Understanding the Reasons, Contexts and Costs of Camouflaging for Autistic Adults

Extending Double Empathy: Effects of Neurotype-Matching on Communication Success in an Expository Context

PURPOSE

Milton's theory of double empathy posits that the difference in communication styles between people of different neurotypes contributes to mutual misunderstandings. The current quasi-experimental study seeks to expand on research indicating that matched neurotype pairs tend to communicate more effectively than mixed neurotype pairs by examining communication across and within neurotypes in an expository language context.

METHOD

Thirty autistic adults and 28 nonautistic adults were paired in either a matched neurotype or mixed neurotype condition. The pairs' interactions involved giving and listening to directions to draw an image. Interactions were recorded, transcribed, and coded for communication accuracy, rate, and clarity. Participants also completed a survey about the rapport they experienced in the interaction.

RESULTS

Matched neurotype pairs were significantly more accurate in their communication than mixed neurotype pairs. Rate was fastest among mixed neurotype pairs, but clarity did not differ significantly across conditions. Matched autistic pairs reported significantly lower rapport than other pairs.

CONCLUSIONS

This finding lends further support to the neurodiversity model by demonstrating that autistic communication is not inherently deficient. Further research is necessary to investigate a variety of influences on rate, clarity, and rapport development. Clinical implications include considerations for neurodiversity-affirming communication supports for expository contexts such as classroom directions or workplace instructions.

Game Changer: Exploring the Role of Board Games in the Lives of Autistic People

This mixed methods paper reports findings from three studies examining the overlap between autism and hobbyist board gaming. The first was a quantitative survey of over 1600 board gamers, showing that autistic individuals are overrepresented in this hobby compared to the general population and that autistic traits measured by the AQ are significantly elevated amongst board gamers. Study 1 also assessed gamers' motivations and preferences and reported key differences as well as similarities between autistic and non-autistic gamers. The second was a qualitative study that reported the results of 13 interviews with autistic individuals who are hobbyist board gamers. Using Interpretive Phenomenological Analysis (IPA), four key themes were uncovered, including a preference for systemising, escapism and passions, the social lubrication effect of games and difficulties with deception. In the third, 28 autistic individuals were introduced to board games in groups of 5-10 over an afternoon. Subsequent focus groups were then analysed using IPA. This analysis uncovered themes around how board games are challenging but encouraged growth and how they were an alternative vehicle for forging social relationships. Through this paper, we discuss how and why board games may be a popular hobby amongst the autistic population, and its potential utility for improving autistic wellbeing.

Herpertz S, Fuchs T. Emotion recognition in autism spectrum condition during the COVID-19 pandemic

LAY ABSTRACT

In the COVID-19 pandemic, wearing face masks became mandatory to prevent the spread of the virus. However, they restrict the ability to recognize emotions to the upper part of the face. Since individuals with autism spectrum condition often tend to look at the lower half of the face, they may be particularly restricted in emotion recognition by people wearing masks, since they are now forced to look at the upper half of the face. The current study compared the recognition of facially expressed emotions between individuals with and without autism spectrum condition. Each photo was shown in three types, once uncovered, once with face mask, and once with sunglasses. Our results revealed a reduction in accuracy of individuals with autism spectrum condition at recognizing emotions in all three stimulus types and exhibited more difficulties distinguishing anger, fear, pride, and embarrassment. During the emotion recognition task, there was no difference in which facial areas the groups looked at. We did not find evidence that the disadvantages of individuals with autism spectrum condition in emotion recognition were due to looking at different areas of the face.

Evaluating an Autistic Burnout Measurement in Women

This study evaluated the suitability of an unpublished autistic burnout assessment tool, focusing on autistic women. Distinguishing autistic burnout from conditions like depression or anxiety is crucial for effective interventions, emphasizing the need for nuanced research and refined measures in understanding and addressing autistic burnout. The Dutch version of the AASPIRE Autistic Burnout Measure (AABM-NL) was evaluated within a sample of 45 autistic women from the Autism Expertise Center. Preliminary findings of the AABM-NL scores demonstrated promising evidence of good internal consistency and convergent validity. Positive associations were observed between AABM-NL scores and a Likert scale assessing identification with autistic burnout, as well as with an instrument measuring physical and psychological complaints (SCL-90-R; Symptom Checklist-90-Revised). Specifically, anxiety, somatization, cognitive-performance deficits, and depression were correlated with the severity of autistic burnout. There was no significant difference between work status and the severity of autistic burnout, implying no employment-related connection. The AABM-NL effectively differentiated between women with and without autistic burnout, with 62 points as a suitable cut-off point. However, these results may not be generalized to women requiring daily living support, individuals beyond outpatient psychiatric settings, or those in institutionalized populations. The preliminary findings provide empirical evidence supporting the use of the AABM-NL as a potential tool for assessing autistic burnout in women receiving outpatient psychiatric care. Its implementation may contribute to programs aimed at recognizing and preventing autistic burnout in women. Further research is needed to enhance intervention strategies for mitigating the risk of autistic burnout.

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.

The Classroom Communication and Collaboration Appraisal: A Comprehensive Tool for Assessing Communication and Collaboration in Classroom Environments

PURPOSE

The aim of this research note is to introduce a new appraisal form, the Classroom Communication and Collaboration (C3) Appraisal, designed to evaluate communication and collaboration within classroom settings.

METHOD

A comprehensive synthesis of the key skills from a broad range of publications on successful communication and collaboration in the classroom was conducted. The resulting appraisal comprises 39 items across six scales: crafting clear messages, appropriateness of communication exchange, active listening, pragmatics and discourse, communication breakdown, and collaboration. To demonstrate its application, an exemplar usage of the C3 Appraisal involving a hearing child and a child with hearing loss engaged in a collaborative learning task is presented.

RESULTS

The C3 Appraisal allowed for the quality and successfulness of the collaborative learning task between the two children to be assessed and quantified across the six scales.

CONCLUSIONS

These findings highlight the utility of the C3 Appraisal as a valuable tool for evaluating communication and collaboration in classroom environments. Next steps are to test the reliability and validity of the C3 Appraisal on a large data set.

"A perfect storm": Autistic experiences of menopause and midlife

LAY ABSTRACT

Previous studies report that menopause can be a very difficult transition for some autistic people. This study focuses on how autistic people experience menopause and what support and information might help them. Autistic Community Research Associates played an important role in the research and co-authored this article. We held four focus groups and eight interviews online with 24 autistic participants who lived in either Canada (n = 13) or the United Kingdom (n = 11). We analysed participant conversations using a method called reflexive thematic analysis. Participants described many intense challenges during menopause. Four themes and eight subthemes were identified across participant groups: (1) Complexity, multiplicity and intensity of symptoms (0 subthemes); (2) Life experience and adversity converging at midlife (three subthemes); (3) The importance of knowledge and connection (two subthemes); and (4) Barriers to support and care (three subthemes). The experiences of our participants may not be the same as other autistic people, and the study could have been more inclusive of diverse autistic groups. However, hearing about the experiences of others may provide reassurance to autistic people who struggle with menopause and let them know they are not alone.

