Camouflaging in Autism: Examining Sex-Based and Compensatory Models in Social Cognition and Communication

Take a Closer Look: Considerations for Autism Spectrum Disorder Assessment in Female Children and Adolescents

Assessment for autism spectrum disorder (ASD) in the pediatric female population entails unique diagnostic complexities. Females are often misdiagnosed, undiagnosed, or receive an ASD diagnosis at a later age than males. Male bias in ASD, masking behaviors, cultural norms, and overlapping neurodevelopmental comorbidities (such as attention deficit/hyperactivity disorder and intellectual disability) contribute to this phenomenon. The authors present two clinical cases evaluated in an interdisciplinary developmental behavioral pediatrics (DBP) team to highlight these considerations. Cases describe adolescent and school aged females with medical complexity who did not initially appear to have ASD symptoms but later were diagnosed with ASD. Patient anonymity is preserved. Best practice recommendations are discussed. Shared decision making, intentional history taking, thorough observation of behavior and restrictive/repetitive/sensory interests in multiple settings, and attention to social communication in the context of cognitive capacity are essential for ASD assessment in pediatric females.

Early developmental milestone clusters of autistic children based on electronic health records

Autistic children vary in symptoms, co-morbidities, and response to interventions. This study aimed to identify clusters of autistic children with a distinct pattern of attaining early developmental milestones (EDMs). The clustering of 5836 autistic children was based on the attainment of 43 gross motor, fine motor, language, and social developmental milestones during the first 3 years of life as recorded in baby wellness visits. K-means cluster analysis detected four EDM clusters: mild (n = 1686); moderate (n = 1691); severe (n = 2265); and global (n = 194). The most prominent cluster differences were in the language domain. The global cluster showed earlier and greater developmental delay across domains, unique early gross motor delays, and more were born preterm via cesarean section. The severe cluster had poor language development prominently in the second year of life, and later fine motor delays. Moderate cluster had mainly language delays in the third year of life. The mild cluster mostly passed milestones. EDM clusters differed demographically, with higher socioeconomic status in mild cluster and lowest in global cluster. However, the severe cluster had more immigrant and non-Jewish mothers followed by the moderate cluster. The rates of parental concerns and provider developmental referrals were significantly higher in the global, followed by the severe, moderate, and mild EDM clusters. Autistic children's language and motor delay in the first 3 years can be grouped by common magnitude and onset profiles as distinct groups that may link to specific etiologies (like prematurity or genetics) and specific intervention programs. Early autism screening should be tailored to these different developmental profiles.

Females evaluated for autism: characteristics and co-occurring and differential DSM-5 diagnoses

Objective: While sex differences in autism spectrum disorder (ASD) have been identified in areas such as neurocognitive functioning, behavior patterns, and diagnostic criteria, less work has focused on differences within females referred for ASD evaluation, including those who did not go on to receive a diagnosis. This study examined psychological and behavioral characteristics and co-occurring and differential DSM-5 diagnoses between pediatric female participants who received an ASD diagnosis (ASD+) and those who did not (ASD-). Method: Data on cognitive functioning, adaptive functioning, internalizing symptoms, externalizing symptoms, and ADOS-2 scores were analyzed among 137 3- to 20-year-old patients. The sample was divided into two age groups (ages 3-8 and ages 9-20) for analyses of between-group differences (ASD+ vs. ASD-) and predictors of group membership. Results: Females in the ASD+ group were significantly younger, had lower cognitive scores, lower internalizing and externalizing symptoms, and had higher Autism Diagnostic Observation Schedule-2 (ADOS-2) scores than those in the ASD- group. ADOS-2 scores were also the only significant predictor of ASD group membership across age groups. The ASD+ group had a higher percentage of intellectual disability while the ASD- group had higher percentages of anxiety disorder, attention-deficit/hyperactivity disorder, and disruptive behavior disorders. Conclusions: Psychological and behavioral presentations among females referred for ASD evaluation varied with age and ASD diagnostic groups. These results highlight potential female differences in ASD referrals and identification of ASD and the need to improve care for females in consideration of demographic factors.

Gender diversity in autistic and neurotypical youth over adolescence and puberty: A longitudinal study

Recent research in autism spectrum disorder (ASD) has suggested a higher prevalence of gender diversity in individuals diagnosed with ASD. Adolescence is a critical period for the consolidation of gender identity, yet the extent to which the experience of gender diversity is stable over adolescence and puberty in autistic youth is poorly understood. The aim of the study was to examine the consistency of gender diversity using the gender diversity screening questionnaire for self- and parent-report of youth (GDSQ-S, GDSQ-P) over a four-year longitudinal study of pubertal development in youth with ASD (N = 140, 36 assigned-female-at birth (AFAB)) and typical development (TD, N = 104, 58 assigned-male-at-birth [AMAB]) and their parents. The extent to which diagnosis (ASD vs. TD), assigned sex (AFAB vs. AMAB) and developmental level (age, puberty) predict GDSQ trajectory over time was explored. There was a significant diagnosis by sex-assigned-at-birth by age interaction for GDSQ-S Gender Diversity, p = 0.002, showing higher scores in autistic AFAB youth over adolescence, and TD AFAB showing initially lower, then increasing levels over adolescence. For GDSQ-P, Gender Incongruence was significantly different between the groups, p = 0.032, showing higher incongruence for autistic AFAB around age 10, decreasing between age 12-14 before increasing again, while TD AFAB evidence the inverse trend. AMAB trends were stable. The significant diagnostic, developmental and sex-based differences indicate AFAB youth experience greater gender diversity that evolves over development. Findings suggest gender identity formation is nuanced and may be influenced by pubertal progression, hormonal patterns, and psychosocial factors. Results underscore the need for enhanced understanding of the unique, dynamic profiles of females-assigned-at-birth.

