The Use and Misuse of the Camouflaging Autistic Traits Questionnaire in Autism Research and Clinical Practice: Issues,Considerations,and Suggestions

Abstract

In this Perspective, we summarize the evidence to date around the use of the Camouflaging Autistic Traits Questionnaire (CAT-Q) as a tool in research and clinical settings, and offer suggestions for its future use. We highlight that the CAT-Q is a useful measure of camouflaging/masking for research purposes, although questions remain regarding sociocultural variation in camouflaging experiences, and its specificity regarding autistic camouflaging compared with impression management more generally. With respect to clinical practice, we note that very little research has examined the use of the CAT-Q in clinical settings to date, and we encourage clinicians to be mindful of this limited evidence base and to refrain from using CAT-Q scores in diagnostic decision-making or as an intervention monitoring/outcome tool.

Community Brief

Why is this topic important?

Camouflaging or masking has received a lot of interest from autistic people, researchers, and clinicians, and the Camouflaging Autistic Traits Questionnaire (CAT-Q) is one of the most common ways to measure camouflaging. However, we have noticed some issues in the ways the CAT-Q is used, which might impact research and clinical outcomes.

What is the purpose of this article?

In this article, we aim to summarize the evidence around using the CAT-Q in research and in clinical settings, and give recommendations for future use, so that researchers and clinicians are less likely to make mistakes.

What personal or professional perspectives do the authors bring to this topic?

The authors are researchers and clinicians who work closely with autistic people who camouflage/mask. Some of the authors were involved in developing the CAT-Q, but do not make any money from it.

What is already known about this topic?

There has been a lot of research using the CAT-Q, and showing that it is a good tool for measuring camouflaging, but not much evidence for it being used in clinical settings, such as autism assessment or postdiagnostic support.

What do the authors recommend?

We recommend more research to evaluate the CAT-Q, particularly across different countries and cultures. We also recommend that other methods of measuring camouflaging are developed to capture aspects of camouflaging that the CAT-Q does not measure. We recommend that clinicians are careful with how they use the CAT-Q, and do not use it to assess whether or not someone is autistic.

How will these recommendations help autistic adults now or in the future?

We hope that more research based on these recommendations will mean we have a more accurate understanding of camouflaging in the future. By following these recommendations, clinicians working with autistic people should use the CAT-Q more accurately and so help autistic people understand themselves and their camouflaging better.

Keywords

camouflaging masking clinical practice research practices

Background

Camouflaging, also known as masking, compensation, or a version of transactional impression management, involves hiding or changing autistic behaviors (whether consciously or not) as a social coping strategy to fit in with non-autistic social environments and norms.^1–3 Camouflaging as a concept is not unique to autism: it has been considered akin to impression management in the general population,^1,4–6 it conceptually overlaps to some extent with social anxiety coping strategies,^7,8 and comparable experiences have been reported in other neurodivergent populations, such as in people with ADHD,^9,10 developmental language disorder,¹¹ and tic disorders.¹² Furthermore, other minoritized and marginalized groups, including LGBTQIA+ and culturally and linguistically diverse people, may also conceal their sexuality, gender, linguistic, cultural, or social background differences to protect themselves from stigma and discrimination (e.g., see Refs.^13,14). However, there can be distinctive features of camouflaging as used by autistic people,¹⁵ such as the use of alternative cognitive processes to compensate for and learn social rules and strategies.¹⁶

Measuring camouflaging in autism research and clinical practice: The Camouflaging Autistic Traits Questionnaire

Several approaches to measuring camouflaging in autistic people have been developed and used to date, including self-report measures, observational approaches, and discrepancy approaches (e.g., exploring the discrepancies between self-reported/internal and observable autistic social and behavioral features; see Ref.¹⁷ for a review; see also Ref.¹⁸ for a critical discussion on the need for measurement precision). These approaches measure different aspects and facets of camouflaging, including the frequency of camouflaging behaviors used, the “effectiveness” of camouflaging, and/or the discrepancy between outwardly neuronormative behaviors and internal and self-perceived social differences and difficulties, respectively.

