Social Camouflaging in Females with Autism Spectrum Disorder: A Systematic Review

Autism spectrum disorder (ASD) is a neurodevelopmental disorder with increasing prevalence, and a male-to-female ratio of 4:1. Research has been suggesting that discrepancy in prevalence may be due to the fact that females camouflage their symptoms. In this study, we aimed to systematically review evidence on the camouflage effect in females with ASD. Following the PRISMA guidelines, we reviewed empirical research published from January 2009 to September 2019 on PubMed, Web of Science, PsychInfo and Scopus databases. Thirteen empirical articles were included in this review. Overall, evidence supports that camouflaging seems to be an adaptive mechanism for females with ASD, despite the negative implications of these behaviours in their daily life.

Social Camouflaging in Females with Autism Spectrum Disorder: A Systematic Review

Autism spectrum disorder (ASD) is a neurodevelopmental disorder with increasing prevalence, and a male-to-female ratio of 4:1. Research has been suggesting that discrepancy in prevalence may be due to the fact that females camouflage their symptoms. In this study, we aimed to systematically review evidence on the camouflage effect in females with ASD. Following the PRISMA guidelines, we reviewed empirical research published from January 2009 to September 2019 on PubMed, Web of Science, PsychInfo and Scopus databases. Thirteen empirical articles were included in this review. Overall, evidence supports that camouflaging seems to be an adaptive mechanism for females with ASD, despite the negative implications of these behaviours in their daily life.

Defining autistic burnout through experts by lived experience: Grounded Delphi method investigating #AutisticBurnout

LAY ABSTRACT

Autistic burnout has been commonly described in social media by autistic people. There is little mention of autistic burnout in the academic literature. Only one recent study has used interviews and reviews of social media descriptions to try to understand autistic burnout. Anecdotally, autistic burnout is a very debilitating condition that reduced people's daily living skills and can lead to suicide attempts. It is suggested that autistic burnout is caused by the stress of masking and living in an unaccommodating neurotypical world. We wanted to create a definition of autistic burnout that could be used by clinicians and the autism community. We used the Grounded Delphi method, which allowed autistic voice to lead the study. Autistic adults who had experienced autistic burnout were considered as experts on the topic, in the co-production of this definition. The definition describes autistic burnout as a condition involving exhaustion, withdrawal, problems with thinking, reduced daily living skills and increases in the manifestation of autistic traits. It is important for future research that there is a specific description of the condition. In practice, it is important for clinicians to be aware that autistic burnout is different from depression. Psychological treatments for depression potentially could make autistic burnout worse. Further awareness of autistic burnout is needed, as well as further research to prove this condition is separate from depression, chronic fatigue and non-autistic burnout.

"Camouflaging" by adolescent autistic girls who attend both mainstream and specialist resource classes: Perspectives of girls, their mothers and their educators

Autistic girls’ heightened social motivation and associated social coping strategies, such as camouflaging, mean they may be less likely to receive appropriate support in mainstream schools. In this research, a multi-informant approach was used to examine the camouflaging strategies used by autistic girls within specialist resource classes attached to mainstream schools (whereby girls transition between resource classes and mainstream classes). Semi-structured interviews were conducted with eight adolescent girls, their parents (eight mothers) and their educators (six teaching assistants/aides and one senior staff member) about the girls’ camouflaging experiences. Using reflexive thematic analysis, four themes were identified: (1) inconsistencies and contradictions in camouflaging, (2) challenges of relationships and ‘finding a tribe’, (3) learning, inclusion and awareness and (4) consequences of camouflaging. These results highlight the challenges that the girls experienced when attempting to hide their autism and fit within both mainstream classes and specialist resource classes. These challenges had significant impacts on the girls’ relationships and learning, as well as consequences for their mental health. The findings highlight the need for increased awareness of how camouflaging presents across the autism spectrum and suggests that individualised, evidence-based support will be essential for enabling autistic girls to flourish in school.

Autistic Self-Advocacy and the Neurodiversity Movement: Implications for Autism Early Intervention Research and Practice

The growth of autistic self-advocacy and the neurodiversity movement has brought about new ethical, theoretical and ideological debates within autism theory, research and practice. These debates have had genuine impact within some areas of autism research but their influence is less evident within early intervention research. In this paper, we argue that all autism intervention stakeholders need to understand and actively engage with the views of autistic people and with neurodiversity as a concept and movement. In so doing, intervention researchers and practitioners are required to move away from a normative agenda and pay diligence to environmental goodness-of-fit, autistic developmental trajectories, internal drivers and experiences, and autistic prioritized intervention targets. Autism intervention researchers must respond to these debates by reframing effectiveness, developing tools to measure autistic prioritized outcomes, and forming partnerships with autistic people. There is a pressing need for increased reflection and articulation around how intervention practices align with a neurodiversity framework and greater emphasis within intervention programmes on natural developmental processes, coping strategies, autonomy, and well-being.

