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 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.

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.

The dimensional structure of the Camouflaging Autistic Traits Questionnaire (CAT-Q) and predictors of camouflaging in a representative general population sample.

OBJECTIVES: Some autistic people "camouflage" their differences by modeling neurotypical behaviors to survive in a neurotypical-dominant social world. It remains elusive whether camouflaging is unique to autism or if it entails similar experiences across human groups as part of ubiquitous impression management (IM). Here we examined camouflaging engagement and theoretical drivers in the general population, drawing on the transactional IM framework and contextualizing findings within both contemporary autism research and the past IM literature. METHODS: A large representative U.S. general population sample (N = 972) completed this survey study. We combined exploratory item factor analysis and graph analysis to triangulate the dimensional structure of the Camouflaging Autistic Traits Questionnaire (CAT-Q) and examined its correspondence with prior autism-enriched psychometric findings. We then employed hierarchical regression and elastic-net regression to identify the predictors of camouflaging, including demographic (e.g., age, gender), neurodivergence (i.e., autistic and ADHD traits), socio-motivational, and cognitive factors. RESULTS: We found a three-factor/dimensional structure of the CAT-Q in the general population, nearly identical to that found in previous autism-enriched samples. Significant socio-motivational predictors of camouflaging included greater social comparison, greater public self-consciousness, greater internalized social stigma, and greater social anxiety. These camouflaging drivers overlap with findings in recent autistic camouflaging studies and prior IM research. CONCLUSIONS: The novel psychometric and socio-motivational evidence demonstrates camouflaging as a shared social coping experience across the general population, including autistic people. This continuity guides a clearer understanding of camouflaging and has key implications for autism scholars, clinicians, and the broader clinical intersecting with social psychology research. Future research areas are mapped to elucidate how camouflaging/IM manifests and functions within person-environment transactions across social-identity and clinical groups.

Cell membrane-camouflaged bufalin targets NOD2 and overcomes multidrug resistance in pancreatic cancer.

AIMS: Multidrug resistance in pancreatic cancer poses a significant challenge in clinical treatment. Bufalin (BA), a compound found in secretions from the glands of toads, may help overcome this problem. However, severe cardiotoxicity thus far has hindered its clinical application. Hence, the present study aimed to develop a cell membrane-camouflaged and BA-loaded polylactic-co-glycolic acid nanoparticle (CBAP) and assess its potential to counter chemoresistance in pancreatic cancer. METHODS: The toxicity of CBAP was evaluated by electrocardiogram, body weight, distress score, and nesting behavior of mice. In addition, the anticarcinoma activity and underlying mechanism were investigated both in vitro and in vivo. RESULTS: CBAP significantly mitigated BA-mediated acute cardiotoxicity and enhanced the sensitivity of pancreatic cancer to several clinical drugs, such as gemcitabine, 5-fluorouracil, and FOLFIRINOX. Mechanistically, CBAP directly bound to nucleotide-binding and oligomerization domain containing protein 2 (NOD2) and inhibited the expression of nuclear factor kappa-light-chain-enhancer of activated B cells. This inhibits the expression of ATP-binding cassette transporters, which are responsible for chemoresistance in cancer cells. CONCLUSIONS: Our findings indicate that CBAP directly inhibits NOD2. Combining CBAP with standard-of-care chemotherapeutics represents a safe and efficient strategy for the treatment of pancreatic cancer.

Sex-related brain connectivity correlates of compensation in adults with autism: insights into female protection.