Currently, the most widely used¹⁹ self-report camouflaging measure in both research and clinical settings is the 25-item self-report Camouflaging Autistic Traits Questionnaire (CAT-Q²⁰), which was codeveloped by several of the authors of this Perspective; see also Ref.²¹ Drawing from autistic people’s experiences,² the CAT-Q was initially developed in English as a research tool to quantify the self-perceived frequency of use of camouflaging behaviors in autistic and non-autistic adults. It was validated in a large online study with autistic and non-autistic adults aged 16 years or older, and demonstrated good internal consistency and test–retest reliability.²⁰

In the initial validation of the CAT-Q, three factors were identified^17,20: Compensation (finding alternative approaches to neuronormative social behaviors, e.g., mimicking others’ body language or studying and imitating social behaviors from films or books). Masking (hiding autistic characteristics, e.g., preventing oneself from stimming in specific situations). Assimilation (strategies to fit in with others and avoid seeming different, such as “performing” as neurotypical). Measurement invariance across assigned-sexes and autistic versus non-autistic groups has been demonstrated.²⁰ Beyond the initial validation study, evidence from a large, representative US general population sample appears supportive of the three-factor structure.⁵ However, further psychometric evaluation is warranted to determine whether the three distinct but related factors is the optimal factor structure and preferable (or not) to the use of a single composite “camouflaging” score. The CAT-Q has been translated into multiple languages, including Swedish, French, Dutch, Italian, Mandarin, Spanish, and Japanese so far,^22–28 although findings regarding the psychometric properties of these translations are inconsistent, especially in relation to factor structure and measurement invariance.

Across several studies, higher CAT-Q self-reported ratings have been consistently associated with higher autistic traits and poorer mental health and well-being, usually with medium effect sizes (see reviews^18,21,29,30). Recent research has suggested that CAT-Q scores may positively correlate more strongly with measures of social anxiety than with measures of autistic characteristics, general anxiety or depression, pointing toward complex interrelations among camouflaging and social anxiety.^1,5,7,8,31 A recent study found that although the overall CAT-Q scores did not change following a social anxiety intervention for autistic adults, the social anxiety and camouflaging change scores were significantly correlated, suggesting that these are distinct but related constructs.³²

In younger age groups, the CAT-Q has recently been psychometrically evaluated with small groups of autistic and non-autistic adolescents in Sweden²⁷ and in Taiwan,²⁶ with good to excellent internal consistency, good test–retest reliability, and good convergent validity with measures of mental health, similar to findings in the adult literature. A parent-report version has also been developed for, and was used with, 12–18-year-old young people in the United Kingdom and Taiwan, although this has not yet been thoroughly psychometrically evaluated.^17,26

The use of the CAT-Q in autism research

There are several considerations regarding the use of the CAT-Q in research, as noted previously.^17,18,33 One key concern is its potential confounding with social anxiety, raising questions as to whether the CAT-Q measures camouflaging behaviors per se, or broader social anxiety-related behaviors.³⁴ For instance, the CAT-Q Masking and Compensation subscales were more strongly associated with social anxiety symptoms (r = 0.25 and 0.45, respectively) than with autistic traits (r = 0.04 and 0.29, respectively).⁷ The CAT-Q Assimilation subscale items have been shown to load together with both social autistic traits and social anxiety items in factor analyses,⁸ and a network analysis across CAT-Q and social anxiety items shows a small number of social anxiety items being grouped together with the CAT-Q Assimilation item community,³¹ suggesting some plausible conceptual and measurement overlap. Prospective follow-up and longitudinal studies are required to understand the extent to which the association between camouflaging and social anxiety reflects a causal directional relationship (e.g., individuals experiencing social anxiety might be more likely to camouflage) and/or whether bidirectional relationships exist (e.g., whether camouflaging and social anxiety reinforce each other over time).