Understanding the Relationships Between Autistic Identity, Disclosure, and Camouflaging

Background

Camouflaging involves concealing an autistic identity, for example, by adopting nonautistic behaviors in social contexts. We currently know little about the relationship between autistic identity and camouflaging. Furthermore, other variables may mediate the relationship between camouflaging and identity, and this study examined whether disclosure (being openly autistic) might mediate the relationship. We predicted that fewer camouflaging behaviors would be associated with higher autistic identity when an individual is more open about being autistic.

Methods

One hundred eighty autistic adults (52% female, 42% male, 5% other gender identities, and 1% preferred not to say) took part in the study. They completed an online survey with measures of camouflaging, autistic identity, and disclosure of autistic status.

Results

We found a significant mediation effect such that autistic identity had an indirect negative effect on camouflaging mediated via disclosure. In other words, higher autistic identity linked to more disclosure, which in turn linked to fewer camouflaging behaviors. However, there was evidence for competitive mediation, such that the direct effect (the relationship between identity and camouflaging ignoring disclosure) was significant, with higher autistic identity linking directly to more camouflaging.

Conclusions

The initial hypothesis was confirmed, with higher autistic identity linked to less camouflaging via disclosure. This finding indicates that camouflaging can reduce when there is high autistic identification, and someone has openly disclosed that they are autistic to others. However, the direct effect between identity and camouflaging suggests that there may be conflicts for someone who identifies strongly with being autistic but continues to camouflage. Other variables may play a role in the relationship between identity and camouflaging, such as fear of discrimination, self-awareness, timing of diagnosis, age, ethnicity, or gender. The findings indicate the importance of safe nondiscriminatory environments where individuals can disclose and express their autistic identity, which may in turn reduce camouflaging.

Lay summary

Why was this study done?: Camouflaging involves hiding or masking being autistic or using strategies to appear as though nonautistic. Past research has found that camouflaging relates to poorer mental health. Given this, we must understand ways to reduce camouflaging. In this study, we looked at the links between camouflaging, autistic identity (a sense of affiliation with the autistic community), and disclosure (being openly autistic). We know from other research that identifying strongly with the autistic community may protect against mental health difficulties, so we wanted to explore the role autistic identity might play in camouflaging.What was the purpose of this study?: The purpose was to understand the relationships between camouflaging, autistic identity, and disclosure. We considered disclosure because someone could have a strong sense of autistic identity but might not be open about this to others. We tested the idea that someone with a strong autistic identity might be more openly autistic, and this then has a knock-on effect that links to less camouflaging.What did the researchers do?: One hundred and eighty autistic adults completed an online survey. They answered questions about camouflaging, autistic identity, and disclosure. They also answered questions about who they were (e.g., age, gender) and autistic characteristics. We analyzed everyone's answers using an analysis called "mediation analysis." This analysis enables us to test how disclosure influences any association between camouflaging and identity.What were the results of the study?: We found that higher autistic identity related to more disclosure, and this then linked to less camouflaging, that is, strong autistic identity can relate to less camouflaging when someone is more openly autistic. We also found that ignoring disclosure, autistic identity directly influenced camouflaging in the opposite way, that is, higher autistic identity contributed to more camouflaging if we do not take disclosure into account. This is known as "competitive mediation" and suggests a complex picture when it comes to identity, disclosure, and camouflaging.What do these findings add to what was already known?: As far as we know, no one has looked at these relationships before. We therefore add to camouflaging research and show that camouflaging might be reduced if autistic people identify strongly and they are able to be openly autistic.What are potential weaknesses in the study?: Participants were recruited online, which means the sample may be biased, and the findings will not apply to all autistic people. We measured disclosure using one question, which could be a problem because individuals might have interpreted the question in different ways. The "competitive mediation" suggests that there are other variables impacting on relationship between identity and camouflaging, which we did not capture.How will these findings help autistic adults now or in the future?: This study indicates that strong autistic identity and being openly autistic could reduce camouflaging, which we know to have negative effects on mental health. However, to enable disclosure, these findings demonstrate the need for safe spaces where autistic people can explore their identity and be openly autistic, without fear of discrimination.

‘I just rolled up my sleeves’: Mothers’ perspectives on raising girls on the autism spectrum

Little previous research has elucidated the everyday experiences of autistic girls or their families. This study used qualitative in-depth interviews to explore mothers’ experiences of the diagnosis, presentation and impact of caring for a daughter with autism. Nineteen women with autistic daughters (aged between 7 and 18) participated in the research, which took place in Ireland. Thematic analysis identified six themes: What’s Going On?; Road to Acceptance; Beyond the Stigma of Autism; Autism: Like a Girl; Mothers Holding It All Together; and Mothers Roll Up Their Sleeves. The analysis suggests that the path of autism in girls in Ireland is marked by diagnostic delays, social stigma, interpersonal difficulties, mental health comorbidities and parental stress. However, these challenges were offset by the resilience of mothers, buttressed by pride in their daughters and support from other women. Results will inform the development of policy and practice that is sensitive to the lived realities of autistic girls and their families.