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.

Brief Report: Self-Reported Medication Use in Individuals Diagnosed with Autism Spectrum Disorder in Adulthood: A U.S. Clinic Sample from 2012 to 2022

PURPOSE

As the understanding of autism spectrum disorder (ASD) across the lifespan has increased, so has the number of individuals being identified with ASD for the first time in adulthood. Understanding co-occurring psychiatric conditions in this subset of the ASD population is a growing focus of research; however, little is known about the rate at which psychiatric medications are prescribed to adults with a first-time diagnosis of ASD. The purpose of this study was to examine self-reported medication use in persons diagnosed with ASD in adulthood in a clinic sample (2012-2022) in the United States.

METHODS

The present study was a retrospective record review. Participants (n = 281) were drawn from an outpatient clinic specializing in the diagnosis of ASD in adults. Participants self-reported previous and current psychiatric medication prescription using a medication checklist.

RESULTS

Approximately 50% of participants self-reported being prescribed at least one psychiatric medication at the time of their initial evaluation appointment. The most commonly prescribed psychiatric medications were antidepressants (23.8%), followed by stimulants (16.7%).

CONCLUSION

Similar to individuals diagnosed with ASD in childhood, those identified with ASD for the first time in adulthood are prescribed psychiatric medication at a much higher rate than their same-age non-autistic peers. These results can inform future research and practice for improving outcomes for autistic adults, particularly those who were undiagnosed for much of their lives.

Autism and the Case Against Job Interviews

Unemployment rates among autistic people are high even among those with low-support needs. While a variety of measures is needed to address this problem, this article defends one that has not been defended in detail and that has profound implications for contemporary hiring practices. Building on empirical research showing that job interviews are a major contributor to autistic unemployment, it argues that such interviews should be abolished in many cases for autistic and non-autistic people alike.

Social Functioning in Children and Adolescents with ADHD and Autism Spectrum Disorder: A Cross-Disorder Comparison

OBJECTIVE

Social functioning can be defined according to three main components: social perception, social performance, and social knowledge. Although they are important in daily life relationships and in children's adaptation, these components have never been tested together in children and adolescents with Attention Deficit/Hyperactivity Disorder (ADHD) or with Autism Spectrum Disorder (ASD) using lab-based tasks. The present study used a cross-disorder approach to compare the performance of children with ADHD and ASD and non-diagnosed (ND) peers utilizing a task that involves these three fundamental social functioning components.

METHODS

Two hundred and twenty-five Italian children (86% boys) aged between 8 and 16 (66 with a clinical diagnosis of ADHD; 51 with a clinical diagnosis of ASD, level 1; 108 ND children) were enrolled. The three groups were matched for age, gender, and IQ. Social functioning was assessed using a lab-based task, including videos of problematic interactions among peers, created ad hoc for the study, and a semi-structured interview based on the Social Information Processing model.

RESULTS

Data were analyzed using one-way ANOVAs and multinomial mixed effects models. Our findings suggested that both groups with ADHD and ASD presented social functioning difficulties in comparison to ND children. However, a different pattern of performance emerged. Children with ADHD showed higher difficulties in social performance than those with ASD, whereas autistic children revealed more difficulties in social perception and in some aspects of social knowledge.

CONCLUSIONS

Our findings have important clinical implications for assessment, intervention, and differential diagnosis, and should encourage clinicians to investigate different aspects of social functioning and identify specific strengths and weaknesses in each social profile.

'Most people have no idea what autism is': Unpacking autism disclosure using social media analysis

LAY ABSTRACT

Autism disclosure - that is sharing their autism diagnosis or identity with a person or people - is a difficult decision for many autistic people. While telling people they are autistic can be positive and helpful, it can also create a lot of problems. What we have learnt is that disclosure is really complicated. Rather than asking research participants questions about what might happen, we looked at what people were saying on public social media posts (Reddit and Twitter) about what did happen. We used three years of posts that were related to autism disclosure from a wide range of adults (autistic and non-autistic). Four main ideas were created from our data, with the key finding being that society does not understand autism. This lack of understanding creates problems for autistic people in work, dating, healthcare and mental health. The remaining ideas were that autistic people should have privacy and be treated with respect, that autistic representation can help society and that non-autistic people need to do more to help autistic people. Our findings support that society needs to do more through autism advocacy, better media representation and more public role models. Increasing the accuracy of understanding of autism across society will mean that autistic people can feel safer to disclose if they want to.

Perceived misdiagnosis of psychiatric conditions in autistic adults

Background

Many autistic people, particularly women, do not receive an autism diagnosis until adulthood, delaying their access to timely support and clinical care. One possible explanation is that autistic traits may initially be misinterpreted as symptoms of other psychiatric conditions, leading some individuals to experience misdiagnosis of other psychiatric conditions prior to their autism diagnosis. However, little is currently known about the frequency and nature of psychiatric misdiagnoses in autistic adults.

Methods

Using data collected in the first half of 2019 from an ongoing longitudinal register of autistic adults in the Netherlands, this study explored the frequency of perceived psychiatric misdiagnoses before receiving an autism diagnosis. Gender differences were also explored. A sample of 1211 autistic adults (52.6% women, mean age 42.3 years), the majority of whom were Dutch and relatively highly educated, was evaluated.

Findings

Results showed that 24.6% (n = 298) of participants reported at least one previous psychiatric diagnosis that was perceived as a misdiagnosis. Personality disorders were the most frequent perceived misdiagnoses, followed by anxiety disorders, mood disorders, chronic fatigue syndrome/burnout-related disorders, and attention-deficit/hyperactivity disorder. Autistic women (31.7%) reported perceived misdiagnoses more frequently than men (16.7%). Women were specifically more likely than men to report perceived misdiagnoses of personality disorders, anxiety disorders, and mood disorders. Women also reported prior psychiatric diagnoses more often in general (65.8% versus 34.2% in men). Within the group of individuals with a prior diagnosis, perceived misdiagnoses were equally likely for men and women.

Interpretation

One in four autistic adults, and one in three autistic women, reported at least one psychiatric diagnosis, obtained prior to being diagnosed with autism, that was perceived as a misdiagnosis. Inaccurate diagnoses are linked to long diagnostic pathways and delayed recognition of autism. These findings highlight the need for improved training of mental health practitioners, in order to improve their awareness of the presentation of autism in adulthood and of the complex relationship between autism and co-occurring conditions. The current study constitutes a first step towards showing that autistic adults, and particularly women, may be at greater risk of experiencing misdiagnoses. Future studies based on larger, more representative samples are required, to replicate current findings and provide more reliable estimates of the overall frequency of misdiagnoses as well as the frequency of misdiagnoses for specific psychiatric conditions.

Funding

This study was made possible by funding from the Netherlands Organisation for Health Research and Development (ZonMW), project number 60-63600-98-834.

