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

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.

Longitudinal Transition Between Regular and Special Education in Autistic Children: Predictors and Policy Effects

Inclusive education policies stimulate children with special educational needs, including autism, to attend regular education. We aimed to explore change over time in school placement and transitions of autistic children since the introduction of an inclusive education policy in the Netherlands (2014) and to examine the role of individual child characteristics. This study used longitudinal data from 2013 to 2021 on autistic children (N = 1463, aged 5-16 years). We expected an increase in regular school placements and transitions to regular schools. Surprisingly, the proportion of children with autism in regular schools slightly decreased. Special school placement was more likely for boys and autistic children with lower intelligence scores, co-occurring conditions or behavioral and peer relation problems. Younger autistic children and those with lower intelligence scores more often transferred from a regular to a special school. The opposite transition was more common in older autistic children and those with higher intelligence scores. The likelihood of special-to-regular transitions did not change, but regular-to-special transitions were more prevalent during the years just after the policy change than in later years. The inclusive policy had little impact on the school placement, and at most led to a delayed drop in referrals to special schools.

High Autistic Traits or Low Social Competence? Correlates of Social Camouflaging in Non-Autistic Adults

Background

Autistic traits have been linked with the use of social camouflaging behavior by non-autistic people. In addition, low social competence (i.e., poor social skills) has also been posited as a possible explanation for the use of social camouflaging by non-autistic people. In this study, we investigated the comparative influence of autistic traits and social competence on three components of social camouflaging (compensation, masking, and assimilation) in a sample of non-autistic adults.

Methods

Using a cross-sectional design, we recruited 284 undergraduate students (28.5% male; 69.7% female; 1.8% not specified) who reported that they had never been diagnosed with autism. Participants completed standardized measures assessing social camouflaging, autistic traits, social competence, and psychological distress via an online questionnaire.

Results

We found that women reported greater use of social camouflaging, and greater social camouflaging use was associated with worse psychological distress. We also found that both social competence and autistic traits were associated with the use of social camouflaging, with higher autistic traits influencing camouflaging use to a greater degree than low social competence. Compared with the use of compensation- and assimilation-based social camouflaging, masking was the least well explained by the current predictors.

Conclusions

We conclude that social competence and autistic traits are important factors influencing the use of social camouflaging by non-autistic adults. However, there are other (unknown) factors that contribute to the use of each aspect of camouflaging by non-autistic individuals, and a deeper understanding of the individual motivations for social camouflaging use is still needed. In turn, this may allow for the development of psychosocial interventions to offset the need for social camouflaging and mitigate the negative psychological consequences often associated with its use.

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.

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.

Friendships in Children with Williams Syndrome: Parent and Child Perspectives

Although children with Williams syndrome (WS) are strongly socially motivated, many have friendship difficulties. The parents of 21 children with WS and 20 of the children themselves participated in a semi-structured interview about the children's friendships. Parents reported that their child had difficulties sustaining friendships and low levels of interaction with peers. Barriers to friendships included difficulties with play and self-regulating behaviour. However, there was within-group variability, with a small number of children reported to have strong friendships. While parents reported friendship challenges, all of the children named at least one friend, and most said that they had never felt excluded by their peers. Future research is needed to determine optimal ways to support children with WS in their friendships.

Naturally occurring low sociality in female rhesus monkeys: A tractable model for autism or not?

BACKGROUND

Autism spectrum disorder (ASD) is characterized by persistent social interaction impairments and is male-biased in prevalence. We have established naturally occurring low sociality in male rhesus monkeys as a model for the social features of ASD. Low-social male monkeys exhibit reduced social interactions and increased autistic-like trait burden, with both measures highly correlated and strongly linked to low cerebrospinal fluid (CSF) arginine vasopressin (AVP) concentration. Little is known, however, about the behavioral and neurochemical profiles of female rhesus monkeys, and whether low sociality in females is a tractable model for ASD.

METHODS

Social behavior assessments (ethological observations; a reverse-translated autistic trait measurement scale, the macaque Social Responsiveness Scale-Revised [mSRS-R]) were completed on N = 88 outdoor-housed female rhesus monkeys during the non-breeding season. CSF and blood samples were collected from a subset of N = 16 monkeys across the frequency distribution of non-social behavior, and AVP and oxytocin (OXT) concentrations were quantified. Data were analyzed using general linear models.

