Commentary: 'Camouflaging' in autistic people - reflection on Fombonne (2020).

Fombonne's (2020) editorial is a thought-provoking appraisal of the literature on 'camouflaging', whereby some autistic people mask or compensate for their autistic characteristics as an attempt to fit in and to cope with disabilities under neurotypical social norms. Fombonne (2020) highlights three issues of contention: (a) construct validity and measurement of camouflaging; (b) camouflaging as a reason for late autism diagnosis in adolescence/adulthood; and (c) camouflaging as a feature of the 'female autism phenotype'. Here, we argue that (a) establishing construct validity and measurement of different aspects of camouflaging is warranted; (b) subjective experiences are important for the differential diagnosis of autism in adolescence/adulthood; and (c) camouflaging is not necessarily a feature of autism in female individuals - nevertheless, taking into account sex and gender influences in development is crucial to understand behavioural manifestations of autism. Future research and clinical directions should involve clarification of associated constructs and measurements, demography, mechanisms, impact (including harms and benefits) and tailored support.

Mental health literacy of ADHD, autism, schizophrenia, and bipolar disorder: a cross-cultural investigation.

BACKGROUND: Mental health literacy (MHL) is linked to help-seeking behaviours. Although lay people are not always well aware of mental health conditions, few international campaigns and interventions have been developed to raise awareness across cultures. AIMS: To investigate MHL cross-culturally and to identify factors that are associated with MHL. METHOD: Using an online survey, 506 participants (103 Greek, 108 UK, 146 USA, 149 other nationality) read and labelled five vignettes of individuals with Autism, ADHD, Schizophrenia, Bipolar disorder and a healthy control. Factors influencing response, confidence and accuracy were compared across all participants, and the effect of various demographics on accurate labelling was compared between countries. RESULTS: Recognition rates were higher than in previous investigations: 75.5% of participants recognised the Healthy vignette, 71.1% ADHD, 61.7% Autism, 56.6% Schizophrenia and 31.6% Bipolar. MHL varied across different countries, with religion, language spoken, and education having the greatest effects. Personal experience of mental illness partially affected MHL. CONCLUSIONS: MHL is relatively high for some mental health conditions, but public knowledge of other conditions is still poor. Factors influencing MHL vary across countries.

Improving Diagnostic Procedures in Autism for Girls and Women: A Narrative Review.

Biases exist in the diagnostic process for autism spectrum disorder (henceforth "autism"), which result in some girls and women being diagnosed later or missed entirely. Current diagnostic tools may not capture the full range of behavioural presentations of autism, leading to under-identification. This review explores why these biases may occur, and how diagnostic procedures could be adapted to better identify autistic girls and women. We recommend that diagnostic assessments are adjusted to capture a broader range of behavioural exemplars of autism; that camouflaging of autistic traits is taken into account; and that care is taken to ensure co-occurring mental health conditions do not overshadow autism diagnosis. We offer recommendations, building on gold-standard diagnostic guidelines, for how diagnostic procedures can be improved for girls and women.

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.

The association between social camouflage and mental health among autistic people in Japan and the UK: a cross-cultural study.

BACKGROUND: To examine the relationship between social camouflage and mental health in Japanese autistic adults and make an international comparison with a sample from the UK. METHODS: This study analysed secondary data of participants with a self-reported diagnosis of autism from Japan (N = 210; 123 men and 87 women) and the UK (N = 305; 181 women, 104, men, and 18 nonbinary). The relationships between the quadratic term of the Camouflaging Autistic Traits Questionnaire and mental health scales, including depression and anxiety, were assessed. RESULTS: The UK sample showed linear relationships, whereas the Japanese sample showed significant nonlinear relationships. The quadratic terms of the Camouflaging Autistic Traits Questionnaire slightly explained generalised anxiety (ß = .168, p = .007), depression (ß = .121, p = .045), and well-being (ß = - .127, p = .028). However, they did not explain the association between social anxiety and the Camouflaging Autistic Traits Questionnaire. LIMITATIONS: Participants had self-reported diagnoses, and while the autism-spectrum quotient provides a cut-off value for screening, it does not enable confirming diagnoses. Mean scores of the Japanese version of the Camouflaging Autistic Traits Questionnaire were lower as compared to the original CAT-Q, which implies that the social camouflage strategy types used by autistic people in Japan and the UK could differ. The cross-sectional design limits causal inferences. CONCLUSION: In the UK, more social camouflage was associated with poorer mental health scores, whereas too little or too much social camouflage was associated with a low mental health score in Japan. The Japanese population is seemingly less aware of and educated on autistic characteristics and considers 'average' behaviour a good thing. This could influence Japanese autistic people's social camouflage use, differing from that of autistic people in the UK. The differences in the relationship between social camouflage and mental health between Japan and the UK could be associated with national-level divergence regarding the culture of autism.