Camouflaging in Autism: Age Effects and Cross-Cultural Validation of the Camouflaging Autistic Traits Questionnaire (CAT-Q)

Given that camouflaging has been suggested to contribute to delayed diagnosis and mental health problems among autistic people, validated measures of the construct are needed. This study describes the psychometric evaluation of the Swedish adaptation of the self-reported Camouflaging Autistic Traits Questionnaire (CAT-Q) in autistic (n = 100) and general population (n = 539) samples aged 10 to 83 years. Analyses indicated good-to-excellent internal consistency and test-retest reliability. Construct validity was supported by autistic participants scoring higher than non-autistic, and autistic females scoring higher than autistic males on the measure. Also as expected, camouflaging was associated with theoretically linked traits, including autistic behaviors and depressive symptoms. On the other hand, the factor structure of the original CAT-Q did not provide a good fit in the Swedish data set, and validity issues were found, particularly in children younger than 15 years, warranting further investigation of the construct validity of the scale. Different age trajectories were observed, where camouflaging behaviors decreased during adulthood in non-autistic people but remained at an elevated level among autistic people.

Understanding the post-diagnostic support priorities of autistic adults in the United Kingdom: A co-produced modified Delphi study

LAY ABSTRACT

Autistic adults in the United Kingdom report that support for themselves and their peers is not suitable for their needs. There has been an increase in adults receiving an autism diagnosis, which many have reported as having a positive impact on their lives. However, the lack of support and understanding after diagnosis, combined with long wait times for an assessment to obtain a diagnosis and to access follow-on support, is having a negative impact on people's lives. This study took place to find out what support autistic people need and want after receiving their diagnosis. It was co-designed with a group of 10 autistic adults which means that the researchers and group members collaboratively designed the research. For the study, 43 autistic adults, diagnosed aged 18 or older, completed three questionnaires. A fourth questionnaire followed that was completed by 139 autistic people who received their diagnosis in adulthood. These questionnaires aimed to help people identify their own priorities when it came to the support they would have liked to receive after being given their autism diagnosis. Participants ranked access to support where they live, training of professionals, support to process the impact of a late diagnosis, use of their preferred mode of contact and a personalised support plan as their top priorities. This demonstrates that local support is highly valued by autistic adults, as are well-trained professionals who offer a range of contact options, support to process a late-in-life autism diagnosis and help to develop and implement support plans.

Dropping the mask: It takes two

LAY ABSTRACT

In some situations, autistic people feel pressure to change their social behaviour by camouflaging. In other situations, autistic people feel they don't need to change their social behaviour. Instead, they feel they can socialise in ways that feel authentic or true to themselves. Past research has tended to focus on autistic people's experiences of camouflaging rather than their experiences of authenticity. In this study, we asked autistic people what it is like for them when they can socialise in ways that feel authentic or true to themselves. Autistic people described authentic-feeling socialising as more free, spontaneous and open than camouflaging. In supportive environments, this kind of socialising had more positive and less negative consequences than camouflaging. Autistic people felt that having self-awareness and acceptance of their own social needs and being around autistic and nonautistic people who were accepting and understanding helped them to socialise in authentic-feeling ways. Autistic people also spoke about communication behaviours they felt nonautistic people should use to help overcome misunderstandings and create autism-friendly social environments. These findings suggest it is helpful for autistic people to have access to supportive and accepting social environments in which they feel able to socialise in ways that feel authentic to them. In creating such social environments, it is important to focus on nonautistic people's knowledge and attitude towards autistic people and also their ability to use helpful communication behaviours.

"Survival classes for a neurotypical world": What French autistic adults want and need after receiving an autism diagnosis

LAY ABSTRACT

Adults receiving an autism diagnosis might not react the same depending on their countries or cultures. We also know that autistic people are rarely asked what they think would be best for them following this diagnosis. In this study, we asked 12 French autistic adults about their experiences of receiving an autism diagnosis as well as what they thought might be useful afterwards. Overall, we found that some experiences were similar to experiences related by English or American participants, but some were specific to the French culture, suggesting that such research should expand into new territories and cultures, especially non-European ones. Our participants also had quite a few ideas as to what would be useful for people in the same situation. Some of the suggestions can be put into action by peers and professionals alike, while others are wishes relating to how our participants would like society to behave toward them and people like them, for example. This article allows for a better comprehension of how cultural differences can impact the experience of receiving an autism diagnosis as an adult and provides some insight into what these adults want and desire following such a diagnosis.

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.

Meaningful Social Inclusion and Mental Well-Being Among Autistic Adolescents and Emerging Adults: Protocol for a Community-Based Mixed Methods Study

BACKGROUND

In the United States, autistic people face high rates of co-occurring mental illnesses and premature death due to self-harm, which are indicators of threats to mental well-being. Social inclusion may enhance mental well-being and resilience among autistic people. According to Simplican and colleague's (2015) model of social inclusion for people with intellectual and developmental disabilities, social inclusion is an interaction between community participation and interpersonal relationships. There is limited research on social inclusion that includes the integration of interpersonal relationships and community participation among autistic people or the impact of social inclusion on the well-being of autistic people. Additionally, little evidence exists regarding how autistic people prefer to be included in the community or form interpersonal relationships.

OBJECTIVE

The long-term objective of this project is to improve social inclusion factors to support the mental well-being of autistic people. This protocol describes a community-based, mixed methods pilot study to develop a definition of meaningful social inclusion for autistic people and to understand the relationship between meaningful social inclusion and mental well-being among autistic adolescents and emerging adults.

METHODS

The project uses a community-based, sequential mixed methods design with a formative phase (Phase 1) that informs a survey phase (Phase 2) and concludes with a process evaluation of the community engagement process (Phase 3). During Phase 1, we will recruit 10 community partners (autistic adults and stakeholders) and conduct sharing sessions to cocreate a definition of meaningful social inclusion and a survey of meaningful social inclusion and well-being. During Phase 2, we will recruit 200 participants (100 autistic adolescents and emerging adults and 100 caregivers) to complete the survey. We will examine whether meaningful social inclusion predicts well-being given sociodemographic factors using ordered logistic regression, with well-being categorized as low, medium, and high. During Phase 3, the community partners from Phase 1 will complete a survey on their experiences with the project.

RESULTS

Ethics approval was obtained for this project in March 2023. We have recruited community partners and started the Phase 1 focus groups as of September 2023. Phase 2 and Phase 3 have not yet started. We expect to complete this study by March 2025.

CONCLUSIONS

Using a community-based, mixed methods approach, we intended to develop a definition of meaningful social inclusion for autistic people and understand the role meaningful social inclusion plays in the well-being of autistic people.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

PRR1-10.2196/52658.

The Social Validity of Behavioral Interventions: Seeking Input from Autistic Adults

Many in the autistic community have expressed concerns regarding the use of behavioral interventions with autistic children, suggesting that these interventions may not be socially valid. Though behavioral interventions have evolved to be more naturalistic and child-centered, little structured research has been done to explicitly seek autistic perspectives on the acceptability of specific components of behavioral interventions. Autistic adults (N = 235) were recruited online to take the Autism Intervention Attitudes Scale (AIAS), a questionnaire designed to gather feedback on common intervention goals and practices. Results indicate that participants find goals and practices that highlight quality of life, safety, and autistic interactions acceptable, while those that focus on normalization based on neurotypical standards are not. An exploratory graph analysis revealed three communities of goals ("uncontroversial goals", "controversial goals", and "social goals"). Comparison between naturalistic and structured intervention components additionally showed that autistic participants favored naturalistic strategies. These findings are in line with known criticisms of behavioral intervention from autistic adults, but also provide more information on the specific ways in which behavioral interventions can be reformed. This information can guide professionals in the development of appropriate goals and decisions around intervention planning.

