autism analysis essay

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Published: 28 May 2021

Advances in autism research, 2021: continuing to decipher the secrets of autism

Julio Licinio ORCID: orcid.org/0000-0001-6905-5884 1 &
Ma-Li Wong 1

Molecular Psychiatry volume 26 , pages 1426–1428 ( 2021 ) Cite this article

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Autism spectrum disorders
Neuroscience

We are proud to publish this Special Issue focused on autism, a topic that has been exceedingly important for Molecular Psychiatry since our inception. It is not too bold a statement to say that we were a fundamental contributor to bringing autism to the forefront of the national discourse. A Pubmed search reveals 403 articles published in Molecular Psychiatry since our founding in 1996. Our first autism article by Vincent et al., published in July 1996, examined the fragile X syndrome gene (FMR1) for mutations in autistic individuals, using single-stranded conformational polymorphism analysis; those authors identified three new FMR1 polymorphisms and identified specific and significant association findings with autism [ 1 ].

In late 2001–early 2002 we received four exciting papers with findings on the genetics of autism that were published together in our March 2002 issue, with an accompanying editorial [ 2 , 3 , 4 , 5 , 6 ]. We issued then a press release that was picked up by Time magazine and served as the basis for their unprecedented May 6, 2002 cover story on autism, featuring as that iconic magazine’s cover a young boy who was visibly autistic [ 7 ]. That was the first time that a person with autism was the cover of a national magazine. The magazine’s cover displayed in big yellow letters “Inside the world of autism” and it had a subtitle stating “More than one million Americans may have it, and the number of new cases is exploding. What scientists have discovered. What families should know.” The full story, by Nash [ 8 ], was entitled: “The Secrets of Autism,” with the following subtitle: “The number of children diagnosed with autism and Asperger’s in the U.S. is exploding. Why?” Time ’s cover article was so successful that their editors expanded that from a single issue into an entire series on autism over multiple issues. That Time series effectively made autism emerge as a mainstream topic of kitchen table conversations across America. As that effort was triggered by our press release and four articles on autism, it is reasonable to boast that Molecular Psychiatry launched the national conversation on autism.

The four papers highlighted in our March 2002 issue were within the first 20 articles that we published on this topic. Now, 383 papers later, we have a much more substantial body of work that further unravels the secrets of autism, the culmination of which is this autism Special Issue, with 26 truly superb papers on autism [ 9 , 10 , 11 , 12 , 13 , 14 , 15 , 16 , 17 , 18 , 19 , 20 , 21 , 22 , 23 , 24 , 25 , 26 , 27 , 28 , 29 , 30 , 31 , 32 , 33 , 34 ]. These extraordinary articles cover essentially all aspects of this disorder, from the training of specialists, to the interface with other disorders, such as polycystic ovarian syndrome and Alzheimer’s disease, and in-depth analyses of genetics, structural and functional imaging, as well as neuroscience, including postmortem brain studies, transcriptome of induced pluripotent stem cell models, assessments of the role of vitamin D, and studies highlighting the contributions of inflammatory mediators to autism.

We have had for over three decades a particular interest on the interface of immune mediators and psychiatric disorders [ 35 ]. It is very rewarding to see the interface of immune mediators and psychiatry evolve from a hypothesis, that we and others explored decades ago, into a broad and established area within psychiatric neuroscience. As we have developed a new model of analysis of the simultaneous contributions of multiple genes and environmental factors to a psychiatric phenotype [ 36 ], were also encouraged to see studies looking at the polygenic risk for autism in the context of childhood trauma, life-time self-harm, and suicidal behavior and ideation [ 30 ], as well in comparison to several other psychiatric disorders [ 32 ].

One paper in this issue, by Frye et al., is highly usual, and particularly intriguing: it investigates the role of the mitochondrion, in the influence of prenatal air pollution exposure on neurodevelopment and behavior in 96 children with autism spectrum disorder [ 22 ]. Second and third trimester average and maximal daily exposure to fine air particulate matter of diameter ≤2.5 µm (PM 2.5 ) was obtained from the Environmental Protection Agency’s Air Quality System. Mediation analysis found that mitochondrial respiration linked to energy production accounted for 25% and 10% of the effect of average prenatal PM 2.5 exposure on neurodevelopment and behavioral symptoms, respectively. Those results suggest that prenatal exposure to PM 2.5 disrupts neurodevelopment and behavior through complex mechanisms, including long-term changes in mitochondrial respiration and that patterns of early development need to be considered when studying the influence of environmental agents on neurodevelopmental outcomes.

We are honored to have initiated the national conversation on autism twenty years ago and we believe that the 403 autism papers published to date in Molecular Psychiatry , including, but not limited to those highlighted in this Special Issue, report major advances in a key area of molecular psychiatry. It is particularly rewarding to see that these articles cover the full spectrum of research translation [ 37 ], from molecules to society.

In future issues, Molecular Psychiatry will continue to publish outstanding advances in autism research.

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Licinio, J., Wong, ML. Advances in autism research, 2021: continuing to decipher the secrets of autism. Mol Psychiatry 26 , 1426–1428 (2021). https://doi.org/10.1038/s41380-021-01168-0

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Autism Spectrum Disorder: A Literature Review Words: 1116
Autism Spectrum Disorder Communication Words: 1445
Literature Review on Autism Spectrum Disorder Words: 2144
Children With Autism Spectrum Disorders Words: 955
Autism and Other Neurological Disorders Words: 913
Autism Spectrum Disorder: Behavior Analysis Words: 2033
Childhood Disorders: Autism Spectrum Disorders Words: 586
Autism Spectrum Disorder and Dialogue Framework Words: 1095
Contributing Factors of Anxiety in Children with Autism Spectrum Disorder Words: 5264
Autism Spectrum Disorder in Children Words: 3382
Social Science Perspectives on the Autism Spectrum Words: 1753
Autism Spectrum Disorder and Immunization Words: 836
Behavior Intervention in Autism Spectrum Disorders Words: 656
Autism Spectrum Disorders: Control and Prevention Words: 1346
Causes and Treatment of Autism in Children Words: 1653
Development and Management of Autism Words: 2325
Mental Disorders: Symptoms and Risk Factors Words: 955
Supporting Students with Autism Spectrum Disorders Words: 1382

Autism Spectrum Disorder Analysis

Introduction, signs and symptoms, diagnostic criteria, differential diagnosis, causes and risk factors, screening tools, interventions.