Lay abstract

Autism in boys has been well researched but very little is known about the everyday experiences of autistic girls or their families. Mothers’ views and insights can be very helpful in increasing knowledge around the unique demands of raising a daughter with autism. This study conducted interviews with Irish mothers to examine their own experiences regarding (a) getting an autism diagnosis for their daughter, (b) their daughters’ personal characteristics and (c) the impact of caring for a daughter with autism. The study suggests that the route to an autism diagnosis for girls in Ireland is made more difficult by delays and missed diagnoses, and often followed by inadequate supports. Mothers described autistic girls as presenting with social challenges and mental health difficulties. Many mothers experienced judgement from other parents and family members, acute stress and mental health struggles. However, these challenges were offset by mothers’ resilience, pride in their daughters and support from other women. The findings of this study highlight the importance of specific support for autistic girls and their families.

"Having All of Your Internal Resources Exhausted Beyond Measure and Being Left with No Clean-Up Crew": Defining Autistic Burnout

Background: Although autistic adults often discuss experiencing "autistic burnout" and attribute serious negative outcomes to it, the concept is almost completely absent from the academic and clinical literature. Methods: We used a community-based participatory research approach to conduct a thematic analysis of 19 interviews and 19 public Internet sources to understand and characterize autistic burnout. Interview participants were autistic adults who identified as having been professionally diagnosed with an autism spectrum condition. We conducted a thematic analysis, using a hybrid inductive-deductive approach, at semantic and latent levels, through a critical paradigm. We addressed trustworthiness through multiple coders, peer debriefing, and examination of contradictions. Results: Autistic adults described the primary characteristics of autistic burnout as chronic exhaustion, loss of skills, and reduced tolerance to stimulus. They described burnout as happening because of life stressors that added to the cumulative load they experienced, and barriers to support that created an inability to obtain relief from the load. These pressures caused expectations to outweigh abilities resulting in autistic burnout. Autistic adults described negative impacts on their health, capacity for independent living, and quality of life, including suicidal behavior. They also discussed a lack of empathy from neurotypical people and described acceptance and social support, time off/reduced expectations, and doing things in an autistic way/unmasking as associated in their experiences with recovery from autistic burnout. Conclusions: Autistic burnout appears to be a phenomenon distinct from occupational burnout or clinical depression. Better understanding autistic burnout could lead to ways to recognize, relieve, or prevent it, including highlighting the potential dangers of teaching autistic people to mask or camouflage their autistic traits, and including burnout education in suicide prevention programs. These findings highlight the need to reduce discrimination and stigma related to autism and disability.

LAY SUMMARY

Why was this study done?: Autistic burnout is talked about a lot by autistic people but has not been formally addressed by researchers. It is an important issue for the autistic community because it is described as leading to distress; loss of work, school, health, and quality of life; and even suicidal behavior.What was the purpose of this study?: This study aimed to characterize autistic burnout, understand what it is like, what people think causes it, and what helps people recover from or prevent it. It is a first step in starting to understand autistic burnout well enough to address it.What did the researchers do?: Our research group-the Academic Autism Spectrum Partnership in Research and Education-used a community-based participatory research approach with the autistic community in all stages of the study. We analyzed 9 interviews from our study on employment, 10 interviews about autistic burnout, and 19 public Internet sources (five in-depth). We recruited in the United States by publicizing on social media, by word of mouth, and through community connections. When analyzing interviews, we took what people said at face value and in deeper social context, and looked for strong themes across data.What were the results of the study?: The primary characteristics of autistic burnout were chronic exhaustion, loss of skills, and reduced tolerance to stimulus. Participants described burnout as happening because of life stressors that added to the cumulative load they experienced, and barriers to support that created an inability to obtain relief from the load. These pressures caused expectations to outweigh abilities resulting in autistic burnout. From this we created a definition:Autistic burnout is a syndrome conceptualized as resulting from chronic life stress and a mismatch of expectations and abilities without adequate supports. It is characterized by pervasive, long-term (typically 3+ months) exhaustion, loss of function, and reduced tolerance to stimulus.Participants described negative impacts on their lives, including health, capacity for independent living, and quality of life, including suicidal behavior. They also discussed a lack of empathy from neurotypical people. People had ideas for recovering from autistic burnout including acceptance and social support, time off/reduced expectations, and doing things in an autistic way/unmasking.How do these findings add to what was already known?: We now have data that autistic burnout refers to a clear set of characteristics, and is different from workplace burnout and clinical depression. We have the start of a model for why autistic burnout might happen. We know that people have been able to recover from autistic burnout and have some insights into how.What are the potential weaknesses in the study?: This was a small exploratory study with a convenience sample. Although we were able to bring in some diversity by using three data sources, future work would benefit from interviewing a wider range of participants, especially those who are not white, have higher support needs, and have either very high or very low educational attainment. More research is needed to understand how to measure, prevent, and treat autistic burnout.How will these findings help autistic adults now or in the future?: These findings validate the experience of autistic adults. Understanding autistic burnout could lead to ways to help relieve it or prevent it. The findings may help therapists and other practitioners recognize autistic burnout, and the potential dangers of teaching autistic people to mask autistic traits. Suicide prevention programs should consider the potential role of burnout. These findings highlight the need to reduce discrimination and stigma around autism and disability.