Understanding the relationship between social camouflaging in autism and safety behaviours in social anxiety in autistic and non-autistic adolescents

BACKGROUND

Social camouflaging (hereafter camouflaging) in autism includes factors such as masking and compensating for one's neurodevelopmental differences, and to assimilate or 'fit in' with non-autistic peers. Efforts to hide one's authentic self and autism traits (masking) resemble impression management (IM) in safety behaviours identified in Clark and Wells' (1995) cognitive model of social anxiety (SA). This study explores the relationship between camouflaging in autism and safety behaviours in SA among autistic and non-autistic adolescents.

METHODS

One hundred fifteen adolescents (14-19 years) with (n = 61; 36 female) and without (n = 54; 37 female) a clinical diagnosis of autism matched on age and SA symptom severity were recruited from clinics, schools and online. Adolescents completed online measures including autism traits, SA symptoms, camouflaging behaviours, SA-related safety behaviours and SA-related negative cognitions. Partial and bivariate Pearson's correlations and structural equation modelling were used to understand the relationship between camouflaging, safety behaviours, autism traits and SA in both groups. Exploratory factor analysis assessed item-level factor cross-loadings between camouflaging and safety behaviours.

RESULTS

Across both groups, masking and IM were significantly associated with SA symptom severity, not autism traits, via SA-related social cognitions. Exploratory factor analysis indicated construct overlap across masking, assimilation, IM and avoidance behaviours and identified factors analogous to self-focused attention, social avoidance and mental rehearsal identified in the Clark and Wells' (1995) model of SA.

CONCLUSIONS

This is the first study using group-matched design to identify that masking (factor in social camouflaging) and IM both relate to SA in autistic and non-autistic adolescents. Assessment and formulation of construct overlap between masking and IM may inform psychoeducation and adaptation of SA treatment for autistic adolescents.

Autistic adults' inclination to lie in everyday situations

LAY ABSTRACT

Differences in social communication and understanding others' mental states may mean that autistic adults are less likely to deceive others than non-autistic individuals. We investigated whether autistic and non-autistic adults differ in their inclination to lie and which psychological factors are involved in the inclination to lie. We found that autistic and non-autistic groups reported a similar inclination to lie, and the extent to which participants viewed lying as acceptable helped to explain their inclination to deceive others. However, the other underlying psychological factors associated with deception inclination differed between autistic and non-autistic groups. Autistic adults' belief about their ability to lie and also how quickly they could lie helped to explain whether they were more or less inclined to lie. For non-autistic adults, their memory and ability to understand others' mental states helped to explain their lie inclination. We discuss these findings and recommend areas for future research.

Leveling Up Dialectical Behavior Therapy for Autistic Individuals with Emotion Dysregulation: Clinical and Personal Insights

Autistic people may experience high emotion and sensory sensitivities and a slow return to baseline emotional state. Dialectical behavior therapy (DBT) was developed to address reactivity, impulsivity, and mood dysregulation in individuals with mood and personality disorders. DBT may be therapeutically beneficial to autistic individuals struggling with these or similar emotional and sensory challenges. This article is a synthesis of the first author's experiences of DBT as an autistic person and professional insights from all authors. We provide an overview of the development of DBT, its foundational components, and adaptations. Using this basis, the first author describes the benefits DBT has had, the modifications that have helped him, and how those modifications may enhance DBT for autistic people. Modifications include visuals, graphics, and a gaming format that target the client's personal interests. The essence of these alterations is to transform life skills and DBT skills into something meaningful and functional. Receptivity of the therapist to the modifications and neurodivergent problem solving may be foundational to therapeutic success. Client-initiated contributions in collaborative therapy may improve autistic participants' understanding, validation, and adherence with DBT. The authors suggest expanding work on DBT modifications for autism in the areas of daily self-monitoring, assessing for preferred visual and gaming formats, and utilizing personal interests.

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.

'Who, When, How to Share': Pilot study of a new disclosure decision-making programme for autistic adults

LAY ABSTRACT

'Who, When, How to Share' is a new programme that aims to support autistic adults in making decisions around sharing their autistic identity with others. The programme involves working through a self-help guide independently over 3 weeks with optional peer support. We wanted to find out if autistic adults would join the programme and find it useful. Thirty-two autistic adults took part in the programme and 19 of them completed it. Most participants who completed the programme liked the programme and found it helpful, but some felt that they needed more time and support to complete it. They suggested that the programme would be more accessible if it was more interactive, such as including videos and other ways to gain feedback on their progress. Surveys filled in by participants before and after the programme suggested that they became more confident and less stressed about sharing their autistic identity with others, but some felt they still needed to build more confidence in order to handle negative attitudes from others. More work is needed to improve and test the programme further.

Longitudinal Follow-Up Study of Social Intervention Outcomes for Children on the Autism Spectrum

A prior randomized trial found a school social intervention yielded significantly better outcomes (social and autism features) immediately following intervention compared to typical school programming (services-as-usual [SAU]) for children on the autism spectrum. In that study, children in the SAU condition subsequently completed a summer social intervention. This study tested longer-term maintenance of effects for children who completed both interventions. A total of 103 children (ages 6-12 years) on the autism spectrum enrolled and 102 completed the initial RCT. Following the summer social intervention, 90 children from the original RCT completed the longer-term follow-up study. In addition to baseline and posttest in the initial RCT, children from both groups were tested at three follow-up points (five total testing points). At the time of first longitudinal follow-up testing, the children were 1.25-4.25 years post-intervention (ages 8-15 years). Longitudinal multilevel model analyses (and follow-up contrasts) revealed significant improvements for both groups post-intervention on measures of emotion recognition, autism features, and social skills, indicating maintenance of post-intervention improvements over the three follow-up testing points. No between-group differences were found for autism features or social skills over time; however, the school social intervention may have yielded somewhat better emotion recognition skills. Exploratory tests found that child IQ, language level, and length of time since completing the intervention did not moderate outcomes. Both social interventions yielded positive and durable longer-term improvements for children on the autism spectrum. [ClinicalTrials.gov, NCT03338530; November 8, 2017; original retrospectively registered trial].

Social Validity of Pivotal Response Treatment for Young Autistic Children: Perspectives of Autistic Adults

The social validity of autism behavioral intervention has been questioned. Naturalistic Developmental Behavioral Interventions (NDBIs) attempt to address some concerns, but it is unclear whether autistic people consider NDBIs socially valid. Social validity of an NDBI, Pivotal Response Treatment (PRT), was investigated through autistic adults commenting on videos of autistic children receiving PRT. Qualitative coding of responses generated three themes: respect for individuals; assessment of intervention implementation; and socioemotional considerations. Although video brevity limits the scope of the present study's conclusions, participants highlighted PRT components that appeared socially valid (e.g., reinforcing attempts, following the child's lead) and aspects appearing invalid (e.g., overemphasis on spoken language). Therefore, adjustments appear necessary for PRT to be fully acceptable to the autistic community.