Autism spectrum disorder (ASD) is a collection of neurological conditions in which a person’s speech, motor motions, and social interaction are disrupted. ASD is categorized as a cognitive disorder as its symptoms usually develop within the first two years of life. Autism is classified as a spectrum condition since its symptoms can range from mild to severe and involve a range of disorders such as Rett syndrome, childhood disintegrative disorder, Kanner’s syndrome, and pervasive developmental disorder. The World Health Organization (WHO) estimates that 1 in every 100 children is autistic (Center for Disease Control and Prevention, 2018). Autism is a neurological difference that rises to the level of disability only when the consequences of that neurological difference interfere with basic functioning. It is technically listed as a disorder under the DSM-5, but that classification is controversial with autistic people who do not experience disability and do not think their neurological differences are abnormal.

Autism spectrum disorder affects people in two ways, leading to different abilities: high functioning and low functioning. High-functioning individuals may have behavior issues but can function independently. Low-functioning individuals have trouble being independent as their symptoms are severe, and they may not be able to talk properly for years after birth. All autistic disorders are part of the spectrum as they range from many types of autistic conditions. Because each child’s severity and presentation differ, predicting their future life highly depends on the individual child and the therapy used. However, a child can have a learning disability or high intelligence quotient, thus excelling in various aspects such as mathematics and art.

Autism spectrum disorder begins in early childhood, often before age three, and can last throughout a person’s life. Some children show ASD symptoms within the first year, while some gain skills and meet developmental milestones until 18 to 24 months when they develop autism symptoms. There are three main autistic spectrum disorder symptoms: delayed milestones, verbal and nonverbal communication issues, and social abnormality. Child milestones include cooing, babbling, and sitting up at an expected age (Campisi et al., 2018). Children with autism do not meet these developmental milestones by age six, such as using facial expressions in conversations and cooing when upset.

Examples of repetitive behavior inherent in autistic children include incoherent repetition of new words, gestures like rocking objects, flapping arms, and organizing objects in strict routines. In addition, the child becomes upset when the routine or arrangement is distorted. The child may get upset over minor behavior changes, focus intently on objects, have an obsessive interest, and have unusual reactions to sensory inputs. Symptoms of issues regarding social behavior involve avoiding eye contact and the inability to engage in communal play, preferring to play alone. The child does not respond to their name, does not like to be touched, and has trouble understanding emotions in a conversation (Lord et al., 2018). An autistic child inappropriately engages in social conversations by being aggressive or passive, does not understand simple directions, and cannot engage in long conversations, only starting a social interaction to request items. In addition, one does not recognize non-verbal cues such as facial expressions and body postures.

A child must meet the criteria for chronic deficiencies in three areas of social communication and interaction, as well as at least two types of repetitive, limited conduct to be diagnosed with an autism spectrum disorder. First, multiple scenarios must highlight persistent deficiencies in social communication and social engagement. These include deficits in understanding social-emotional interactions, including failure to engage in continuous dialogue, inability to initiate or respond to social encounters, and limited sharing of interests (Hodges, Fealko, & Soares, 2020). Face expressions, gestures, eye contact, and body language are examples of nonverbal communication characteristics lacking in social interactions. Furthermore, there is a deficiency in building and maintaining relationships due to a lack of interest in peers and difficulties in modifying conduct to fit social circumstances.

The second primary diagnostic criteria entail repetitive and restricted behavior patterns manifested by two of the four criteria symptoms. The first includes repetitive motor movements and lining objects in a familiar pattern. The second symptom consists of an insistence on following routines and developing extreme distress at the slight distortion of arrangement. The third primary criteria include an obsessive interest in unusual objects and increased fixation for long hours. The fourth primary criterion consists of an abnormal interest in sensory aspects of the environment, such as varying responses to pain, sounds, and texture. The other minor criteria entail the development of symptoms in the early life and significant impairment in social life due to the condition. People who receive a diagnosis have different levels of severity pertaining to the considerable symptoms entailing social communication and repetitive behavior.

There are five differential diagnoses for ASD, including Rett syndrome, Language disorders, social communication disorders, and attention deficit hyperactivity disorder. Rett syndrome entails disruption of social interactions during the first four years, affecting many young girls who meet the diagnostic criteria for autism spectrum disorder. However, most individuals improve social interaction skills; thus, autistic symptoms do not affect milestone development. Language disorders and social communication disorders affect communication and social skills in children. These diseases are not associated with atypical nonverbal communication or incoherent repetitive behavior; hence the diagnosis of social communication disorder takes precedence over autism spectrum disorder.

Attention deficit hyperactivity disorder (ADHD) symptoms such as easy distraction and obsessive focus are inherent in ASD. An ADHD diagnosis is considered when attention difficulties exceed the standard hyperactivity in people of similar age (Lord et al., 2018). In addition, most autistic individuals have psychiatric symptoms that are not included in the diagnostic formulation, such as depression and anxiety disorders. Medical conditions associated with ASD include sleep issues, epilepsy, and constipation. These conditions are noted under specific specifiers during diagnosis.

There is no known cause of ASD, but several theories and risk factors are involved in developing the condition, including genetic and environmental factors. Genetic mutation is the leading cause of ASD as the condition is hereditary. The most prominent gene mutation is when the body produces chemicals against its tissues leading to abnormal development. Environmental factors include advanced parental age, viral infections, and birth weight that increases the risk of ASD.

The risk factors in ASD involve gender, as males are four times more likely to be diagnosed with the condition than females (Center for Disease Control and Prevention, 2018). Families with children or relatives with the condition are at an increased risk of having another child with ASD. Complications associated with ASD include disrupted learning in settings with agemates through social interactions. Routines interfere with adaptive skills regarding planning and organization. In adulthood, individuals have difficulties establishing independence and gaining meaningful employment.

Diagnostic tools assess ASD in children but should not be used as the basis for diagnosis without medical practitioner approval. The diagnostic tool relies on parents’ and caregivers’ observations of their children’s behavior. There are four major diagnostic tools, including the ADI-R (Autism Diagnostic Interview-Revised), ADOS (Autism Diagnostic Observation Schedule), and DISCO tool (Diagnostic Interview for Social and Communication Disorders). The ADI-R is a clinical diagnostic instrument for assessing autism in children and adults aged 18 months and above (Parmeggiani, Corinaldesi, & Posar, 2019). The tool focuses on social interactions, reciprocity, communication and language, and repetitive behaviors.

The ADOS tool is the standardized assessment tool as it does not base its diagnosis on developmental milestones but current behavior skills and behavior (Parmeggiani, Corinaldesi, & Posar, 2019). The ADOS tool evaluates individuals at all developmental levels in all aspects. DISCO tool (Diagnostic Interview for Social and Communication Disorders) entails a semi-structured interview designed to assess an individual’s skills from birth to the present. The tool collects information regarding each individual’s skills and challenges, not ASD features.

