A patient appears socially confident in the therapeutic conversation, maintains eye contact, and can seemingly effortlessly engage with the other person. At the same time, she reports significant exhaustion after social contacts, difficulties with changes, and the feeling of having to constantly "analyze" social situations.
Especially in adults, such a discrepancy can complicate the diagnosis of a Autism Spectrum Disorder (ASD) . One possible reason is camouflaging – that is, the attempt to hide, compensate for, or adapt autistic traits to social expectations.
What does camouflaging mean?
In autism research, camouflaging is used as an umbrella term for various strategies. These include, for example, consciously practicing social rules, mimicking other people, deliberately making eye contact, or suppressing behaviors perceived as "inappropriate."
Hull et al. described camouflaging as a process in which autistic traits are hidden or compensated for in social situations. Studies show that particularly autistic women often report using such strategies. Camouflaging has also been associated with a later diagnosis and psychological distress.
These are not necessarily consciously employed strategies. What was originally learned consciously can become automated over the years.
Why is this relevant for diagnostics?
The diagnostic conversation is a special situation: it is structured, time-limited, and provides clear social conditions.
This can lead to autistic traits being less visibly apparent than in everyday life. A person may, for example, have learned to make eye contact or adhere to typical conversation rules, even though this requires significant concentration.
Therefore, direct behavioral observation should not be considered in isolation. For diagnostics, developmental history, everyday experiences, and information from different areas of life are also relevant.
What questions can be helpful?
For psychotherapists, it may be useful to not only ask if a person can manage social situations, but how they do it.
For example:
"How much preparation do you need for social situations?"
"Are there behaviors that you consciously use because you know they are socially expected?"
"How do you feel after longer social contacts?"
"What happens when you cannot rely on your usual strategies?"
"Do you feel that you learn social rules rather than understand them intuitively?"
"What behaviors have you consciously unlearned over the course of your life?"
Particularly interesting can be discrepancies between external adaptation and subjective effort.
Camouflaging is not a diagnostic criterion.
Camouflaging should not be understood as evidence of an autism spectrum disorder. Not every social adaptation is camouflaging, and not every person with ASD camouflages in the same way.
For diagnostics, this means: An inconspicuous appearance in conversation should not automatically be interpreted as evidence against autism. At the same time, a suspected "masking" should not replace careful differential diagnostics.
The overall view remains crucial from developmental history, current symptoms, daily functioning, behavioral observation, and other diagnostic information.
Conclusion
Camouflaging can contribute to autistic traits being less visible in the diagnostic setting. Especially in adults, it can therefore be helpful to not only consider observable behavior but also to inquire about the effort behind that behavior.
Sources
Hull, L. et al. (2017). “Putting on My Best Normal”: Social Camouflaging in Adults with Autism Spectrum Conditions. Journal of Autism and Developmental Disorders.
Hull, L. et al. (2019). Gender differences in self-reported camouflaging in autistic and non-autistic adults. Autism.
Cook, J. et al. (2021). Camouflaging in autism: A systematic review. Clinical Psychology Review.
NICE. Autism spectrum disorder in adults: diagnosis and management (CG142).