Dr. Jeremy Sharp (00:37)
Hey folks, I am really glad to have NovoPsych Psychometric sponsoring the show. If you do structured assessment work, then you will likely love NovoPsych. NovoPsych brings 150 plus standardized measures into one platform. What I particularly like is the extra layer of psychometric interpretation. So it helps you understand what scores actually mean. So the results are easier to communicate. If you are interested in high quality measures for personality, disability, ADHD, or autism,
You can try NovoPsych with a 15 day free trial via the link in the show notes, is novopsych.com slash testing psychologist. That’s N-O-V-O-P-S-Y-C-H.com slash testing psychologist.
Dr. Jeremy Sharp (01:20)
All right, folks, hey, welcome back. We are wrapping up our autism mini series today with episode number four in the series. If you haven’t listened to the previous three episodes, I would encourage you to go back and listen. They do kind of build on one another, but if you can’t check out the whole series, go back to episode three at least, because that’s where I introduce this concept and do a nice overview of camouflaging and masking and what the literature says. And today we’re gonna take that further and tackle the somewhat provocative question, I think, that’s at the heart of this camouflaging and masking literature, which is, if someone can suppress their autistic traits to the point of appearing neurotypical and perhaps evading diagnosis for many years, do they truly have autism? So we examine the implications for diagnostic validity and, of course, clinical practice.
Before I transition to the conversation, of course, I would like to invite any of you who are practice owners who want to have a spacious getaway in Colorado this summer to work on your business and get some focus support for three and a half, four days where you just get to zone in on your business and work through problems that you’re having and hopefully make some pretty strong connections with other folks who get it. You can check out Crafted Practice, which is my in-person business retreat here in Colorado. This is the fourth summer that I’ve done it.
It is magical in many ways and you can get more info at thetestingpsychologist.com slash crafted practice. Okay. Let’s jump to this conversation around masking and camouflaging.
Dr. Jeremy Sharp (03:09)
All right, everybody want to open this discussion with a little bit of a diagnostic paradox, right? So consider this scenario here. We have a woman in her thirties seeking an autism evaluation. She describes a lifetime of feeling different, exhausting efforts to fit in sensory sensitivities and intense interests. But during the ADOS 2, she makes appropriate eye contact.
engages in reciprocal conversation and shows no obvious repetitive behaviors. Her scores on the ADOS fall below the diagnostic cutoff. Does this woman have autism? This might sound familiar. This is a question that comes up, I would say, multiple times a week in our practice for our clinicians who work with adults, which includes myself and a couple others.
So, I’ve heard this discussion many times in the Facebook group and even on my own podcast when Donna Henderson was here several years ago. We touched on this briefly, but it really gets at this question of masking as an effective strategy. And if it’s so effective that an individual can appear neurotypical, what implications does that have for diagnosis?
So, just to make this super clear, autism spectrum disorder is defined by observable deficits in social communication and interaction. In the DSM-5-TR, the criteria requires persistent deficits that limit and impair everyday functioning. But if someone can camouflage these deficits so effectively that they are not observable during assessment, how can they meet criteria for a disorder characterized by observable deficits, right?
A little bit of a philosophical problem here. This is super important. This is not, I would say, merely an academic question, as I already alluded to. mean, we are facing this question in our practice, and individuals are facing this question from the client side, you know, because it determines, you know, who receives the diagnosis, and then diagnosis often determines access to services and accommodations and support and self-understanding and a host of other things.
So, If we get this wrong, this has real consequences for real people.
Let’s transition for a bit into the facts, so to speak. So our diagnostic manual, the DSM-5 TR now, has a pretty specific framework. And I want to go over what the manual actually says. First thing is that compensation is explicitly recognized now. So the DSM-5 TR directly addresses this scenario of.
camouflaging or masking. it states that, quote, intervention, compensation and current supports may mask difficulties, that being autistic characteristics, difficulties in at least some contexts. All right. So that’s sufficiently vague as to almost be unhelpful, but it does acknowledge that intervention or compensation, that’s the key word here, may mask difficulties in some contexts.
And then it goes on to say, without cognitive or language impairment may be making great efforts to mask these deficits, again, referring to autistic symptoms. So the DSM-5-TR has some statements explicitly recognizing the concept of camouflaging or masking. There’s also the currently or by history clause in the diagnostic criteria. So the manual does specify that diagnosis can be based on deficits present currently or by history.
