Good Social Skills Despite Poor Theory of Mind: Exploring Compensation in Autism Spectrum Disorder

Background: It is proposed that some individuals with Autism Spectrum Disorder (ASD) can ‘compensate’ for their underlying difficulties (e.g., in theory of mind; ToM), thus demonstrating relatively few behavioural symptoms, despite continued core cognitive deficits. More broadly, the phenomenon of compensation may have the potential to explain heterogeneity in outcome, the female autism phenotype, and late diagnosis. The mechanisms underpinning compensation, however, are largely unexplored, as is its potential impact on mental health.

Objectives: This study aimed to estimate compensation patterns in adolescents with ASD, by contrasting overt social behaviour with ToM task performance, in order to compare the characteristics of ‘Low’ and ‘High’ Compensators.

Methods: 136 autistic adolescents, from the ongoing Social Relationships Study, completed a range of cognitive tasks, the Autistic Diagnostic Observation Schedule (ADOS), and a self-report anxiety questionnaire. Participants were assigned compensation group status; High Compensators demonstrated good ADOS scores despite poor ToM performance, while Low Compensators demonstrated similarly poor ToM, accompanied by poor ADOS scores.

Results: High Compensators demonstrated better IQ and executive function (EF), but greater self-reported anxiety, compared to Low Compensators. Such differences were not found when comparing individuals who had good ToM performance with good versus poor ADOS scores. Other core autistic characteristics (weak central coherence, non-social symptoms) did not differentiate the High and Low Compensators.

Conclusions: IQ, EF and anxiety appear to be implicated in the processes by which certain autistic individuals can compensate for their underlying ToM difficulties. This tendency to compensate does not appear to reflect the severity of ‘hit’ for ASD per se, suggesting that well compensated individuals are not experiencing a milder form of ASD. The construct of compensation in ASD has a number of implications for research and clinical practice. The findings have informed a novel theoretical framework for understanding compensation in ASD and other neurodevelopmental disorders.