A Randomized Trial Utilizing EEG Brain Computer Interface to Improve Facial Emotion Recognition in Autistic Adults

PURPOSE

Many individuals with autism spectrum disorder (ASD) experience challenges with facial emotion recognition (FER), which may exacerbate social difficulties in ASD. Few studies have examined whether FER can be experimentally manipulated and improved for autistic people. This study utilized a randomized controlled trial design to examine acceptability and preliminary clinical impact of a novel mixed reality-based neurofeedback program, FER Assistant, using EEG brain computer interface (BCI)-assisted technology to improve FER for autistic adolescents and adults.

METHODS

Twenty-seven autistic male participants (M age: 21.12 years; M IQ: 105.78; 85% white) were randomized to the active condition to receive FER Assistant (n = 17) or waitlist control (n = 10). FER Assistant participants received ten sessions utilizing BCI-assisted neurofeedback training in FER. All participants, regardless of randomization, completed a computerized FER task at baseline and endpoint.

RESULTS

Results partially indicated that FER Assistant was acceptable to participants. Regression analyses demonstrated that participation in FER Assistant led to group differences in FER at endpoint, compared to a waitlist control. However, analyses examining reliable change in FER indicated no reliable improvement or decline for FER Assistant participants, whereas two waitlist participants demonstrated reliable decline.

CONCLUSION

Given the preliminary nature of this work, results collectively suggest that FER Assistant may be an acceptable intervention. Results also suggest that FER may be a potential mechanism that is amenable to intervention for autistic individuals, although additional trials using larger sample sizes are warranted.

Neurobiology of cognitive abilities in early childhood autism

This perspective considers complexities in the relationship between impaired cognitive abilities and autism from a maturational, developmental perspective, and aims to serve as a helpful guide for the complex and growing investigation of cognitive abilities and Autism Spectrum Disorder (ASD). Low Intelligence Quotient (IQ) and ASD are frequently co-occurring. About 37% of 8-year old children and 48% of 4-year old children diagnosed with ASD also have Intellectual Disability, with IQ below 70. And, low IQ in early infancy, including below 1 year of age, carries a 40% greater chance of receiving ASD diagnosis in early childhood. We consider the evidence that may explain this co-occurrence, including the possibility that high IQ may "rescue" the social communication issues, as well as the possible role of critical periods during growth and development. We consider how early low IQ may subsume a part of a subgroup of individuals with ASD, in particular, those diagnosed with autism in very early childhood, and we provide neurobiological evidence in support of this subtype. Moreover, we distinguish the concept of early low IQ from the delay in speech onset in preschool and school-aged children, based on (i) age and (ii) impairments in both verbal and non-verbal domains. The etiology of these early-diagnosed, early low IQ ASD cases is different from later-diagnosed, average or higher-IQ cases, and from children with speech delay onset. Given recent interest in formulating new subtypes of autism, rather than continuing to conceive of ASD as a spectrum, as well as new subtypes that vary in the degree of severity along the spectrum, we identify gaps in knowledge and directions for future work in this complex and growing area.

Maternal behaviours disrupted by Gprasp2 deletion modulate neurodevelopmental trajectory in progeny

Autism spectrum disorders (ASDs) are known to present sex-specific differences. At the same time, understanding how maternal behaviours are affected by pathogenic mutations is crucial to translate research efforts since rearing may recursively modulate neurodevelopment phenotype of the progeny. In this work, we focused on the effects of Gprasp2 deletion in females and its impact in progeny care and development. Female mice, wild-type (WT), Gprasp2+/- (HET) or Gprasp2-/- (KO) mutants and their progeny were used and behavioural paradigms targeting anxiety, memory, maternal care, and other social behaviours were performed. Analysis of communication was carried out through daily recordings of ultrasonic vocalizations in isolated pups and cross-fostering experiments were performed to understand the effect of maternal genotype in pup development. We found that Gprasp2-/- females presented striking impairments in social and working memory. Females also showed disruptions in maternal care, as well as physiological and molecular alterations in the reproductive system and hypothalamus, such as the structure of the mammary gland and the expression levels of oxytocin receptor (OxtR) in nulliparous versus primiparous females. We observed alterations in pup communication, particularly a reduced number of calls in Gprasp2 KO pups, which resulted from an interaction effect of the dam and pup genotype. Cross-fostering mutant pups with wild-type dams rescued some of the early defects shown in vocalizations, however, this effect was not bidirectional, as rearing WT pups with Gprasp2-/- dams was not sufficient to induce significant phenotypical alterations. Our results suggest Gprasp2 mutations perturb social and working memory in a sex-independent manner, but impact female-specific behaviours towards progeny care, female physiology, and gene expression. These changes in mutant dams contribute to a disruption in early stages of progeny development. More generally, our results highlight the need to better understand GxE interactions in the context of ASDs, when female behaviour may present a contributing factor in postnatal neurodevelopmental trajectory.

