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Camouflaging in autism: A systematic review

Open access
Cook, Julia, Hull, Laura, Crane, Laura, Mandy, William·2021·Clinical Psychology Review
DOI 10.1016/j.cpr.2021.102080
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Abstract

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.

AI snapshot

Written from the paper’s full text.

TL;DR

This systematic review synthesizes 29 quantitative studies of camouflaging in autistic people and those with high autistic traits. It finds consistent links between self-reported camouflaging and higher autistic traits/diagnosis, female gender, and poorer mental health, but measurement heterogeneity and unrepresentative samples limit firm conclusions.

Key findings

  • Adults with more self-reported autistic traits, and often those with an autism diagnosis, report greater camouflaging; one study suggested the diagnostic association was driven by autistic traits rather than the label itself.
  • Most included studies found autistic females/girls/women camouflaged more than autistic males/boys/men, with no study showing the reverse; evidence on non-binary people was limited, though one study found non-binary autistic people camouflaged at levels similar to autistic women.
  • Eight of ten adult studies supported an association between greater self-reported camouflaging and poorer mental health, including anxiety, depression, psychological distress, suicidality, and lower wellbeing; findings using internal-external discrepancy measures were less consistent.
  • Two broad measurement approaches emerged: self-report methods, which may capture “camouflaging intent,” and internal-external discrepancy methods, which may capture “camouflaging efficacy”; the CAT-Q was used in 13 of 19 self-report studies.

Methods

  • PROSPERO-registered systematic review following PRISMA; databases searched from inception to October 2020, with an updated search in May 2021, plus grey literature and reference checking.
  • From 2160 unique citations and 104 full-text reviews, 29 studies met inclusion criteria: 18 adult studies and 11 child/adolescent studies, totaling 2254 adults and 1077 children/adolescents with autism diagnoses or high autistic traits.
  • Data were extracted and cross-checked by reviewers, study quality was assessed with the Mixed Methods Appraisal Tool, and findings were narratively grouped by five research questions; meta-analysis was not possible due to measurement differences.

Limitations

  • The authors state that the search may not have been exhaustive, that their own involvement in the camouflaging field may have introduced bias, and that the review lacked participatory design and autistic input.
  • The review reports that most studies failed to obtain representative samples (n=23) and many did not describe participant flow (n=17); participant characterization was generally poor, with samples mostly white, university-educated adult females/women diagnosed in adulthood and mostly white male children/adolescents.
  • The text makes evident further constraints: cross-sectional designs prevent causal inference, non-binary samples were underpowered, online questionnaire recruitment likely excluded some autistic people, and the CAT-Q had not been validated for adolescents in several included studies.

Model-written summary. Check it against the paper before relying on it.

Integrity signals

Registry

Crossref · 10.1016/j.cpr.2021.102080

Cites

85 of 85 references verified0 citation errors · 0 not checkable

Statistics

Nothing to recompute.

Claims the paper makes

0 of 127 cited sources checked · 0 supported · 0 flagged

  • Findingnone given

    The current methods for measuring camouflaging seem to capture two constructs: intent to camouflage and effectiveness of camouflaging.

    “Current approaches to measuring camouflaging appear to measure 'camouflaging intent' and 'camouflaging efficacy'.”
    Quote in the paperSubstantial claim
  • Findingnone given

    The designs of studies in this area are constrained by inadequate participant characterisation and poor representativeness.

    “Study designs are limited by poor participant characterisation and representativeness.”
    Quote in the paperSubstantial claim
  • Findingnone given

    Greater self-reported camouflaging is linked to poorer mental health outcomes.

    “Higher self-reported camouflaging is associated with worse mental health outcomes.”
    Quote in the paperSubstantial claim
  • Findingnone given

    No prior review has systematically identified and described methods for measuring camouflaging.

    “To date, no review has systematically identified and described methods of measuring camouflaging, nor has it systematically examined the measurement properties of these methods.”
    Quote in the paperSubstantial claim
  • Findingnone given

    There are differences in camouflaging related to sex and gender.

    “Sex and gender differences exist in camouflaging.”
    Quote in the paperNot a substantial claim
  • Classified as probably not a substantial claim. 56
  • May combine two claims. 38
  • The quote only partly states this claim. 1

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Findingown data

    After removing duplicates, 2160 unique citations were screened, 104 full-text articles were reviewed, and 29 studies were included.

