The relationship between camouflaging and mental health in autistic children and adolescents

Characteristics of Japanese teenage suicide attempters: a retrospective study comparing suicide attempters with young adults

BACKGROUND

Teenage suicide-related behaviors have been highlighted in Japan in recent years, but the background factors and characteristics of these behaviors have not been clarified. Therefore, we investigated the characteristics of teenage suicide attempters who were admitted to an emergency room.

METHODS

The subjects were suicide attempters in their teens and twenties who were admitted to the Critical Care Medical Center of Nippon Medical School Hospital between January 1, 2010 and December 31, 2021. The means of suicide attempt, sociodemographic data, psychiatric diagnoses, and causes and motives for suicide attempts were retrospectively examined from medical records. Teenage suicide attempters were compared to those in their twenties in regard to the acquired data, and logistic regression analysis was conducted to evaluate the influence on teenage suicide attempts by the aspects that have been shown to be closely associated with teenage suicides.

RESULTS

Among 860 suicide attempters between 2010 and 2021, 59 (6.9%) were teenage suicide attempters and 216 (25.1%) were suicide attempters in their twenties. The large number of females, the history of self-harm, the great number of drug overdoses as a means of attempting suicide, and the large number of individuals with psychiatric disorders, especially with mood disorders and personality disorders, were commonly shared by suicide attempters both in their teens and twenties. On the other hand, family problems, school problems and autism spectrum disorder significantly influenced mostly teenage suicide attempters.

CONCLUSIONS

It was suggested that teenage suicide attempters may have attempted suicide due to environmental difficulties and conflicts about not being able to escape from them. It has become clear that teenage suicide attempters have unique characteristics and background factors, and that it is important to take these into account when taking measures to prevent teenage suicides.

A Multi-Method Approach for the Identification of Social Functioning Profiles in Autistic Adolescents and Young Adults Without Intellectual Disability

Given the diverse nature of the autism spectrum and the complex, context-dependent nature of Social Functioning (SF), this study aims to delineate profiles of SF in young people with autism. Using a multi-method approach, it aims to gain a comprehensive understanding of social difficulties in people with ASD. This study also examines the co-occurrence of mental health issues within these profiles, which can exacerbate social impairments. This understanding is essential for designing interventions and support systems tailored to the specific needs of people with ASD. 49 autistic individuals aged 12 to 30, without intellectual disability were recruited. A combination of measures was used to thoroughly assess SF. Latent profile analysis was employed to identify distinct profiles of social functioning. A control group of 60 non-autistic people served as a reference for these profiles. Mental health difficulties were evaluated through clinical interviews and questionnaires. Two profiles of SF were identified, illustrating two ways of managing the cost of social interactions. Compared to controls, one was more socially withdrawn, spending more time alone, while the other spent a similar amount of time alone but interacted less with others. A different prevalence of mental health problems was observed within these profiles. This study highlighted two SF profiles in young people with ASD, revealing different approaches to managing social interactions. These results show that people with ASD do not have uniform strengths and difficulties of SF, and that mental health problems exert a significant influence on different aspects of SF.

Exploring the association between social camouflaging and self- versus caregiver-report discrepancies in anxiety and depressive symptoms in autistic and non-autistic socially anxious adolescents

LAY ABSTRACT

Social camouflaging or masking refers to strategies autistic individuals adopt to hide their autism persona when trying to fit in. It is unclear whether camouflaging is only applicable to social differences unique to autism, or more generally to any types of social difference, such as experiences of mental health difficulties. We asked 43 autistic and 39 non-autistic adolescents (aged 14-19 years, all of whom showed similarly high levels of social anxiety) and their primary caregivers to complete questionnaires about their mental health (anxiety and depression) and autistic traits, and adolescents self-reported camouflaging behaviours. We wondered if camouflaging may be used to hide mental health difficulties reported by young people and affect caregiver report on symptom severity. We found that adolescents who self-reported greater levels of autistic traits, anxiety and depression symptoms compared with their caregivers reported greater camouflaging. Adolescents who agreed on having high levels of autistic traits and anxiety symptoms with their caregivers reported greater camouflaging behaviours. We discuss how having high levels of autistic traits and anxiety may increase adolescents' camouflaging behaviours to hide social differences, which may contribute towards poor mental health outcomes. We think it is important to talk with adolescents about how camouflaging social and mental health difference can have negative impacts for mental health as well as possible positive social gains.