There is no standardized treatment for autism spectrum disorder as most treatment options manage the symptoms but do not cure the condition. All states must provide early intervention services for children under three years. Interventions available for managing ASD symptoms are behavioral therapies, including applied behavioral analysis (ABA), occupational therapy, speech therapy, and pharmacological and physical therapy. The most effective intervention entails ABA as it works to maximize functional independence and quality of life while minimizing the associated impacts of ASD deficiencies (Campisi et al., 2018). ABA therapies focus on reinforcing skills that form the foundation of developmental milestones while decreasing negative behaviors.

The treatment uses positivity to break down complex behaviors into smaller tasks that are easy to learn. The goals of ABA therapy entail promoting a child’s social development by removing harmful behaviors, thus helping children develop life skills. The children can apply the positive skills to new situations, thus reducing the impact of the condition. The applicable ABA therapies in autism intervention include Early Intensive Behavioral Intervention (EIBI), Pivotal Response Training, and Discrete Trial Teaching. New research into interventions discovered that cannabis extracts are a safe and efficient treatment for ASD symptoms in children.

Autism spectrum disorder is categorized as a mental condition as individuals do not fit within society’s normal standards in the social construction of the neurotypical brain. Autism is on a spectrum as its condition depends on the severity of the case, including Rett syndrome, childhood disintegrative disorder, Kanner’s syndrome, and pervasive developmental disorder. Autism becomes a disorder if it causes significant distress and impairs the daily functioning of individuals.

The condition has no defined cause or cure but prevents individuals from performing specific actions. Autism spectrum disorder affects people differently, but most symptoms entail social and behavioral incoherence. Autistic individuals have issues in social situations as they cannot communicate effectively and have limited knowledge of social cues and behaviors, such as trouble controlling their pitch. In addition, people with the condition are sensitive to perceptions such as lights and smell. Some individuals are high functioning becoming experts in different fields, while others are low functioning and thus have learning disabilities. Autistic individuals are usually introverted and do not reciprocate gestures or start or maintain conversations. They have extreme routine practices and get offended when distorted.

For an individual to be diagnosed with ASD, one must exhibit symptoms of social inactiveness and repetitive behavior in children below the age of three, as it’s the most critical time for neurological development. Genetics and environmental factors such as advanced parental age, viral infections, increased birth weight, family genetics and gender increase the susceptibility to the condition. The most effective intervention is using applied behavioral analysis as it maximizes functionality while minimizing the associated impacts of ASD deficiencies.

Campisi, L., Imran, N., Nazeer, A., Skokauskas, N., & Azeem, M. W. (2018). Autism spectrum disorder. British Medical Bulletin , 127 (1). Web.

Centers for Disease Control and Prevention. (2018). Autism Spectrum Disorder (ASD) . Centers for Disease Control and Prevention. Web.

Hodges, H., Fealko, C., & Soares, N. (2020). Autism spectrum disorder: definition, epidemiology, causes, and clinical evaluation. Translational Pediatrics , 9 (Suppl 1), S55–S65. Web.

Lord, C., Elsabbagh, M., Baird, G., & Veenstra-Vanderweele, J. (2018). Autism spectrum disorder. The lancet , 392 (10146), 508-520. Web.

Parmeggiani, A., Corinaldesi, A., & Posar, A. (2019). Early features of autism spectrum disorder: a cross-sectional study . Italian journal of pediatrics , 45 (1), 1-8. Web.

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Research, clinical, and sociological aspects of autism.

$\nPaul Whiteley$

ESPA Research, Unit 133i Business Innovation Centre, The Robert Luff Laboratory, Education & Services for People With Autism Research, Sunderland, United Kingdom

The concept of autism continues to evolve. Not only have the central diagnostic criteria that define autism evolved but understanding of the label and how autism is viewed in research, clinical and sociological terms has also changed. Several key issues have emerged in relation to research, clinical and sociological aspects of autism. Shifts in research focus to encompass the massive heterogeneity covered under the label and appreciation that autism rarely exists in a diagnostic vacuum have brought about new questions and challenges. Diagnostic changes, increasing moves towards early diagnosis and intervention, and a greater appreciation of autism in girls and women and into adulthood and old age have similarly impacted on autism in the clinic. Discussions about autism in socio-political terms have also increased, as exemplified by the rise of ideas such as neurodiversity and an increasingly vocal dialogue with those diagnosed on the autism spectrum. Such changes are to be welcomed, but at the same time bring with them new challenges. Those changes also offer an insight into what might be further to come for the label of autism.

Introduction

Although there is still debate in some quarters about who first formally defined autism ( 1 ), most people accept that Kanner ( 2 ) should be credited as offering the first recognised description of the condition in the peer-reviewed scientific literature. The core diagnostic features covering issues in areas of social and communicative interaction alongside the presence of restricted and/or repetitive patterns of behaviour ( 3 ) described in his small caseload still remain central parts of the diagnosis today. The core issue of alterations in social cognition affecting emotion recognition and social attention ( 4 ) remain integral to the diagnosis of autism. The additional requirement for such behaviours to significantly impact on various areas of day-to-day functioning completes the diagnostic criteria.

From defining a relatively small group of people, the evolution of the diagnostic criteria for autism has gone hand-in-hand with a corresponding increase in the numbers of people being diagnosed. Prevalence figures that referred to 4.5 per 10,000 ( 5 ) in the 1960s have been replaced by newer estimates suggesting that 1 in 59 children (16 per 1,000) present with an autism spectrum disorder (ASD) in 2014 ( 6 ). The widening of the definition of autism has undoubtedly contributed to the significant increase in the numbers of people being diagnosed. It would be unacceptably speculative however, to define diagnostic changes as being the sole cause of the perceived prevalence increases.

Alongside the growth in numbers of people being diagnosed with autism so there have been changes in other areas related to autism; specifically those related to the research, clinical practice and sociological aspects of autism. Many of the changes have centred on key issues around the acceptance that autism is an extremely heterogeneous condition both in terms of presentation and also in relation to the genetic and biological complexity underlying its existence. That autism rarely exists in some sort of diagnostic vacuum is another part of the changes witnessed over the decades following the description of autism.

In this paper we highlight some of the more widely discussed changes in areas of research, clinical practice and sociological terms in relation to autism. We speculate on how such changes might also further develop the concept of autism in years to come.

Autism Research

As the definition of autism has subtly changed over the years, so ideas and trends in autism research have waxed and waned. The focus on psychology and behaviour as core descriptive features of autism has, in many respects, guided research and clinical views and opinions about the condition. Social cognition, including areas as diverse as social motivation, emotion recognition, social attention and social learning ( 4 ), remains a mainstay of research in this area. The rise of psychoanalysis and related ideas such as attachment theory in the early 20th century for example, played a huge role in the now discredited ideas that maternal bonding or cold parenting were a cause of autism. The seemingly implicit need for psychology to formulate theories has also no doubt played a role in perpetuating all-manner of different grand and unifying reasons on why autism comes about and the core nature of the condition.

