Dr. Jeremy Sharp (00:35)
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 (01:33)
Okay, everybody, we are back chatting about camouflaging and masking. This is quite a topic. So try to do, like I said, a relatively comprehensive overview of the literature, at least as we know it here. So I want to start with this section first of defining camouflaging. Okay. So let’s imagine that you spend every social interaction consciously calculating what to say and when to smile.
where to look, how long to maintain eye contact. And then I want you to imagine that what comes naturally to others requires constant exhausting effort for you. You can also picture becoming so good at this performance that no one, not even professionals, can tell that you are struggling. This, in a nutshell, is camouflaging.
So the formal definition, though, is camouflaging refers to conscious or unconscious strategies that individuals, often autistic individuals, employ to hide or compensate for or mask their often autistic characteristics in social settings. So the goal in camouflaging is to appear, quote, non-autistic or to fit in with the neurotypical social expectations.
The research thus far has identified three components of camouflaging. This is from a study in 2019 from Hull and colleagues. The first is compensation. So this is using alternative cognitive strategies to navigate social situations. Examples would be preparing scripts for conversations, studying social rules intellectually, and using logic to decode emotions. That’s compensation.
The second is masking, which many of us have heard of. and often equate with camouflaging, but at least in the literature, it’s a pillar of camouflaging, not one and the same. So the second component is masking. This is suppressing behaviors considered atypical or not neurotypical. Examples would be forcing eye contact, suppressing stims or stimming, and hiding sensory discomfort somehow.
The third component is assimilation. So this refers to imitating neurotypical behaviors. Examples be like copying others facial expressions, mirroring body language, and adopting other presumably neurotypical folks interests to have conversation topics.
Dr. Jeremy Sharp (04:13)
All right. So, recapping just a bit, the three components of camouflaging are compensation, masking, and assimilation.
A component of this as well, not a formal component, but a piece to consider is sort of a mismatch between internal and external features. right. So camouflaging essentially creates a mismatch between external observable features and the internal lived experience of an individual.
OK. So the underlying, again, in many cases, autistic profile remains unaffected even when the behavioral presentation is modified according to the literature. So this individual, often autistic individuals, still have the same neurological differences. They have just learned to hide them. So that’s an overview of camouflaging and how we have defined it in the literature, at least thus far.
Dr. Jeremy Sharp (05:05)
The next component that I want to talk about is measuring camouflaging. All right. At this point, there are two primary approaches. There are self-report measures.
One of the biggest ones that many of you have likely heard of is the Camouflaging Autistic Traits Questionnaire or the CAT-Q. It is the most widely used measure to assess camouflaging at this point from a self-report standpoint. It’s got a 24, sorry, 25 item full form and then a validated nine item short form called the CAT-Q SF. It assesses the self-perceived camouflaging efforts and intentions of an individual.
And it has three subscales that match those components that we just talked about, compensation, masking, and assimilation. So that’s the cat cue. Psychometric properties are pretty good. The internal consistency is sitting at about a 0.94. Test retest reliability is acceptable. It’s about a 0.77. Let’s see. Measurement.
Variance is good across genders and diagnostic groups and there’s been cross-cultural validation in Swedish, French, and Italian samples. So, Cat Q, most well-known self-report measure of camouflaging. That’s a little summary of what we know about it thus far. The second method though of measuring camouflaging looks at what we call discrepancy methods.
So this is essentially calculating the difference between underlying cognitive difficulties like, you know, theory of mind deficits, for example, and the observed autistic traits or self-reported autistic traits and externally observed autistic traits. So calculating the difference between, again, either underlying cognitive concerns and the observed autistic traits or self-reported autistic traits and externally observed autistic traits.
So the idea is that if someone has high underlying difficulties but low observable traits, then they must be camouflaging. I’ll say that again. The idea here with the discrepancy method is that if someone has high underlying difficulties represented through cognitive results or self-report, but low observable traits, they must be camouflaging.
This is where we run into a little bit of a problem with a relationship between these ideas, though. So self-report and discrepancy measures are only weakly to moderately correlated. So there’s an R of 0.2 to 0.47. What does this mean? This suggests that they may capture distinct aspects of camouflaging. So self-report captures intention and effort.
whereas discrepancy captures effectiveness. So someone might be trying very hard to camouflage, which would result in high self-report, but not succeed, which would result in a low discrepancy. Or someone might camouflage effectively, which is high discrepancy, without being fully aware of it, which would result in lower self-report. So this can account for some of this.
kind of weak to moderate correlation between self-report and discrepancy measurement.
Key point to consider here, adults with high autistic traits but no diagnosis did have higher discrepancy camouflaging scores than diagnosed adults. Self-reported scores were similar between the two groups, though. So what does this mean? This means that effective camouflaging theoretically may reduce the likelihood of an autism diagnosis. That kind of makes intuitive sense.
