The first scientific study of compensatory strategies — techniques to camouflage autism — finds that they have both positive and negative outcomes, increasing social integration, but possibly also resulting in poor mental health for autistic people, and could be a barrier to diagnosis.
Compensatory strategies used by autistic people have been investigated and collated in a qualitative study using an online survey of 136 adults, published in The Lancet Psychiatry journal. 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 nonetheless reported social difficulties. 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.
“Compensation is born from necessity. We have extensive experience of how cruel people are.”
The study looked into what compensatory strategies participants used, whether the strategies used were similar in diagnosed and undiagnosed people, and how the strategies affected diagnosis. The team identified several strategies used by people with and without an autism diagnosis. Such strategies were used equally by people who were formally diagnosed as autistic and those who were not.
Are compensatory strategies the same as masking?
Compensation is an adaptive process whereby new behaviours are generated in order to avoid negative outcomes. It is different from masking, where presumed undesirable behaviours are hidden or stopped. In the case of people with autism, people may use past experience or logic to respond to social situations to increase opportunities and “fit in” with society. However, they continue to be autistic at a neurocognitive level and this can lead to challenges in diagnosing and supporting individuals.
The research found that participants modulated compensatory efforts "after logically assessing the costs versus benefits." For example, "compensation was considered worthwhile to make a positive impression towards a friendship, but not for interactions with inconsequential strangers. In superficial interactions, masking was preferred over compensatory strategies to conserve resources."
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.” Another participant said: “Compensation is born from necessity. We have extensive experience of how cruel people are.”
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.”
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.
The authors note some limitations, including that their sample included a high proportion of female, late diagnosed and well educated participants. Because of self-reporting it may not have captured subconscious behaviours. Future research should take both of these limitations into account, using more representative population samples and quantitative measures. Additionally, the role of other factors that affect social pressure, such as multiple intersecting identities and their role in compensation, could be investigated in future.
Lucy Livingston, lead author of the study, says:
“Until now, no study has directly investigated compensatory strategies used by autistic people in social situations and we provide evidence for their existence and modulation by various factors. Because they present a barrier to diagnosis of autism, increasing awareness of compensatory strategies among clinicians will help detection and the provision of support for autistic people who use them. We hope this study will lead to the refinement of diagnostic manuals which currently contain little guidance on compensatory strategies in autism and co-occurring mental health conditions.”
In a linked Comment article, Dr Julia Parish Morris of the Centre for Autism Research at the Children’s Hospital of Philadelphia, USA, says:
“Although many people compensate during social interaction, it can be an especially exhausting and distressing exercise for people with autism spectrum disorder. This finding begs the question: should subjective distress be listed in the diagnostic criteria for autism spectrum disorder? For example, DSM-5 could be revised to read: “Symptoms cause clinically significant impairment in social, occupational, or other important areas of current functioning [-including subjective distress].”