As time moved on and science witnessed the rise of psychiatric genetics, where subtle changes to the genetic code were correlated with specific behavioural and psychiatric labels, so autism science also moved in the same direction. Scientific progress allowing the genetic code to be more easily and more cost-effectively read opened up a whole new scientific world in relation to autism and various other labels. It was within this area of genetic science that some particularly important discoveries were made: (a) for the vast majority of people, autism is not a single gene “disorder,” and (b) genetic polymorphisms whilst important, are not the only mechanism that can affect gene expression. Mirroring the role of genetics in other behavioural and psychiatric conditions ( 7 ), the picture that is emerging suggests that yes, there are genetic underpinnings to autism, but identifying such label-specific genetic issues is complicated and indeed, wide-ranging.

What such genetic studies also served to prove is that autism is heterogeneous. They complemented the wide-ranging behavioural profiles that are included under the diagnostic heading of autism. Profiles that ranged from those who are profoundly autistic and who require almost constant attention to meet their daily needs, to those who have jobs, families and are able to navigate the world [seemingly] with little or minimal support for much of the time.

It is this heterogeneity that is perhaps at the core of where autism is now from several different perspectives. A heterogeneity that not only relates to the presentation of the core traits of autism but also to how autism rarely manifests in a diagnostic vacuum ( 8 ). Several authors have talked about autism as part of a wider clinical picture ( 9 , 10 ) and how various behavioural/psychiatric/somatic issues seem to follow the diagnosis. Again, such a shift mirrors what is happening in other areas of science, such as the establishment of the Research Domain Criteria (RDoC) project ( 11 ). RDoC recognised that defining behavioural and psychiatric conditions on the basis of presented signs and symptoms does not necessarily “reflect” the relevant underlying processes and systems that might be important. It recognised that in order to deliver important clinical information about how and why a condition manifests, or the best strategies to intervene, research cannot just singularly start with the label. Science and clinical practice need more information rather than just a blanket descriptive label such as autism.

To talk about autism as a condition that also manifests various over-represented comorbid labels also asks a fundamental question: is the word “comorbidity” entirely accurate when referring to such labels? ( 12 ). Does such comorbidity instead represent something more fundamental to at least some presentations of autism or is it something that should be seen more transiently? Numerous conditions have been detailed to co-occur alongside autism. These include various behavioural and psychiatric diagnoses such as depression, anxiety and attention-deficit hyperactivity disorder (ADHD) ( 13 ). Other more somatic based conditions such as epilepsy ( 14 ), sleep ( 15 ) and various facets of gastrointestinal (GI) functioning ( 16 ) have also been discussed in the peer-reviewed science literature. Some of these co-occurring conditions have been described in the context of specific genetic conditions manifesting autism. Issues with the BCKDK (Branched Chain Ketoacid Dehydrogenase Kinase) gene for example, have been discussed in the context of autism, intellectual (learning) disability and epilepsy appearing together ( 17 ). Such a diagnostic combination is not unusual; autism often being described as the primary diagnosis with epilepsy and learning disability seen as “add-ons.” But should this be the case? Other evidence pointing to the possibility that epilepsy might under some circumstances beget autism ( 18 ) suggests that under some circumstances, such co-occurring conditions are so much more than just co-occurring or comorbid.

Other evidence for questioning the label “comorbid” comes from various animal models of autism. Accepting that one has to be particularly careful about extrapolating from animal models of autism to the more complex presentation of autism in humans ( 19 ), various models have suggested that autism may for some, fundamentally coexist with GI or bowel issues ( 20 , 21 ). Such observations have been noted across different animal models and cover important issues such as gut motility for example, that have been talked about in the context of autism ( 22 ).

Similarly, when one talks about the behavioural and psychiatric comorbidity in the context of autism, an analogous question arises about whether comorbidity is the right term. Anxiety and depression represent important research topics in the context of autism. Both issues have long been talked about in the context of autism ( 1 , 13 , 23 ) but only in recent years have their respective “links” to autism been more closely scrutinised.

Depression covers various different types of clinical presentations. Some research has suggested that in the context of autism, depressive illnesses such as bipolar disorder can present atypically ( 24 ). Combined with other study ( 25 ) suggesting that interventions targeting depressive symptoms might also impact on core autistic features, the possibility that autism and depression or depressive symptoms might be more closely linked than hitherto appreciated arises. Likewise with anxiety in mind, similar conclusions could be drawn from the existing research literature that anxiety may be a more central feature of autism. This on the basis of connections observed between traits of the two conditions ( 26 ) alongside shared features such as an intolerance of uncertainty ( 27 ) exerting an important effect.

A greater appreciation of the heterogeneity of autism and consideration of the myriad of other conditions that seem to be over-represented alongside autism pose serious problems to autism research. The use of “autism pure” where research participants are only included into studies on the basis of not having epilepsy or not possessing a diagnosis of ADHD or related condition pose a serious problem when it comes to the generalisation of research results to the wider population. Indeed, with the vast heterogeneity that encompasses autism, one has to question how, in the context of the current blanket diagnosis of autism or ASD, one could ever provide any universal answers about autism.

Autism in the Clinic

As mentioned previously, various subtle shifts in the criteria governing the diagnosis of autism have been witnessed down the years. Such changes have led to increased challenges for clinicians diagnosing autism from several different perspectives. One of the key challenges has come about as a function of the various expansions and contractions of what constitutes autism from a diagnostic point of view. This includes the adoption of autism as a spectrum disorder in more recent diagnostic texts.

The inclusion of Asperger syndrome in the DSM-IV and ICD-10 diagnostic schedules represented an expansion of the diagnostic criteria covering autism. Asperger syndrome defined by Hans Asperger ( 28 ) as autistic features without significant language impairment and with intelligence in the typical range, was included in the text for various different reasons. Allen Frances, one of the architects of the DSM-IV schedule, mentioned the importance of having a “ specific category to cover the substantial group of patients who failed to meet the stringent criteria for autistic disorder, but nonetheless had substantial distress or impairment from their stereotyped interests, eccentric behaviors, and interpersonal problems ” ( 29 ). It is now widely accepted that the inclusion of Asperger syndrome in diagnostic texts led to an increase in the number of autism diagnoses being given.

More recent revisions to the DSM criteria covering autism—DSM-5—included the removal of Asperger syndrome as a discrete diagnosis on the autism spectrum ( 30 ). Instead, a broader categorisation of autism spectrum disorder (ASD) was adopted. The reasons for the removal of Asperger syndrome from DSM-5 are complex. The removal has however generally been positively greeted as a function of on-going debates about whether there are/were important differences between autism and Asperger syndrome to require a distinction ( 31 ) alongside more recent revelations about the actions of Asperger during World War II ( 32 ). Studies comparing DSM-IV (and its smaller revisions) with DSM-5 have also hinted that the diagnostic differences between the schedules may well-impact on the numbers of people in receipt of a diagnosis ( 33 ).