Pourcain B, Robinson EB, Bourgeron T, Baron-Cohen S, Børglum AD, Martin HC, Warrier V. An axis of genetic heterogeneity in autism is indexed by age at diagnosis and is associated with varying developmental and mental health profiles

There is growing recognition that earliest signs of autism need not clearly manifest in the first three years of life. To what extent is this variation in developmental trajectories associated with age at autism diagnosis? Does the genetic profile of autism vary with age at autism diagnosis? Using longitudinal data from four birth cohorts, we demonstrate that two different trajectories of socio-emotional behaviours are associated with age at diagnosis. We further demonstrate that the age at autism diagnosis is partly heritable (h2 SNP = 0.12, s.e.m = 0.01), and is associated with two moderately correlated (rg = 0.38, s.e.m = 0.07) autism polygenic factors. One of these factors is associated with earlier diagnosis of autism, lower social and communication abilities in early childhood. The second factor is associated with later autism diagnosis, increased socio-emotional difficulties in adolescence, and has moderate to high positive genetic correlations with Attention-Deficit/Hyperactivity Disorder, mental health conditions, and trauma. Overall, our research identifies an axis of heterogeneity in autism, indexed by age at diagnosis, which partly explains heterogeneity in autism and the profiles of co-occurring neurodevelopmental and mental health profiles. Our findings have important implications for how we conceptualise autism and provide one model to explain some of the diversity within autism.

Diurnal cortisol profiles in autistic adolescents and young adults: Associations with social difficulties and internalizing mental health symptoms

Several autism-related characteristics, such as social difficulties, may contribute to high perceived stress and increased exposure to stressful life events in some autistic individuals. Repeated exposure to stress might lead to the dysfunction of the hypothalamic-pituitary-adrenocortical-axis and be a vulnerability factor for developing mental health difficulties. Previous studies show contradictory findings on salivary cortisol in autism. In the current study, we investigated diurnal cortisol profiles in autistic adolescents and young adults, as well as their associations with social difficulties, stress exposure, and mental health symptoms. Autistic (n = 48, Mage = 17.6) and nonautistic (n = 51, Mage = 18.4) participants collected salivary cortisol at home six times a day for 2 days. Social difficulties, exposure to stressful life events/bullying, and mental health symptoms were assessed with questionnaires and clinical interviews. Similar diurnal cortisol slopes (DCS) and cortisol awakening responses were observed between the groups, but autistic participants showed higher total cortisol output (AUCG, area under the curve with respect to ground) during the day (b = 19.09, p = 0.009). In the autistic group, more severe social difficulties were associated with flatter DCS (b = 0.01, p = 0.007). Finally, cortisol alterations were associated with self-reported mental health symptoms, especially in autistic females in analyses uncorrected for multiple comparisons. In conclusion, our results do not indicate autism-related group-level alterations in most diurnal cortisol measures, but autistic youth showed higher total cortisol (AUCG) compared with nonautistic peers. More detailed investigation of interindividual variability in cortisol profiles within autistic people might give us important insights into vulnerability to developing stress-related mental health difficulties.

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.

Cognitive emotion regulation difficulties increase affective reactivity to daily-life stress in autistic adolescents and young adults