Socioeconomic determinants of early childhood development: evidence from Pakistan

This study investigates the socioeconomic determinants of early childhood development (ECD) in Pakistan by utilizing the data of sixth wave of the Multiple Indicator Cluster Survey (MICS) conducted in the four provinces of the country. The findings of the study reveal that mother's education, father's education, economic status of the household as measured by household's wealth index quintile, region of residence (province), child's gender, disability, nutrition and the practices used by the adult members of the household to discipline child are important determinants of ECD. The study highlights the crucial role of family background and importance of addressing the issue of malnutrition to foster child development.

Electrophysiological Measures of Listening-in-Noise With and Without Remote Microphone System Use in Autistic and Non-Autistic Youth

OBJECTIVES

This study examined the neural mechanisms by which remote microphone (RM) systems might lead to improved behavioral performance on listening-in-noise tasks in autistic and non-autistic youth.

DESIGN

Cortical auditory evoked potentials (CAEPs) were recorded in autistic (n = 25) and non-autistic (n = 22) youth who were matched at the group level on chronological age ( M = 14.21 ± 3.39 years) and biological sex. Potentials were recorded during an active syllable identification task completed in quiet and in multi-talker babble noise with and without the use of an RM system. The effects of noise and RM system use on speech-sound-evoked P1-N1-P2 responses and the associations between the cortical responses and behavioral performance on syllable identification were examined.

RESULTS

No group differences were observed for behavioral or CAEP measures of speech processing in quiet or in noise. In the combined sample, syllable identification in noise was less accurate and slower than in the quiet condition. The addition of the RM system to the noise condition restored accuracy, but not the response speed, to the levels observed in quiet. The CAEP analyses noted amplitude reductions and latency delays in the noise compared with the quiet condition. The RM system use increased the N1 amplitude as well as reduced and delayed the P2 response relative to the quiet and noise conditions. Exploratory brain-behavior correlations revealed that larger N1 amplitudes in the RM condition were associated with greater behavioral accuracy of syllable identification. Reduced N1 amplitude and accelerated P2 response were associated with shorter syllable identification response times when listening with the RM system.

CONCLUSIONS

Findings suggest that although listening-in-noise with an RM system might remain effortful, the improved signal to noise ratio facilitates attention to the sensory features of the stimuli and increases speech sound identification accuracy.

Social competence in autism: A structural equation modeling approach

Autistic individuals present with difficulties in social competence (e.g., navigating social interactions and fostering relationships). Clinical interventions widely target social cognition and social behavior, but there is inconsistent understanding of the underlying components of social competence. The present study used structural equation modeling to examine social cognition and social behavior and explore the relationship between these latent constructs. Autistic youth (ages 10-17; n = 219) and their caregivers participated in this study. Constructs of social cognition and social behavior were captured using caregiver-report and self-report rating scales, as well as observational measures and direct clinical assessments (e.g., NEPSY-II). Measurement models of social cognition and social behavior demonstrated adequate to good fit. Correlational models demonstrated adequate to poor fit, indicating latent constructs of social cognition and social behavior are not closely related in autistic youth. Exploratory examination of a subsample of male youth (n = 157) evidenced improved model fit of social behavior, specifically. Findings tease apart social cognition and social behavior as cohesive and separable constructs; results do not support a structural relationship between social cognition and social behavior. Noted treatment implications include consideration of how targeting social cognition and social behavior together or separately may support autistic youth's progress toward reaching their identified therapeutic goals and supporting their self-directed social development.

Cross-cultural variation in experiences of acceptance, camouflaging and mental health difficulties in autism: A registered report

Recent findings suggest that stigma and camouflaging contribute to mental health difficulties for autistic individuals, however, this evidence is largely based on UK samples. While studies have shown cross-cultural differences in levels of autism-related stigma, it is unclear whether camouflaging and mental health difficulties vary across cultures. Hence, the current study had two aims: (1) to determine whether significant relationships between autism acceptance, camouflaging, and mental health difficulties replicate in a cross-cultural sample of autistic adults, and (2) to compare these variables across cultures. To fulfil these aims, 306 autistic adults from eight countries (Australia, Belgium, Canada, Japan, New Zealand, South Africa, the United Kingdom, and the United States) completed a series of online questionnaires. We found that external acceptance and personal acceptance were associated with lower levels of depression but not camouflaging or stress. Higher camouflaging was associated with elevated levels of depression, anxiety, and stress. Significant differences were found across countries in external acceptance, personal acceptance, depression, anxiety, and stress, even after controlling for relevant covariates. Levels of camouflaging also differed across countries however this effect became non-significant after controlling for the covariates. These findings have significant implications, identifying priority regions for anti-stigma interventions, and highlighting countries where greater support for mental health difficulties is needed.

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.

Examining the Process and Impact of Social Problem Solving in Autistic Children

Social problem solving (SPS) represents a social cognitive reasoning process that gives way to behavior when individuals are navigating challenging social situations. Autistic individuals have been shown to struggle with specific aspects of SPS, which, in turn, has been related to social difficulties in children. However, no previous work has measured how SPS components not only relate to one another but also discretely and conjointly predict autism-related symptoms and social difficulties in autistic children, specifically. Fifty-eight autistic children (44 male; 6-10 years old, Mage=8.67, SDage=1.31) completed a self-administered, computerized assessment of SPS. To elucidate how SPS components discretely, and combined, contribute to autism-related symptoms and social difficulties, commonality analyses were conducted for each measure assessing autism-related symptoms and social difficulties. Socially normative problem identification, goal preference, and solution preference were related to fewer parent-reported autism-related social difficulties. Measures related to autism symptomatology, social perspective taking, and emotion recognition were not significantly associated with discrete SPS components in this sample. The problem identification aspect of SPS contributed the most unique variance to parent-reported autism-related social difficulties, while shared variance across all SPS components accounted for substantial variance in both parent-reported autism-related social difficulties models. Results suggest that SPS components are interrelated, but distinct, constructs in the autistic population. These findings not only further clarify the impact of SPS components on autism-related symptoms and social difficulties, but also have implications for refining SPS-focused interventions in the autistic population.