RESULTS

Non-social behavior frequency and mSRS-R scores were continuously distributed across the general female monkey population, as previously found for male monkeys. However, dominance rank significantly predicted mSRS-R scores in females, with higher-ranking individuals showing fewer autistic-like traits, a relationship not previously observed in males from this colony. Females differed from males in several other respects: Social behavior frequencies were unrelated to mSRS-R scores, and AVP concentration was unrelated to any social behavior measure. Blood and CSF concentrations of AVP were positively correlated in females; no significant relationship involving any OXT measure was found.

LIMITATIONS

This study sample was small, and did not consider genetic, environmental, or other neurochemical measures that may be related to female mSRS-R scores.

CONCLUSIONS

Dominance rank is the most significant predictor of autistic-like traits in female rhesus monkeys, and CSF neuropeptide concentrations are unrelated to measures of female social functioning (in contrast to prior CSF AVP findings in male rhesus monkeys and male and female autistic children). Although preliminary, this evidence suggests that the strong matrilineal organization of this species may limit the usefulness of low sociality in female rhesus monkeys as a tractable model for ASD.

Autistic pupils' experiences in primary and post-primary schools: A scoping review and consultation with autistic pupils in Ireland

Background and aims

Autistic pupils have the right to be heard in matters concerning their education and to be active agents in shaping their school experiences. Despite this, educational policies and research have rarely included the voices of autistic children, failing to identify what they consider to be beneficial and meaningful in their own education. This study aimed to (i) summarise existing literature exploring autistic pupils' experiences at school from their own perspectives and (ii) identify gaps for future research through a consultation with autistic pupils.

Methods

A scoping review was conducted to identify studies exploring first-person accounts of autistic pupils' school experiences (primary and secondary; aged 4-18 years) published between 2005 and 2023. Thematic analysis was conducted to identify overarching thematic categories across the included studies. Review findings were discussed through a consultation with a Child and Youth Advisory Group (CYAG) comprised of autistic pupils in Ireland (N = 3), to seek feedback and inform a future research agenda.

Main contribution

Thirty-six studies were included in the review and six themes were identified: Experiences of feeling misunderstood, of bullying and masking, of feeling excluded, of anxiety, of sensory needs in school, and of being overwhelmed during transitions. Consultation with the CYAG highlighted that these six themes were consistent with autistic pupils' experiences but that reports of positive experiences were missing in the literature.

Conclusions

This study identified several gaps in the literature on the school experiences of autistic pupils, based on both the scoping review and consultation with the CYAG. While the CYAG validated the themes identified in existing literature, there is a need for greater diversity in the samples included and increased focus on the potential positive aspects of the school experience. Implications. These findings have important research implications. In particular, further studies are needed with autistic pupils at primary school level, including those who are minimally or non-speaking, as well as ensuring pupils with positive school experiences are also represented. Findings also highlight the need for continued collaboration with autistic pupils themselves in matters concerning their education.

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.

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.

Lived experiences of depression in autistic children and adolescents: A qualitative study on child and parent perspectives

BACKGROUND

Depression is highly prevalent in autistic children and adolescents. Despite this, little is known about the nature of the autistic child's subjective experience of depression and the impact of depression on their lives.

METHODS

We therefore conducted a qualitative study using thematic analysis with 7 autistic children and adolescents and their parents to identify common themes and individual differences. All children had previously experienced at least one depressive episode.

RESULTS

Six main themes were identified: (1) Autism related experiences; (2) Difficulties with peer relationships; (3) Co-occurring relationships between anxiety and depression; (4) Impactful pessimism and anhedonia; (5) Impactful difficulties with focus and concentration and (6) Feelings of irritability, including aggressive behaviours. Parent's accounts of their children's experience of depression mirrored the child's perspective. Novel findings included reports of depression related restriction of diet variety and masking of mental health difficulties. Children and parents linked being autistic and developing depression, referring to the difficulties of being autistic in a complex, neurotypical world.

CONCLUSIONS

These results highlight key challenges that autistic children and their families experience, calling for increased awareness of the impact of depression on autistic young people.