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.

Exploring autistic adults' psychosocial experiences affecting beginnings, continuity and change in camouflaging over time: A qualitative study in Singapore.

LAY ABSTRACT: Over their lifetimes, many autistic people learn to camouflage (hide or mask) their autism-related differences to forge relationships, find work and live independently in largely non-autistic societies. Autistic adults have described camouflaging as a 'lifetime of conditioning . . . to act normal' involving 'years of effort', suggesting that camouflaging develops over an autistic person's lifetime and may start early on, in childhood or adolescence. Yet, we know very little about why and how autistic people start to camouflage, or why and how their camouflaging behaviours continue or change over time. We interviewed 11 Singaporean autistic adults (9 male, 2 female, 22-45 years old) who shared their camouflaging experiences. We found that autistic adults' earliest motivations to camouflage were largely related to the desire to fit in and connect with others. They also camouflaged to avoid difficult social experiences (such as being teased or bullied). Autistic adults shared that their camouflaging behaviours became more complex and that, for some, camouflaging became a part of their self-identity over time. Our findings suggest that society should not pathologise autistic differences, but instead accept and include autistic people, to reduce the pressure on autistic people to hide who they truly are.

A comparison of methods for measuring camouflaging in autism.

Interest in social camouflaging has led to a multiplicity of measurement methods of uncertain validity. This two-part investigation first used a systematic review ("Study 1") to identify and appraise methods used to quantify camouflaging of autistic traits, using the Consensus-based Standards for the Selection of Health Status Measurement Instruments checklist. A total of 16 distinct measurement tools were identified; all are in the preliminary phases of psychometric evaluation. The systematic review highlighted: (1) the need for parent-report tools which specifically measure camouflaging; and (2) a lack of studies looking at associations between different methods of camouflaging, which limits understanding of their validity. "Study 2" aimed to begin to address these gaps in knowledge. We created a parent-report version of the Camouflaging Autistic Traits Questionnaire (CAT-Q) and evaluated its concurrent validity in autistic young people by examining associations with the self-report CAT-Q and a discrepancy measure. Discriminant validity was investigated by comparing all three methods of measuring camouflaging to a measure of social skills, to test whether they assess a construct distinct from social ability. The self- and parent-report CAT-Q were significantly related (r = 0.47, 95% CI = 0.24-0.65), and were related weakly (r = 0.20, 95% CI = -0.06 to 0.43) and strongly (r = 0.46, 95% CI = 0.23-0.64), respectively, to the discrepancy approach. No measure was associated with social skills. Improving the psychometric properties of these methods, and introducing a novel parent-report measure, may help selection of appropriate methods in future research and integration into clinical practice.

The relationship between explicit and implicit personality: Evidence from the Big Five and trait emotional intelligence.

The main aim of this study is to introduce an implicit personality assessment method (e.g., implicit association test) to Kuwait. We adapted an existing personality-related implicit association test (IAT; Big Five IAT), while also constructed the first trait EI IAT based on Petrides' four-factor model. We investigated the psychometric properties of the implicit association test through assessing the reliability of scores and also their relationship with their corresponding explicit measures. The measures were administered to 1458 university students in Kuwait. The zero-order correlations showed that the explicit and implicit measurement approaches led to non-converging constructs in the case of both trait EI and the Big Five. Lastly, we believe that we were successfully able to introduce the concept of personality-related implicit association tests to the Kuwaiti sample. Subsequently, the IATs presented in our study will allow researchers to study a relatively new personality field, that is the implicit personality.

'The key to this is not so much the technology. It's the individual who is using the technology': Perspectives on telehealth delivery for autistic adults during the COVID-19 pandemic.