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.

A dual design thinking - universal design approach to catalyze neurodiversity advocacy through collaboration among high-schoolers

Introduction

Neurodiversity describes the fact that humans all have different brains with unique qualities that contribute to society. Though understanding of neurodiversity is gaining traction among the general public, there remains considerable stigma and prejudice toward neurodiverse people. One way to combat these issues is to teach individuals about neurodiversity and encourage them to develop advocacy skills. Development of such knowledge is especially important for adolescents, as they have the capacity to make small (e.g., interpersonal interactions) and large (e.g., school-wide) impacts.

Methods

Eighty-nine high schoolers participated in a two-week virtual summer camp in 2022; research consent/assent was obtained from 19 (11 neurodiverse/neurodivergent). Campers learned about neurodiversity, Universal Design for Learning (UDL), and Design Thinking (DT) through lectures from researchers and neurodivergent people, as well as group activities and discussions. Campers worked in small groups to design a neurodiversity advocacy project based on the principles of UDL and DT. Each group was facilitated by camp counselors-some of whom were neurodiverse-who were all committed to neurodiversity advocacy. Participants completed questionnaires about autism, ADHD, and dyslexia pre- and post-camp. Some also completed optional post-camp interviews.

Results

Pre-camp stigma toward neurodiverse conditions was generally low. However, autism stigma was significantly higher than dyslexia stigma (Z = -2.24, p = 0.025). After camp, autism stigma decreased (Z = -2.98, p = 0.003;) and autism [t(13) = 3.17, p = 0.007] and ADHD [t(13) = 2.87, p = 0.013] knowledge improved. There were no significant changes in ADHD or dyslexia stigma or dyslexia knowledge. Participants reported enjoying collaborating with other campers and learning about UDL and DT. Thematic analysis of interviews generated four themes: Increased Understanding of Neurodiversity; Increasing Empathy and Becoming Less Judgmental; Creating a Neurodiverse Community; and More Awareness is Needed.

Discussion

This pilot investigation suggests that a virtual summer camp can be effective in improving attitudes toward and knowledge of neurodiversity. Qualitative analysis indicated participants became more accepting after the camp, both in terms of being less judgmental toward neurodiverse people and more self-accepting among neurodivergent campers. Future research should investigate the long-term effects of such a program, particularly with diverse samples of students.

Compassion focused therapy for self-stigma and shame in autism: a single case pre-experimental study

Introduction

Exposure to public stigma can lead to the internalization of autism-related stigma (i.e., self-stigma), associated with negative health, occupational and social outcomes. Importantly, self-stigma is linked to shame and social isolation. Although elevated self-stigma has been reported in autistic adults, to the best of our knowledge, interventions designed to target this issue are lacking. Compassion is an effective way to reduce the emotional correlates of self-stigma (i.e., shame) and their impacts on mental health. However, no study has investigated whether compassion focused therapy (CFT) can effectively reduce self-stigma in autistic adults. The present study aims at investigating whether and how self-compassion improvement following CFT may reduce self-stigma and shame in an autistic individual.

Methods

A single case pre-experimental design (SCED) was used with weekly repeated measures during four phases: (i) pure baseline without any intervention (A), (ii) case conceptualization (A'), (iii) intervention (B) where CFT was delivered, (iv) follow-up without intervention (FU). The participant is a 46-year-old autistic man with high self-stigma and shame. Self-report measures of self-compassion and self-stigma and a daily idiographic measure of shame were used.

Results

There was a large increase in self-compassion between pure baseline (A) and the intervention phase (A'B) (Tau-U = 0.99), maintained at follow-up. Similarly, there was a moderate decrease of self-stigma (Tau-U = 0.32). In contrast, when we compared the whole baseline phase AA' (i.e., considering the conceptualisation phase as baseline) to the intervention (B), there was no change in self-stigma (Tau-U = -0.09). There was no change in self-stigma between the intervention (B) and follow-up (Tau-U = -0.19). There was a moderate decrease in daily shame reports between the baseline (AA') and the intervention (B) (Tau-U = 0.31) and a moderate decrease between the pure baseline (A) and intervention phase (A'B) (Tau-U = 0.51).

Conclusion

CFT was feasible for this autistic client and our results show that CFT led to the improvement of self-compassion. Changes on self-stigma measures were moderate. Self-stigma may need more time to change. Because self-stigma is involved in poorer social functioning and mental health in autistic adults, our results are promising and suggesting conducting more large-scale studies on CFT in autistic adults.

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

BACKGROUND

To examine the relationship between social camouflage and mental health in Japanese autistic adults and make an international comparison with a sample from the UK.

METHODS

This study analysed secondary data of participants with a self-reported diagnosis of autism from Japan (N = 210; 123 men and 87 women) and the UK (N = 305; 181 women, 104, men, and 18 nonbinary). The relationships between the quadratic term of the Camouflaging Autistic Traits Questionnaire and mental health scales, including depression and anxiety, were assessed.

RESULTS

The UK sample showed linear relationships, whereas the Japanese sample showed significant nonlinear relationships. The quadratic terms of the Camouflaging Autistic Traits Questionnaire slightly explained generalised anxiety (β = .168, p = .007), depression (β = .121, p = .045), and well-being (β = - .127, p = .028). However, they did not explain the association between social anxiety and the Camouflaging Autistic Traits Questionnaire.

LIMITATIONS

Participants had self-reported diagnoses, and while the autism-spectrum quotient provides a cut-off value for screening, it does not enable confirming diagnoses. Mean scores of the Japanese version of the Camouflaging Autistic Traits Questionnaire were lower as compared to the original CAT-Q, which implies that the social camouflage strategy types used by autistic people in Japan and the UK could differ. The cross-sectional design limits causal inferences.

CONCLUSION

In the UK, more social camouflage was associated with poorer mental health scores, whereas too little or too much social camouflage was associated with a low mental health score in Japan. The Japanese population is seemingly less aware of and educated on autistic characteristics and considers 'average' behaviour a good thing. This could influence Japanese autistic people's social camouflage use, differing from that of autistic people in the UK. The differences in the relationship between social camouflage and mental health between Japan and the UK could be associated with national-level divergence regarding the culture of autism.