So that means a past observable difficulties can satisfy the diagnostic criteria even if current presentation appears superficially typical. This is I guess a crucial kind of escape valve from the paradox. Now that still raises the question of what counts as observable difficulties and who is reporting that they observed those difficulties. Do we rely on self report. Do we go by collateral report.
How does that happen? So that is an important question. But there’s also another element to touch on here, which is the social demands exceed capacities component. So the diagnostic criteria also explicitly acknowledge that symptoms may not become fully manifest until social demands exceed limited capacities. Symptoms can also be masked by learned strategies in later life.
So the language here was intentionally included to capture individuals who develop compensation strategies.
There’s another line of inquiry here that we could go through, which is, I guess you would call it like the cost of social interaction inquiry. So again, the DSM-5-TR, it instructs clinicians to inquire about the tolls of social interaction. So do you find social interactions exhausting? Do you have difficulty concentrating due to mental effort in monitoring social conventions?
These are just a couple of questions that we can use to elicit that cost of social interaction concept.
Dr. Jeremy Sharp (08:23)
All right. So we have covered the DSM-5 TR approach to masking and camouflaging. I want to revisit the paradox itself, define that a little bit more, and talk about how we work through this in more detail. I think, like I said earlier, the philosophically challenging part of this is that autism is fundamentally defined by
Deficits in social awareness and theory of mind and understanding social cues. That’s a huge part of the diagnosis, right? And meta-analytic evidence would confirm that autistic adults at least show relatively large impairments in theory of mind and emotion perception and processing compared to neurotypical adults.
Yet, camouflaging appears to require precisely these abilities, okay? Knowing what neurotypical behavior looks like, and understanding what others expect and modulating ones presenting, you know, presentation correctly or accordingly. So how can someone lack social insight yet possess enough social awareness to convincingly mask their deficits? Well, there’s a potential resolution here in the idea that compensation is not the same as intact ability.
So, the important thing to keep in mind here is that camouflaging does not necessarily require intact social cognition. It actually requires a lot of executive functioning and pattern recognition and learned behavioral scripts. research looking at cognitive predictors of camouflaging in autistic adolescents anyway found that executive functioning abilities, not theory of mind, predicted camouflaging.
That seems super important. And similarly in autistic adults, camouflaging was most strongly associated with executive dysfunction, perceived social cognition differences, and identity related processes, not with actual social cognitive abilities. So this may mean that autistic individuals who camouflage are not actually using intuitive social understanding; they’re using compensatory cognitive strategies that bypass social cognitive deficits.
So essentially, and this is, I think, something that we’ve leaned on and heard, at least informally over the years, that, you know, autistic individuals who are camouflaging effectively, quote unquote, are applying rules, not reading minds or social cues.
So want to talk a little bit more about this concept of camouflaging more as rule-based learning and not an intuitive understanding. So qualitative research has shown that autistic adults describe their camouflaging strategies as such. They report learning social behaviors through explicit observation and memorization and conscious application of rules rather than through intuitive social understanding.
So this is fundamentally different from neurotypical social cognition, right? Where one autistic adult described it as putting on my best normal, putting on my best normal. So a deliberate performance of sorts that’s based on learned scripts and not spontaneous social fluency. Camouflaging process involves masking, like we’ve talked about. So suppressing autistic behaviors and compensation.
So using those alternative strategies to achieve social goals. Compensation might include things like preparing conversation topics in advance, consciously monitoring facial expressions, following explicit rules about eye contact during or duration, limiting observed social behaviors without understanding their underlying social meaning, and so forth.
So these are just a few examples of what compensation might look like within the camouflaging. construct. So again, these are effortful, cognitively demanding strategies that work around social cognitive deficits rather than reflecting their absence. And that awareness is of difference, not of social nuance. So importantly, what drives the camouflaging is not sophisticated social insight, but rather like an awareness of being different and fear of negative judgment.
So autistic adults who camouflage report perceiving themselves as social misfits and experiencing stigma and feeling pressure to conform, not necessarily understanding the subtle social dynamics that they’re navigating. So they know they are different and that this difference leads to rejection or could lead to rejection.