    “As can be seen in Figure 1, after removal of duplicates, 2160 unique citations were screened for eligibility, of which 104 full-text articles were reviewed and 29 studies were identified as eligible for inclusion in the systematic review.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Findingown data

    Adults ranged in age from 16 to 82 years, with a mean age of 36.47 years.

    “Adults ranged in age from 16 to 82 with a mean age of 36.47 years.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Findingreasoning

    Three chiefly qualitative studies were included because each included a quantitative measure of camouflaging.

    “Three studies involving chiefly qualitative design were included because each included a quantitative measure of camouflaging (Cook et al., 2021;Hull et al., 2017;Livingston, Shah, & Happé et al., 2019).”
    Quote in the paperSubstantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Findingown data

    The majority of studies (n=23) used solely quantitative methods, and three used mixed methods.

    “The majority of studies (n = 23) involved solely quantitative methodologies and a further three used mixed methods designs (Cage et al., 2018;Jedrzejewska & Dewey, 2021;Livingston et al., 2020).”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Findingown data

    Eighteen included studies examined camouflaging in adults, and 11 examined it in children and adolescents.

    “Eighteen of the included studies examined camouflaging in adults, and 11 examined camouflaging in children and adolescents.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Findingown data

    The majority of adult participants reported female sex or identified as women (60.1%).

    “The majority of participants reported female sex or identified as womenfoot_0 (60.1%) and were formally diagnosed with autism (95.9%).”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Findingown data

    Studies were either open worldwide (n=9) or restricted to the UK (n=10), USA (n=8), Australia (n=1), or Poland (n=1).

    “Studies were either open to individuals worldwide to participate (but conducted in English; n=9) or were restricted to individuals located in the UK (n=10), USA (n=8), Australia (n=1), or Poland (n=1).”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Findingown data

    Participants were typically diagnosed in adulthood (M=32.98 years) across the seven studies reporting mean age at diagnosis.

    “Participants were typically diagnosed in adulthood (M=32.98 years) across the seven studies reporting mean age at diagnosis.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Findingown data

    Child/adolescent participants ranged in age from 5 to 18 years, with a mean age of 11.90 years.

    “Child/adolescent participants ranged in age from 5 to 18 years with a mean age of 11.90 years.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Findingown data

    Only four studies measured IQ, and participants in these studies had average to above average intelligence (Full Scale IQ M=112.35).

    “Only four studies measured IQ and participants in these studies were of average to above average intelligence (Full Scale IQ, M=112.35).”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Findingcitation

    Nine adult studies and four child/adolescent studies used the Camouflaging Autistic Traits Questionnaire (CAT-Q).

    “Nine adult studies and four child/adolescent studies used the Camouflaging Autistic Traits Questionnaire (CAT-Q; Hull et al., 2019).”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites Hull et al., 2019 source

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Findingown data

    Most child/adolescent participants were male sex or identified as boys (62.9%).

    “Most participants were of male sex or identified as boys 3 (62.9%)and were formally diagnosed with autism (94.7%).”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Findingown data

    Almost half of participants in the one study reporting comorbidities had co-occurring diagnoses (40.7%).

    “Almost half of the participants in the one study reporting comorbidities had co-occurring diagnoses (40.7%).”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Findingcitation

    Two studies used modified versions of the Girls Questionnaire for Autism Spectrum Conditions (GQ-ASC).

    “Two studies used modified versions of the Girls Questionnaire for Autism Spectrum Conditions (GQ-ASC; Attwood et al., 2011).”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites Attwood et al., 2011

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Findingown data

    Most child/adolescent participants were formally diagnosed with autism (94.7%).

    “Most participants were of male sex or identified as boys 3 (62.9%)and were formally diagnosed with autism (94.7%).”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Findingnone given

    One additional study used a parent-report measure of masking.

    “One additional study used a parent-report measure of masking.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Findingcitation

    Internal consistency for the Camouflaging subscale of the modified GQ-ASC was ω=0.67.

    “Internal consistency for the Camouflaging subscale was 𝜔= 0.67.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Findingcitation

    Four studies using the CAT-Q involved adolescent samples, although the CAT-Q is yet to be validated for autistic adolescents.