Moreover, the CAT-Q was developed to capture camouflaging behaviors based on autistic people’s experiences—it was not designed or intended as a screening measure of autistic traits. Nonetheless, some studies report statistically significant, but mostly small- to medium-effect size, camouflaging group differences (with autistic teens or adults reporting somewhat more camouflaging behaviors than non-autistic participants; e.g., see Refs.^23,26,35) while other studies report no significant group mean differences between autistic and non-autistic individuals in the total or subscale CAT-Q scores (e.g., the original CAT-Q Masking subscale^7,20,36; and in some translated versions of the CAT-Q^27,28) Receiver operating characteristic curve analyses in a recent study²⁷ further show that the Swedish CAT-Q did not have adequate sensitivity and specificity in distinguishing between autistic and non-autistic participants, with sensitivity not exceeding 0.51–.58. Although examining group differences in research can provide insights into group differences in average patterns of camouflaging, such analyses can easily be misinterpreted—particularly outside academic and research settings—as suggesting that the CAT-Q may serve as a “screening” or “diagnostic” discriminator between autistic and non-autistic people. This is not the case. There is currently no theoretical or empirical justification for using the CAT-Q as a proxy of autistic traits to differentiate between autistic and non-autistic individuals.

In addition, there may be age, cohort, gender, and/or sociocultural effects in camouflaging behaviors. Although autistic adults may maintain similar CAT-Q scores over time, at least based on a recent study with two annual follow-ups,³⁷ it has been suggested that camouflaging behaviors tend to decrease with age in non-autistic adults.^1,27 Gender influences have also been reported, with some, but not all, studies indicating that autistic women tend to report more camouflaging behaviors than autistic men,^21,38 and gender-diverse autistic adults report higher Compensation subscale scores than cisgender autistic adults.³⁸ Sociocultural effects in camouflaging have also been noted,³ with studies in several different countries (e.g., see Refs.^25,28,39) showing at least some differences in CAT-Q measurement properties and associations with mental health in different ethnic and sociocultural contexts. However, age, cohort, gender, or sociocultural effects and influences are often not considered in research to date largely conducted with adult participants spanning in age from their early 20s to late 70s.

More extensive examinations of the CAT-Q are therefore needed to clarify the most appropriate research contexts and applications for its use, and to inform the development of alternative methods for measuring camouflaging across ages, abilities, and sociocultural contexts. Notably, the various factor structures found in different language versions of the CAT-Q highlight the limitation and caution of a direct comparison of scores across sociocultural contexts, and the need to develop complementary methods to capture camouflaging in local sociocultural contexts with enhanced validity.

The use of the CAT-Q in clinical settings

Although initially developed as a research tool to measure the frequency of use of camouflaging behaviors, the CAT-Q is increasingly being incorporated into clinical settings. However, there is currently little to no empirical evidence examining whether, how, or for/with whom the CAT-Q is used in clinical practice, nor exploring and clarifying the specific clinical purposes it may serve.

This Perspective draws from our research and clinical experiences, informal discussions with some clinicians in the United Kingdom, the United States, Canada, Taiwan, and Australia, as well as from reviewing public online resources that describe or recommend the use of the CAT-Q for clinical purposes. Currently, it seems that clinicians tend to use the CAT-Q within broader mental health or autism-specific clinical settings in the following two main ways: 1.

as part of screening, triage, and/or autism and related neurodevelopmental diagnostic assessments; and/or

to facilitate information gathering, formulation, and support planning as part of well-being, mental health, postidentification, or related psychosocial care services for autistic people.

Below, we discuss both potentially problematic or concerning clinical use and likely helpful use of the CAT-Q in relation to (1) and (2).