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.

Sex modulation of faces prediction error in the autistic brain

Recent research suggests that autistic females may have superior socio-cognitive abilities compared to autistic males, potentially contributing to underdiagnosis in females. However, it remains unclear whether these differences arise from distinct neurophysiological functioning in autistic males and females. This study addresses this question by presenting 41 autistic and 48 non-autistic adults with a spatially filtered faces oddball paradigm. Analysis of event-related potentials from scalp electroencephalography reveal a neurophysiological profile in autistic females that fell between those of autistic males and non-autistic females, highlighting sex differences in autism from the initial stages of face processing. This finding underscores the urgent need to explore neurophysiological sex differences in autism and encourages efforts toward a better comprehension of compensation mechanism and a clearer definition of what is meant by camouflaging.

Perspectives on Autism Spectrum Disorder Diagnosis, Symptoms, Treatment and Gender Roles: A Qualitative Study of Similarities and Differences between Sexes

This study aims to compare the experiences of women and men of different age groups with regard to their first autism spectrum disorder (ASD) diagnosis, symptoms, treatment, and gender roles to inform our understanding in clinical practice of differences as well as similarities. Semi-structured interviews were conducted amongst 22 women (n = 12) and men (n = 10) in three adult age groups regarding their diagnostic process, symptoms, treatment, and gender roles. Participants also filled out questionnaires on gender traits, social support, coping, and quality of life. Framework analysis guidelines were followed to identify subthemes within the three pre-defined key themes of the semi-structured interviews, and quantitative analyses were performed on the questionnaire results. Women often had caregiver roles and were more focused on social and family-oriented life aspects than men. Family and societal expectations may have been different for women from an early age onward and were considered burdensome by some, but not all. Views on ASD diagnosis, symptoms, and treatment were largely individually determined. The questionnaire results mostly showed no significant sex differences. Perceived gender roles differed between participants. In diagnosis and treatment, awareness of general gender differences and gender roles is important, but inter-individual differences and similar experiences in men should not be overlooked.

Promoting Quality of Life: Suggestions for Mental Health Care Providers Working with Young Autistic Adults

There is a growing population of autistic adults in need of supports from a service delivery system that, at present, fails to accommodate their needs adequately and equitably. Unfortunately, there is a shortage of trained behavioral health service providers to meet the needs of young autistic adults. Quality of life (QoL), or one's perception of, and satisfaction with, life in relation to held goals and expectations, has been identified as a key outcome of interest by autistic self-advocates. By supporting autistic clients to hone their strengths and interests, integrate various aspects of their identity, identify goals, and connect to appropriate resources, providers can promote clients' self-knowledge and self-determination, in the service of improving QoL. In this Perspectives article, we offer concrete recommendations to mental health providers, including those who do not specialize in autism, with the goal of supporting implementation of evidence-based strategies that improve QoL and promote self-determination among young autistic clients.

Sexual, physical, and emotional aggression, experienced by autistic vs. non-autistic U.S. college students

ObjectiveTo compare rates of aggression victimization for autistic vs. non-autistic U.S. college students. Participants: n = 1,411 autistic and n = 218,430 non-autistic students from 78 colleges. Methods: We used a three-way interaction term to examine moderation of the relationship between autism and sexual, physical and emotional aggression victimization by depression and sense of belonging. Results: Autistic students were nearly twice as likely as non-autistic students to report past-year emotional victimization (44% vs. 26%, p < 0.001), and more likely to report physical victimization (8.4% vs. 5.7%, p < 0.001). Autistic students who experienced sexual assault were 2.23 times more likely than non-autistic students to report it affected academic performance (80.4% vs. 36.0%, p < 0.001). At both low and high levels of depression, sense of belonging was protective against physical and sexual victimization for autistic students more than for non-autistic students. Conclusions: Institutions of higher education should prioritize preventing and responding to interpersonal aggression against autistic students.

Content Analysis of Abstracts Published in Autism Journals in 2021: The year in Review

PURPOSE

Ever since Leo Kanner first described autism in 1943, the research in this field has grown immensely. In 2021 alone, 5837 SCOPUS indexed documents were published with a title that contained the words: "autism", "autistic", or "ASD". The purpose of this study was to examine the most common topics of autism research in 2021 and present a geographical contribution to this research.

METHODS

We performed a content analysis of 1102 abstracts from the articles published in 11 Autism journals in 2021. The following journals, indexed by the SCOPUS database, were included: Autism, Autism Research, Molecular Autism, Journal of Autism and Developmental Disorders, Research in Autism Spectrum Disorders, Focus on Autism and Other Developmental Disabilities, Education and Training in Autism and Developmental Disabilities, Review Journal of Autism and Developmental Disorders, Advances in Autism, Autism and Developmental Language Impairments, and Autism in Adulthood.