    “Whilst yet to be validated for use with autistic adolescents, four studies using the CAT-Q involved adolescent samples (Bernadin et al. 2021;Hull, Petrides, & Mandy, 2021;Jedrzejewska & Dewey, 2021;Jorgenson et al., 2020).”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Findingown data

    Child and adolescent samples ranged from N=33 to N=236, with a total of 1077 participants.

    “Child and adolescent samples ranged from N=33 to N=236 with a total of 1077 children and adolescents with an autism diagnosis or high levels of autistic traits included across all studies.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Findingnone given

    Internal consistency for the Social Masking scale of the Q-ASC was α=.61.

    “Internal consistency for the Social Masking scale was α =.61.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Findingown data

    Mean Full Scale IQ for child/adolescent participants was in the average range (99.93).

    “Mean Full Scale IQ was in the average range (99.93).”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Findingown data

    Three adult studies and six child/adolescent studies used internal-external discrepancy approaches.

    “As can be seen in Table 3, three adult studies and six child/adolescent studies used internal-external discrepancy approaches.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Findingown data

    Most child/adolescent participants in the two studies reporting ethnic group/race were white (75.8%).

    “Most participants in the two studies reporting ethnic group/race were white (75.8%).”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Findingown data

    General anxiety (54.8%) and depression (53.1%) were common among participants in the five studies reporting co-occurring mental health conditions.

    “General anxiety (54.8%) and depression (53.1%) were common amongst participants in the five studies reporting cooccurring mental health conditions.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Findingown data

    Overall, results suggested that higher levels of self-reported camouflaging are associated with having an autism diagnosis or higher autistic traits in adult samples.

    “Overall, results suggested that higher levels of self-reported camouflaging are associated with having an autism diagnosis or higher autistic traits in adult samples.”
    Quote in the paperSubstantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Findingown data

    Reported internal consistency for Cassidy et al.'s camouflaging questions was α=.75.

    “Reported internal consistency for the questions was α=.75.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Findingcitation

    Internal consistency for Cage and Troxell-Whitman's set of camouflaging contexts was α=0.95.

    “Internal consistency for the set of camouflaging contexts was α=0.95.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Findingcitation

    Gender was a suggestive predictor of camouflaging, with female or non-binary identification predicting higher Total CAT-Q scores.

    “gender was a suggestive predictor of camouflaging such that identifying as female or non-binary predicted higher Total CAT-Q scores.”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites Perry et al., 2021

      Not checked in the free run.

  • May combine two claims.

    Findingcitation

    Compared with autistic males, autistic females reported camouflaging in more situations, more often, and for more time.

    “compared to autistic males, autistic females reported camouflaging across more situations, more frequently and for more of the time (Cassidy et al., 2018).”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites Cassidy et al., 2018 source

      Not checked in the free run.

  • May combine two claims.

    Findingcitation

    High compensators had significantly higher Full Scale IQ and Verbal IQ, but not Non-Verbal IQ, than low compensators.

    “Livingston, Colvert, et al. (2019) found high compensators demonstrated significantly higher Full Scale IQ and Verbal IQ (but not Non-Verbal IQ) scores than low compensators.”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites Livingston, Colvert, et al., 2019

      Not checked in the free run.

  • May combine two claims.

    Findingcitation

    One adult study suggested that higher camouflaging may be linked to better executive functioning in autistic women but not autistic men.

    “Lai et al. (2017) suggested that higher camouflaging scores may be associated with better executive functioning abilities for autistic women but not autistic men.”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites Lai et al., 2017 source

      Not checked in the free run.

  • May combine two claims.

    Findingcitation

    Spontaneously reported camouflaging was associated with higher depression but not anxiety or stress scores.

    “Spontaneously reported camouflaging (in text responses to questions about autism acceptance and mental health) was associated with higher depression, but not anxiety or stress scores (Cage et al., 2018).”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites Cage et al., 2018 source

      Not checked in the free run.

  • May combine two claims.

    Findingcitation

    In one validated self-report study, older age suggestively predicted lower total CAT-Q scores, while older age at diagnosis suggestively predicted higher total CAT-Q scores.

    “older age suggestively predicted lower total CAT-Q scores while older age at diagnosis suggestively predicted higher total CAT-Q scores (Perry et al., 2021).”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites Perry et al., 2021

      Not checked in the free run.

  • May combine two claims.

    Findingcitation

    Higher camouflaging scores were associated with greater depressive symptoms in men but not women.