(Mis)Using the CAT-Q in screening, triage, and/or diagnostic assessment

Assessment of autistic characteristics

In many services (e.g., in several National Health Service UK trusts), adults referred for an autism assessment may be screened or triaged to determine whether they should be referred for a comprehensive autism diagnostic assessment. Based on our readings, searches across different websites, and discussions with clinicians and researchers, it seems that the CAT-Q is sometimes incorporated in screening, triage, or diagnostic assessments as a tool to help guide decisions around who should be referred for a comprehensive autism diagnostic assessment or who may eventually be diagnosed as autistic. In some services, the CAT-Q has been incorporated or suggested as a screen alongside other established and commonly used screening measures of autistic characteristics, such as the Autism Spectrum Quotient⁴⁰ or the Social Responsiveness Scale-2⁴¹. Examples can be found in clinical recommendation articles,⁴² and on the websites of certain private autism assessment services and autism information organizations. In some of these settings, we have read or heard that higher CAT-Q scores are being interpreted as an indicator of specific “internalized” autism presentations (explaining why autistic characteristics are less observable), or as an explanation for why an individual eventually diagnosed as autistic does not meet the algorithm or criteria thresholds using tools that measure diagnostic, core features of autism. For instance, when other validated observational diagnostic tools such as the Autism Diagnostic Observation Schedule (ADOS-2⁴³) do not reach the cutoff for an “autism” or “autism spectrum” classification, it is sometimes suggested that the CAT-Q can be used to identify autistic individuals who would otherwise meet diagnostic thresholds, if not for their ability to mask their autistic behaviors.

As the CAT-Q was not designed nor validated to measure autistic characteristics as set out in diagnostic criteria, CAT-Q scores cannot, and should not, be used to suggest “above” or “below” cutoff reports or autistic versus non-autistic group membership. In other words, the CAT-Q is not a screening tool for autism, and the autism screening measures used should reflect measurement of autistic traits regardless of whether or not these may be camouflaged.⁴⁴ Importantly, there are no threshold or cutoff scores on the CAT-Q regarding the extent of camouflaging in different groups or the presence of autistic characteristics. Evidence suggests that not all autistic people camouflage, that autistic people camouflage to different degrees in different contexts, that camouflaging strategies vary widely, and that non-autistic people as well as people with other neurodivergence or other differences may also camouflage at high levels.^15,20,45 Therefore, the CAT-Q should not be treated or used as equivalent to measures of autistic characteristics for screening, triage, or diagnosis.

At the same time, incorporating the CAT-Q as part of one’s comprehensive assessment toolbox of multiple measures, informants, and approaches may aid the assessment by providing additional information to inform expert case discussion and decision-making for clinical formulation. Specifically, using the CAT-Q may provide insights into the extent to which the individual, as they were growing up, developed masking or compensatory strategies to understand and behave in different social situations. Such information may be particularly relevant to clinical information needed to establish the autism diagnostic criterion C of the DSM-5-TR,⁴⁶ namely that autistic characteristics and features must be present in the early developmental period (but may not become fully manifest until social demands exceed limited capacities or may be masked by learned strategies in later life).⁴⁷ Inviting autistic adults to complete the CAT-Q, and then following up with more in-depth developmental inquiries could provide useful information regarding the extent to which an autistic person may be hiding or changing autistic social or behavioral characteristics in social situations currently, and the extent to which they may have been carefully “studying” or “learning” social rules and conventions over time to navigate complex social environments, when most non-autistic people tend to acquire such learnings more intuitively.¹⁶

To determine the extent to which a person’s current and/or historical features meet the diagnostic criteria for autism, clinicians should conduct a comprehensive developmental interview to collect evidence of autistic characteristics and experiences in childhood, adolescence, and adulthood. They also need to gather current information on social and behavioral autistic features via self- and informant-reported measures of autistic characteristics, in-depth interviews, and through clinicians observing the person’s presentation and behaviors, ideally on more than one occasion. The clinicians should integrate this developmental interview with information from the CAT-Q among other measures and follow-up discussions of the responses to develop a fuller picture of the individual’s social experiences and ways of navigating social environments over time and across different contexts (for instance, at work vs. at home). Such information needs to be interpreted and understood in a developmental and biopsychosocial framework to support a diagnostic clinical formulation.⁴⁴ However, we emphasize again that although useful as an information gathering tool (together with comprehensive information gathering on autistic characteristics across the person’s lifespan), the CAT-Q is not a screening tool for autism, as there is no threshold or cutoff score at which an individual might be considered to “be camouflaging” or “be camouflaging because they are autistic.”

