Camouflaging (also known as masking) in autism and ADHD refers to the use of strategies to mask or hide traits associated with these conditions.
In autism, individuals may camouflage social communication difficulties, sensory sensitivities, or repetitive behaviors by mimicking others’ social skills, suppressing stimming, or forcing eye contact.
In ADHD, individuals may camouflage inattention, hyperactivity, or impulsivity by overcompensating with organization strategies, masking restlessness, or hiding impulsive thoughts.
Camouflaging can lead to late or missed diagnoses, as the individual’s struggles may not be apparent. It can also result in exhaustion, stress, and mental health issues due to the constant effort required to maintain a façade.
Camouflaging may prevent individuals from receiving appropriate support and accommodations, negatively impacting their well-being and quality of life.
van Der Putten, W. J., Mol, A. J. J., Groenman, A. P., Radhoe, T. A., Torenvliet, C., van Rentergem, J. A., & Geurts, H. M. (2024). Is camouflaging unique for autism? A comparison of camouflaging between adults with autism and ADHD. Autism Research. https://doi.org/10.1002/aur.3099
Key Points
- The main findings of this study on camouflaging in autism and ADHD include:
- Adults with ADHD reported more camouflaging behavior than the comparison group, but less than autistic adults.
- Autistic adults scored higher on the compensation and assimilation subscales of the Camouflaging Autistic Traits Questionnaire (CAT-Q-NL) compared to adults with ADHD.
- Autism traits, but not ADHD traits, significantly predicted camouflaging behavior, independent of diagnosis.
- The research highlights the need for more general measures of camouflaging behavior, independent of diagnosis, to compare camouflaging across different groups.
- The study’s relevance extends beyond autism, as camouflaging may play a role in late diagnoses and mental health difficulties in people with ADHD.
Rationale
Camouflaging, the use of strategies to minimize the visibility of one’s autism traits, is thought to contribute to late autism diagnoses and mental health difficulties (Bargiela et al., 2016; Livingston et al., 2019).
However, it is unclear whether only autistic people camouflage or if people with other neurodevelopmental conditions, such as ADHD, also use similar strategies (Fombonne, 2020).
Investigating camouflaging in ADHD is important because, like autistic people, those with ADHD experience stigma, may receive late diagnoses, and report elevated levels of mental health difficulties (Asherson & Agnew-Blais, 2019; Franke et al., 2018; Mueller et al., 2012).
This study aims to determine whether camouflaging is unique to autism by comparing camouflaging between people with autism, ADHD, and a comparison group.
Method
Procedure
This preregistered study (AsPredicted #41811) used a cross-sectional design, with participants completing online questionnaires.
Sample
The study included 105 adults in the ADHD group, matched by age and sex with 105 adults in the autism group and 105 in the comparison group (Part 1). Part 2 included 477 adults with an ADHD and/or autism diagnosis.
Measures
- Camouflaging Autistic Traits Questionnaire (CAT-Q-NL): This self-report questionnaire measures camouflaging behavior, specifically the use of strategies to minimize the visibility of one’s autism traits. It consists of 25 items describing different types of camouflaging strategies, and participants indicate their agreement with each statement on a seven-point Likert scale.
- ADHD Self-Report (ADHD-SR): This self-report questionnaire measures ADHD symptoms in childhood and adulthood. It consists of 23 items for each life stage, and participants indicate the frequency of each behavior on a four-point Likert scale. The ADHD-SR aims to assess the presence and severity of ADHD symptoms.
- Autism Spectrum Quotient (AQ): This self-report questionnaire measures the level of autism traits in an individual. It consists of 50 items, and participants indicate their agreement with each statement on a four-point Likert scale. The AQ aims to quantify the degree to which an individual possesses traits associated with autism spectrum conditions.
Statistical measures
ANOVAs, MANOVAs, and multiple regression analyses were used to compare camouflaging between groups and explore the relationship between camouflaging, autism traits, and ADHD traits.
Results
The study found that adults with ADHD reported more total camouflaging than the comparison group, but less than autistic adults.
Autistic adults scored higher on the compensation and assimilation subscales of the CAT-Q-NL compared to adults with ADHD. Autism traits, but not ADHD traits, significantly predicted camouflaging behavior, independent of diagnosis.