LAY ABSTRACT

Previous research has shown that autistic individuals report high levels of perceived stress and have an increased likelihood of developing mental health difficulties. Increase in individuals' negative emotions in relation to perceived stress (i.e. affective reactivity to stress) is a known risk factor for mental health difficulties. In this study, we investigated perceived daily stress and affective reactivity to stress in autistic (n = 39, age = 18.4) and non-autistic (n = 55, age = 18.1) adolescents and young adults. We used the ecological momentary assessment, a technique that allows to assess individuals repeatedly in their daily life using their smartphone. Moreover, participants filled a questionnaire to evaluate the strategies they use to regulate emotions when faced with difficulties. Finally, a clinical interview and a parent-report questionnaire were used to assess mental health symptoms. Autistic youth reported higher levels of perceived daily stress compared with non-autistic peers. Moreover, they showed increased affective reactivity to stress related to their daily activities. Autistic participants reported more emotion regulation difficulties (e.g. more repetitive thinking of difficulties) compared with non-autistic participants. Difficulties in emotion regulation increased negative emotions in relation to stress and might contribute to the severity of mental health symptoms. We conclude that adolescents and young adults with autism report high perceived stress in their daily lives. To minimize the negative impact of stress and the development of mental health symptoms, people supporting autistic young people could focus on stress management skills and the strategies that the youth use to manage emotions.

Differently different?: A commentary on the emerging social cognitive neuroscience of female autism

Autism is a neurodevelopmental condition, behaviourally identified, which is generally characterised by social communication differences, and restrictive and repetitive patterns of behaviour and interests. It has long been claimed that it is more common in males. This observed preponderance of males in autistic populations has served as a focussing framework in all spheres of autism-related issues, from recognition and diagnosis through to theoretical models and research agendas. One related issue is the near total absence of females in key research areas. For example, this paper reports a review of over 120 brain-imaging studies of social brain processes in autism that reveals that nearly 70% only included male participants or minimal numbers (just one or two) of females. Authors of such studies very rarely report that their cohorts are virtually female-free and discuss their findings as though applicable to all autistic individuals. The absence of females can be linked to exclusionary consequences of autism diagnostic procedures, which have mainly been developed on male-only cohorts. There is clear evidence that disproportionately large numbers of females do not meet diagnostic criteria and are then excluded from ongoing autism research. Another issue is a long-standing assumption that the female autism phenotype is broadly equivalent to that of the male autism phenotype. Thus, models derived from male-based studies could be applicable to females. However, it is now emerging that certain patterns of social behaviour may be very different in females. This includes a specific type of social behaviour called camouflaging or masking, linked to attempts to disguise autistic characteristics. With respect to research in the field of sex/gender cognitive neuroscience, there is emerging evidence of female differences in patterns of connectivity and/or activation in the social brain that are at odds with those reported in previous, male-only studies. Decades of research have excluded or overlooked females on the autistic spectrum, resulting in the construction of inaccurate and misleading cognitive neuroscience models, and missed opportunities to explore the brain bases of this highly complex condition. A note of warning needs to be sounded about inferences drawn from past research, but if future research addresses this problem of male bias, then a deeper understanding of autism as a whole, as well as in previously overlooked females, will start to emerge.

A meta-ethnography of autistic people's experiences of social camouflaging and its relationship with mental health

LAY ABSTRACT

Some autistic people describe trying to hide autistic behaviour and seem more neurotypical. Researchers called this 'social camouflaging' and have linked it with mental health difficulties. We used a step-by-step approach to identify research where autistic people talk about social camouflaging to explore the relationship between camouflaging and poor mental health. Thirteen studies were combined. The results describe how society negatively impacts autistic people's mental health, and camouflaging is a way to try and cope with this. Many autistic people find their camouflaging strategies have accidental negative consequences which also affect their mental health. Strategies which seemed 'successful' involved a lot of self-monitoring, were very mentally demanding or were very habitual and seemed to have more of an effect on mental health. This might be important for clinicians who support autistic people with mental health difficulties.

Self-processing and social functioning in autistic preschoolers

There is evidence of weak self-processing in autism spectrum disorder (ASD), including diminished self-reference effects (SREs) in memory. Because smaller SREs in older ASD children and adults are sometimes associated with worse social functioning, we examined this relation for the first time in ASD preschoolers (n = 21). Following a self-performed task, children completed tests of self/other source memory, verbal ability, imitation and mentalizing. Although the ASD children were outperformed on the socio-cognitive measures by non-autistic preschoolers (n = 20), they still showed a significant SRE. Moreover, the SRE, but not the socio-cognitive variables, was a significant predictor of children's social functioning as rated by parents. Larger SREs were linked with better social functioning, while children with stronger autism traits showed no memory advantage for information encoded self-referentially. These findings support previous research showing that self-processing impairments in ASD are mainly apparent for individuals with greater social difficulties.