This awareness in itself is sufficient to motivate camouflaging even without deep understanding of neurotypical, quote unquote, social cognition. And research confirms that camouflaging is primarily a socially motivated response to stigma and rejection, not a reflection of social cognitive ability. So the strongest predictor, though, of camouflaging is fear of negative evaluation. Autistic to perceive greater stigma and pressure to conform engage in more camouflaging.
Also mentioned in the last episode that there is a relationship between camouflaging and social anxiety, which you’ll probably recognize the overlap there between fear of negative evaluation and the diagnostic criteria for social anxiety. So on the whole, this is more of a, I guess, defensive response to repeated social failure and not evidence of social competence again.
One way of looking at this that might be helpful is to think of it like kind of like a computational model. So kind of like different processing, but the same goal. So there’s a recent theoretical work, I suppose, that sort of re-conceptualized camouflaging as a form of impression management that autistic and neurotypical people both engage in, but through different computational mechanisms. So what does that mean?
Essentially, autistic individuals face distinct computational challenges in social prediction and may rely more heavily on explicit rule-based processing rather than implicit social learning. So the effort required reveals the underlying deficit that neurotypical social behavior is automatic and intuitive while camouflage behavior is deliberate and exhausting precisely because it must compensate for absent intuitive social cognition. All right.
So we’re trying to resolve this paradox here a little bit. So the ability to camouflage does not contradict the presence of social cognitive deficits. It actually confirms them in a way. So if social cognition were intact, camouflaging would be unnecessary and effortless.
The very fact that autistic individuals must consciously learn, rehearse, and apply social behaviors that neurotypical individuals perform relatively automatically demonstrates the persistence of the underlying social cognitive differences. Camouflaging is not evidence of neurotypical social ability. It’s more evidence of compensatory cognitive effort in the face of persistent social cognitive deficits. That’s a mouthful.
So going back to the woman in our opening example, she may make appropriate eye contact during ADOS, for example, but she does so by consciously counting seconds and reminding herself to look at the examiner’s face, not because she intuitively understands the social function of eye contact, necessarily. She’s learned the rule. She’s not acquired the intuition.
The deficit remains only the observable behavior has changed. And speaking of observable behavior, this is where we’re going to call back to the, some of the limitations, I think, of the standardized assessment tools that we have. I talked in the first episode of the mini series about the ADOS2 sensitivity problem, right?
So again, ADOS2 considered widely to be a gold standard observational tool in diagnosing autism has well-documented limitations in detecting autism in individuals who camouflage. Sensitivity of module four, which is primarily used with older adolescents and adults, may be inadequate for highly functioning adults or those with low support needs, particularly women, as camouflaging and learned behavior in social situations can reduce the number of items that can be scored in the ADOS2 algorithm.
Most importantly, research emphasizes that scores lower than the cutoff alone should not be taken as reason to rule out autism spectrum conditions.
One of the criterion standards for autism diagnosis is not any single test, of course, but rather best estimate clinical consensus, agreement within a multidisciplinary team based on developmental history and observation. A 2025 meta-analysis found that standardized tools show varying sensitivity and specificity.
The ADOS had about 90 % sensitivity like we talked about, only about 70 to 80 % specificity. And so the authors again concluded that diagnostic tools should be regarded as adjunctive aids rather than comprehensive substitutes for diagnosis.
So diagnoses are most valid and reliable when based on multiple sources of information, including clinicians’ observations, caregiver history, and when possible, self-report.
So we get a lot of self-report, especially from adults who are seeking autism assessment. But we have to combine that with our own observations and these tools that we have. Again, keeping in mind that just because someone can kind of mimic or employ behaviors that appear to meet social conventions does not mean that it is intuitive necessarily.
So I want to pivot just a little bit and talk more about the neurobiology going on here. So camouflaging, I think a good way to think of it is, know, camouflaging changes behavior, but not neurobiology. So again, camouflaging is defined as behaviors that mask the presentation of autism spectrum disorders features in social context.
But the underlying autistic profiles unaffected theoretically, yielding a mismatch between external observation features and the internal lived experience of autism. That was a quote from some research. So this is the key distinction. Camouflaging is a behavioral overlay and not a neurobiological cure.