Shifts in the diagnostic text covering autism represent only one challenge to autism in the clinical sense. Other important factors continue to complicate the practice of diagnosing autism. Another important issue is a greater realisation that although the presence of observable autistic features are a necessary requirement for a diagnosis of autism, such features are also apparent in various other clinical labels. Autistic features have been noted in a range of other conditions including schizophrenia ( 34 ), personality disorders ( 35 ) and eating disorders ( 36 ) for examples. Coupled with the increasingly important observation that autism rarely exists in a diagnostic vacuum, the clinical challenges to accurately diagnosing autism multiply as a result.

The additional suggestion of “behavioural profiles” within the autism spectrum adds to the complexity. Terms such as pathological demand avoidance (PDA) coined by Newson and colleagues ( 37 ) have started to enter some diagnostic processes, despite not yet being formally recognised in diagnostic texts. Including various autistic traits alongside features such as “resisting and avoiding the ordinary demands of life” and the “active use of various strategies to resist demands via social manipulation,” debate continues about the nature of PDA and its diagnostic value ( 38 ).

Early diagnosis and intervention for autism have also witnessed some important clinical changes over the years. Driven by an acceptance of the idea that earlier diagnosis means that early intervention can be put in place to “ameliorate” some of the more life-changing effects of autism, there has been a sharp focus on the ways and means of identifying autism early and/or highlighting those most at risk of a diagnosis. It's long been known that there is a heritable aspect to autism, whether in terms of traits or diagnosis ( 39 ). In this respect, preferential screening for autism in younger siblings when an older child has been diagnosed is not an uncommon clinical sentiment ( 40 ). Other work looking at possible “red flags” for autism, whether in behaviour ( 41 ) or in more physiological terms still continue to find popularity in both research and clinical terms.

But still however, autism continues to confound. As of yet, there are only limited reliable red flags to determine or preclude the future presence of autism ( 42 ). Early behavioural interventions for autism have not yet fulfilled the promise they are said to hold ( 43 ) and autism is not seemingly present in the earliest days of development for all ( 44 , 45 ). There is still a way to go.

Autism in a modern clinical sense is also witnessing change in several other quarters. The traditional focus of autism on children, particularly boys, is being replaced by a wider acceptance that (a) autism can and does manifest in girls and women, and (b) children with autism age and mature to become adults with autism. Even the psychological mainstay of autism—issues with social cognition—is undergoing discussion and revision.

On the issue of autism presentation in females, several important themes are becoming more evident. Discussions about whether there may be subtle differences in the presentation of autism in females compared to males are being voiced, pertinent to the idea that there may be one or more specific female phenotypes of autism ( 46 ). Further characterisation has hinted that sex differences in the core domain of repetitive stereotyped behaviours ( 47 ) for example, may be something important when it comes to assessing autism in females.

Allied to the idea of sex differences in autism presentation, is an increasing emphasis on the notion of camouflaging or masking ( 48 ). This masking assumes that there may active or adaptive processes on-going that allow females to hide some of their core autistic features and which potentially contributes to the under-identification of autism. Although some authors have talked about the potentially negative aspects of masking in terms of the use of cognitive resources to “maintain the mask,” one could also view such as adaptation in a more positive light relating to the learning of such a strategy as a coping mechanism. Both the themes of possible sex differences in presentation and masking add to the clinical complexity of reliably assessing for autism.

Insofar as the growing interest in the presentation of autism in adulthood, there are various other clinical considerations. Alongside the idea that the presentation of autism in childhood might not be the same as autism in adulthood ( 49 ), the increasing number of people receiving a diagnosis in adulthood is a worthy reminder that autism is very much a lifelong condition for many, but not necessarily all ( 50 ). The available research literature also highlights how autism in older adults carries some unique issues ( 51 ) some of which will require clinical attention.

Insofar as the issue of social cognition and autism, previous sweeping generalisations about a deficit in empathy for example, embodying all autism are also being questioned. Discussions are beginning debating issues such as how empathy is measured and whether such measurements in the context of autism are as accurate as once believed ( 52 ). Whether too, the concept of social cognition and all the aspects it encompasses is too generalised in its portrayal of autism, including the notion of the “double empathy problem” ( 53 ) where reciprocity and mutual understanding during interaction are not solely down to the person with autism. Rather, they come about because experiences and understanding differ from an autistic and non-autistic point of view. Such discussions are beginning to have a real impact on the way that autism is perceived.

Autism in Sociological Terms

To talk about autism purely through a research or clinical practice lens does not do justice to the existing peer-reviewed literature in its entirety. Where once autism was the sole domain of medical or academic professionals, so now there is a growing appreciation of autism in socio-political terms too, with numerous voices from the autism spectrum being heard in the scientific literature and beyond.

There are various factors that have contributed to the increased visibility of those diagnosed with autism contributing to the narrative about autism. As mentioned, the fact that children with autism become autistic adults is starting to become more widely appreciated in various circles. The expansion of the diagnostic criteria has also played a strong role too, as the diagnostic boundaries of the autism spectrum were widened to include those with sometimes good vocal communicative abilities. The growth in social media and related communication forms likewise provided a platform for many people to voice their own opinions about what autism means to them and further influence discussions about autism. The idea that autistic people are experts on autism continues to grow ( 54 ).

For some people with autism, the existing narrative about autism based on a deficit model (deficits in socio-communicative abilities for example) is seemingly over-emphasised. The existing medical model of autism focusing such deficits as being centred on the person does not offer a completely satisfying explanation for autism and how its features can disable a person. Autism does not solely exist in a sociological as well as diagnostic vacuum. In this context, the rise and rise of the concept of neurodiversity offered an important alternative to the existing viewpoint.

Although still the topic of some discussion, neurodiversity applied to autism is based on several key tenets: (a) all minds are different, and (b) “ neurodiversity is the idea that neurological differences like autism and ADHD are the result of normal, natural variation in the human genome ” ( 55 ). The adoption of the social model of disability by neurodiversity proponents moves the emphasis on the person as the epicentre of disability to that where societal structures and functions tend to be “ physically, socially and emotionally inhospitable towards autistic people ” ( 56 ). The message is that subtle changes to the social environment could make quite a lot of difference to the disabling features of autism.