Camouflaging is not a universal autistic characteristic

As a self-report measure, the CAT-Q ratings represent a continuous distribution of behaviors across the entire population, including those who do and do not meet the diagnostic criteria for autism.⁵ There is evidence of heightened CAT-Q scores among individuals with other conditions such as ADHD, social anxiety, and depression,^7,10 and in other minoritized groups,⁴⁸ as well as a range of endorsement of CAT-Q items in the general population, suggesting that camouflaging behaviors are not specific or unique to autism. On the contrary, some autistic people may engage in very little or no camouflaging. Thus, when the CAT-Q is included as one tool in a comprehensive assessment, the CAT-Q score alone should not be the basis for confirming or disconfirming an autism diagnosis.

Importantly, camouflaging is not a diagnostic criterion of autism within either the DSM-5-TR or the ICD-11, although there is reference to masking and compensation when explaining heterogeneity in the developmental course and diagnostic features of some autistic people. At this stage, there is little evidence to suggest camouflaging should be included in the diagnostic criteria for an autism diagnosis, while there is considerable evidence to show that camouflaging is not specific nor unique to autistic people, as many other neurodivergent or minoritized people camouflage.⁴⁹ Some recent measures of autistic traits in adults have included items, and a subscale, relating to camouflaging (e.g., the Concise Autism Trait Inventory⁵⁰), which can provide useful information, however we caution against the assumption that all autistic people camouflage, or that camouflaging should be used as evidence of autism when observational or other gathered historical and current information is not consistent with the diagnostic features of autism. It is heartening to see that in a recent survey of clinicians, only 8% agreed that camouflaging should be considered a “sign” of autism.⁵¹ We do argue that there are some cases where historical evidence of autistic characteristics across development (via self-report, accounts from other informants, and clinical information gathering and observations) can be combined with evidence of camouflaging (and, most importantly, its development over time) to inform a diagnostic formulation of autism,⁴⁷ but that camouflaging is only one piece of data informing the clinical diagnostic decision.

To date, some sex and gender differences in levels of camouflaging have been reported in autistic and non-autistic people,¹⁹ suggesting that clarifying camouflaging, especially learned strategies and approaches to understand and manage social situations, may be particularly useful when understanding the experiences of autistic women and those assigned female at birth,^38,52 in both assessment and therapeutic contexts. However, autistic people of all sexes and genders report varying levels of camouflaging, so it is not appropriate to consider camouflaging solely as a sex- or gender-specific phenomenon.

Much of the existing research using the CAT-Q has drawn on online-recruited autistic adults self-reporting their diagnosis or self-identifying as autistic. These studies, most of which include autistic or possibly autistic adults (often the majority women) with high rates of co-occurring mental health or other neurodevelopmental conditions, have made important contributions to our understanding of camouflaging. Nevertheless, online samples may underrepresent autistic people often seen in clinical services, for instance, those with intellectual disability, those with little spoken language, or those with complex physical, mental, or other neurodevelopmental conditions. As such, the extent to which the broader population camouflages, and whether the CAT-Q is an appropriate tool to measure camouflaging for them, is unclear. Further research is needed to examine whether and how camouflaging is used by autistic people in studies within clinical settings, and the utility of the CAT-Q in clinical settings. Research should also explore if additional or alternative methods of measuring camouflaging would be beneficial.

Clinicians may find it helpful to use CAT-Q ratings, alongside other information regarding social coping experiences and strategies throughout one’s life, to inform detailed conversations with the individual regarding their experiences and to help clinicians make sense of multifaceted assessment information for the overall diagnostic formulation, following best practice guidelines.^44,53 For instance, a clinician might identify items or subscales within the CAT-Q that the participant highly endorsed and use this as a starting point in the assessment interview to discuss their social coping experiences in different situations, and how these evolve over time. This may contribute to exploring dilemmas or contradictions in the assessment data, for instance, if there is a discrepancy between observed and self-reported autistic characteristics or between current autism presentation and developmental/historical information. For example, an individual may endorse autistic traits above established screening cutoff scores for possible autism when completing self-report measures of autistic traits, and when that same individual provides extensive clinical information relating to social, communication, and behavioral autistic characteristics. If that individual also endorses high use of certain camouflaging behaviors in the CAT-Q, but few current autistic behaviors are observed by the clinician in an ADOS-2 or other semistructured assessment session, then—and assuming the clinician coded the assessment tool reliably and in a valid way—this discrepancy needs to be investigated further alongside in-depth clinical discussions to aid the diagnostic formulation.