Dr. Jeremy Sharp (20:38)
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novopsych.com slash testing psychologist. That’s N-O-V-O-P-S-Y-C-H dot com slash testing psychologist.
Dr. Jeremy Sharp (21:43)
Comprehensive meta-analysis of probably 75 studies involving like 3000 autistic adults found significant impairments across multiple cognitive domains compared to neurotypical adults.
Even those without intellectual disability. And the largest deficits were in social cognition, like theory of mind, motion perception, but also included processing speed and verbal learning and memory and reasoning and problem solving. So these cognitive patterns persist regardless of behavioral presentation.
There’s some recent neuroimaging research that has used AI and has identified some robust, quote, robust individualized functional brain fingerprints of ASD psychopathology. OK, so that is quite a mouthful. Again, I take a little bit of issue with that quote, but that is the quote.
So I’m going to leave that there. it has distinguished autistic individuals from neurotypical controls with high accuracy across multiple independent cohorts and features associated with the default mode network and cognitive control systems and social processing regions consistently differentiated autistic adults. these neural signals predicted severity of social communication deficits. So that’s super exciting. Just knowing the nature of some of this research, I want to see this replicated for sure to see it for. if this is legit.
Importantly, all these brain-based markers, though, exist independent of observable behavior. So just strengthening that perspective. Autism is, I think, now understood as a condition resulting from overall brain reorganization beginning early in development.
It’s a neurodevelopmental concern with patterns of altered connectivity that sometimes remain stable into adulthood as different individuals use adaptive and compensatory mechanisms to address their challenges. So the use of compensation doesn’t eliminate the underlying neurobiological difference, it just represents the brain’s adaptive response to them.
All right, so let’s talk a little bit about this functional impairment question. This is another aspect of the diagnosis that there has to be functional impairment. So I’m going to go back to this exhaustion concept that we talked about. So the DSM-5 TR explicitly states that clinicians have to inquire about the toll of social interaction.
We talked about this. Whether individuals find social interaction exhausting or have difficulty concentrating due to mental effort in monitoring social conventions. Okay, just reiterating that. So again, this recognizes that functional impairment can manifest as effort and exhaustion rather than observable failure. I’ll say that one more time. Functional impairment can manifest as effort and exhaustion rather than observable failure.
There are some mental health consequences of this multiple systemic reviews have documented that camouflaging is associated with significant mental health burden. A 2023 study of, let’s see, or is a meta analysis. reviewed 58 studies found that camouflaging is particularly social convention response linked to adverse psychological outcomes, including being overlooked, under supported and burned out as well as low self-esteem and identity confusion.
Okay, those are pretty serious. In children and adolescents, camouflaging is a significant predictor of internalized symptoms, including anxiety and depression and somatic complaints. So it’s important to ask about camouflaging for kids as well. So the relationship between camouflaging and mental health appears complex and potentially bi-directional with some evidence saying that it may vary across subgroups as well.
Now, in terms of employment and relationships, while camouflaging may help secure employment and form social relationships in the short term, it comes with some pretty serious costs like stress and anxiety and depression and, quote unquote, autistic burnout.
So this creates the paradox. The very strategy that enables social participation may simultaneously cause significant harm representing a form of functional impairment that wouldn’t exist in other, you accommodating environments. So definitely a paradox there. I’m to talk a little bit more about autistic burnout as a diagnostic indicator specifically.
So the phenomenon of autistic burnout, which is characterized by chronic exhaustion and loss of skills and reduced tolerance to stimuli is increasingly recognized as a consequence of sustained camouflaging. And this, I think, represents functional impairment that may not be visible during a brief clinical assessment, but profoundly affects quality of life. So we have to be paying attention to that and asking about it.
Okay, so how do we resolve all of this? I mean, this is hard. And I undertook this episode or the series, I suppose, trying to resolve this question because we wrestle with this so much in our practice. And I’ll be honest, I’ve been surprised by what the research shows and some of these conclusions. But at least at this point, it seems more definitive that autism is present. Many of you are probably saying like, yes, of course, obviously.
And there are many folks out there, I think, who have been rightfully skeptical of this question, like I said, of, know, can you truly mask and camouflage behaviors when, you know, the criteria for the disorder almost like precludes that.