Using a life course health development framework to combat stigma-related health disparities for individuals with intellectual and/or developmental disability (I/DD)

In the U.S., 1 in 6 children has an intellectual and/or developmental disability (I/DD). This population experiences a multitude of negative health outcomes across the life course, relative to the general population. Stigma-the social devaluation of individuals with certain characteristics, identities, or statuses within interpersonal, educational, healthcare, and policy contexts-is a potentially preventable contributor to health disparities. To date, existing approaches for addressing and preventing stigma are limited to discrete and siloed interventions that often fail to address the lifelong, cumulative impacts of the specific types of stigma experienced by the I/DD population. In the current paper, we describe three elements of Life Course Health Development (LCHD)-a novel translational framework that draws on evidence from biology, sociology, epidemiology, and psychology-that healthcare providers can use to prevent stigma-related health disparities and improve outcomes for individuals with I//DDs. We discuss the utility of targeting prevention to sensitive periods; prioritizing interventions for the most damaging types of stigmas; and leveraging supports from multiple service systems and sectors. By incorporating evidence from life course science into efforts to address stigma-related health disparities, providers can more effectively and strategically prevent and combat stigma-related health disparities for the I/DD population in childhood and across the life course.

Case report: Treatment-resistant depression, multiple trauma exposure and suicidality in an adolescent female with previously undiagnosed Autism Spectrum Disorder

High rates of co-occurring depression are commonly reported in youth with Autism Spectrum Disorder (ASD), especially in individuals without intellectual disability (ID). Depression in ASD undermines adaptive behavior and is associated with a higher risk of suicidality. Females with ASD may be particularly vulnerable due to their greater use of camouflaging strategies. Indeed, in comparison to males, ASD is underdiagnosed in females, despite higher rates of internalizing symptoms and suicidality. Trauma exposure may also play a role in the development of depressive symptoms in this population. Moreover, evidence for effective treatments of depression in autistic youth are lacking, with ASD individuals frequently experiencing low efficacy and side effects. We present the case of an adolescent female with previously undiagnosed ASD without ID, admitted for active suicidal plans and a treatment-resistant depression (TRD), occurred after a COVID-19 lockdown in the context of cumulative exposure to stressful life events. Comprehensive clinical assessments performed at intake confirmed severe depression with suicidality. Intensive psychotherapy and different changes in medications were carried out (SSRI, SNRI, SNRI + NaSSA, SNRI + aripiprazole), all of which were ineffective, with persistent suicidal thoughts, often requiring intensive individual monitoring. The patient was finally successfully treated with lithium augmentation of fluoxetine, with no side effects. During hospitalization she was also evaluated by an ASD specialized center, where a diagnosis of ASD was made according to the Autism Diagnostic Observation Schedule (ADOS) and the Autism Diagnostic Interview-Revised (ADI-R) scores, as well as to clinical judgment of a senior psychiatrist. The present case report shows that clinicians should not overlook undiagnosed autism as a possible cause of TRD, especially in females without ID, where higher rates of under diagnosis may be in part related to their greater use of camouflage. It also suggests that ASD underdiagnosis and resulting unmet needs may be involved in vulnerability to stressful experiences, depression, and suicidality. Furthermore, it shows the complexity of providing care to TRD in youth with autism, suggesting that an augmentation therapy with lithium, a commonly recommended therapeutic strategy for refractory depression in typically developing samples, may also be effective in this population.

A systematic review of the experiences of autistic young people enrolled in mainstream second-level (post-primary) schools

LAY ABSTRACT

Internationally, more autistic pupils are being educated in mainstream schools. Some people have voiced concerns that this policy roll-out is happening before examining the effective outcomes for autistic students. Concerns have also been expressed regarding a lack of the voices of autistic pupils themselves within research and policy. This study was undertaken in order to gather literature that explores the views and experiences of autistic young people in relation to their mainstream school placement at the secondary level. This study aims to summarise the existing literature and provide a new, more complete account of the school experiences of this cohort. After an extensive search, 33 studies were identified by the authors as meeting a set of inclusion criteria. All of the studies included in this review elicited the views and perspectives of at least one autistic young person regarding their mainstream secondary school placement. Upon carefully analysing these studies, the authors developed three key themes as follows: 'Demands of mainstream placements', 'Social participation' and 'Impacts on the student'. Our analysis revealed that for many autistic young people, mainstream school is a complex and demanding social environment. Further research that prioritises the voices and perspectives of this cohort is essential as inclusive policy and practice continues to develop.

