"Disguising Autism": Investigating the Processes Underlying Masking in Autism

Autism Spectrum Disorder refers to a neurodevelopmental spectrum condition primarily characterised by persistent difficulties in social communication and interaction, alongside repetitive and restrictive behaviours. It is thought that some autistic individuals can 'mask' their underlying social difficulties and overtly demonstrate relatively few behavioural symptoms despite continued cognitive differences, perhaps through recruitment of executive function abilities (Livingston & Happé, 2017).
The general aim of the proposed research is to empirically develop a conceptual framework of compensation in autism. This will consist of two major strands of research. First, the evaluation of the executive function abilities underpinning masking and secondly, modelling the complex relationship between masking and mental health.
Executive function (EF) has been previously proposed as a theoretically-plausible mechanism underlying masking (Johnson, 2012; Livingston & Happé, 2017). Supporting this assertion, high compensators have been found to exhibit greater EF than low compensators (Livingston et al., 2018). Part of the project will focus on replications and extensions of this previous research.
To quantify masking, autistic adults will complete tests that measure the 'internal status' of social cognition, such as the Edinburgh Social Cognition Test (Baksh, Abrahams, Auyeung, & MacPherson, 2018), and external behavioural presentation will be assessed using the Autistic Diagnostic Observation Schedule (Lord, Rutter, DiLavore, Risi, Gotham, & Bishop, 2012). Following past research, the contrast between these external and internal measures is considered to reflect an operationalization of masking. A battery of EF tests tapping into distinct facets of EF will also be administered to identify the specific facets of EF which may underly masking.
Research has suggested links between masking and negative mental health consequences such as anxiety, depression, and burnout (Cage & Troxell-Whitman, 2019; Hull et al., 2018; Livingston, Colvert, Bolton, & Happé, 2018). However, the causal mechanisms underlying the association between compensation and poor mental health remain unknown. A mixed-methods approach will be utilised to develop a model of the relationship between masking and mental health. Interviews with autistic adults who self-identify as regularly engaging with masking. The interviews will focus on the experience of masking, the reasons motivating masking, and the perceived consequences for mental health, and Interpretive Phenomenological Analysis will be used as the method of analysis. The resultant themes determined through analysis of the interviews will be used to identify candidate risk factors underlying the relationship between masking and mental health. Psychometric instruments capturing these risk factors will then be identified, and a large sample of autistic adults will complete these instruments alongside measures of masking and mental health symptomology. A structural equation modelling approach will be used to estimate whether the identified factors mediate the relationship between masking and poor mental health.
The masking framework developed through the project will increase our understanding of the lived experience of autistic people, enhancing the abilities of clinicians to provide optimal support to autistic people. Understanding of the relationship between masking and mental health will facilitate the development of appropriate support and interventions for autistic people, helping to remediate the mental health inequalities experienced by autistic people. Knowledge derived from the exploration of masking may also improve clinical practice and access to services as masking has been proposed to play a key role in misdiagnosis and gender-biases in diagnosis. Finally, the masking framework developed throughout the PhD research can be utilised to improve the validity of autism research more generally.