The male preponderance in autism spectrum disorder (ASD) led to the hypothesis that aspects of female biology are protective against ASD. Females with ASD (ASD-F) report more compensatory behaviors (i.e. "camouflaging") to overcome ASD-related social differences, which may be a mechanism of protection. No studies have examined sex-related brain pathways supporting camouflaging in ASD-F, despite its potential to inform mechanisms underlying the ASD sex bias. We used functional connectivity (FC) to investigate "sex-atypical" and "sex-typical" FC patterns linked to camouflaging in adults with ASD and examined multimodal coherence of findings via structural connectometry. Exploratory associations with cognitive/emotional functioning examined the adaptive nature of FC patterns. We found (i) "sex-atypical" FC patterns linked to camouflaging in the hypothalamus and precuneus and (ii) "sex-typical" patterns in the right anterior cingulate and anterior parahippocampus. Higher hypothalamic FC with a limbic reward cluster also correlated with better cognitive control/emotion recognition. Structural connectometry validated FC results with consistent brain pathways/effect patterns implicated in ASD-F. In summary, "male-typical" and "female-typical" brain connectivity patterns support camouflaging in ASD-F in circuits implicated in reward, emotion, and memory retrieval. "Sex-atypical" results are consistent with fetal steroidogenic/neuroinflammatory hypotheses. However, female genetics/biology may contribute to "female-typical" patterns implicated in camouflaging.

Autistic traits and camouflaging behaviors: a cross-sectional investigation in a University student population.

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.

Validation of the Italian version of the Camouflaging Autistic Traits Questionnaire (CAT-Q) in a University population.

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.

Good social skills despite poor theory of mind: exploring compensation in autism spectrum disorder.

BACKGROUND: It is proposed that some individuals with Autism Spectrum Disorder (ASD) can 'compensate' for their underlying difficulties (e.g. in theory of mind; ToM), thus demonstrating relatively few behavioural symptoms, despite continued core cognitive deficits. The mechanisms underpinning compensation are largely unexplored, as is its potential impact on mental health. This study aimed to estimate compensation patterns in ASD, by contrasting overt social behaviour with ToM task performance, in order to compare the characteristics of 'Low' and 'High' Compensators. METHODS: A total of 136 autistic adolescents, from the ongoing Social Relationships Study, completed a range of cognitive tasks, the Autistic Diagnostic Observation Schedule (ADOS) and a self-report anxiety questionnaire. Participants were assigned compensation group status; High Compensators demonstrated good ADOS scores despite poor ToM performance, while Low Compensators demonstrated similarly poor ToM, accompanied by poor ADOS scores. RESULTS: High Compensators demonstrated better IQ and executive function (EF), but greater self-reported anxiety, compared with Low Compensators. Such differences were not found when comparing individuals who had good versus poor ADOS scores, when ToM performance was good. Other core autistic characteristics (weak central coherence, nonsocial symptoms) did not differentiate the High and Low Compensators. CONCLUSIONS: IQ, EF and anxiety appear to be implicated in the processes by which certain autistic young people can compensate for their underlying ToM difficulties. This tendency to compensate does not appear to reflect the severity of 'hit' for ASD per se, suggesting that well-compensated individuals are not experiencing a milder form of ASD. The construct of compensation in ASD has implications for research and clinical practice.

Innovations in skin camouflaging techniques: Where are we scientifically?

OBJECTIVE: Cutaneous disorders can impact on the psycho-social well-being of children and adults alike, which has been reviewed elsewhere (Body Image 27, 2018 and 98). The present review sets out to evaluate progressions in skin masking and camouflaging techniques together with evaluating the efficacy of these. There does not appear to have been any recent reviews about innovations in skin camouflaging techniques. METHODS: Using the National Centre for Biotechnology Information PubMed database, a search was made for all studies published between 2000 and 2019 that met defined inclusion criteria. A total of seven relevant publications were identified. RESULTS: Of the seven studies identified, skin camouflaging improved quality of life in three studies and reduced anxiety, depression and social isolation in others. Of the camouflaging methods used, liquidized simulated second skin technology (Microskin™) appears to look particularly promising. This method of colour matching and a spray/stippling application uses a technology that binds to the epidermis of the skin helping to overcome previous concerns about the colour, coverage and application of camouflage and masking bases. Two studies showed that this innovative mode of camouflaging raised confidence, feelings of happiness and social experiences in children and adolescents with burn scarring. Very few studies reported drawbacks of camouflaging techniques, with limited colour matches and 'itching' appearing to be the main shortcomings. New technologies now appear to be addressing these. CONCLUSION: Results show that there is wide variation in the quality and modes of skin camouflaging. Of the methods used, simulated second skin technology appears to be an important and effective therapy for individuals with cutaneous skin disorders. Training schemes along with increased awareness of this technique must now be communicated to medical professionals who come into contact with children and adults who could benefit physically, psychologically and socially from this therapy.