    “Lai et al. (2017) found that higher camouflaging scores were associated with greater depressive symptoms in men but not women”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites Lai et al., 2017 source

      Not checked in the free run.

  • May combine two claims.

    Findingcitation

    Greater self-reported camouflaging is associated with increased social anxiety, general anxiety, and depressive symptoms.

    “increased social anxiety, general anxiety, and depressive symptoms (Hull et al., 2019;Hull, Levy, et al., 2021)”
    Quote in the paperSubstantial claim0 of 2 sources checked
    • cites Hull et al., 2019 source

      Not checked in the free run.

    • cites Hull, Levy, et al., 2021

      Not checked in the free run.

  • May combine two claims.

    Findingcitation

    High compensators had high self-report anxiety, but not parent-report anxiety, compared with low compensators.

    “Livingston, Colvert, et al. (2019) reported that high compensators demonstrated high self-report (but not parent-report) anxiety compared to low compensators.”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites Livingston, Colvert, et al., 2019

      Not checked in the free run.

  • May combine two claims.

    Findingcitation

    Greater self-reported camouflaging is associated with decreased well-being, though one study did not find this.

    “decreased well-being (Hull et al., 2019; although see Perry et al., 2021).”
    Quote in the paperSubstantial claim0 of 2 sources checked
    • cites Hull et al., 2019 source

      Not checked in the free run.

    • cites Perry et al., 2021

      Not checked in the free run.

  • May combine two claims.

    Findingown data

    The remaining included studies found null results, and no study found the opposite pattern of higher camouflaging in males or boys or men.

    “The remaining included studies found null results and no study found the converse effect of higher camouflaging in males or boys/men.”
    Quote in the paperSubstantial claim

  • The quote only partly states this claim.

    Findingcitation

    Preliminary findings from two included studies suggest that stigma and not feeling accepted contribute to increased camouflaging among people with higher autistic traits.

    “preliminary findings from two included studies suggest that experiences of stigma and not feeling accepted play a role (Cage et al., 2018;Perry et al., 2021).”
    Quote in the paperNot a substantial claim0 of 2 sources checked
    • cites Cage et al., 2018 source

      Not checked in the free run.

    • cites Perry et al., 2021

      Not checked in the free run.

  • May combine two claims.

    Findingcitation

    Camouflaging is not specific to females and girls or women, because it is consistently documented in autistic males and boys or men.

    “the consistent documentation of camouflaging in autistic males and boys/men also shows that camouflaging is not specific to females and girls/women (Lai et al., 2017;Hull, Lai, et al., 2020).”
    Quote in the paperSubstantial claim0 of 2 sources checked
    • cites Lai et al., 2017 source

      Not checked in the free run.

    • cites Hull, Lai, et al., 2020

      Not checked in the free run.

  • May combine two claims.

    Findingreasoning

    A more nuanced understanding of sex and gender differences in camouflaging is currently lacking, partly because included studies did not comprehensively characterise participants' gender identity.

    “a more nuanced understanding of sex and gender differences in camouflaging is currently lacking, owing in part to included studies largely failing to provide a comprehensive characterisation of participants' gender identity via the description of the multiple components of sex and gender.”
    Quote in the paperSubstantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Findingown data

    In two adult studies, it was unclear whether the reported sex/gender measure referred to sex or gender.

    “In the remaining two studies it was unclear if the measurement of sex/gender reported referred to sex or gender.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S4 (based).

    Findingnone given

    This is the first review to systematically appraise and synthesise evidence on autistic camouflaging in children and adults of all sexes and genders.

    “This is the first review to systematically appraise and synthesise the current evidence base pertaining to autistic camouflaging in children and adults of all sexes and genders.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Findingown data

    In one child study, it was unclear whether the reported sex/gender measure referred to sex or gender.

    “In one study it was unclear if measurement of sex/gender reported referred to sex or gender.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Findingown data

    Child studies reported sex only in six studies, what authors called sex/gender in two, and gender only in two.

    “In describing sex and gender or participants, child studies reported sex only (n = 6); what was termed sex/gender by authors (n = 2); and gender only (n = 2).”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Findingown data

    Adult studies reported gender only in eight studies, both sex and gender in three, and sex only in two.

    “In describing sex and gender of participants, adult studies reported: gender only (n = 8); sex and gender (n = 3); sex only (n = 2).”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Findingreasoning

    Dean et al. (2017) was excluded because it did not present quantitative data measuring camouflaging.