LAY ABSTRACT: The COVID-19 pandemic meant that a lot of healthcare services had to move online, such as to video-calls, or to telephone. However, not many studies have looked at how autistic adults feel about this kind of service delivery. It is important to know this, as autistic people may have poorer health than non-autistic people, and they may also struggle to access services more than non-autistic people. This study asked 11 autistic adults (aged 27-67 years), seven family members/carers (aged 44-75) reporting about autistic adults and six service providers about their experiences of accessing or providing a telehealth service. These experiences were collected through interviews, which were then analysed through thematic analysis. Two main themes were: technology aids communication and access - except when it doesn't, and in/flexibility. The themes pointed out some positive aspects of telehealth delivery, including improved communication and decreased stress. The themes also pointed out negative aspects of telehealth, such as increased rigidity of the healthcare system, amplifying pre-existing barriers. Because autistic people have many barriers to accessing healthcare, this study encourages researchers and healthcare providers to think about how such barriers could be addressed through telehealth, and about the possible limitations of telehealth for some autistic people.

Gendered play behaviours in autistic and non-autistic children: A population-based cohort study.

LAY ABSTRACT: Non-autistic children tend to show gendered patterns of play behaviours - boys are more likely to play with 'masculine' toys, and girls are more likely to play with 'feminine' toys. However, little is known about whether autistic children follow these patterns as well. We looked at the masculinity and femininity of autistic and non-autistic children's play behaviours at multiple time points. Parents reported their children's play behaviours at ages 30, 42 and 57 months, and children reported their own play behaviours at 8 years old. We found no difference between autistic and non-autistic girls, who both showed more feminine play behaviours as they got older. Autistic boys' play behaviours were reported as less masculine than non-autistic boys at 42 and 57 months, and at 8 years old. We also found that non-autistic boys' play tended to become more masculine as they got older, but this was not the case for autistic boys. Our findings suggest that differences in autistic and non-autistic boys' play behaviours may develop at around 42 months old.

Trait emotional intelligence profiles of professionals in Kuwait.

Trait emotional intelligence concerns people's perceptions of their emotional world. Our aims for this study are to examine (a) the trait emotional intelligence (EI) profiles across different professions in Kuwait; (b) the incremental validity of trait EI in predicting job performance; and (c) the relationship between trait EI, job attitudes, and job performance. The sample comprised 314 professionals in Kuwait in seven different professions: Bankers, Engineers, Healthcare providers, Lawyers, Military, Policemen, and Teachers. Firstly, the results showed that the Military scored the lowest global trait emotional intelligence and three of four factors. Secondly, the results showed that global trait EI incrementally predicted job performance over job attitudes in Policemen and Engineers but not in other professions. Lastly, the results showed that job attitudes partially mediated the relationship between trait EI and job performance. These findings call for the importance of trait emotional intelligence trainings for professionals in Kuwait as it affects important job-related variables. The limitations of this study and the directions for future studies have been discussed.

Understanding Camouflaging as a Response to Autism-Related Stigma: A Social Identity Theory Approach.

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.

Self-reported camouflaging behaviours used by autistic adults during everyday social interactions.

LAY ABSTRACT: Camouflaging can be thought of as the process through which autistic people modify their natural social behaviours to adapt to, cope within or influence the largely neurotypical (non-autistic) social world. Many autistic people experience negative reactions to their natural or intuitive social behaviours when interacting with non-autistic people. Over time, in response to these negative reactions, autistic people's social behaviour often changes. We refer to autistic people's changed behaviours as 'camouflaging behaviours'. Research exploring camouflaging behaviours is still at an early stage. This study investigated camouflaging behaviours used by autistic adults in everyday social interactions using a research method that was new to the field of autism. Specifically, 17 autistic adults were filmed taking part in a common everyday social situation - a conversation with a stranger. With the help of the video of this conversation, they then showed and described their camouflaging behaviours to a researcher. These autistic people identified and described a total of 38 different camouflaging behaviours. The detailed and specific information provided by autistic adults about camouflaging behaviours generated important new insights into the ways in which autistic people adapt to, cope within and influence the neurotypical (non-autistic) social world.

The impact of early stages of COVID-19 on the mental health of autistic adults in the United Kingdom: A longitudinal mixed-methods study.