Mutations associated with autism lead to similar synaptic and behavioral alterations in both sexes of male and female mouse brain

Autism spectrum disorder (ASD) is a neurodevelopmental disorder based on synaptic abnormalities. The estimated prevalence rate of male individuals diagnosed with ASD prevails over females is in a proportion of 4:1. Consequently, males remain the main focus in ASD studies in clinical and experimental settings. Meanwhile, some studies point to an underestimation of this disorder in females. In this work, we studied the sex differences of the synaptic and behavioral phenotypes of ASD mouse models. Juvenile male and female Shank3Δ4-22 and Cntnap2-/- mutant mice and their WT littermates were used in the experiments. The animals were subjected to a Three-Chamber Sociability Test, then euthanized, and the whole cortex was used for the evaluation of the synaptic phenotype. Protein levels of glutamatergic (NR1) and GABAergic (GAD1 and VGAT) neuronal markers were measured. Protein level of synaptophysin (Syp) was also measured. Dendritic spine density in somatosensory neurons was analyzed by Golgi staining methods. Spine Density and GAD1, NR1, VGAT, and Syp levels were significantly reduced in Shank3Δ4-22 and Cntnap2-/- mice compared to the control group irrespective of sex, indicating impaired synaptic development in the mutant mice. These results were consistent with the lack of differences in the three-chamber sociability test between male and female mice. In conclusion, female ASD mice of both mutations undergo similar synaptic aberrations as their male counterparts and need to be studied along with the male animals. Finally, this work urges the psychiatry scientific community to use both sexes in their investigations.

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

OBJECTIVES

Some autistic people "camouflage" their differences by modeling neurotypical behaviors to survive in a neurotypical-dominant social world. It remains elusive whether camouflaging is unique to autism or if it entails similar experiences across human groups as part of ubiquitous impression management (IM). Here we examined camouflaging engagement and theoretical drivers in the general population, drawing on the transactional IM framework and contextualizing findings within both contemporary autism research and the past IM literature.

METHODS

A large representative U.S. general population sample (N = 972) completed this survey study. We combined exploratory item factor analysis and graph analysis to triangulate the dimensional structure of the Camouflaging Autistic Traits Questionnaire (CAT-Q) and examined its correspondence with prior autism-enriched psychometric findings. We then employed hierarchical regression and elastic-net regression to identify the predictors of camouflaging, including demographic (e.g., age, gender), neurodivergence (i.e., autistic and ADHD traits), socio-motivational, and cognitive factors.

RESULTS

We found a three-factor/dimensional structure of the CAT-Q in the general population, nearly identical to that found in previous autism-enriched samples. Significant socio-motivational predictors of camouflaging included greater social comparison, greater public self-consciousness, greater internalized social stigma, and greater social anxiety. These camouflaging drivers overlap with findings in recent autistic camouflaging studies and prior IM research.

CONCLUSIONS

The novel psychometric and socio-motivational evidence demonstrates camouflaging as a shared social coping experience across the general population, including autistic people. This continuity guides a clearer understanding of camouflaging and has key implications for autism scholars, clinicians, and the broader clinical intersecting with social psychology research. Future research areas are mapped to elucidate how camouflaging/IM manifests and functions within person-environment transactions across social-identity and clinical groups.

Exploring the mediating effect of camouflaging and the moderating effect of autistic identity on the relationship between autistic traits and mental wellbeing

Mental health difficulties are prevalent among autistic adults. Camouflaging (behaving differently to fit in) may be a mechanism by which autistic traits and mental health difficulties relate to each other, but little research has considered the role of different facets of camouflaging. Additionally, autistic identity might buffer against camouflaging and mental health difficulties. This research aims to explore the mediating effects of camouflaging behaviours on the relationship between autistic traits and both positive and negative mental wellbeing, as well as how autistic identity might moderate the relationship between autistic traits and camouflaging, and also mental health. Data were available for 627 autistic adults, recruited through volunteer databases and social media. Participants completed measures of autistic traits, anxiety, depression, positive wellbeing, camouflaging behaviours (compensating for difficulties, masking, and assimilating/putting on an act) and autistic identity. Mediation and moderated mediation models were tested, applying 95% bootstrapped CIs (10,000 resamples) and including age, gender and diagnosis as covariates. There were no significant direct effects between autistic traits and mental wellbeing. Assimilation was a significant mediator of all mental wellbeing measures, and compensation was a significant mediator of positive wellbeing only. Autistic identity was not a significant moderator. Assimilation and compensation should be considered when offering psychological interventions to support mental wellbeing of autistic people. Additional research into external drivers of camouflaging (e.g. stigma) and mechanisms by which camouflaging impacts mental wellbeing, such as autonomy, authenticity, skill mastery and community, may identify other areas of support. Concurrently, societal change is necessary to reduce the need to camouflage.

An internet-based behavioral intervention for adults with autism spectrum disorder - A randomized controlled trial and feasibility study

Background

The increased prevalence of Autism Spectrum Disorder (ASD) diagnoses in combination with psychiatric comorbidity, has led to an increased need for effective interventions. The evidence for internet-based interventions for several mental health problems is established but has not been evaluated for adults with ASD.

Objective

The aim of this randomized controlled trial is to evaluate the feasibility and effects of an internet-based intervention targeting quality of life and psychiatric symptoms (depression and anxiety) in adults with ASD.

Methods

84 participants were randomly allocated to intervention (n = 42) or control (n = 42). The 18-week internet-based intervention covered a range of themes related to difficulties common in ASD, and exercises based on cognitive behavioral strategies. Participants were provided with individual feedback following each module and were invited to regular chat sessions with peer participants. The primary outcomes were subjective quality of life and sense of coherence, and secondary outcomes were symptoms of depression and anxiety. All outcomes were measured at five occasions and analysed with linear mixed effect models. Participant satisfaction and adherence was also analysed.

Results

Participant satisfaction and adherence was satisfactory but no significant interaction between group and time was found for any outcome measure. Autistic traits were negatively related to quality of life and sense of coherence and positively related to anxiety and depressive symptoms.

Conclusions

This internet-based intervention showed feasibility regarding adherence and participant satisfaction. However, no significant effects on quality of life, sense of coherence or psychiatric symptoms were found, likely due to limitations in the design and methodology of this specific trial in combination to the heterogeneity of the group. Individuals with ASD may require interventions that are flexible and individually tailored in regard to both format, content and therapeutic support. The current trial provides useful information and suggestions for the future research on internet-based interventions for ASD.

Exploring Identity Importance for Autistic Adults and Associations with Disclosure Experiences: A Brief Report

Background

A strong autistic identity can help to support mental well-being, reduce anxiety and depression, increase self-esteem, and strengthen a shared community for autistic people. Autistic people are regularly faced with a decision to disclose their autistic identity to others and report a range of experiences after disclosure. The purpose of this brief report was to examine the association between identity and disclosure decisions in a sample of autistic adults to gather preliminary evidence justifying future research. Specifically, we were interested in learning more about how autistic identity is associated with one's approach to disclosure, while also exploring associations with other identities such as ethnic, gender, sexual, and religious identity.

Methods

Participants (N = 111) completed an online questionnaire about their intersecting identities and their approach to disclosure. The research team that conducted this study was composed of both autistic and nonautistic researchers.

Results

Results demonstrated that participants who felt their autistic identity and sexual identity were highly important also reported frequent disclosure of being autistic. Religious, gender, and ethnic identity were not associated with one's disclosure decisions or their disclosure outcomes.

Conclusion

Overall, the results of this study emphasize the link between autistic and sexual identities and autism disclosure, but more research in this space is needed to better support the wider autism community.