    “Dean et al. (2017) This study quantitatively compared playground activities (type of activity and time spent in activity) between autistic and non-autistic boys and girls.Qualitive data was provided describing camouflaging behaviours.Thus, this study did not present quantitative data measuring camouflaging.”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites Dean et al. (2017) source

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  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Findingown data

    Bargiela et al. (2016) was excluded because it presented only qualitative data on camouflaging in late diagnosed women.

    “Bargiela et al. (2016) Presented only qualitative data regarding camouflaging in late diagnosed women.”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites Bargiela et al. (2016) source

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Findingown data

    The mean FSIQ of child participants across studies was 99.93.

    “99.93”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Findingreasoning

    Head et al. (2014) was excluded because it did not report quantitative data measuring camouflaging.

    “Head et al. (2014)The authors compared autistic and non-autistic children's scores on a self-report measure of friendship quality, understanding, and empathy.Thus, this study did not report quantitative data measuring camouflaging.”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites Head et al. (2014) source

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Findingown data

    Among child studies, 40.7% had a comorbid diagnosis.

    “40.7 Co-morbid diagnosis”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Findingown data

    Among adult studies, 53.1% of participants had depression.

    “53.1 Depression”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Findingreasoning

    Lehnhardt et al. (2016) was excluded because it presented data on abilities that may be associated with camouflaging rather than camouflaging itself.

    “Lehnhardt et al. (2016) The authors compared differences in cognitive, executive functioning, and mentalising abilities between late diagnosed autistic men and women.The authors discussed these abilities as potentially enabling camouflaging.Thus, this study presented data on abilities that may be associated with camouflaging rather than camouflaging per se.”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites Lehnhardt et al. (2016) source

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Findingown data

    The mean age of child participants across studies was 11.90 years.

    “11.90”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Findingown data

    The mean age of adult participants across studies was 36.47 years.

    “36.47 32.98”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Findingreasoning

    Tierney et al. (2016) was excluded because it presented only qualitative data on camouflaging in autistic girls.

    “Tierney et al., (2016) Presented only qualitative data regarding camouflaging in autistic girls.”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites Tierney et al. (2016) source

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Findingreasoning

    Cook et al. (2018) was excluded because it presented only qualitative data on masking in autistic girls and their mothers.

    “Cook et al. (2018) Presented only qualitative data regarding masking in autistic girls and their mothers.”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites Cook et al. (2018)

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Findingown data

    The mean FSIQ of adult participants across studies was 112.35.

    “112.35”
    Quote in the paperNot a substantial claim

  • Classified as probably not a substantial claim.

    Premisecitation

    Study samples in the field lack representativeness.

    “Recent discussions and commentaries highlight potential problems within the field including variations in operationalisations and measurement approaches, under-established validity and reliability across measures, and a lack of representativeness within study samples (Fombonne, 2020;Lai et al., 2020;Williams, 2021).”
    Quote in the paperSubstantial claim0 of 3 sources checked
    • cites Fombonne, 2020 source

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    • cites Lai et al., 2020

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    • cites Williams, 2021

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  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Study design and conductown data

    The review protocol was registered with PROSPERO.

    “This review protocol was registered online with PROSPERO, the international prospective register of systematic reviews (registration number: CRD42019141410).”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Study design and conductcitation

    Study quality was assessed using the Mixed Methods Appraisal Tool (MMAT).

    “Study quality was assessed using the Mixed Methods Appraisal Tool (MMAT; Hong et al., 2018).”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites Hong et al., 2018 source

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Study design and conductown data

    Reviewers did not assess studies for which they were authors, except for one study.

    “Reviewers did not assess studies for which they were also authors, with the exception of one study (Cook, Crane, Bourne et al., 2021) on which all four reviewers were authors.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Study design and conductcitation

    The review followed the most current PRISMA guidelines.

    “The most current version of the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines for conducting systematic reviews was followed throughout the review process (Page et al., 2021).”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites Page et al., 2021 source

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  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Study design and conductreasoning

    The review proceeded as planned except that one research question was added after the search.

    “Our review proceeded as planned except that one research question (”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Study design and conductnone given

    Data extraction was performed independently by each author for about 25% of included studies.