RESULTS

According to the analysis, the main research topics were: mental health, social communication, social skills, quality of life, parenting stress, ADHD, Covid-19, self-efficacy, special education, and theory of mind. In relation to geographic distribution, most studies came from the USA, followed by the UK, Australia, and Canada.

CONCLUSION

Research topics were aligned with the priorities set by stakeholders in autism, most notably persons with autism themselves and their family members. There is a big gap in research production between developed countries and developing countries.

Psychometric Properties of the Dutch Contextual Assessment of Social Skills (CASS): An Independent Observational Outcome Measure of Social Skills in Autistic Adolescents

The goal of this study was to translate and adapt the original 9-item of the Contextual Assessment of Social Skills (CASS) to a Dutch version and assess its psychometric qualities. Autistic adolescents aged 12 to 18 years (n = 99) took part in a randomized controlled trial. In this study, pre-intervention data were utilized. The original CASS was adapted to ensure cultural relevance and the content validity was assessed. Data was used to assess reliability and structural validity, using confirmatory factor analysis. 4-item were added to the CASS during the adaptation to better align with the objectives of the experimental intervention. The original 9-item had inter-item correlations between .01 and .70. The Cronbach's alpha for the original 4-item total score was moderate (α = .69), while for a 7-item total score, it was high (α = .86). This 7-item total score had a sufficient model fit (Comparative Fit Index = .90). This total score had a significant correlation with the Assertion subscale of the Social Skills Improvement System-Adolescent (SSIS-A) (r = 0.26, p < .01), and the Social Responsiveness Scale-2 (SRS-2) total score (r = - .21, p = .04) indicating sufficient convergent validity. The CASS total score was not correlated with the Repetitive and Restricted Behavior scale of the SRS-2 (r = - .08, p = .43), indicating sufficient divergent validity. The Dutch CASS can be considered a conceptually sound and reliable observational instrument for assessing social conversational skills in Dutch autistic youth. Further evaluation of its feasibility when implemented in practice, outside of clinical research, is needed.Trial registration: Dutch trail register NTR6255 (NL6117) 08/02/2017 https://www.trialregister.nl/trial/6117.

Sensory Integration Approaches for Children and Youth in Occupational Therapy Practice

This AOTA Position Statement describes the role of occupational therapy practitioners in providing services to children and youth with a variety of sensory processing patterns and sensory integrative dysfunction. It also serves as a resource for policymakers, funding and reimbursement sources, and caregivers.

Psychosocial factors associated with camouflaging in autistic people and its relationship with mental health and well-being: A mixed methods systematic review

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.

Aging on the Autism Spectrum: Physical Activity in Individuals Receiving State Services in the United States

This study explores factors associated with participation in moderate physical activity and muscle strengthening activity in adults with autism receiving state services (age: 18-78 years). Researchers analyzed the National Core Indicators-In Person Survey (2017-2018) data using multilevel mixed effects logistic regression. Older adults on the autism spectrum engaged in both moderate physical activity and muscle strengthening activity less often than younger adults on the autism spectrum (OR 0.99; p < 0.05; OR 0.98; p < 0.001). Individuals reportedly in fair/poor health had 50% lower odds of engaging in moderate physical activity and 30% lower odds of engaging in muscle strengthening compared to those in good/ excellent health (OR 0.50; p < 0.001; OR 0.70; p < 0.001). Moderate physical activity/muscle strengthening initiatives may help foster this group's healthy aging.

Development and Parasympathetic Regulation in Male and Female Adolescents with Autism Spectrum Disorder: A Two-Timepoint Longitudinal Study

Prolonged dysregulation of the autonomic nervous system (ANS) may increase propensity for physical or psychiatric illness. The current study examined differences in respiratory sinus arrhythmia (RSA) regulation in 215 adolescents with or without autism spectrum disorder (ASD) at Time 1 (T1; 10-13 years old) and 1 year later (Time 2; T2). Linear mixed effects models demonstrated lower RSA regulation in ASD, and a small interaction effect, showing blunted change in RSA from T1 to T2. Developmental differences in RSA regulation were particularly notable in females with ASD and those taking psychotropic medications. Results expand previous findings of reduced parasympathetic regulation in ASD by revealing a blunted developmental slope, indicating diagnostic differences may persist or worsen over time, particularly in females.

Sex Differences on the ADOS-2

The sex difference in the prevalence of autism spectrum disorder (ASD) may be magnified by sex differences on diagnostic measures. The current study compared autistic males and females on items on the gold-standard diagnostic measure, the Autism Diagnostic Observation Schedule, Second Edition (ADOS-2). In a sample of 8-to-17-year old autistic individuals from research (n = 229) and clinical settings (n = 238), females were less likely to show atypicalities on most items related to social-communication behaviors and on total and subscale scores. When controlling for overall intensity of symptomatology, no sex differences survived statistical corrections. Diagnostic criteria and/or gold-standard assessments may be less sensitive to female presentations of ASD and/or autistic females may exhibit fewer or less intense behaviors characteristic of ASD.