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.

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.

Ableism, Code-Switching, and Camouflaging: A Letter to the Editor on Gerlach-Houck and DeThorne (2023)

PURPOSE

This letter to the editor is in response to the Gerlach-Houck and DeThorne (2023) epilogue regarding their proposal for speech-language pathologists to offer Autistic code-switching (Autistic masking and camouflage) as a viable, non-ableist social communication tool that Autistic clients may choose to use in "high-stakes" social situations. In connection with Autistic code-switching, the authors reference "the debate" regarding code-switching in "African American Vernacular English speakers," specifically, whether "standard" English should be encouraged as a way to access "conventional forms of success."

CONCLUSION

Professionally training Autistic clients to "code-switch" with the goal of improving the client's chances of accessing conventional forms of success is essentially training Autistic masking and camouflaging. This type of therapy reinforces to both the Autistic client, as well as society, the position that hiding a person's Autistic traits is a pathway to acceptance and success. Autistic camouflaging has detrimental ramifications for mental health outcomes; perpetuates both internalized and societal stigma; hinders bias and discrimination deconstruction; reinforces ableist values; and fails to dismantle power inequities and social barriers that lead to marginalization, oppression, and exclusion.

"I need them for my autism, but I don't know why": Exploring the friendship experiences of autistic children in UK primary schools

Background and aims

Autistic children can experience challenges in making and maintaining friendships, and middle childhood (ages 6-12) may be particularly challenging as social networks become more complex. However, a large proportion of research into these experiences is based on adult reports or focuses on the experiences of adolescents, meaning that the voices of younger children are absent. Due to the exclusion of younger children from research, we have a limited understanding of their first-hand experiences of their friendships and the support they receive, which has implications for friendship support and wellbeing. This study aimed to amplify the voices of younger autistic children to explore their first-hand experiences of friendships and highlight areas of social support which may be most beneficial to primary-aged autistic children.

Methods

This study used novel creative methods to support interviews with 19 autistic primary school-aged children to explore their experiences of friendship. Parent-led interviews and scrapbooks supported the children in discussing the challenges and strengths of their friendships.

Results

Children discussed the challenges and strengths of their friendships including the impact of social norms on the need to have friends and their support needs in this area of life. Children also discussed gaps in their current friendships and how they would like to see these filled. It was clear that not all children required or wanted neurotypical-style friendships, with many valuing companionship and gameplay over intimacy. Analysis highlighted the heterogeneity of autistic children's friendships, especially in relation to gender and age, calling for more tailored and individualized support.

Conclusion and implications

Results from the current study show that autistic children can and do have successful friendships but that these friendships may differ from those of their non-autistic peers. The study further adds to the existing literature by showing that younger autistic children can be included in research by using differentiated, accessible and creative methods, and that they are able to voice their opinions on matters surrounding support. It also calls for a tailored approach to supporting autistic children in school and speaking with children to give them autonomy over the support they want to receive.

Diversity and Classification of Genetic Variations in Autism Spectrum Disorder

Autism spectrum disorder (ASD) is a neurodevelopmental condition with symptoms that affect the whole personality and all aspects of life. Although there is a high degree of heterogeneity in both its etiology and its characteristic behavioral patterns, the disorder is well-captured along the autistic triad. Currently, ASD status can be confirmed following an assessment of behavioral features, but there is a growing emphasis on conceptualizing autism as a spectrum, which allows for establishing a diagnosis based on the level of support need, free of discrete categories. Since ASD has a high genetic predominance, the number of genetic variations identified in the background of the condition is increasing exponentially as genetic testing methods are rapidly evolving. However, due to the huge amount of data to be analyzed, grouping the different DNA variations is still challenging. Therefore, in the present review, a multidimensional classification scheme was developed to accommodate most of the currently known genetic variants associated with autism. Genetic variations have been grouped according to six criteria (extent, time of onset, information content, frequency, number of genes involved, inheritance pattern), which are themselves not discrete categories, but form a coherent continuum in line with the autism spectrum approach.