    “Each author independently extracted data for ≈25% of included studies.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Study design and conductown data

    Each author cross-checked data for a separate 25% of included studies.

    “Each author then cross-checked data for a separate ≈25% of included studies.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Study design and conductown data

    Each study was independently rated by two reviewers.

    “Each study was independently rated by two reviewers (i.e., either JC and LC or WM and LH).”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Study design and conductown data

    Full texts were evaluated for inclusion independently by two reviewers.

    “After exclusion of research according to these broad criteria, the full texts of remaining publications were evaluated for inclusion independently by JC and LH.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Interpretationnone given

    Camouflaging likely involves both conscious and unconscious use of behavioural and cognitive strategies.

    “camouflaging likely involves both the conscious and unconscious employment of behavioural and cognitive strategies.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Interpretationcitation

    Because the ADOS was developed using predominantly white male samples, its scores may partly reflect deviation from a stereotypically male autistic presentation rather than change through camouflaging.

    “given that the ADOS was developed using predominately white, male samples, scores on this measure may reflect, at least in part, the degree to which an individual's behavioural presentation ordinarily deviates from the stereotypically male autistic presentation, rather than the degree to which an individual's behavioural presentation is changed via camouflaging (Pearson & Rose, 2021).”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites Pearson & Rose, 2021 source

      Not checked in the free run.

  • Classified as probably not a substantial claim.

    Interpretationreasoning

    Self-report methods can be conceptualised as measuring camouflaging attempts, efforts, or intentions.

    “self-report methodologies could be conceptualised as measuring camouflaging attempts, efforts, or intentions”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Premisecitation

    The CAT-Q showed potential as a measure of self-perceived camouflaging, with sound internal consistency and test-retest reliability and generally expected relations with gender, autistic traits, and mental health and wellbeing.

    “the CAT-Q showed potential as measure of self-perceived camouflaging, demonstrating sound internal consistency and test-retest reliability and performing generally as expected when tested in relation to gender, autistic traits, and mental health and wellbeing”
    Quote in the paperSubstantial claim0 of 2 sources checked
    • cites Hull et al., 2019 source

      Not checked in the free run.

    • cites Fombonne, 2020 source

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Interpretationcitation

    The link between greater self-reported autistic traits and better social communication performance may be driven by social insight or reasoning rather than camouflaging.

    “the relationship between greater self-report levels of autistic traits and improved performance on measures of social communication may be driven by social insight or reasoning as opposed to camouflaging (Livingston et al., 2020).”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites Livingston et al., 2020 source

      Not checked in the free run.

  • Classified as probably not a substantial claim.

    Interpretationreasoning

    Internal-external discrepancy methods may capture how far camouflaging behaviours and strategies translate into observable social behaviour, labelled camouflaging efficacy.

    “internal-external discrepancy methods may capture the extent to which these behaviours and strategies (as well as behaviours and strategies operating outside of conscious awareness) translate into observable social behaviour, and we label this 'camouflaging efficacy'.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Interpretationcitation

    Internal-external discrepancy and self-report approaches likely measure distinct but potentially converging elements of camouflaging.

    “It is likely that internal-external discrepancy and self-report approaches measure distinct but potentially converging elements of camouflaging (Lai et al., 2020).”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites Lai et al., 2020

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S2 (checkable).

    Interpretationnone given

    Self-report methods may measure the extent to which individuals consciously use camouflaging behaviours and strategies, labelled camouflaging intent.

    “Self-report methodologies may measure the extent to which individuals consciously employ camouflaging behaviours and strategies, and we label this 'camouflaging intent'.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Interpretationreasoning

    The findings provide preliminary evidence that autistic females and girls or women consciously engage in more camouflaging than autistic males and boys or men, with more noticeable effects.

    “these findings provide preliminary evidence that compared to autistic males and boys/men, autistic females and girls/women appear to consciously engage in more camouflaging, with more noticeable effects.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Interpretationreasoning

    The current evidence base appears to support the idea that camouflaging is more associated with autistic females and girls or women and may partly explain their higher rates of missed or late diagnosis.

    “the current evidence base appears to support suggestions that camouflaging is more associated with the experiences of autistic females and girls/ women, and may partially explain increased rates of missed or late diagnosis found amongst them”
    Quote in the paperSubstantial claim0 of 3 sources checked
    • cites Duvekot et al., 2017 source

      Not checked in the free run.

