Self-Report of “Camouflaging” Behaviors in Women Is Related to Autism Symptoms and Mental Health but Not Executive Functioning

Background: Autistic women may “camouflage” their differences to appear more typical during social interactions and formal assessments such as the ADOS-2. Camouflaging may cause some to be overlooked for diagnosis of autism or misdiagnosed, delaying access to appropriate interventions. To improve diagnostic accuracy, others (e.g., Lai et al., 2016) have attempted to quantify camouflaging and explore clinical correlates and potential mechanisms, such as executive functioning (EF) skills which allow the individual to inhibit autistic tendencies and switch to typical behaviors. A new self-report measure of camouflaging, the Camouflaging Autistic Traits Questionnaire (CAT-Q; Hull et al., 2018), was only recently published.

Objectives: We sought to explore the camouflaging phenomenon in the diagnostic “gray zone,” where camouflaging can mean the difference between receiving a diagnosis of ASD and not. Accordingly, we investigated a sample that included high-functioning women with ASD as well as undiagnosed (potentially camouflaged) women with the broader autism phenotype. To examine the clinical significance and potential mechanisms of camouflaging, we assessed and explored associations between camouflaging and autism symptoms, indicators of mental health, and EF (inhibition and switching).

Methods: Our sample includes women without intellectual impairment (N=51; age M=24 years; IQ M=114; 15 had a previous autism diagnosis) who reported impairing symptoms associated with ASD per elevated scores on the BAPQ (total score>3). Participants were recruited through local clinics, a university counseling center, and social media. We administered measures through an online survey platform and in-person visits. Measures included the CAT-Q, BAPQ, ADOS-2, WASI-II (IQ), DASS-21 (psychological distress), TSCS-2 (self-concept), Suicidal Behaviors Questionnaire, and D-KEFS Trail-Making and Color-Word Interference (EF). Before analyses, outliers were Winsorized to 2*SD above/below the mean. Pearson and Spearman (non-normal variables) correlation coefficients were calculated.

Results: A majority of participants (53%; n=27), including a majority of participants with a previous ASD diagnosis (53%; n=8), had CAT-Q total scores higher than the average score of the ASD group in the CAT-Q validation sample (our sample: M=4.72; SD=0.83; ASD validation sample: M=4.79; SD=0.99). Similar to findings in the validation sample, our sample showed significant associations between CAT-Q total scores and BAPQ total scores (r=0.28, p<0.05) and indicators of mental health (DASS-21: r=0.27, p=0.05; TSCS-2: r=-0.39, p<0.01). CAT-Q total scores were not associated with suicidal behavior (ρ=0.09, p=0.52), EF (Trails Condition 4: ρ=-0.1, p=0.47; Color-Word Condition 4: ρ=-0.15, p=0.31), or IQ (r=-0.03, p=0.81).

Conclusions: Our findings provide support for the validity of the CAT-Q and reinforce the clinical relevance of the camouflaging construct. The lack of association between self-reported camouflaging and suicidal behaviors speaks to the complexity of factors influencing suicidality. The lack of hypothesized association between camouflaging and EF leaves open the question of which cognitive abilities allow some individuals to camouflage while others seem unable to do so. Future directions include investigating alternate potential mechanisms of camouflaging behavior, as well as exploring the temporal relationship between camouflaging and psychological distress since distress may motivate and/or result from camouflaging.