OBJECTIF: Les troubles cutanés pouvant avoir un impact sur le bien-être psychosocial des enfants et des adultes a été examiné ailleurs. La présente revue vise à évaluer les progressions dans les techniques de masquage et de camouflage de la peau ainsi qu'à évaluer l'efficacité de ces techniques. Il ne semble pas y avoir eu de critiques récentes sur les innovations dans les techniques de camouflage de la peau. MÉTHODES: À l'aide de la base de données pubmed du Centre national d'information sur la biotechnologie, une recherche a été effectuée sur toutes les études publiées entre 2000 et 2019 qui satisfaisaient aux critères d'inclusion définis. Au total, sept publications pertinentes ont été identifiées. RÉSULTATS: Des sept études identifiées, le camouflage de peau a amélioré la qualité de vie dans trois études et a réduit l'inquiétude, la dépression et l'isolement social dans les autres. Parmi les méthodes de camouflage utilisées, la technologie simulée de la seconde peau (MicroskinTM) semble particulièrement prometteuse. Cette méthode d'appariement des couleurs et d'application par pulvérisation / par points utilise une technologie qui se lie à l'épiderme de la peau, ce qui permet de surmonter les problèmes de couleur, de couverture et d'application des bases de camouflage et de masquage. Deux études ont montré que ce mode de camouflage novateur augmentait la confiance, le sentiment de bonheur et les expériences sociales chez les enfants et les adolescents atteints de brûlures. Très peu d'études ont signalé les inconvénients des techniques de camouflage, les correspondances de couleurs limitées et les «démangeaisons¼ semblant être les principales lacunes. Les nouvelles technologies semblent maintenant répondre à ces problèmes. CONCLUSION: Les résultats montrent qu'il existe une grande variation dans la qualité et les modes de camouflage de la peau. Parmi les méthodes utilisées, la technologie de la seconde peau simulée semble être un traitement important et efficace pour les personnes souffrant de troubles cutanés. Les programmes de formation associés à une sensibilisation accrue à cette technique doivent maintenant être communiqués aux professionnels de la santé qui entrent en contact avec des enfants et des adultes susceptibles de tirer un bénéfice physique, psychologique et social de cette thérapie.

Gorillas with white sclera: A naturally occurring variation in a morphological trait linked to social cognitive functions.

Human eye morphology is considered unique among the primates in that humans possess larger width/height ratios (WHR), expose a greater amount of visible sclera (SSI; width of exposed eyeball/width of visible iris), and critically, have a white sclera due to a lack of pigmentation. White sclera in humans amplifies gaze direction, whereas the all-dark eyes of apes are hypothesized to conceal gaze from others. This study examines WHR and SSI in humans (N = 13) and gorillas (N = 85) engaged in direct and averted gazes and introduces a qualitative assessment of sclera color to evaluate variations in sclera pigmentation. The results confirm previous findings that humans possess a larger WHR than gorillas but indicate that humans and gorillas display similar amounts of visible sclera. Additionally, 72% (N = 124) of gorilla eyes in this sample deviated from the assumed all-dark eye condition. This questions whether gaze camouflage is the primary function of darkened sclera in non-human primates or whether other functional roles can be ascribed to the sclera, light or dark. We argue that white sclera evolved to amplify direct gazes in humans, which would have played a significant role in the development of ostensive communication, which is communication that both shows something and shows the intention to show something. We conclude that the horizontal elongation of the human eye, rather than sclera color, more reliably distinguishes human from great ape eyes, represented here by gorillas.

Exploring camouflaging by the Chinese version Camouflaging Autistic Traits Questionnaire in Taiwanese autistic and non-autistic adolescents: An initial development.