Although a popular idea in many quarters, the concept of neurodiversity is not without its critics both from a scientific and sociological point of view ( 57 ). Certain key terms often mentioned alongside neurodiversity (e.g., neurotypical) are not well-defined or are incompatible with the existing research literature ( 58 ). The idea that societal organisation is a primary cause of the disability experienced by those with the most profound types of autism is also problematic in the context of current scientific knowledge and understanding. Other issues such as the increasing use of self-diagnosis ( 59 ) and the seeming under-representation of those with the most profound forms of autism in relation to neurodiversity further complicate the movement and its aims.

The challenges that face the evolving concept of neurodiversity when applied to autism should not however detract from the important effects that it has had and continues to have. Moving away from the idea that autistic people are broken or somehow incomplete as a function of their disability is an important part of the evolution of autism. The idea that autism is something to be researched as stand-alone issue separate from the person is something else that is being slowly being eroded by such a theory.

The concept of autism continues to evolve in relation to research, clinical practice and sociological domains. Such changes offer clues as to the future directions that autism may take and the challenges that lie ahead.

The continuing focus on the huge heterogeneity and comorbidity clusters that define autism are ripe for the introduction of a new taxonomy for describing the condition. A more plural definition—the autisms—could represent one starting position ( 60 ) encompassing a greater appreciation that (a) there is variety in the presentation of the core features of autism, (b) there are seemingly several different genetic and biological pathways that bring someone to a diagnosis of autism, (c) different developmental trajectories are an important facet of the autism spectrum, and (d) the various “comorbidities” that variably present alongside autism may offer important clues about the classification of autism. Some authors have stressed that a multi-dimensional conceptualisation may be more appropriate than a categorical concept ( 61 ) but further investigations are required.

In relation to the proposed pluralisation of the label, several long held “beliefs” about autism are also ripe for further investigation. The idea that autism is innate and presents in the earliest days in all does not universally hold ( 45 ). The finding that some children experience a period of typical development and then regress into autism ( 62 ) is becoming more readily discussed in research and clinical circles, albeit not universally so. Similarly, the belief that autism is a lifelong condition for all is also not borne out by the peer-reviewed literature ( 63 ). Terms such as optimal outcome ( 64 ) might not be wholly appropriate, but do nonetheless, shed light on an important phenomenon noted in at least some cases of autism where diagnostic cut-off points are reached at one point but not another. These and other important areas provide initial support for the adoption of the idea of the plural autisms.

Allied to the notion of “the autisms” is the requirement to overhaul the terminology around the use of the “level of functioning” phrase ( 65 ). “High functioning” is typically used to describe those people on the spectrum who present with some degree of communicative language, possess typical or above-average intelligence and who can seemingly traverse the world with only minimal levels of support. “Low functioning”, conversely, is used to describe those with significant support needs who may also be non-communicative. Aside from the societal implications of labelling someone “low functioning” and the possible connotations stemming from such a label, such functioning categorisation do not seemingly offer as accurate a representation as many people might think. The high-functioning autistic child who for example, has been excluded from school on the basis of their behaviour, cannot be readily labelled “high-functioning” if the presentation of their autistic behaviours has led to such a serious outcome. This on the basis that part of the diagnostic decision to diagnose autism is taken by appreciation of whether or not presented behaviours significantly interfere with day-to-day living ( 3 ). What might replace functioning labels is still a matter for debate. The use of “levels of support requirement” utilised in current diagnostic criteria offer a template for further discussions. Such discussions may also need to recognise that the traits of autism are not static over a lifetime ( 51 ) and support levels may vary as a result.

Whatever terminology is put forward to replace functioning labels, there is a need to address some very apparent differences in the way that parts of the autism spectrum are viewed, represented and included in research. Described as the “understudied populations” by some authors ( 66 ) those with limited verbal communicative language and learning disability have long been disadvantaged in research terms and also in more general depictions of autism. In more recent times, there has been a subtle shift to acknowledge the bias that exists against those with a more profound presentation of autism ( 67 ). Further developments are however required to ensure that such groups are not excluded; not least also to guarantee the generalisability of autism research to the entire spectrum and not just one portion of it.

On the topic of generalisability to the entire autism spectrum, the moves to further involve those diagnosed with autism in research, clinical and sociological discussions presents opportunities and obstacles in equal measure. The application of the International Classification of Functioning, Disability and Health (ICF) to autism ( 68 ) to measure “health-related functioning” represented a key moment in autism participatory research. Taking on board various views and opinions about autism, the development of the ICF core autism sets has allowed those with autism and their significant others to voice their opinions about autism ( 69 ).

Such joint initiatives are to be welcomed on the basis of the multiple perspectives they offer including lived experience of autism. But with such participation, so questions are also raised about how representative such opinions are to the entire autism spectrum ( 70 ). Questions on whether those who are able to participate in such initiatives “can ever truly speak for the entire autism spectrum?” are bound to follow. Questions also about whether such first-hand reports are more important than parental or caregiver input when it comes to individuals on the autism spectrum are likewise important to ask. This bearing in mind that those with autism participating in such initiatives bring with them the same potential biases as researchers and clinicians carry with them about the nature of autism, albeit not necessarily in total agreement.

The translation of research findings into clinical practice represents another important issue that has yet to be suitably addressed. Although covering a sizeable area, several important stumbling blocks have prohibited the move from “bench to bedside” when it comes to autism research. The focus for example, on the overt behavioural presentation of autism, has in some senses continued to hinder the translational progress of more biological-based findings into autism practice. Nowhere is this seemingly more evident than when it comes to the over-representation of gastrointestinal (GI) issues in relation to autism and their management or treatment. Despite multiple findings of such issues being present ( 16 ), very little is seemingly offered despite autism-specific screening and management guidance being in place for nearly a decade at the time of writing ( 71 ). Other quite consistently reported research findings in relation to low functional levels of vitamin D ( 72 ) for example, have similarly not sparked massive shifts in clinical practices. Ignoring such potentially important clinical features contributes to a state of relative health inequality that is experienced by many on the autism spectrum.

Without trying to prioritise some areas over others, there are some important topics in relation to autism that are becoming important to autism research and clinical practice. Many of these topics are more “real life” focused; taking into account the impact of autism or autistic traits on daily living skills and functioning. These include issues such as the truly shocking early mortality statistics around autism ( 73 ) and the need for more detailed inquiry into the factors around such risks such as suicide ( 74 ) and self-injury ( 75 ) and wandering/elopement ( 76 ) alongside the considerable influence of conditions such as epilepsy.

Although already previously hinted at in this paper, the nature of the relationship between autism and various “comorbid” conditions observed to be over-represented alongside is starting to become more widely discussed in scientific circles. Whether for example, moves to intervene to mitigate issues such as depression in relation to autism might also have knock-on effects on the presentation of core autistic features is something being considered. Interest in other topics such as employment, ageing, parenting and the worrying issue of contact with law enforcement or criminal justice systems ( 77 ) are also in the ascendancy.

