Autism spectrum disorder today is characterized by social communication impairments and by repetitive and restricted behaviors. There is limited understanding of why some autistic people appear neurotypical in their behaviors, despite having autism-related cognitive difficulties or differences. Some adjustment techniques involve "masking", such as learning by past experience or logic to respond to social situations to"fit in" in varied situations, but people continue to be autistic at a neurocognitive level and so masking and compensation can lead to challenges in diagnosing and supporting those individuals.
For a small study, the authors advertised to recruit participants for their study via social media and with the National Autistic Society. 136 adults were asked to complete an online study. Of the participants, 58 had a clinical diagnosis, 19 self-identified without a formal diagnosis and 59 were not diagnosed or self-identified, but reported social difficulties. The study looked into what compensatory strategies participants used, whether the strategies used were similar in diagnosed and undiagnosed people, and how compensatory strategies affected diagnosis.
The participants were asked to self-report autistic traits by completing a ten-item autism spectrum questionnaire and then a series of open questions about their social compensatory strategies. They also reported how successful and tiring their strategies were, and the likelihood of their recommending them to others with social difficulties.
The team identify several strategies used by people with and without an autism diagnosis (including behavioural masking such as holding back true thoughts or suppressing atypical behaviours, shallow and deep compensation such as planning and rehearsing conversations or learning rules about verbal and non-verbal behaviours, and accommodation strategies such as going out of your way to be helpful - for a full list see ), which were used equally by people who were formally diagnosed with autism and those who were not.
Shallow strategies such as laughing after joke cues were common in participants who reported more autistic traits and were linked to negative consequences of compensation. Crucially these shallow strategies are more difficult in stressful situations or when tired.
Participants used their intellectual and planning abilities to regulate social behaviour and follow social norms - making eye contact - preplanning social niceties - asking others questions about themselves - and switching between social rules. These strategies were more difficult when distracted or stressed, but crucially, they did not reduce participants' internal social cognitive difficulties.
There were wide-ranging motivations for using these strategies, most notably social motivation and a desire to develop meaningful relationships. One participant says: "With compensation, I have a job in which people respect my work and ask for my help and opinions...I am liked by my colleagues and friends...I haven't lived on the edge, lost and lonely, as I could have. I have been super super lucky."
There was also a perception that neurotypical individuals could "see through" these strategies. One participant reported: "There are obvious flaws, if you are observant - I repeat myself or use tv/film phrases and sometimes say things that are out of place." And another noted: "I feel like I am acting most of the time and when people say that I have a characteristic, I feel like a fraud because I've made that characteristic appear." (See panel in paper for other participant quotes).
The use of these strategies was linked with poor mental health, and autism diagnosis and support appeared to be affected too. 47 out of 58 of the diagnosed participants were diagnosed late in adulthood. The other 11 were diagnosed before the age of 18 years.
External environments were found to affect compensation and it may be the case that people with autism present as neurotypical in certain situations but not in others. Clinicians should be aware of this when measuring compensation and diagnosing autism. Recent evidence suggests that only 40% of UK general practitioners--the first point of contact for individuals seeking diagnosis--are confident in identifying autism spectrum disorder.
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