A Potential Biomarker of Brain Activity in Autism Spectrum Disorders: A Pilot fNIRS Study in Female Preschoolers

Autism spectrum disorder (ASD) refers to a neurodevelopmental condition whose detection still remains challenging in young females due to the heterogeneity of the behavioral phenotype and the capacity of camouflage. The availability of quantitative biomarkers to assess brain function may support in the assessment of ASD. Functional Near-infrared Spectroscopy (fNIRS) is a non-invasive and flexible tool that quantifies cortical hemodynamic responses (HDR) that can be easily employed to describe brain activity. Since the study of the visual phenotype is a paradigmatic model to evaluate cerebral processing in many neurodevelopmental conditions, we hypothesized that visually-evoked HDR (vHDR) might represent a potential biomarker in ASD females. We performed a case-control study comparing vHDR in a cohort of high-functioning preschooler females with ASD (fASD) and sex/age matched peers. We demonstrated the feasibility of visual fNIRS measurements in fASD, and the possibility to discriminate between fASD and typical subjects using different signal features, such as the amplitude and lateralization of vHDR. Moreover, the level of response lateralization was correlated to the severity of autistic traits. These results corroborate the cruciality of sensory symptoms in ASD, paving the way for the validation of the fNIRS analytical tool for diagnosis and treatment outcome monitoring in the ASD population.

Camouflage and masking behavior in adult autism

Introduction

Autism spectrum disorder (ASD) is characterized by persistent deficits in social communication and social interaction across multiple contexts. Social camouflaging was first shown to be a characteristic of autistic persons, who actively try to disguise and compensate for their autism features in social contexts in an effort to socially blend in better. Recently, an increasing, though still insufficient, number of studies has been conducted on the concept of camouflage; however, different aspect of it, from psychopathology and etiology to its complications and consequences, are not clearly defined. We aimed to systematically review the existing literature on camouflage in autistic adults to describe the correlates of camouflage, motivations for exhibiting camouflage behavior, and the potential impacts of camouflage on the mental health of autistic individuals.

Methods

We followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) checklist guidelines to conduct a systematic review. The databases of PubMed and Scopus, and PsycInfo were searched for eligible studies. Studies were published between January 1st, 1980, to April 1st, 2022.

Results

We included 16 articles, of which four studies were qualitative and 11 were quantitative. One study used a mix method. The assessment tools used for camouflage, the correlates of camouflage including autism severity, gender, age, cognitive profile and neuroanatomical correlates, reasons for camouflage and the impacts of camouflaging behavior on mental health are discussed in this review.

Discussion

In synthesizing the literature, we conclude that camouflage seems to be more common among females who report more autistic symptoms themselves. There may also be some differences between men and women in reasons of exhibiting it and its neuroanatomical correlates. Further research is needed as to why this phenomenon is more prevalent in females with implications for gender related cognitive and neuroanatomical differences. Effects of camouflage on mental health and daily life measures of individuals such as employment, university graduation, relationship, financial status, and quality of life should be studied with more details in future studies.

A comparison of self-report and discrepancy measures of camouflaging: Exploring sex differences in diagnosed autistic versus high autistic trait young adults

Camouflaging describes masking or compensating for autistic traits and/or related difficulties. Some evidence suggests autistic females camouflage more than autistic males, potentially contributing to delayed or missed diagnosis. Studies predominantly adopt self-report measures of camouflaging, potentially reflecting a person's intent to camouflage without accurately measuring effectiveness (i.e., success in fulfilling the intended effect of minimizing the appearance of autistic traits) of camouflaging. Discrepancy scores between underlying cognitive difficulties (e.g., theory of mind) and observed autistic traits (henceforth camoToM ), or between self-reported autistic traits and observed autistic traits (henceforth camoSRS ), may provide a more accurate measure of camouflaging effectiveness. Three measures of camouflaging administered to autistic males (n = 46) and females (n = 40), and adults with equally high levels of autistic traits but no diagnosis (n = 45 males, n = 43 females) recruited from a large population-based sample were compared. Self-report measures of camouflaging were significantly correlated with camoSRS scores only. Both discrepancy scores were correlated with each other. Adults with high autistic traits, but no diagnosis, had higher discrepancy camouflaging scores than diagnosed adults, but self-reported scores were similar. Diagnosed females scored higher than diagnosed males across all camouflaging measures, but no sex difference occurred in the high trait group. This might indicate that autistic females have higher intentions and greater effectiveness when camouflaging, compared with autistic males. For camoSRS only, high trait males scored significantly higher than diagnosed males; no group difference occurred for females. These results suggest that, despite all participants intending to camouflage to some extent, effective camouflaging as measured by discrepancy scores is higher in undiagnosed high autistic trait individuals. One interpretation is that effective camouflaging reduces the likelihood of autism diagnosis in males and females with high autistic traits.

Sex-specific mechanisms for eating disorder risk in men and women with autistic traits: the role of alexithymia

BACKGROUND

A poorly understood relationship exists between eating disorders (ED) and autism spectrum conditions (ASC: henceforth 'autism'). ED are more prevalent in autistic people and people with high autistic traits, and autistic features are prognostic of longer illness. Aiming to understand what increases the risk of ED in relation to autism and autistic traits, previous research has implicated alexithymia as a causal mechanism in this relationship. These studies could not, however, disentangle whether alexithymia explains the relationship between ED pathology and autistic traits directly or through its impact on anxious/depressive symptoms, which in turn result in higher ED symptomatology. Moreover, despite evidence for sex differences in the aetiology of ED, little research has examined the impact of sex on these relationships.