Conclusions

Autism as a diagnostic label continues to evolve in research, clinical practice and sociological terms. Although the core features described by Kanner and others have weathered such evolution, important shifts in knowledge, views and opinions have influenced many important issues around those core behaviours. As well as increasing understanding of autism, many of the changes, past and present, have brought about challenges too.

Author Contributions

All authors contributed equally to the writing and review of this manuscript.

This paper was fully funded by ESPA Research using part of a donation from the Robert Luff Foundation (charity number: 273810). The Foundation played no role in the content, formulation or conclusions reached in this manuscript.

Conflict of Interest

The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

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Keywords: autism, research, clinical, sociological, knowledge, future

Citation: Whiteley P, Carr K and Shattock P (2021) Research, Clinical, and Sociological Aspects of Autism. Front. Psychiatry 12:481546. doi: 10.3389/fpsyt.2021.481546

Received: 28 June 2019; Accepted: 30 March 2021; Published: 29 April 2021.

Reviewed by:

Copyright © 2021 Whiteley, Carr and Shattock. This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY) . The use, distribution or reproduction in other forums is permitted, provided the original author(s) and the copyright owner(s) are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms.

*Correspondence: Paul Whiteley, paul.whiteley@espa-research.org.uk

Disclaimer: All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher.

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Autism Adulthood
v.3(1); March 2021

A Conceptual Analysis of Autistic Masking: Understanding the Narrative of Stigma and the Illusion of Choice

Amy pearson.

1 School of Psychology, Faculty of Health and Wellbeing, University of Sunderland, Sunderland, United Kingdom.

Kieran Rose

2 The Autistic Advocate and Infinite Autism, County Durham, United Kingdom.

Autistic masking is an emerging research area that focuses on understanding the conscious or unconscious suppression of natural autistic responses and adoption of alternatives across a range of domains. It is suggested that masking may relate to negative outcomes for autistic people, including late/missed diagnosis, mental health issues, burnout, and suicidality. This makes it essential to understand what masking is, and why it occurs. In this conceptual analysis, we suggest that masking is an unsurprising response to the deficit narrative and accompanying stigma that has developed around autism. We outline how classical social theory (i.e., social identity theory) can help us to understand how and why people mask by situating masking in the social context in which it develops. We draw upon the literature on stigma and marginalization to examine how masking might intersect with different aspects of identity (e.g., gender). We argue that although masking might contribute toward disparities in diagnosis, it is important that we do not impose gender norms and stereotypes by associating masking with a “female autism phenotype.” Finally we provide recommendations for future research, stressing the need for increased understanding of the different ways that autism may present in different people (e.g., internalizing and externalizing) and intersectionality. We suggest that masking is examined through a sociodevelopmental lens, taking into account factors that contribute toward the initial development of the mask and that drive its maintenance.

Lay summary

Why is this topic important.

Autistic masking is a complicated topic. We currently think that masking includes things such as making eye contact even if it makes you feel uncomfortable, or not talking about your interests too much for fear of being labeled “weird.” There is a lot about masking that we do not know yet, but it is important to understand masking as we think that it might have a negative effect on autistic people.

What was the purpose of this article?

The purpose of this article was to look at current explanations of masking, and try to figure out what is missing.

What do the authors conclude?

We conclude that work on masking needs to think about autistic people in a different way. Autistic people grow up in a social world and experience a lot of negative views about autism and autistic people. We argue that we need to understand how this social world and the trauma that can come from being part of it contributes toward masking. We also argue against the idea that masking is a “female” thing that occurs as a result of there being a “female-specific” subtype of autism, because this might make it harder for some people to get a diagnosis (e.g., nonbinary people, and men and women who do not fit with any of the current criteria). Instead we argue that people need to recognize that autism does not look like one “type” of person, and try to separate ideas about masking from ideas about a person not fitting a stereotype.

What do the authors recommend for future research on this topic?

Though masking is called a “social strategy,” there has not been a lot of social theory applied to masking research. We recommend that researchers use theories about how people try to fit in, and theories about how people exclude and hurt people who are different. This can help us to understand why autistic people mask. We also stress the need to understand that masking is not necessarily a choice, and that there are many unconscious aspects. We argue that researchers should try to find out when masking starts to happen (e.g., in childhood) and what makes people feel like they need to keep up the mask. We also recommend lot more research into autistic identity, and how different parts of identity (including things such as gender, race, and co-occurring conditions) might mean that someone has to mask more (or less), or in different ways.

How will this analysis help autistic adults now and in the future?

We hope that this analysis will help researchers to understand that some aspects of masking might be unique to autistic people, but some aspects might be like other kinds of “pretending to be normal” that other people who are socially excluded use to try and fit in. We hope that our suggestions can help to improve our understanding of masking, and lead to research that makes life better for autistic people.

Introduction

Autistic masking (also referred to in the literature as camouflaging, 1 compensation, 2 and most recently “adaptive morphing” 3 ) is the conscious or unconscious suppression of natural responses and adoption of alternatives across a range of domains including social interaction, sensory experience, cognition, movement, and behavior. Masking is an emerging research area, and as such there is variation in the terminology used to describe these experiences. Although some scholars draw a conceptual distinction between masking/camouflaging/compensation 1 , 4 and which aspects constitute subcomponents of another, we use masking here holistically as an umbrella term to refer to the collection of these experiences, as it is the term that has been used by the autistic community themselves. 5–7 Masking has been suggested to relate to several key issues in the lives of autistic people, such as relationships and diagnosis, 8 suicidality, 9 and burnout. 10 Thus, gaining a precise understanding of what masking is and how it manifests in the lives of autistic people is essential. This article aims to examine the literature so far, pinpointing factors that have gone unexplored, and ideas for future research that build up a holistic picture integrative of both internal and external aspects of masking. Although autistic masking is the focus of this article, we ask the reader to stay mindful that (1) many autistic people experience neurodivergence and/or marginalization (social exclusion) on multiple axes (i.e., autistic and dyslexic) and that (2) many of these factors might have relevance to other neurodivergent and/or marginalized groups, and are not necessarily limited to autistic people.