There is very limited research regarding whether and how camouflaging is considered during real diagnostic assessments. A recent survey of autistic adults and clinicians with experience in adult autism diagnostic assessment revealed that over 80% of each of these groups felt that camouflaging influences the autism assessment process.⁵¹ Clinicians were not asked if they had any concerns regarding the integration of camouflaging to a comprehensive diagnostic assessment, although one theme identified was that camouflaging (“masking”) affected clinicians’ interpretation of diagnostic tools, suggesting some impact. Only 19% of autistic participants thought that camouflaging had been considered during their own assessment, compared with 73% of clinician participants who reported taking camouflaging into account during assessments. While the authors acknowledge that the clinicians included in this study may not represent those performing assessments across the general population, it nevertheless suggests that there is a need to better communicate with people being assessed about whether and how camouflaging is being considered during an assessment. This was reflected in the survey, where 51% of clinicians called for better and more validated tools to assess camouflaging.⁵¹ The CAT-Q and future methods of measuring camouflaging could offer one approach as a starting point for further discussion of how camouflaging may impact the individual.

Use of the CAT-Q to inform formulation and understanding of autistic people’s mental health and well-being in clinical settings

In several cross-sectional qualitative and quantitative studies, higher camouflaging, as measured by the CAT-Q, has been consistently associated with greater self-reported generalized anxiety, depression, social anxiety, and suicidality^7,21,30,54; for this reason, clinicians in assessment and therapeutic settings also use the CAT-Q when they wish to explore with their autistic clients how camouflaging may be related to their mental health, well-being, and/or identity. Camouflaging may also be useful to explore when considering differential and concurrent diagnoses or when identifying safety behaviors associated with social anxiety. One follow-up study found no overall relationship between camouflaging and mental health in autistic adults across a 2-year period, but those who camouflaged more at baseline may have slightly increased mental health problems.⁵⁵ Except for this study, while cross-sectional associations between camouflaging and mental health have been consistently reported, the directionality and temporal sequence of this relationship remain largely unclear.

Within clinical settings, the CAT-Q is also increasingly being used as a measure to support discussion and understanding of autistic clients’ psychosocial stressors and experiences motivating camouflaging, such as stressful life events, discrimination, and stigma (see Refs.^30,56 for reviews), and/or the impact that these may have on the individual (see also Ref.⁵¹) For instance, the CAT-Q may be used to quantify and discuss camouflaging strategies that an individual may find hard to identify on their own and to prompt more in-depth discussion of specific strategies, when and how they are used, and the consequences. This information can be useful for diagnostic formulation of mental health issues and as part of therapeutic formulation of an autistic client’s well-being.

The CAT-Q may also be helpful when considering postidentification or postdiagnostic supports. If a person scores highlyi on the overall CAT-Q or on subscales, it may suggest a high level of stigma, shame, or other psychosocial pressures and motivations around their autism-related experiences,^3,30 which could be explored, understood, and supported. As such, CAT-Q data could point to a need for, and assist with, further exploration of the person’s social and psychological experiences: for instance, supporting the autistic person to reframe their earlier negative social experiences; consider where, with whom, and how they can be their authentic selves; and develop a more positive autistic identity and optimal impression management that benefits, rather than exhausts or distresses them.¹⁵ Using the CAT-Q as an initial exploration of psychosocial experiences could contribute to the development and implementation of interventions on their social environment, for example, changing attitudes of those around the autistic person,⁵⁷ and/or individual work with the autistic person toward processing and making sense of their social differences and ways of coping toward self-acceptance and self-care.⁵⁸