METHODS

Focusing on the association between autistic traits and ED psychopathology, we examined independent mediating effects of alexithymia and anxious/depressive symptoms, as well as sequential mediation effects where alexithymia affects ED psychopathology via its impact on anxious/depressive symptoms. Participants were 198 men and 265 women with formally diagnosed and suspected ED, who completed an online survey of standardised scales.

RESULTS

In men, higher autistic traits were associated with ED psychopathology sequentially via greater alexithymia and through that, greater depressive/anxious symptoms. In women, alexithymia mediated the relationship between autistic traits and ED psychopathology both directly and sequentially through its impact on anxious/depressive symptoms. Interestingly, depressive/anxious symptoms also mediated that relationship independently from alexithymia.

CONCLUSIONS

While cross-sectional, these findings suggest that the relationship between autistic traits and ED symptomatology is mediated by other variables. In support of its proposed role in the aetiology of ED, alexithymia was directly associated with ED symptoms in women. It also affected ED symptoms indirectly, in all participants, via its effect on depressive/anxious symptoms. Interventions focusing on alexithymia may facilitate recovery not only via their effect on ED, but via their effect on other forms of state psychopathology which contribute to the maintenance and development of ED. Sex differences, however, reflect that alternative therapeutic targets for men and women may be beneficial.

Sex Differences in Neurodevelopmental Disorders: A Key Role for the Immune System

Sex differences are prominent defining features of neurodevelopmental disorders. Understanding the sex biases in these disorders can shed light on mechanisms leading to relative risk and resilience for the disorders, as well as more broadly advance our understanding of how sex differences may relate to brain development. The prevalence of neurodevelopmental disorders is increasing, and the two most common neurodevelopmental disorders, Autism Spectrum Disorder (ASD) and Attention-Deficit/Hyperactivity Disorder (ADHD) exhibit male-biases in prevalence rates and sex differences in symptomology. While the causes of neurodevelopmental disorders and their sex differences remain to be fully understood, increasing evidence suggests that the immune system plays a critical role in shaping development. In this chapter we discuss sex differences in prevalence and symptomology of ASD and ADHD, review sexual differentiation and immune regulation of neurodevelopment, and discuss findings from human and rodent studies of immune dysregulation and perinatal immune perturbation as they relate to potential mechanisms underlying neurodevelopmental disorders. This chapter will give an overview of how understanding sex differences in neuroimmune function in the context of neurodevelopmental disorders could lend insight into their etiologies and better treatment strategies.

Examining shortened versions of the Social Responsiveness Scale for use in autism spectrum disorder prediction and as a quantitative trait measure: Results from a validation study of 3-5 year old children

Background

The Social Responsiveness Scale (SRS) is a 65-item measure yielding a continuous score capturing autism-related traits. Scores based on SRS item subsets have been analytically examined but administration of shortened versions has not been evaluated prospectively.

Objective

The goal of this study was to compare psychometric properties of two shortened versions of the SRS to the full 65-item SRS, in young children from both a clinical and general population setting.

Methods

Study participants (aged 3-5 years) were drawn from the AJ Drexel Autism Institute clinic (n = 154) and Kaiser Permanente Northern California (n = 201) and block randomized to receive either the 16-item short SRS, a newly developed computer adaptive testing-SRS, or the published full-length SRS. Total scores across the three SRS administration methods were scaled to facilitate comparisons. Scores were plotted to assess distributional properties, while Receiver Operating Characteristic analysis was used to estimate Area Under the Curve (AUC) and address predictive ability.

Results

Overall, distributional properties of the three administration methods were highly comparable, with shortened measures demonstrating similar ability to capture the range of the distribution and case non-case separation as the full SRS. In addition, AUC values were high (0.91-0.97) and comparable across the administration methods, though there was evidence of difference in predictive ability across measures for females (AUC for full SRS = 0.99 vs. 0.84 for short). Within individual comparisons of short versus full scores (available only for participants at the general population site) suggested underestimation of actual full SRS scores with the CAT-SRS.

Conclusions

Our findings broadly support the construct validity and performance of shortened SRS versions examined here, though the full measure may be needed to more accurately assess traits consistent with ASD diagnosis in females. This work suggests opportunities for collection of ASD-related phenotype in settings where participant burden or feasibility considerations may have otherwise prohibited such measurement.

Levels of Self-representation and Their Sociocognitive Correlates in Late-Diagnosed Autistic Adults

The cognitive representation of oneself is central to other sociocognitive processes, including relations with others. It is reflected in faster, more accurate processing of self-relevant information, a "self-prioritisation effect" (SPE) which is inconsistent across studies in autism. Across two tasks with autistic and non-autistic participants, we explored the SPE and its relationship to autistic traits, mentalizing ability and loneliness. A SPE was intact in both groups, but together the two tasks suggested a reduced tendency of late-diagnosed autistic participants to differentiate between familiar and unfamiliar others and greater ease disengaging from the self-concept. Correlations too revealed a complex picture, which we attempt to explore and disentangle with reference to the inconsistency across self-processing studies in autism, highlighting implications for future research.