Similar overall expression, but different profiles, of autistic traits, sensory processing, and mental health between young adult males and females

Recent trends suggest that autism is more common in females than traditionally held. Additionally, some argue that females express autistic traits differently than males. Dimensional views of autism could shed light on these issues, especially with regards to understudied behavioral areas, such as sensory processing. We examined autistic traits, sensory processing, anxiety, and related behaviors in a large sample of neurotypical young adult males and females (n = 1,122; 556 female; ages 19-26). Participants completed an online survey containing questionnaires related to the above. Between groups statistical analyses, as well as within groups correlations and mediation analyses containing these constructs were then computed. We also carried out a cluster analysis to establish groups with behavioral similarities and estimate within-cluster male/female ratios. Results showed modest differences in the overall expression of autistic traits and sensory processing, if any, between males and females. Conversely, more detailed examination of survey subtests and mediation analyses revealed differing profiles between these groups. Cluster analysis uncovered a group comprised of both males (69.8%) and females (30.2%) who exhibited elevated degrees of autism-related behaviors, suggesting a higher proportion of females than would be predicted by traditional ratios. Taken together, these findings suggest that males and females may not differ as much as previously thought in their general levels of autistic traits or sensory processing, but may present with distinct profiles of such behaviors. These novel results add to our understanding of autistic traits in females and have the potential to positively influence diagnostic and support practices.

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.

"I Was Like a Bird Without Wings": Autistic Women's Retrospective Experiences in General Schools

Autistic individuals' experience of the inclusion process is poorly understood, especially that of female pupils. This study retrospectively explored the views of autistic women who were included in general schools throughout childhood and adolescence, from elementary to high school, to understand their unique experiences and learn more about their needs in general schools. Semi-structured interviews were conducted, data were thematically analyzed, and key issues emerged pertaining to each educational level. The women described a complex journey within the general education system. Their responses highlight the need for greater attention to autistic females' patterns of behavior in research and practice. Implications and recommendations for educators and schools are provided, and directions for future research are outlined.

Diagnostic assessment of autism in adults - current considerations in neurodevelopmentally informed professional learning with reference to ADOS-2

Services for the assessment and diagnosis of autism in adults have been widely criticized and there is an identified need for further research in this field. There is a call for diagnostic services to become more accessible, person-centered, neurodiversity affirming, and respectful. There is a need for workforce development which will increase capacity for diagnostic assessment and support for adults. ADOS-2 is a gold-standard diagnostic assessment tool for autism recommended in clinical guidelines. However, diagnostic procedures such as the ADOS-2 are rooted in the medical model and do not always sit comfortably alongside the neurodiversity paradigm or preferences of the autistic community. Training and educational materials need to account for the differences between these approaches and support clinicians to provide services which meet the needs of the adults they serve. The National Autism Implementation Team worked alongside ADOS-2 training providers to support clinicians in Scotland, to provide effective and respectful diagnostic assessment. The team engaged with clinicians who had attended ADOS training to identify areas of uncertainty or concern. Training materials were developed to support ADOS assessors to incorporate key principles including "nothing about us without us"; "difference not deficit"; "environment first"; "diagnosis matters," "language and mindsets matter"; and "a neurodevelopmental lens," to support the provision of neurodiversity affirming assessment practice. The National Autism Implementation Team also provided examples of actions which can be undertaken by clinicians to improve the assessment experience for those seeking a diagnosis. Training materials are based on research evidence, clinical experience, and the needs and wishes of autistic people.

Organizational benefits of neurodiversity: Preliminary findings on autism and the bystander effect

Although the bystander effect is one of the most important findings in the psychological literature, researchers have not explored whether autistic individuals are prone to the bystander effect. The present research examines whether autistic employees are more likely to report issues or concerns in an organization's systems and practices that are inefficient or dysfunctional. By bringing attention to these issues, autistic employees may foster opportunities to improve organizational performance, leading to the development of a more adaptive, high performing, and ethical culture. Thirty-three autistic employees and 34 nonautistic employees completed an online survey to determine whether employees on the autism spectrum (1) are more likely to report they would voice concerns about organizational dysfunctions, (2) are less likely to report they were influenced by the number of other witnesses to the dysfunction, (3) if they do not voice concerns, are more likely to acknowledge the influence of other people on the decision, (4) are less likely to formulate "elaborate rationales" for their decisions to intervene or not, and (5) whether any differences between autistic and nonautistic employees with regards to the first two hypotheses, intervention likelihood and degree of influence, are moderated by individual differences in camouflaging. Results indicate that autistic employees may be less susceptible to the bystander effect than nonautistic employees. As a result, autistic employees may contribute to improvements in organizational performance because they are more likely to identify and report inefficient processes and dysfunctional practices when they witness them. These preliminary findings suggesting potential benefits of neurodiversity in the workplace are promising. However, further research is required.

Towards the measurement of autistic burnout

LAY ABSTRACT

Autistic burnout has been talked about by autistic adults for some time on blogs and in social media. Now, research describes fatigue, exhaustion and other related symptoms experienced by autistic people. We need new ways to help identify autistic burnout. In this study, we tested a new questionnaire called the AASPIRE Autistic Burnout Measure, and we investigated things that are linked to worse autistic burnout. We also trialled a group of Autistic Burnout Severity Items that we made. Working with an autistic researcher, we made the Autistic Burnout Severity Items based on published definitions of autistic burnout. Autistic adults (n = 141) who had experienced autistic burnout completed an online survey. We found that autistic burnout was connected to masking and depression. The Autistic Burnout Measure tool was associated with depression but not with masking. It was not very accurate in telling apart participants who were currently experiencing burnout versus those who were reporting on their past experience. The Autistic Burnout Severity Items might have problems with subscales adding together to measure autistic burnout. More work is needed on how to measure autistic burnout. Our research and other recent studies show autistic people experience a combination of exhaustion, withdrawal and problems with their concentration and thinking. Burnout seems to be linked to the stress experienced by autistic people in their daily lives. We need more research to understand the difference between autistic burnout and other conditions and experiences. We need to develop assessment tools that can help identify this burnout.

Linehan's biosocial model applied to emotion dysregulation in autism: a narrative review of the literature and an illustrative case conceptualization

Emotion dysregulation (ED) is a transdiagnostic difficulty prevalent in autism spectrum condition (ASC). Importantly, recent research has suggested that ED is involved in self-harm and suicidality. Pre-existing models on the etiology of ED in ASC focus mainly on biological factors to ASC features, such as sensory sensitivities, poor flexibility, and sensitivity to change. However, although psychosocial factors seem to play a role in the emergence of ED in ASC as well (e.g., childhood maltreatment and camouflaging), there is a lack of a comprehensive model conceptualizing biosocial factors involved in ED in autistic people. Linehan's biosocial model (1993) is one of the leading etiological models of ED in borderline personality disorder (BPD). It conceptualizes ED as emerging from transactions between a pre-existing emotional vulnerability in the child and an invalidating developmental environment. Beyond its clinical relevance, Linehan's model has gathered empirical evidence supporting its pertinence in BPD and in other psychiatric disorders. Although ASC and BPD are two distinct diagnoses, because they may share ED, Linehan's biosocial model might be useful for understanding the development of ED in ASC. Hence, this article aims to provide an application and extension of Linehan's model to conceptualize ED in ASC. To do so, we conducted a narrative review of the literature on ED and its underlying factors in ASC from a developmental perspective. To investigate the pertinence of the biosocial model applied to ED in autistic people, we were interested on data on (i) ED and its behavioral correlates in ASC, in relation to the biosocial model, (ii) the potential biological and psychosocial correlates of ED in ASC and (iii) the overlapping difficulties in ASC and BPD. Finally, to assess the pertinence of the model, we applied it to the case of an autistic woman presenting with ED and suicidal behaviors. Our review and application to the case of an autistic woman suggest that ED in ASC encompasses factors related to both biological and psychosocial risk factors as conceptualized in the BPD framework, although in both domains ASC-specific factors might be involved.