As autistic individuals tend to have disproportionately high rates of mental health issues⁵⁹ and camouflaging may be one of several contributing factors,⁶⁰ the potential relationship between camouflaging and the person’s well-being may also be explored as part of therapeutic or other psychosocial support work. However, we recommend that clinicians take an individualized approach to camouflaging when supporting autistic adults. For some individuals, camouflaging may be a compelled, unwanted, and harmful response to negative treatment by others, for which support to safely “drop the mask” toward disclosure and acceptance may help. For others, camouflaging, as part of the ubiquitous impression management experiences of human beings, may be a pragmatic, protective, functional, and necessary set of strategies to get through complex social situations, succeed in education or work, maintain relationships, and reduce harm.³⁰ In discussions between one of the authors and two of their research team’s autistic advisors, the advisors have highlighted that camouflaging should not be something clinicians necessarily encourage autistic clients to fully “drop”; rather, they emphasized the need for an individualized, nuanced, and contextual understanding of camouflaging—its benefits, the need for it, and its costs and alternatives (see also Ref.⁵⁸) Clinicians should avoid making assumptions about the motivations for, extent of, and impact of camouflaging for any individual. Rather, they should collaborate to recognize that the goal of therapeutic support is not to eliminate camouflaging, but to support autistic people to reflect on when, where, and with whom they may be able to express themselves more authentically—or when they might choose disclosure and request reasonable adjustments instead of camouflaging.

Relatedly, we also suggest that clinicians collaboratively identify meaningful individualized therapeutic goals and outcomes to monitor with their autistic clients, rather than relying solely on changes in camouflaging as an indicator of intervention/support impact. At present, there is very little research exploring change or continuity in camouflaging across meaningful time points. To our knowledge, two published studies have assessed change, both suggesting that CAT-Q scores remain broadly stable over 1–2 years, with only small declines in camouflaging at the group level.^37,55 Further investigation of how camouflaging evolves across the lifespan—and whether the CAT-Q is sensitive to change—would help researchers and clinicians contextualize camouflaging stability or change over time, or following support provision. Because the CAT-Q measures camouflaging frequency, changes in scores are unlikely to capture potential changes in other aspects of camouflaging, such as its intentionality, effort, goal-attainment, or impact. Therefore, changes in CAT-Q scores should not currently be interpreted as a stand-alone measure of clinical outcomes.

Use of the CAT-Q in child and adolescent clinical settings

As the CAT-Q was developed and validated for use with adults initially, we have so far focused on using the CAT-Q in adult settings. While there are approaches to measuring camouflaging, which may be suitable for use with children and adolescents, such as the discrepancy approaches,^61,62 these may be more time-consuming and/or have limited validation in research settings.¹⁷ A parent-reported CAT-Q has been developed,¹⁷ which asks parents or carers to report on camouflaging behaviors observed or reported by their child. Although the parent-reported CAT-Q correlates positively with self-reported CAT-Q scores with a medium effect size (r ∼ 0.4) in adolescents in the United Kingdom¹⁷ and Taiwan,²⁶ it has not undergone a thorough psychometric evaluation, and its use in children and in people with different cognitive abilities is essentially unknown. If older children and adolescents, and/or their caregivers, can report on camouflaging strategies, the CAT-Q may be a useful tool to gather information as we outlined earlier. However, we again emphasize that camouflaging presence or amount, especially the CAT-Q total and subscale scores, should not be used as a metric of autism-related traits for screening or diagnosing autism in children or adolescents.

A key challenge in identifying camouflaging in pediatric clinical settings is that little is known about the presentation, nature, and development of camouflaging earlier in life. Although some studies report that autistic people are able to identify and describe their camouflaging from middle childhood onward,^63,64 it is not yet clear (a) whether, and to what extent, these behaviors and experiences differ from the impression management strategies described by typically developing children and adolescents⁶⁵ or experimentally inferred in even earlier stages of life⁶⁶; (b) when such behaviors and experiences begin; and (c) whether or how they may be uniquely experienced in autistic children and adolescents. As such, at present, we recommend caution when using any tool, including the CAT-Q, to measure camouflaging in children and adolescents, in research as well as clinical settings.