    • cites Dworzynski et al., 2012 source

      Not checked in the free run.

    • cites Head et al., 2014 source

      Not checked in the free run.

  • May combine two claims.

    Interpretationreasoning

    Because effect sizes for sex and gender differences were often small to moderate, the real-life camouflaging experiences of these groups may be broadly similar.

    “given the effect sizes were often small-to-moderate for sex and gender differences, the real-life camouflaging experiences of these groups may be broadly similar.”
    Quote in the paperSubstantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Premisecitation

    High rates of co-occurring mental health difficulties are found among autistic adults.

    “given the high rates of co-occurring mental health difficulties found amongst autistic adults (Lever & Geurst, 2016).”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites Lever & Geurst, 2016 source

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Premisecitation

    Some people in real-world autistic communities identify as autistic or are self-diagnosed.

    “Some members of real-world autistic communities are self-identified or self-diagnosed(Sarrett, 2016).”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites Sarrett, 2016 source

      Not checked in the free run.

  • May combine two claims.

    Interpretationreasoning

    Because the evidence base is limited in participant characterisation and representativeness, the conclusions cannot be applied to the autistic community as a whole.

    “However, the evidence base was limited regarding participant characterisation and representativeness, suggesting that conclusions cannot be applied to the autistic community as a whole.”
    Quote in the paperSubstantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Study design and conductnone given

    The review's search may not have been exhaustive.

    “our search may not have been exhaustive.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Study design and conductnone given

    The review did not use participatory design and is therefore limited by a lack of autistic input.

    “the review did not involve participatory design and thus is limited by a lack of autistic input.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Study design and conductreasoning

    The authors' familiarity with the topic likely improved their ability to draw conclusions and identify limitations, but may have increased risk of bias.

    “Whilst our familiarity with the topic likely improved our ability to draw conclusions about and identify limitations within the evidence base, it may have increased the risk of bias.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Study design and conductreasoning

    The authors acknowledge being embedded in the camouflaging field, which may have affected the review.

    “we acknowledge that we are embedded within the camouflaging field and that this may have had an impact on the review.”
    Quote in the paperNot a substantial claim
86 of 86

Claims other papers make about this one

Each is checked against this paper’s own text: does it say what the citing paper says it does?

  • Reduced social involvement in some autistic people may be a consequence of exhaustion from camouflaging (emulating typical non-autistic interaction style), not necessarily lower social motivation.

    “An important nuance to make here, is that although some autistic people show less involvement in social interaction, this might not necessarily be the result of lower social motivation, but rather it may be a consequence of exhaustion from trying to emulate a typical non-autistic style of interaction, known sometimes as camouflaging (e.g., Cook et al., 2021; Livingston et al., 2019).”

    From Innovations of the ICD-11 in the Field of Autism Spectrum Disorder: A Psychological Approach (2022) · cites this paper as Cook et al., 2021

    The review defines camouflaging as presenting a non-autistic social style and reports that autistic people describe it as exhausting (introduction; mental health and wellbeing section, pages not provided). It does not say that exhaustion causes reduced social involvement or establish that reduced involvement reflects exhaustion rather than lower social motivation. (LLM, conf=0.83)

    Experimental — accuracy not yet measured

  • Many Autistic adults report negative subjective outcomes as a result of having to meet inappropriate and unrealistic benchmarks, such as feeling they have to pass as neurotypical and mask or camouflage their Autistic behaviors.

    “Additionally, many Autistic adults report negative subjective outcomes as a result of having to meet inappropriate and unrealistic benchmarks, such as feeling they have to “pass” as neurotypical and mask or “camouflage” their Autistic behaviors (Bargiela et al., 2016; Cage & Troxell-Whitman, 2019; Cook et al., 2021; Hull et al., 2017; Livingston et al., 2019).”

    From Neurodiversity and Autism Intervention: Reconciling Perspectives Through a Naturalistic Developmental Behavioral Intervention Framework (2022) · cites this paper as Cook et al., 2021

    In “What is the relationship between camouflaging and mental health or wellbeing outcomes?” (page not provided), the review reports that autistic people describe camouflaging as exhausting and associated with anxiety, stress, sadness, and identity confusion. It also describes masking autistic characteristics to present a non-autistic social style. But in “Research into Camouflaging in Autism: Current Findings” (page not provided), it explicitly says the evidence cannot establish a causal relationship; it does not establish that these outcomes result from having to meet inappropriate or unrealistic benchmarks. (LLM, conf=0.86)

    Experimental — accuracy not yet measured

  • Females with autism spectrum disorder perform better in interpersonal predictive tasks, suggesting a better social and cognitive profile in females with autism spectrum disorder without intellectual disability that potentially may play a role in social camouflaging.

