“Masking” in Individuals with Autism Spectrum Disorder 

Autism spectrum disorder (ASD) is a multifaceted developmental disorder consisting of persistent deficits in social communication and interaction, as well as restricted, repetitive behaviors, interests, and activities.¹ Some individuals with ASD learn to use certain behaviors and strategies to minimize or conceal their symptoms so they can be perceived as neurotypical. The term “masking” (also referred to as “camouflaging”) is used to describe these coping strategies.^1-5

Masking may offer certain benefits to people with ASD, but it also can lead to delayed diagnosis or treatment, and may negatively affect their mental health.^6,7 Clinicians need to be able to recognize masking behaviors so they can identify individuals with underlying social communication difficulties.⁶ This article describes masking by individuals with ASD, and its reasons, implications, and consequences.

“Masking” Behaviors in Autism Spectrum Disorder

The diagnostic criteria for ASD are defined in the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, Text Revision (DSM-5-TR).¹ The DSM-5-TR criteria specify that symptoms of ASD must be present in an individual’s early developmental period, but they may not become noticeable until social demands exceed one’s limited capacities, or they may be disguised by learned behaviors.¹

Individuals with ASD — particularly males — also may have one or more comorbid intellectual developmental disorders.^1,3,6 However, individuals with ASD who have minimal or no cognitive impairment may have more subtle displays of their symptoms and may be better able to hide these deficits through masking.¹

Behaviors that a person with ASD might use to mask their symptoms include the following^3,5,6:

• Making and maintaining eye contact despite being uncomfortable doing so;
• Rehearsing conversations;
• Mimicking others’ mannerisms and styles;
• Mimicking conversations;
• Adjusting the volume of their speech; and
• Not standing too close to others.

Individuals with ASD often learn to use masking behaviors over time. They may become adept at looking at others when speaking to them, using scripted phrases during conversations, or mimicking others’ facial expressions, gestures, and mannerisms. However, their limitations in social interaction might be revealed when (for example) a person with ASD who has learned to effectively use storytelling to fit in tends to speak in monologues instead of engaging in typical back-and-forth conversation.⁶

“Masking” vs “Camouflaging”

While many researchers and clinicians use the terms masking and camouflaging interchangeably, others make distinctions between various types of these behaviors. Based on the personal experiences of individuals with ASD, Hull et al developed the Camouflaging Autistic Traits Questionnaire (CAT-Q), a 25-item self-report questionnaire, and administered it to 354 adults with ASD.⁴ Using a self-report method allowed the participants to describe their own behaviors across various situations. 

The findings suggested there are 3 subtypes of camouflaging behaviors: compensation, masking, and assimilation.^2,4 Compensation for social deficits related to ASD includes using rehearsed phrases and mimicking the observed mannerisms of others.^2,4 Masking autistic traits involves having an intense awareness and monitoring of one’s behavior to present a non-autistic persona to others.^2,4 Assimilation is using behavioral techniques to blend in better in uncomfortable social situations without letting others see the discomfort (for example, by forcing oneself to interact via performing and pretending).^2,4

Why People with Autism Spectrum Disorder Use “Masking”

In addition to wanting to fit in better and avoid being stigmatized, people with ASD have other reasons for engaging in masking. Cage et al evaluated masking in 262 adults with ASD.⁷ The participants described the reasons they use masking behaviors, as well as the contexts in which they most often use masking. Based on the responses, Cage et al categorized reasons for masking as conventional (those that served a functional purpose such as at work or school) and relational (those that served to ease everyday social interactions and relationships).⁷

Conventional reasons include the following⁷:

• To communicate their ideas or work; 
• To perform well at their job or at school; 
• To aid working with classmates or colleagues; 
• To get others to take them, their ideas, or their work seriously; 
• To get a job; 
• To reduce awkwardness in social interactions; 
• To impress their superiors at work or school; 
• To demonstrate responsibility; and
• To get a promotion.

Relational reasons include the following⁷:

• To make friends; 
• To seem attractive to a potential romantic partner; 
• To appear likable; 
• To bond with others; 
• To fit in with others; 
• To demonstrate my successes; 
• To express trustworthiness; and 
• To express intelligence.

Four reasons did not fit into either category⁷: “To reduce stigma, stereotypes or discrimination against you”; “Because it is expected of you”; “To find a flat or house to live,” and “To make others feel more comfortable.”

Participants were also permitted to provide “other” reasons for masking that weren’t among the 21 reasons included on the questionnaire. These other reasons were grouped into 5 themes as follows⁷:

• Fitting in and passing in a neurotypical world (most common);
• Avoiding retaliation and bullying by others;
• Concerns about impression made when not camouflaging;
• Habit; and 
• Internalized stigma (least common).

Adverse Effects of “Masking” in Autism Spectrum Disorder

While individuals with ASD may experience benefits from masking, it also can be detrimental. Masking can delay the diagnosis of ASD or lead to misdiagnosis, thus preventing individuals from receiving prompt, appropriate treatment.^2,4 Mental health disorders are common among people with ASD, and masking might make exacerbate these conditions. In their study of the CAT-Q, Hull et al found that masking behaviors were associated with higher levels of social anxiety, anxiety, and depression.⁴ A greater amount of masking was associated with poorer mental health outcomes.⁴ Masking also may create problems related to having a sense of identity and experiencing anxiety and stress due to feeling that one cannot be one’s “true” self.⁷

Cage et al examined the experiences of patients who reported “switching” between using masking behavior in certain situations and not using it in others. The levels of stress reported by people who switched were equal to those reported by individuals who frequently used masking, and both groups had higher stress than patients with ASD who used masking less often.⁷ This suggests that masking in some situations but not others could be as burdensome as masking all of the time.⁷ Although individuals who switch do not have to face the stress of having to consistently mask their identity, they do have to constantly evaluate the risk of having their autistic identity exposed in each new context.⁷ This can result in exhaustion and burnout.

“Masking” in Women with Autism Spectrum Disorder

While ASD affects both genders, males are diagnosed more often, and typically earlier in life. These differences in diagnosis might be because in general, females appear to be more likely to use masking strategies, and to use them more effectively.^2-4

Cage et al found that women with ASD are more likely than men to engage in masking for conventional reasons, such as in an effort to succeed at work or school.⁷ Women who use masking have reported that the practice takes extreme cognitive effort and leaves them feeling anxious and exhausted.^3,5 Females who use masking may be more aware of their autistic symptoms and the difficulties these symptoms create in social contexts.² This self-awareness and the stress associated with hiding their symptoms can have a negative mental and emotional impact.²

Conclusion

To fit in better and for other reasons, individuals with ASD may choose to use behavioral strategies to mask their deficits in social communication and interaction. While masking can help patients with ASD in certain areas, such as in engaging in work or school or in forming relationships, it can come at a cost. Masking may delay proper diagnosis of the disorder. It can be physically and mentally exhausting, stressful, and lead to increased anxiety and depression.