Social engagement and loneliness in school-age autistic girls and boys

OBJECTIVES

This study examines the relationship between social engagement and loneliness in female and male autistic children and adolescents in school-based social settings. Secondary aims sought to explore the emergence of loneliness across different age groups and differences in social engagement and loneliness between genders.

METHODS

This study conducted an analysis of previously collected data from two multi-site randomized control trials. This study included 58 autistic students (29 females, 29 males) between the ages 6 through 18 years. Female and male participants were matched on age and intelligence quotient. Concurrent mixed methods were used to examine participants' social engagement and loneliness.

RESULTS

Findings revealed a significant relationship between joint engagement and loneliness, such that autistic students reported more loneliness when they were mutually engaged with social groups than when they were isolated or alone. Positive correlations between joint engage and loneliness were identified in elementary-age girls and secondary-age boys, suggesting that being mutually engaged with peers leads to increased loneliness. Negative correlations between parallel and loneliness identified in secondary-age boys suggested that boys in close proximity to peers felt less lonely than boys who were mutually engaged with peers. Qualitative analysis of social behaviors indicated that elementary girls and secondary boys were more likely to be mutually engaged or in close proximity to activities, but they had difficulty sustaining this engagement throughout the entire social period. Secondary girls and elementary boys, on the other hand, were more likely to be solitary and less likely to engage with peer groups.

CONCLUSION

Study findings highlight the relationship between social engagement and loneliness in school-based autistic populations, and that more engagement itself can lead to more loneliness for younger girls and older boys. The influence of age and gender on engagement and loneliness highlights a need to tailor social interventions to leverage existing social strengths.

A Letter to the Editor Regarding Bambara et al. (2021), "Using Peer Supports to Encourage Adolescents With Autism Spectrum Disorder to Show Interest in Their Conversation Partners"

PURPOSE

The purpose of this letter is to address interpretations regarding Bambara et al.'s (2021) study and help resolve potential for further missteps within this line of research.

CONCLUSION

There is clear value in teaching skills that are wanted by autistic people. The primary issue within the article is that it does not acknowledge the double empathy problem and is constructed based on only a neurotypical system of interpretation or communication style. What is being promoted is to address skills autistic participants request.

Understanding Stigma in Autism: A Narrative Review and Theoretical Model

The experience of stigma by autistic people is relatively understudied, despite contributing to a range of poor outcomes and having an overarching impact on well-being. The current review of the literature synthesizes research to determine what is currently known and presents a theoretical model of autism stigma. Autism stigma is primarily influenced by a public and professional understanding of autism in combination with interpretation of visible autistic traits. Moderating factors include the quality and quantity of contact with autistic people, cultural factors, sex and gender, individual differences, and diagnostic disclosure. Stigma can reduce well-being as well as increase the presence of camouflaging behaviors, which mask autistic traits. Caregivers of autistic people can experience stigma by association, that is, affiliate stigma, which can impact their own well-being. A variety of interventions and approaches to reduce stigma are discussed, including "autism friendly" spaces, positive media representation, educational and psychosocial training for the public and professionals, as well as cultural and systemic shifts that foster inclusivity and recognize neurodiversity.

Camouflaging in autism: A systematic review

Some autistic people employ strategies and behaviours to cope with the everyday social world, thereby 'camouflaging' their autistic differences and difficulties. This review aimed to systematically appraise and synthesise the current evidence base pertaining to autistic camouflaging. Following a systematic search of eight databases, 29 studies quantifying camouflaging in children and adults with autism diagnoses or high levels of autistic traits were reviewed. The multiple methods used to measure camouflaging broadly fell under two different approaches: internal-external discrepancy or self-report. These approaches appear to relate to two distinct but potentially connected elements of camouflaging: observable behavioural presentations and self-perceived camouflaging efforts. While significant variation was noted across individual study findings, much of the existing literature supported three preliminary findings about the nature of autistic camouflaging: (1) adults with more self-reported autistic traits report greater engagement in camouflaging; (2) sex and gender differences exist in camouflaging; and (3) higher self-reported camouflaging is associated with worse mental health outcomes. However, the research base was limited regarding participant characterisation and representativeness, which suggests that conclusions cannot be applied to the autistic community as a whole. We propose priorities for future research in refining the current understanding of camouflaging and improving measurement methods.