Social Anxiety in Autistic People: Does the Clark and Wells Model fit?

PURPOSE

Cognitive behaviour therapy based on the Clark and Wells (1995) model is a first-line treatment for neurotypical people seeking support for social anxiety. While autistic people frequently report high social anxiety, it is unclear how appropriate the model is for this population.

METHODS

Over 300 autistic and non-autistic adults completed an online survey measuring key variables of the Clark and Wells model (socially-related negative thoughts, safety behaviours, self-focused attention). Using multiple regression and structural equation modelling, we assessed whether these variables accounted for the link between autism and social fears.

RESULTS

In multiple regression, autistic people experienced greater social fears than expected based on Clark and Wells variables, and safety behaviours were less predictive of social fears in autistic people. In structural equation modelling, Clark and Wells variables only mediated half the link between autistic traits and social fears. In exploratory analysis, we found that distress relating to uncertainty was an additional variable that needed to be taken into consideration in the relationship between autistic traits and social fears.

CONCLUSION

The Clark and Wells variables were relevant in autism, but did not fully explain elevated social fears in autistic people, which suggests that other factors are also important in accounting for social anxiety in autistic people. This means that therapy informed by the model may not be optimal for autistic people. We recommend further research developing adapted therapy for social anxiety in autistic people.

Applications of identity-based theories to understand the impact of stigma and camouflaging on mental health outcomes for autistic people

Autistic people have long been conceptualized from a deficit-based model of disability, but recent self-advocates and scholars have asserted the importance of recognizing autism as both a disability and an important part of a person's social identity. The autistic identity is subject to specific stigma and stressors beyond everyday discrimination and prejudice, which can have many downstream implications on mental health and well-being. Prior research on camouflaging has explained both quantitatively and qualitatively how autistic people conform to norms and mask their autistic traits to better fit in with non-autistic societal standards. Given this paradigm shift in understanding autistic peoples' lived experiences, researchers must also begin to reshape the theories guiding their work in order to improve diagnosis, intervention, and supports. This review examines the extant research on identity-related stigma and camouflaging and their subsequent impacts on mental health outcomes in autism. A model is proposed integrating identity-based theories-specifically the social model of disability, social identity theory, and minority stress model-to explain relationships across research areas and better explain the experiences of autistic people. We discuss how identity-based theories can be applied in autism research to better understand the impacts of stigma and camouflaging on autistic peoples' lived experiences and reduce disparities in their mental health outcomes.

The workplace masking experiences of autistic, non-autistic neurodivergent and neurotypical adults in the UK

Masking entails hiding or concealing one's traits during social interactions. Research suggests that masking is particularly common for autistic people, though many non-autistic people also conceal aspects of their identity. Existing research has identified the key motivations and consequences of masking. No research to date, however, has considered how this might be affected by the social context in which masking is employed. This study compared the masking experiences of 285 autistic, 88 non-autistic neurodivergent and 99 neurotypical adults within a context in which masking is expected to be highly prevalent, namely the workplace. We used reflexive thematic analysis to explore the motivations, consequences, and contextual differences of workplace masking compared to other social contexts. Workplace masking was considered by participants in all three groups to be an adaptive response to a range of socially grounded workplace challenges and was usually employed as a strategy to safeguard against the threat of negative social and employment outcomes. Our non-autistic neurodivergent and autistic participants, however, reported experiencing unique pressures to mask, given the limited understanding of neurodiversity in workplaces and society more broadly. These findings have important implications for the wider masking literature and for workplace practice.

Social Knowledge & Performance in Autism: A Critical Review & Recommendations

Autistic social challenges have long been assumed to arise from a lack of social knowledge ("not knowing what to do"), which has undergirded theory and practice in assessment, treatment, and education. However, emerging evidence suggests these differences may be better accounted for by difficulties with social performance ("doing what they may know"). This distinction has important implications for research, practice, policy, and community support of autistic people. This review examines the theoretical and clinical implications and empirical status of the knowledge-performance distinction in autism. Current evidence suggests that social knowledge deficits are neither definitional nor reliably related to outcomes in autism. Prioritizing social knowledge, then, may produce unanticipated, problematic consequences in terms of accuracy of assessment, intervention effectiveness, and promotion of stigma. It may also yield unrealistic expectations around the value of knowledge for autistic people and their families, yielding important ethical considerations. Conversely, recent evidence highlights performance-related factors as being especially promising for better modeling and addressing social challenges in autism. Prioritizing performance, then, may offer new directions for assessment, substantially different intervention opportunities, and novel methods of inclusion and affirmation. This review touches upon each of these domains and implications, integrates these developments with broader models of social competence in youth, and provides direction for future research and practice regarding social competence in autism.

Is camouflaging autistic traits associated with defeat, entrapment, and lifetime suicidal thoughts? Expanding the Integrated Motivational Volitional Model of Suicide

INTRODUCTION

The current study explored whether camouflaging autistic traits is associated with defeat and entrapment and lifetime suicidal thoughts, as predicted by the Integrated Volitional Model of Suicide (IMV model).

METHODS

180 UK undergraduate students (76.7% female 18-67 years) completed a cross-sectional online survey from February 5 to March 23, 2020, including self-report measures of defeat and entrapment (SDES), autistic traits (AQ-10), depression (PHQ-9), anxiety (GAD-7), camouflaging autistic traits (CAT-Q), and lifetime suicidal thoughts and behaviors (SBQ-R item 1).

RESULTS

After controlling for age, gender, current depression, and anxiety symptoms, autistic traits accounted for significantly more of the variance in defeat and entrapment (1.1%), and camouflaging accounted for a further 3.2% of the variance. The association between autistic traits and lifetime suicidality was significantly mediated by camouflaging, defeat, and entrapment. After controlling for age, gender, current depression, and anxiety symptoms, defeat and entrapment (but not camouflaging) accounted for significantly more variance in lifetime suicidal thoughts. The interaction between camouflaging, defeat and entrapment predicted significantly less variance in lifetime suicidal thoughts than either variable alone.

CONCLUSION

Results suggest that camouflaging autistic traits is a transdiagnostic risk factor for lifetime suicidality, relevant to the defeat and entrapment constructs of the IMV model.

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.