Dr. Jeremy Sharp (08:56)
All right, let’s move to this question of who is camouflaging. So we’re going to talk about prevalence across different populations here. First, autistic versus non-autistic. There is some meta-analytic data out there to confirm that autistic individuals score significantly higher on camouflaging measures than neurotypical counterparts. This is, I would say, the most robust finding in the literature. That said,
Camouflaging is not unique to autism by any means. So a representative US general population study of about a thousand people found that the cat cue demonstrates a nearly identical three factor structure in the general population as in autism enriched samples. So camouflaging appears to reflect a broader phenomenon of impression management that occurs across human groups.
It is not specific to autism. is important. The takeaway from this, think, is that everyone adjusts their behavior in social situations to some degree. There was a study looking at masking in the workplace. Okay, this compared autistic to non-autistic neurodivergent and neurotypical adults. Findings here show that all three groups engaged in workplace masking as an adaptive response to social challenges. That said, autistic and the non-autistic neurodivergent participants reported experiencing unique pressures to mask.
Given their limited understanding of neurodiversity. I’m to wrap up this section just by saying that context does matter. So for adolescents, autistic participants did camouflage more than non-autistic peers in offline contexts. whether you’re online or offline matters, at least for adolescents. But online, autistic participants camouflage less than they do offline.
This again makes intuitive sense to me, just given the nature of communication online versus offline, and that online communication tends to be more text-driven versus in-person reading, facial expressions, body language, et cetera. digital communication, I think, reduces the camouflaging demands just because there’s no eye contact, there’s more time to formulate responses, and that kind of thing. Let’s shift over to some sex and gender and age patterns.
Dr. Jeremy Sharp (12:31)
Hey, everyone. I’m really excited that NovoPsych Psychometrics is sponsoring the show. NovoPsych is a platform for psychologists who care deeply about assessment and testing and want their self-report measures to be the very best. NovoPsych has an extensive library of 150 standardized instruments with strong coverage across the presentations many of us assess every day, like disability, functional impact, autism, ADHD, and a wide range of symptom measures.
You can also use it for broad personality assessments like the Big Five or go deeper when you’re looking to understand personality pathology. What makes NovoPsych different isn’t just the range of scales, it is the quality of the experience. So I really appreciate the depth of psychometric info that it provides and the clear graphs and visualizations that make results easier to interpret and communicate. If you want to try NovoPsych psychometrics, you can access a 15 day free trial via the link in the show notes, which is
novopsych.com slash testing psychologist. That’s N-O-V-O-P-S-Y-C-H dot com slash testing psychologist.
Dr. Jeremy Sharp (13:36)
Alright, we’ll start with sex differences. So across studies, females consistently report higher camouflaging scores than males. This is true in both autistic and non-autistic populations. And meta-analysis of, I think it was 17 independent studies, showed that females displayed consistently higher scores across all the Cat Q subscales. Why? That’s a good question. Why is this happening?
Possible explanations include that females have greater social motivation and desire for connection, just that baseline. There are higher social expectations placed on females. There are better baseline social skills, providing more raw material to work with, so to speak. Females have earlier and more intensive social learning, and there is greater awareness among females of social failures and their consequences.
Dr. Jeremy Sharp (11:08)
Let’s shift to gender identity for a second. Some considerations here. There is some research to suggest that gender identity, not just biological sex, relates to camouflaging as well. So non-binary and transgender individuals may show different patterns. This is good to know. But the takeaway here, I think, is that this certainly requires more research to really flesh out the dynamics here.
As far as age, this is interesting as well. So in non-autistic individuals, camouflaging behaviors decrease during adulthood. However, in autistic individuals, camouflaging remains at a relatively elevated level throughout the lifespan. So takeaway here is that neurotypical folks might, quote unquote, grow out of impression management concerns as they get older, whereas autistic folks maybe can’t afford to.
And then lastly, in this section, there is a cross-cultural consideration. The original cat cue factor structure did not provide a good fit in some non-English samples. This is important, particularly, you know, problematic in children younger than 15 years old. And cultural norms around social behavior obviously affect camouflaging patterns.
Dr. Jeremy Sharp (15:43)
All right, let’s talk about the kind of mental health impact, I suppose, of camouflaging. So the consistent finding here is that research pretty consistently links higher self-reported camouflaging to worse mental health outcomes, like depression, anxiety, suicidal ideation, autistic burnout, lower quality of life, et cetera.
There is a double-edged sword here, though, where qualitative research identifies camouflaging as having both benefits and costs. Right. So the benefits are it can be a pragmatic way of exerting agency and control and securing employment and forming relationships. But the costs include being overlooked, under supported burnout, negative impacts on social relationships, low self-esteem, identity confusion. It’s a long list.
In terms of the identity costs, many autistic individuals describe not knowing who they really are after years of performing and camouflaging. And the mask becomes so habitual that the authentic self feels a bit inaccessible. And this, course, contributes to identity confusion and existential distress. There’s also some exhaustion for sure. So camouflaging requires constant cognitive effort by the end of a workday or social event.