    “There is also a sex difference in performance, as females with ASD perform better in interpersonal predictive tasks, suggesting better social and cognitive profile in females with ASD without intellectual disability that potentially may play a role in social camouflaging (Cook et al., 2021; Dean et al., 2017).”

    From Predictive coding in neuropsychiatric disorders: a systematic transdiagnostic review. (2025) · cites this paper as Cook et al., 2021

    Split into 2 atoms — 0 confirmed, 1 partially supported, 0 disputed, 0 misattributed, 1 unverifiable. Expand the claim to see per-atom verdicts.

    Experimental — accuracy not yet measured

  • Camouflaging is commonly described by autistic people as exhausting and is associated with elevated risk for anxiety, depression and suicidality.

    “Camouflaging is commonly described by autistic people as exhausting and is associated with elevated risk for anxiety, depression and suicidality”

    From Innovations of the ICD-11 in the Field of Autism Spectrum Disorder: A Psychological Approach (2022) · cites this paper as Cook et al., 2021

  • Camouflaging requires sustained effort, is more typical of females although common in all genders, and can have deleterious impact on mental health and well-being.

    “Such camouflaging requires sustained effort, is more typical of females (although it is common in all genders), and can have deleterious impact on mental health and well-being (Cook et al., 2021).”

    From Innovations of the ICD-11 in the Field of Autism Spectrum Disorder: A Psychological Approach (2022) · cites this paper as Cook et al., 2021

Cites

Flagged first, then by citations

1 of the 86 references couldn’t be matched to a known paper.

Research works printed but not linked: 1

  1. Gould, 2006, Missed diagnosis or misdiagnosis? Girls and women on the autism spectrum, Good Autism Practice (GAP), 12, 34

Cited by

Sorted by citations

Related

Authors
Cook, J., Hull, L., Crane, L., & Mandy, W.
Affiliations
University College London (GB)
Corresponding author
Cook, Julia
ORCID
Venue
Clinical Psychology Review
Publisher
Elsevier BV
Published
2021-11
Volume
89
Pages
102080
ISSN
0272-7358 (ISSN-L)
DOI
10.1016/j.cpr.2021.102080
OpenAlex
W3198172085
Cited by
554
References
86
Citations by year
2026: 157 · 2025: 134 · 2024: 124 · 2023: 82 · 2022: 49 · 2021: 5 · 2020: 1 · 2017: 1
FWCI
9.51
Type
journal article
Language
en
Open access
Licence
Locations
  • Clinical Psychology Review (publishedVersion)
  • PubMed (publishedVersion)
  • UCL Discovery (University College London) (submittedVersion)
  • University of Birmingham Research Portal (University of Birmingham) (submittedVersion)
  • Bristol Research (University of Bristol) (submittedVersion)
  • Explore Bristol Research (submittedVersion)
Funders
University College London
Topics
  • Life Sciences › Neuroscience › Cognitive Neuroscience › Autism Spectrum Disorder Research
  • Social Sciences › Psychology › Clinical Psychology › Family and Disability Support Research
  • Health Sciences › Medicine › Psychiatry and Mental health › Child Nutrition and Feeding Issues
Keywords
autism spectrum disorder, autistic traits, coping strategies, sex and gender differences, mental health outcomes, children and adults with autism
MeSH terms
Adaptation, Psychological, Adult, Autistic Disorder, Child, Humans, Sex Factors, Self Report

About these checks

Registry, retraction, Cites and statistics results are computed, not judged, with one exception: a printed reference that no index lists is read once by a model before it counts as a citation error. Claims are extracted by a model and kept only when their quote appears verbatim in the text; each cited source is then checked, with a model’s help, for whether it says what the claim relies on. Those verdicts can be wrong — read the claim’s quote and the cited source before relying on one.

Claims read by deepseek-v4.1-flash under definition version 3 (extract-v3) on 2026-10-05.

Classified by jev-1.13-20260917 (gold-guideline-v0.2) on 2026-10-05.

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