centre for Addiction and Mental Health and The Hospital for Sick Children, Department of Psychiatry, University of Toronto, Toronto, ON, Canada
- Autism Research Centre, Department of Psychiatry, University of Cambridge, Cambridge, UK
- Department of Psychiatry, National Taiwan University Hospital and College of Medicine, Taipei, Taiwan
| | - Simon Baron-Cohen
- Autism Research Centre, Department of Psychiatry, University of Cambridge, Cambridge, UK
| | - Carrie Allison
- Autism Research Centre, Department of Psychiatry, University of Cambridge, Cambridge, UK
| | - Paula Smith
- Autism Research Centre, Department of Psychiatry, University of Cambridge, Cambridge, UK
| | - K V Petrides
- London Psychometric Laboratory, University College London, London, UK
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Abstract
Camouflaging of autistic characteristics in social situations is hypothesised as a common social coping strategy for adults with autism spectrum conditions (ASC). Camouflaging may impact diagnosis, quality of life, and long-term outcomes, but little is known about it. This qualitative study examined camouflaging experiences in 92 adults with ASC, with questions focusing on the nature, motivations, and consequences of camouflaging. Thematic analysis was used to identify key elements of camouflaging, which informed development of a three-stage model of the camouflaging process. First, motivations for camouflaging included fitting in and increasing connections with others. Second, camouflaging itself comprised a combination of masking and compensation techniques. Third, short- and long-term consequences of camouflaging included exhaustion, challenging stereotypes, and threats to self-perception.
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Affiliation(s)
- Laura Hull
- Research Department of Clinical, Educational & Health Psychology, University College London, London, UK.
- Department of Psychology, University College London, 26 Bedford Way, London, WC1H 0AP, UK.
| | - K V Petrides
- London Psychometric Laboratory, University College London, London, UK
| | - Carrie Allison
- Autism Research Centre, Department of Psychiatry, University of Cambridge, Cambridge, UK
| | - Paula Smith
- Autism Research Centre, Department of Psychiatry, University of Cambridge, Cambridge, UK
| | - Simon Baron-Cohen
- Autism Research Centre, Department of Psychiatry, University of Cambridge, Cambridge, UK
| | - Meng-Chuan Lai
- Autism Research Centre, Department of Psychiatry, University of Cambridge, Cambridge, UK
- Child and Youth Mental Health Collaborative at the Centre for Addiction and Mental Health and The Hospital for Sick Children, Department of Psychiatry, University of Toronto, Toronto, ON, Canada
- Department of Psychiatry, National Taiwan University Hospital and College of Medicine, Taipei, Taiwan
| | - William Mandy
- Research Department of Clinical, Educational & Health Psychology, University College London, London, UK
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Abstract
Mental health difficulties are highly prevalent in individuals on the autism spectrum. The current study examined how experiences and perceptions of autism acceptance could impact on the mental health of autistic adults. 111 adults on the autism spectrum completed an online survey examining their experiences of autism acceptance, along with symptoms of depression, anxiety and stress. Regression analyses showed that autism acceptance from external sources and personal acceptance significantly predicted depression. Acceptance from others also significantly predicted stress but acceptance did not predict anxiety. Further analyses suggested that experiences of "camouflaging" could relate to higher rates of depression. The current study highlights the importance of considering how autism acceptance could contribute to mental health in autism.
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Affiliation(s)
- Eilidh Cage
- Department of Psychology, Royal Holloway, University of London, Egham Hill, Egham, Surrey, TW20 0EX, UK.
| | - Jessica Di Monaco
- Department of Psychology, Royal Holloway, University of London, Egham Hill, Egham, Surrey, TW20 0EX, UK
| | - Victoria Newell
- Department of Psychology, Royal Holloway, University of London, Egham Hill, Egham, Surrey, TW20 0EX, UK
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Abstract
Mental health difficulties are highly prevalent in individuals on the autism spectrum. The current study examined how experiences and perceptions of autism acceptance could impact on the mental health of autistic adults. 111 adults on the autism spectrum completed an online survey examining their experiences of autism acceptance, along with symptoms of depression, anxiety and stress. Regression analyses showed that autism acceptance from external sources and personal acceptance significantly predicted depression. Acceptance from others also significantly predicted stress but acceptance did not predict anxiety. Further analyses suggested that experiences of "camouflaging" could relate to higher rates of depression. The current study highlights the importance of considering how autism acceptance could contribute to mental health in autism.
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Affiliation(s)
- Eilidh Cage
- Department of Psychology, Royal Holloway, University of London, Egham Hill, Egham, Surrey, TW20 0EX, UK.
| | - Jessica Di Monaco
- Department of Psychology, Royal Holloway, University of London, Egham Hill, Egham, Surrey, TW20 0EX, UK
| | - Victoria Newell
- Department of Psychology, Royal Holloway, University of London, Egham Hill, Egham, Surrey, TW20 0EX, UK
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Livingston LA, Happé F. Conceptualising compensation in neurodevelopmental disorders: Reflections from autism spectrum disorder. Neurosci Biobehav Rev 2017; 80:729-742. [PMID: 28642070 PMCID: PMC7374933 DOI: 10.1016/j.neubiorev.2017.06.005] [Citation(s) in RCA: 189] [Impact Index Per Article: 27.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2017] [Revised: 05/25/2017] [Accepted: 06/13/2017] [Indexed: 11/24/2022]
Abstract
Within research into neurodevelopmental disorders, little is known about the mechanisms underpinning changes in symptom severity across development. When the behavioural presentation of a condition improves/symptoms lessen, this may be because core underlying atypicalities in cognition/neural function have ameliorated. An alternative possibility is 'compensation'; that the behavioural presentation appears improved, despite persisting deficits at cognitive and/or neurobiological levels. There is, however, currently no agreed technical definition of compensation or its behavioural, cognitive and neural characteristics. Furthermore, its workings in neurodevelopmental disorders have not been studied directly. Here, we review current evidence for compensation in neurodevelopmental disorders, using Autism Spectrum Disorder as an example, in order to move towards a better conceptualisation of the construct. We propose a transdiagnostic framework, where compensation represents the processes responsible for an observed mismatch between behaviour and underlying cognition in a neurodevelopmental disorder, at any point in development. Further, we explore potential cognitive and neural mechanisms driving compensation and discuss the broader relevance of the concept within research and clinical settings.
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Affiliation(s)
- Lucy Anne Livingston
- MRC Social, Genetic and Developmental Psychiatry Centre, Institute of Psychiatry, Psychology and Neuroscience, King's College London, De Crespigny Park, London, SE5 8AF, UK.
| | - Francesca Happé
- MRC Social, Genetic and Developmental Psychiatry Centre, Institute of Psychiatry, Psychology and Neuroscience, King's College London, De Crespigny Park, London, SE5 8AF, UK.
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