Conversational adaptation in children and teens with autism: Differences in talkativeness across contexts

Successful social communication is complex; it relies on effectively deploying and continuously revising one's behavior to fit the needs of a given conversation, partner, and context. For example, a skilled conversationalist may instinctively become less talkative with a quiet partner and more talkative with a chattier one. Prior research suggests that behavioral flexibility across social contexts can be a particular challenge for individuals with autism spectrum condition (ASC), and that difficulty adapting to the changing needs of a conversation contributes to communicative breakdowns and poor social outcomes. In this study, we examine whether reduced conversational adaptation, as measured by talkativeness, differentiates 48 verbally fluent children and teens with ASC from 50 neurotypical (NT) peers matched on age, intelligence quotient, and sex ratio. Participants completed the Contextual Assessment of Social Skills with two novel conversation partners. The first acted interested in the conversation and talked more (Interested condition), while the second acted bored and talked less (Bored condition). Results revealed that NT participants emulated their conversation partner's behavior by being more talkative in the Interested condition as compared to the Bored condition (z = 9.92, p < 0.001). In contrast, the ASC group did not differentially adapt their behavior to the Bored versus Interested context, instead remaining consistently talkative in both (p = 0.88). The results of this study have implications for understanding social communication and behavioral adaptation in ASC, and may be valuable for clinicians interested in improving conversational competence in verbally fluent individuals with autism. LAY SUMMARY: Social communication-including everyday conversations-can be challenging for individuals on the autism spectrum. In successful conversations, people tend to adjust aspects of their language to be more similar to their partners'. In this study, we found that children and teens with autism did not change their own talkativeness in response to a social partner who was more or less talkative, whereas neurotypical peers did. These findings have clinical implications for improving conversational competence in verbally fluent individuals with autism.

Sex differences in automatic emotion regulation in adolescents with autism spectrum disorder

Autism may be underdiagnosed in females because their social difficulties are often less noticeable. This study explored sex differences in automatic facial emotion processing in 45 adolescents with autism spectrum disorder (22 female, 23 male), age 10-16 years, performing active target detection task and Go/NoGo tasks where faces with positive and negative emotional expressions served as irrelevant distractors. The combined sample demonstrated more accurate performance on the target detection (response initiation) than the Go/NoGo task (response inhibition), replicating findings previously reported in typical participants. Females exhibited greater difficulty than males with response initiation in the target detection task, especially in the context of angry faces, while males found withholding a response in the Go/NoGo block with happy faces more challenging. Electrophysiological data revealed no sex differences or emotion discrimination effects during the early perceptual processing of faces indexed by the occipitotemporal N170. Autistic males demonstrated increased frontal N2 and parietal P3 amplitudes compared to females, suggesting greater neural resource allocation to automatic emotion regulation processes. The associations between standardized behavioral measures (autism severity, theory of mind skills) and brain responses also varied by sex: more adaptive social functioning was related to the speed of perceptual processing (N170 latency) in females and the extent of deliberate attention allocation (P3 amplitudes) in males. Together, these findings suggest that males and females with autism may rely on different strategies for social functioning and highlight the importance of considering sex differences in autism. LAY SUMMARY: Females with autism may exhibit less noticeable social difficulties than males. This study demonstrates that autistic females are more successful than males at inhibiting behavioral responses in emotional contexts, while males are more likely to initiate a response. At the neural level, social functioning in females is related to the speed of automatic perceptual processing of facial cues, and in males, to the extent of active attention allocation to the stimuli. These findings highlight the importance of considering sex differences in autism diagnosis and treatment selection.

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.

Greater Social Competence Is Associated With Higher Interpersonal Neural Synchrony in Adolescents With Autism

Difficulty engaging in reciprocal social interactions is a core characteristic of autism spectrum disorder. The mechanisms supporting effective dynamic real-time social exchanges are not yet well understood. This proof-of-concept hyperscanning electroencephalography study examined neural synchrony as the mechanism supporting interpersonal social interaction in 34 adolescents with autism spectrum disorder (50% female), age 10-16 years, paired with neurotypical confederates of similar age. The degree of brain-to-brain neural synchrony was quantified at temporo-parietal scalp locations as the circular correlation of oscillatory amplitudes in theta, alpha, and beta frequency bands while the participants engaged in a friendly conversation. In line with the hypotheses, interpersonal neural synchrony was significantly greater during the social interaction compared to the baseline. Lower levels of synchrony were associated with increased behavioral symptoms of social difficulties. With regard to sex differences, we found evidence for stronger interpersonal neural synchrony during conversation than baseline in females with autism, but not in male participants, for whom such condition differences did not reach statistical significance. This study established the feasibility of hyperscanning during real-time social interactions as an informative approach to examine social competence in autism, demonstrated that neural coordination of activity between the interacting brains may contribute to social behavior, and offered new insights into sex-related variability in social functioning in individuals with autism spectrum disorders.

Diagnostic- and sex-based differences in depression symptoms in autistic and neurotypical early adolescents

LAY ABSTRACT

Depression is more common in autistic adolescents than their neurotypical peers, but the effects of diagnosis and sex on the severity and types of depressive symptoms remain unclear. The study explored diagnostic- and sex-based differences in depressive symptoms in 212 autistic and neurotypical early adolescents. Results show that autism spectrum disorder and female may pose elevated risks, and depressive symptoms related to interpersonal problems and negative self-esteem are more frequent in autism spectrum disorder. Autistic males and females endorsed similar severity and type of depressive symptoms, but unique differences emerged when compared to sex-matched neurotypical peers. Exploratory analyses in a clinical subsample of early adolescents with elevated depressive symptoms (Children's Depression Inventory, Second Edition, Total T-score ⩾60) revealed more endorsement of beliefs of worthlessness in autistic early adolescents. Findings suggest initial intervention targets for treating depression in autistic early adolescents.

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.