LAY ABSTRACT: During the COVID-19 pandemic, high levels of depression, anxiety and stress have been reported in the general population. However, much less has been reported about the impact of COVID-19 on the mental health of autistic people. What we did: In the present study, we investigated how the mental health of autistic adults in the United Kingdom changed during the early stages of the COVID-19 pandemic. In total, 133 participants completed an online survey at two different time points. Of the 133 participants, 70 completed the survey at the first time point just before the onset of the national lockdown. This allowed us to look at changes in their mental health, from before the lockdown to 10 to 15 weeks during lockdown. All participants (133) told us about their experiences of the pandemic. What we found: While many autistic adults told us that their mental health worsened, people's experience varied. For some autistic adults, aspects of mental health (e.g. anxiety, stress) actually improved. Participants also described social changes that had occurred, at home and in the outside world. They described feelings of uncertainty during the pandemic, and discussed how the pandemic had affected some of their previous coping strategies. Participants also told us about their difficulties in accessing healthcare services and food during the early stages of the pandemic. In our article, we discuss these findings and focus on what needs to change to ensure that autistic people are better supported as the pandemic continues.

Camouflaging in autism: A systematic review.

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.

Cognitive Predictors of Self-Reported Camouflaging in Autistic Adolescents.

Camouflaging involves masking and/or compensating for autistic characteristics and has been identified in autistic individuals through a variety of different methods. Individual variation in the extent, processes and outcomes of camouflaging has been reported in autistic adults, and there has been some investigation of camouflaging by autistic adolescents. This study was conducted to better understand how some of these individual differences emerge, by examining potential mechanisms (theory of mind, executive function, intelligence quotient and age) involved in camouflaging by 58 autistic adolescents aged 13-18 years (29 females, 29 males). Fewer executive function difficulties predicted greater use of total camouflaging strategies and the compensation subscale, but not the masking or assimilation subscales; no other predictors reached statistical significance. These findings suggest that individual differences in executive function ability may underlie variation in the use of camouflaging by adolescents. The total variance explained in the model was small, suggesting the need to examine other factors which may underpin camouflaging. The implications of this finding for the relationship between camouflaging and well-being are discussed, along with the distinction between attempts to camouflage and the efficacy of those attempts. LAY SUMMARY: Camouflaging involves hiding your autism or finding ways around difficulties in order to fit in during social situations. This study found that autistic teenagers with good executive function abilities camouflage their autism more than those who struggle with executive function (which includes planning, goal-direction and memory). This may have implications for teenagers' mental health and their social functioning.

Camouflaging in an everyday social context: An interpersonal recall study.

LAY ABSTRACT: Many autistic people report that, despite personal costs, they use strategies to hide their autistic characteristics or appear non-autistic at work, school or university, when speaking with health professionals, or while socialising with certain friends and family members. These strategies are often referred to as camouflaging. This study explores camouflaging during everyday social interactions. A total of 17 autistic adults were filmed taking part in a common everyday social situation - a conversation with a stranger. They then watched the video of this conversation with a researcher and answered questions about camouflaging. These autistic people told us that they (1) had a strong desire to socialise with and be valued by other people but, because of negative past experiences, they often felt unsure about their ability to do so; (2) used camouflaging to help them to socialise and be valued by others; (3) experienced negative consequences when camouflaging (e.g. fatigue, anxiety and difficulties in friendships); and (4) sometimes socialised in more autistic ways instead of camouflaging. This study shows us how autistic people often change their behaviour because of the way they are treated by nonautistic people and that autistic people may benefit from programmes that help them to socialise in more authentically autistic ways, but only if their autistic social behaviour is met with understanding and acceptance from non-autistic people.

'We have been in lockdown since he was born': a mixed methods exploration of the experiences of families caring for children with intellectual disability during the COVID-19 pandemic in the UK.

OBJECTIVES: This study aimed to explore the experiences of parents caring for children with intellectual and developmental disabilities (IDD) during the UK national lockdown in spring 2020, resulting from the COVID-19 pandemic. DESIGN: Participants were identified using opportunity sampling from the IMAGINE-ID national (UK) cohort and completed an online survey followed by a semistructured interview. Interviews were analysed using thematic analysis. SETTING: Interviews were conducted over the telephone in July 2020 as the first UK lockdown was ending. PARTICIPANTS: 23 mothers of children with intellectual and developmental disabilities aged 5-15 years were recruited. RESULTS: Themes reported by parents included: managing pre-existing challenges during a time of extreme change, having mixed emotions about the benefits and difficulties that arose during the lockdown and the need for appropriate, individualised support. CONCLUSIONS: Our findings confirm observations previously found in UK parents of children with IDD and provide new insights on the use of technology during the pandemic for schooling and healthcare, as well as the need for regular check-ins.

Sex/Gender Differences in Camouflaging in Children and Adolescents with Autism.

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.