Camouflaging in autism: A cause or a consequence of mental health difficulties?

Camouflaging ([un]consciously hiding one's autism traits) is hypothesized to be an underlying mechanism explaining elevated levels of mental health difficulties in autistic adults. As previous studies investigating this relationship were all cross-sectional, the direction of this association remains unclear. Therefore, we investigated whether (1) camouflaging predicts a change in mental health difficulties and (2) mental health difficulties predict a change in camouflaging. For this, 332 autistic adults aged 30 to 84 years (157 women) filled in the Dutch Camouflaging Autistic Traits Questionnaire, Symptom Checklist-90 Revised, and Autism Spectrum Quotient at two timepoints with an average time interval of 2 years. Preregistered multilevel analyses showed a negative interaction between initial camouflaging and time, indicating that people with higher initial levels of camouflaging showed a decrease in mental health difficulties, while for lower initial levels of camouflaging there was an increase. However, this effect was small. Initial mental health difficulties did not predict changes in camouflaging behavior, but findings were inconsistent across total camouflaging and assimilation. Thus, we did not find strong evidence for camouflaging to be associated with development of mental health difficulties. However, future research is needed before we can draw strong conclusions about directionality and causality.Plain Language SummaryWhen autistic people use strategies to hide their autism traits, we refer to this as camouflaging. It has been thought that camouflaging could be a reason why autistic people develop mental health difficulties more often than non-autistic people. Research has shown that, in general, people who report more camouflaging behavior also report more mental health difficulties. However, we do not know whether camouflaging can be a reason for people to develop mental health difficulties or whether mental health difficulties may explain why autistic people use camouflaging strategies. Therefore, in this study we investigated whether (1) camouflaging is a predictor for a change in mental health difficulties and (2) mental health difficulties are a predictor for a change in camouflaging. For this study, 332 autistic adults aged 30 to 84 years (157 women) filled in questionnaires about camouflaging, mental health difficulties, and autism traits at two moments with an average of 2 years between measurements. We found that people with a higher level of initial camouflaging showed a decrease in mental health difficulties, while for people with lower levels of initial camouflaging behavior there was an increase in mental health difficulties. However, this effect was small. Initial mental health difficulties did not seem to predict a change in camouflaging behavior. Thus, we did not find evidence that camouflaging was followed by an increase in mental health difficulties. Therefore, future research is needed before we can draw strong conclusions about what comes first and what causes what, camouflaging or mental health.