Autistic individuals may be completely depleted or individuals who are masking or camouflaging heavily. Social hangover, so to speak, can last for days. The effort is invisible to others leading to kind of a lack of understanding and support. So what questions remain here, at least in this mental health section? Directionality, I think, is an important question.
Because it remains unclear. So does camouflaging cause mental health difficulties? Do mental health difficulties drive camouflaging? Do both share common causes like social rejection experiences, for example? And so ultimately more longitudinal research I think is needed to untangle these relationships.
Dr. Jeremy Sharp (17:41)
Before I wrap up, I am going to talk about some limitations here and validity concerns. Particularly around the construct itself of camouflaging. So the most critical perspective here, I think, is that despite widespread use and popularity, there are significant concerns about the construct validity of camouflaging. So concern number one, there is conceptual inconsistency. So this comes from a review of, gosh, nearly 400 studies.
And this just found inconsistency in one, which terms are used. So is it camouflaging, masking, compensating, or impression management? Two, whether studies reference established conceptual literature. Three, whether the terms are used interchangeably or distinctly. And four, just how the terms are defined. So all of this just kind of raises questions about whether the same construct has been investigated across these studies.
The second concern with all this is the confound with social anxiety. So the Cat Q may also measure behaviors associated with social anxiety rather than autism specific camouflaging. This has been the biggest criticism that I have heard over the years since the Cat Q came on the scene.
Research in autistic and non-autistic adolescents matched on social anxiety severity, found that masking and impression management were significantly associated with social anxiety symptom severity but not autism traits. So that’s interesting. That’s compelling, right? And then an exploratory factor analysis found that construct overlap across masking, assimilation, impression management, and avoidance behaviors.
Third concern in this realm is limited autism specificity have alluded to this. So again, the Cat Q demonstrates similar factor structure and predictive relationships in the general population, as in autistic samples. There are significant predictors of camouflaging in the general population, such as social comparison, public self-consciousness, internalized social stigma, and social anxiety.
These all overlap with findings in autistic camouflaging studies as well. So there’s not a lot of separation between, at least from what we know right now, between autism-specific populations and the general population. We also have to consider this impression management framework.
So theoretical work has reconsidered autistic camouflaging under the unifying framework of impression management rather than a separate construct. So impression management is the kind of ubiquitous human tendency to adjust behavior across social contexts. Everybody does it, but autistic individuals may do it more intensely, more consciously, and at greater cost is what we think. So there are two facets of impression management. There’s intentional use. So this is purposeful impression management driven by like social motivation pressures. Okay.
This predicts poor mental health. There’s also a facet of self-efficacy. So this is kind of a self-perceived impression management capacity. And that’s supported by executive functioning and perspective taking. This is actually linked to better mental health in neurotypical individuals. And then there is an autism-specific twist to all of this.
So in individuals with elevated autistic traits, both greater impression management, intentional use, and self-efficacy were linked to poor mental health. So for autistic individuals, even being good at impression management doesn’t protect mental health. So that suggests that there’s maybe something qualitatively different about the autistic experience of social performance. Again, this seems intuitive, but it’s good to put some data.
What are some of the limitations and future directions for research here? All right, who’s been studied? Studies thus far have predominantly featured white, female, late diagnosed autistic adults, and individuals with likely at least average intellectual and or verbal abilities. So who has been underrepresented here? Autistic males, which is interesting.
They’re typically overrepresented individuals diagnosed in childhood, autistic people with co-occurring intellectual or language difficulties, those with greater support needs, and racially and ethnically diverse populations, of course. Why does this matter? Because conclusions about camouflaging may not apply to the autistic community as a whole. We might be describing a phenomenon specific to a particular subset of autistic individuals, namely white female late diagnosed individuals.
And the construct might look very different in populations that we have not yet studied well. So in the future, we need to clarify the associated constructs and the measurements. We need to examine directionality between predictors and consequences. We need to investigate intersectionality and sociocultural influences. Develop multiple measures, I think, that delineate motivations for camouflaging, ability to camouflage, effortfulness of camouflaging.
And perceived effectiveness of camouflaging. And of course, we need more representative samples.
Dr. Jeremy Sharp (23:02)
So the bottom line, think, terms of takeaways, camouflaging is a clinically meaningful but imperfectly defined construct at this point.
Research has kind of outpaced validation efforts up until now. The construct may overlap substantially with social anxiety and just general impression management, but lived experience of autistic individuals, whatever we call it, is real and consequential.
So as we transition to episode four and start to wrap up the mini series here, we’re gonna talk about, if camouflaging can make autism invisible, this raises kind of a profound question in that autism is defined by observable social deficits, for lack of better word. So if someone can mask those challenges so effectively that they don’t meet diagnostic criteria, do they truly have autism? Like I said, in the final episode, this is the last puzzle piece that we will chat about. So stay tuned. If you haven’t
followed or subscribed to the podcast. Now’s a great time to do it and be on the lookout for the last episode in this autism mini series.
Click here to listen to the podcast instead.