So if somebody has the underlying neurobiological profile of autism, you know, experiences the internal phenomenology of autism and has to expend significant effort to appear neurotypical, then they probably have autism. right? The ability to camouflage is not evidence against the diagnosis necessarily. It’s a manifestation of the diagnosis. And there are three kind of converging lines of evidence just to pull all this together.
So first, the DSM-5-TR explicitly addresses a scenario through its currently or by history clause. It’s recognition that symptoms may be masked by learned strategies and its instruction to assess the effort and toll of social interaction. Second, the neurobiology is relatively clear in that camouflaging changes behavioral presentation, but not the underlying brain differences or cognitive profile or individual experience.
And then third, the functional impairment is present. It’s just shifted. from observable social failure to kind of invisible exhaustion, mental health burden, and identity confusion.
So at this point, current expert consensus emphasizes that in adults with suspected autism, subjective experiences are important for the differential diagnosis and careful understanding of the individual’s diagnosis as perceived by the patient and informants and a clear delineation of coping or camouflaging strategies that have developed over time. These are all important in making an accurate us.
OK, so returning again, once again, to our opening case, the woman who scored below the ADOS 2 cutoff but describes a lifetime of feeling different and exhausting efforts to fit in. She could receive an autism diagnosis if her developmental history and self-reported experience and the total of her compensatory strategies support it. The ADOS 2 score is just one piece of data and, of course, not the final arbiter.
So bringing it home a little bit more, slowly but surely, talk about implications for clinical practice.
I think clinicians that are assessing adults for autism, particularly women and late diagnosed individuals, have to one, explicitly inquire about camouflaging characteristics and their costs, two, obtain detailed developmental history from multiple sources, three, consider historical symptoms that may have been masked, four, not rely solely on observational measures like the ADOS2, and five, assess the effort and exhaustion associated with social interaction, not just observable social failure.
There are some dangers around false negatives. So of course, if you fail to diagnose autism and someone who camouflages well, that can have serious consequences, right? Denial of access to services, accommodations, community, continued exhaustion without understanding its source and increased risk of mental health crisis and autistic burnout.
Okay, okay. I think the paradox that we’ve been talking about reveals something fundamentally important about psychiatric diagnoses, which is that we are not diagnosing the presence or absence of observable behaviors in a vacuum, but rather, you know, we’re identifying a neurobiological condition that manifests differently depending on individual capacities and learn strategies and environmental commands.
The validity of the diagnosis is not just contingent on a single snapshot of behavior, but on the comprehensive understanding of the person’s neurobiology and development and internal experience and functional adaptation. So all these things are kind of coming together, you know, to create this diagnostic assessment, right? So the question of If you can mask it, do you have it? I think reveals a real tension between behavioral observation and neurobiological reality. The answer, at least at this point, from both the diagnostic manual and the scientific literature seems clearer than I thought, just being honest, in that autism is defined by the underlying neurobiological profile and its impact on the individual, not by whether that impact is immediately visible to an observer.
Camouflaging is not necessarily evidence of neurotypicality. It is evidence of the extraordinary effort that some folks have to expend to navigate a world that’s not designed for their traits and attributes and neurology. All right.
So the ability to camouflage autistic symptoms does not negate the diagnosis. I think it just transforms how we assess for it. Clinicians have to look beyond surface behavior to the underlying neurobiology and developmental history and internal experience and the hidden costs of compensation for folks. And the diagnostic paradox, I think, is resolved a bit when we recognize that autism is not simply what we can observe in a 45-minute session.
But what exists in the brain and the biography of the person, and the exhausting daily effort to bridge two different ways of being in the world. So with that, I’m gonna wrap this up. This has been pretty heavy, especially this last episode. There’s a lot, there’s a lot to continue to dive into here, but it’s been illuminating, at least for me, and I hope that it’s given you a lot to consider.
As we continue to move forward in making the best diagnoses that we possibly can. So I’m gonna wrap up this autism mini series. definitely going to be revisiting questions around autism in the future. And we bring on more and more experts to answer some of these questions. In the meantime, if you have thoughts, questions, comments, send them over to me, Jeremy at thetestingpsychologist.com. Would love to continue this discussion as we again, just try to do the best work that we can.
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