LAY ABSTRACT: Camouflaging is a coping strategy used by some autistic and other neurodivergent people to fit in neurotypical social contexts. The self-reported Camouflaging Autistic Traits Questionnaire has been validated for use in research with adults in some Western societies, but not in non-Western cultural-ethnic groups. We translated Camouflaging Autistic Traits Questionnaire into traditional Chinese and examined the use of this measure in Taiwanese adolescents via both self-report and caregiver-report in 100 autistic and 105 non-autistic adolescents. Both self-reported and caregiver-reported Chinese version Camouflaging Autistic Traits Questionnaire were composed of two factors (i.e. a "compensation-masking" subscale and an "assimilation" subscale). Both adolescent self-reported and caregiver-reported Chinese version Camouflaging Autistic Traits Questionnaire total score and subscales were reliable in measurement, and they highly correlated with each other. Taiwanese autistic adolescents were more likely to camouflage than non-autistic adolescents, especially on assimilation. Female autistic adolescents showed higher assimilation than male autistic adolescents. Higher camouflaging, especially assimilation, was associated with higher stress in autistic and non-autistic adolescents alike. Both self-reported and caregiver-reported Chinese version Camouflaging Autistic Traits Questionnaire were reliable and offered meaningful information to help us understand the social coping experiences of autistic and non-autistic adolescents.

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.

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.

Is camouflaging unique for autism? A comparison of camouflaging between adults with autism and ADHD.

Camouflaging (using (un)conscious strategies to appear as non-autistic) is thought to be an important reason for late autism diagnoses and mental health difficulties. However, it is unclear whether only autistic people camouflage or whether people with other neurodevelopmental or mental health conditions also use similar camouflaging strategies. Therefore, in this preregistered study (AsPredicted: #41811) study, we investigated if adults with attention-deficit/hyperactivity-disorder (ADHD) also camouflage. Adults aged 30-90 years filled in the Dutch Camouflaging Autistic Traits Questionnaire (CAT-Q-NL), the ADHD Self-Report (ADHD-SR) and the Autism Spectrum Quotient (AQ). We investigated differences in camouflaging between adults with ADHD, autism, and a comparison group in an age and sex-matched subsample (N = 105 per group). We explored if autism and ADHD traits explained camouflaging levels in adults with an autism and/or ADHD diagnosis (N = 477). Adults with ADHD scored higher on total camouflaging and assimilation subscale compared to the comparison group. However, adults with ADHD scored lower on total camouflaging, and subscales compensation and assimilation than autistic adults. Autism traits, but not ADHD traits, were a significant predictor of camouflaging, independent of diagnosis. Thus, camouflaging does not seem to be unique to autistic adults, since adults with ADHD also show camouflaging behavior, even though not as much as autistic adults. However, as the CAT-Q-NL specifically measures camouflaging of autistic traits it is important to develop more general measures of camouflaging, to compare camouflaging more reliably in people with different mental health conditions. Furthermore, focusing on camouflaging in adults with ADHD, including potential consequences for late diagnoses and mental health seems a promising future research avenue.

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.

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.

The relationship between camouflaging and mental health: Are there differences among subgroups in autistic adults?

LAY ABSTRACT: When autistic people use strategies to hide their autistic characteristics, we call this camouflaging. Autistic adults suggested that camouflaging can result in mental health difficulties. That is, people who report to camouflage also report mental health difficulties. However, since there are many differences between autistic people, this relationship may also differ between subgroups. Therefore, in this study we investigated whether camouflaging and mental health difficulties are related and whether this relationship is equal for all autistic adults. For this study, 352 autistic adults aged 30-84 years filled in the Dutch Camouflaging Autistic Traits Questionnaire to measure camouflaging and the Symptom Checklist-90 Revised to measure mental health difficulties. We found that camouflaging was moderately related to mental health difficulties. This means that people who report more camouflaging also report more mental health difficulties. When we looked closer, we found that this relationship was strong for only a small subgroup of autistic adults. In most other autistic adults, there was a small or no relationship between camouflaging and mental health difficulties. Therefore, it is important that clinicians are aware of camouflaging and its possible relationship with mental health difficulties, but that they do not generalize the negative consequences to everyone.

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.

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.