Suggestions for use of the CAT-Q in clinical settings based on current evidence

To conclude, we summarize some of our reflections on the ways in which the CAT-Q may be used to support clinical practice, based on the empirical evidence to date and our research, clinical, and lived experiences. We note that several of these recommendations were also suggested by clinicians and autistic individuals in a recent study exploring how camouflaging influences adult autism assessments.⁵¹

Given the insufficient evidence to date, the CAT-Q should not be used to screen for autism, nor should cutoff scores be applied to classify individuals as “high” or “low” camouflagers, to infer “high or low-masking autism,” or to determine autistic status. Similarly, the CAT-Q should not be used as the primary or sole measure to evaluate clinical interventions or track therapeutic outcomes over time. In brief, the CAT-Q is not a screening or diagnostic tool, and its total or subscale scores should not be used to determine diagnostic or intervention decisions. Rather, information collected from the CAT-Q may serve as a starting point for a detailed developmental exploration of whether and how a person may have learned to modify autistic behavioral characteristics in social situations over time. Such detailed information, collected through clinical interview, the CAT-Q, and other assessments, may then contribute to a diagnostic formulation.

Therefore, the CAT-Q as a measure of self-reported aspects of camouflaging behaviors may be used currently in adult assessment settings: 1.

To contribute to multimethod comprehensive assessments as part of a range of standardized measures.

To deepen understanding of the autistic person’s lived experiences across development, specifically through (a) exploring their social coping strategies and experiences growing up, including stigmatization, discrimination, and other psychosocial experiences; (b) facilitating discussions aiming to foster a stronger autistic identity and adaptive impression management strategies that can support social coping and well-being; and (c) informing clinical psychosocial formulation of well-being, including collaborative exploration of strategies to enhance well-being, which may involve reevaluating their use of camouflaging.

Future Directions

Overall, the limited evidence to date suggests that measuring camouflaging could potentially be useful as part of exploring and understanding autistic adults’ psychosocial experiences, particularly when considering their mental health and psychosocial well-being. However, much more research is needed to determine the usefulness of the CAT-Q in clinical settings, from the perspectives of both clients and clinicians. Understanding how camouflaging manifests and is experienced in young people and in people with higher support needs remains a major research gap. Other (existing and novel) methods of measuring camouflaging may be more useful within mental health settings, as the CAT-Q only measures the frequency of use of a limited range of camouflaging strategies. Tools to capture an individual’s motivations for camouflaging, the effort it takes, their capability to do so, and the impacts (both positive and negative) it has will be worth developing and evaluating.

More information is also needed regarding the CAT-Q’s utility as an information gathering and/or assessment tool with autistic people and with people with other conditions where social coping and masking experiences may also be salient, such as social anxiety, depression, ADHD, tic disorders, language disorders, and learning disabilities.

These important gaps suggest that the following questions could be prioritized in future research: 1.

How does camouflaging develop over time and in whom? When does it begin, why, and how does it change at different developmental stages?

How can information about camouflaging, including information collected by the CAT-Q, other existing or novel measurement approaches, and clinical interview, be helpful and effective in assisting clinical decision-making in relation to autism diagnosis, differential diagnosis, and mental health care provision?

What are the impacts of camouflaging over time, for different individuals? Prospective longitudinal research is needed to establish directional relationships.

Are there other ways we can improve current measures, including the CAT-Q, or develop new ways to measure camouflaging, which capture its different facets, including the effort, effectiveness, and consequences of camouflaging for the individual over and above the frequency of use of camouflaging behaviors?

Can the CAT-Q or other camouflaging measures be used to assess psychosocial and well-being clinical outcomes following therapeutic support?

Footnotes

Authorship Confirmation Statement

B.R.H., L.H., M.-C.L., I.M., and W.M.: Conceptualization, investigation, writing—original draft, and writing—review and editing.

Author Disclosure Statement

The authors have no financial conflicts of interest to declare. L.H., M.-C.L., and W.M. were part of the team who developed the original CAT-Q, but receive no financial gains from this freely available resource. There are no other conflicts of interest to disclose. The article has been submitted solely to Autism in Adulthood.

Funding Information

This return L.H. is funded by a Prudence Trust Research Fellowship. M.-C.L. received funding support from the Canadian Institutes of Health Research (Sex and Gender Science Chair, GSB 171373), CAMH Foundation, and womenmind. M.-C.L. has received editorial honorarium from SAGE Publications.

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