Insight
This study provides valuable insights into camouflaging behavior in adults with ADHD, revealing that they do engage in camouflaging, although to a lesser extent than autistic adults.
The findings suggest that camouflaging is not unique to autism and may be relevant to people with other neurodevelopmental conditions.
The study highlights the need for more general measures of camouflaging behavior, independent of diagnosis, to better understand and compare camouflaging across different groups.
Future research should focus on the specific camouflaging strategies used by adults with ADHD, the potential consequences of camouflaging (e.g., mental health difficulties and late diagnoses), and the development of more inclusive measures of camouflaging.
Strengths
This study had several methodological strengths, including:
- Preregistered study design, ensuring transparency and reducing potential bias
- Age and sex-matched groups for more accurate comparisons
- Use of validated measures (CAT-Q-NL, ADHD-SR, AQ)
- Inclusion of a comparison group without autism or ADHD
- Exploration of both group differences and the relationship between camouflaging, autism traits, and ADHD traits
Limitations
However, there are many limitations to take into consideration, including:
- The CAT-Q-NL was developed based on the experiences of autistic adults, potentially not capturing all camouflaging strategies used by adults with ADHD
- Psychometric properties of the CAT-Q-NL have not been investigated in adults with ADHD
- The study relied on self-reported diagnoses and traits, which may be subject to bias
- The cross-sectional design does not allow for causal inferences
Implications
This study’s findings have significant implications for understanding and supporting adults with ADHD.
Clinicians and researchers should be aware of the potential impact of camouflaging in people with ADHD, as it may contribute to late diagnoses and mental health difficulties.
The results underscore the need for more inclusive measures of camouflaging and further research on the specific strategies used by adults with ADHD, as well as the consequences of camouflaging.
By recognizing and addressing camouflaging in ADHD, appropriate mental health care and support can be provided more effectively.
References
Asherson, P., & Agnew-Blais, J. (2019). Annual research review: Does late-onset attention-deficit/hyperactivity disorder exist? Journal of Child Psychology and Psychiatry, 60(4), 333–352. https://doi.org/10.1111/jcpp.13020
Bargiela, S., Steward, R., & Mandy, W. (2016). The experiences of late-diagnosed women with autism spectrum conditions: An investigation of the female autism phenotype. Journal of Autism and Developmental Disorders, 46(10), 3281–3294. https://doi.org/10.1007/s10803-016-2872-8
Fombonne, E. (2020). Camouflage and autism. Journal of Child Psychology and Psychiatry, 61(7), 735–738. https://doi.org/10.1111/jcpp.13296
Franke, B., Michelini, G., Asherson, P., Banaschewski, T., Bilbow, A., Buitelaar, J. K., Cormand, B., Faraone, S. V., Ginsberg, Y., Haavik, J., Kuntsi, J., Larsson, H., Lesch, K.-P., Ramos-Quiroga, J. A., Réthelyi, J. M., Ribases, M., & Reif, A. (2018). Live fast, die young? A review on the developmental trajectories of ADHD across the lifespan. European Neuropsychopharmacology, 28(10), 1059–1088. https://doi.org/10.1016/j.euroneuro.2018.08.001
Livingston, L. A., Shah, P., & Happé, F. (2019). Compensatory strategies below the Behavioural surface in autism: A qualitative study. The Lancet Psychiatry, 6(9), 766–777. https://doi.org/10.1016/S2215-0366(19)30224-X
Mueller, A. K., Fuermaier, A. B. M., Koerts, J., & Tucha, L. (2012). Stigma in attention deficit hyperactivity disorder. ADHD Attention Deficit and Hyperactivity Disorders, 4(3), 101–114. https://doi.org/10.1007/s12402-012-0085-3
Keep Learning
Here are some reflective questions related to this study that could prompt further discussion:
- How might the findings of this study inform clinical practice and support for adults with ADHD?
- What are the potential consequences of camouflaging for individuals with ADHD, and how can these be addressed?
- How can future research build upon this study to better understand camouflaging in ADHD and develop more inclusive measures of camouflaging behavior?
- What role might stigma play in the camouflaging behaviors of adults with ADHD, and how can this stigma be reduced?