Social Context

The historical social context in which autism and research about autistic people are situated is essential to understanding what masking is and why it occurs. Autism is a form of neurodivergence, characterized by differences to the nonautistic population in several domains, including social and cognitive style, and sensory processing. 11 Since the 1940s, conceptualizations of autism 12 , 13 have mainly derived from a medical model of disability and “otherness” in which autism (and by consequence, autistic people) has been framed as something to “fix,” “cure,” or in need of intervention 14 due to perceived deficits in social communication, repetition, and restriction. The core traits associated with an autism diagnosis are traits found across the human condition 15 and it is their shared presence and profile that differentiate autistic and nonautistic people, however, they are often labeled as being “extreme” manifestations. 16 A diagnosis of autism is rooted in the specification that one must experience “significant impairment” to be classified as autistic. As such autistic “traits,” “behaviors,” and experiences cannot be labeled autism unless they are experienced negatively or are said to cause “impairment.” As a result, autistic people are viewed as being on the fringe of human normality both in academia, and in society in general. 17–19

With a pathologized status comes the experience of stigma, dehumanization, and marginalization. 20 Stigma refers to the possession of an attribute that marks persons as disgraced or “discreditable,” 21 marking their identity as “spoiled.” Stigmatized persons may attempt to conceal these spoiled aspects of their identity from others, attempting to “pass” as normal. 21 Investigation of “passing” and “concealment” has been explored in depth in other stigmatized populations 22 ; however, the application of stigma in autism research is a relatively new endeavor. 22 , 23 Stigma impacts both on how an individual is viewed and treated by others and how that treatment is internalized and interacts with one's identity. 20 , 24

Research has shown that dehumanizing attitudes toward autistic people are still highly prevalent 25 despite years of campaigning for awareness and acceptance, and 80% of the stereotypical traits associated with autism are rated negatively by nonautistic people. 26 These findings are consistent with the study of Goffman on “stigma,” 21 suggesting that familiarity with the stigmatized does not reduce negative attitudes toward them. Rose 27 explains: “We move, communicate and think in ways that those who do not move, communicate and think in those ways struggle to empathise with, or understand, so they ‘Other’ us, pathologize us and exclude us for it.” This stigma can manifest in negative social judgments toward autistic people 28 who are more likely to report negative life experiences 29 including bullying 30 and victimization. 29 Thus acknowledging the social context in which autistic ways of being are stigmatized and derided 14 , 20 , 31 is essential for understanding reasons that masking may occur, and what can be done to reduce the pressure to mask and associated impact.

Masking and Social Identity

As a marginalized group, autistic people are consistently presented with the message that their way of being in the world is abnormal, defunct, or impaired. 6 , 20 , 31 The social norms of autistic people differ to those of the dominant social group, and “passing as normal” or attempting to pass as normal might relieve external consequences (such as bullying) while increasing internal consequences (such as exhaustion and burnout). 32 However, the application of social theory to understanding masking is so far sparse. Goffman described the process of concealment at length in “stigma,” 21 the impact that conscious and unconscious norms and societal expectations place upon stigmatized persons and the lengths they might go to conceal their otherness. Although masking has been referred to as “social camouflage,” there has been minimal focus 33 , 34 on the role that the social sphere plays in the development and maintenance of masking. A person's identity is shaped by myriad factors, not least the social environment that they inhabit. 31 Here we discuss ways in which social theory can be applied to providing a meaningful understanding of masking.

The development of the social self is argued, in part, to arise through the process of reflection of how we are perceived by others. 35 Self-perception theory 36 suggests that who we perceive ourselves to be is influenced by multiple factors, such as point in the lifespan, or the aspects of our life we are asked to consider (e.g., family and work). This begins to develop in childhood, where we explore different roles through engagement with caregivers and play, and begin to examine ourselves through the lens of the “generalized other” 37 (the theoretical outsider through whom we imagine what others might think of who we are). We consider which parts of ourselves we want the world to see, which parts are acceptable. 38 Over time, the generalized other is replaced partially through interaction with conspecifics, although we still imagine how they might respond to us through the generalized lens. This is in essence a mentalizing process. Working out what someone might think of us by attempting to adopt their mindset. Goffman described this process in “The Presentation of Self in Everyday Life” 39 as one that allows us to manage and control how others perceive us, a form of impression management. In this regard, monitoring how we appear in different social situations is a part of the broader human social experience and not limited to concealing “spoiled” traits. Here the concept of masking is incompatible with the idea of autistic mindblindness. 40 To mask one must be aware of how others might potentially view them and suppress aspects of their identity accordingly. The idea that an autistic person might suppress aspects of themselves to “fit in” is also at odds with theories that suggest that autistic people are uninterested in social affiliation. 41 , 42 This assumption, however, might account for the lack of discourse around how social identity theories intersect with autistic masking. The fluctuation of human identity across different social contexts has been well explored in the psychological literature, 43 and it is acknowledged that our individual and collective selves may differ. This is yet to be explored in any detail among autistic people.

Social Identity Theory 44 argues that our self-perception is dependent upon temporal (i.e., point in the lifespan) and situational (i.e., what is going on at the time) factors, with our identity on a continuum between our personal perception of how we see ourselves as an individual and how we see ourselves as members of a particular group or collective. Our personal and group identities comprise many factors, including our gender, race/ethnicity, sexuality, interests, and personality traits. We may place emphasis on different aspects as we move through different contexts and environments, minimizing aspects of our identity based on their perceived relevance to the current situation and/or group we are in. These contextual shifts may form part of the impression management strategies described by Goffman 21 and are impacted by stigma. Goffman described how a “discreditable” person may attempt to avoid stigma or identification by carefully monitoring how they appear to others, whereas a “discredited” (already identified) person may perform the same monitoring to avoid further stigma. The identities of autistic people are often stigmatized at both the individual level (i.e., being labeled by others as “odd” or “weird,”) 32 and at the group level (i.e., harmful stereotypes about autistic people 26 , 32 ) in a way that intersects with other aspects of their identity, leading to what Milton describes as psychoemotional disablement (of autistic identity). 23 This stigma occurs for both autistic people who disclose (the discredited) and those who do not (the discreditable), relating to what Botha et al. 32 have referred to as a “double bind.”

It is possible that autistic people experience the same contextual identity shifts as nonautistic people in certain aspects of identity (i.e., between interacting with colleagues/friends, e.g.; there is currently very little empirical examination of this), but experience psychological stress specifically from the masking of their autistic self because contextual shifts do not involve the hiding of one's “true self.” 1 Rather, emphasis is simply placed on a different aspect of identity as opposed to concealing it. An alternative possibility is that aspects of identity that nonautistic people commonly view as more easily contextualized are for autistic people inherently related to their experiences as an autistic person. For example, experiencing a passionate singular focus on a favorite topic may make a shift away from that aspect of one's identity more difficult, blurring the line between contextual identity shifts and masking. A recent investigation by Schneid and Raz 33 found that general impression management and masking were interlinked for autistic people and could not be divorced from one another.

One possible area for exploration in understanding the relationship between contextual identity shifts and masking is the relationship between monotropism 35 , 45 and identity. Monotropism is a theory of autistic cognition grounded in an understanding of attention as interest driven and more singular in focus. 45 It states that with limited attentional resources, autistic focus cannot be split between “performing a task well” and “losing awareness of information relevant to all other tasks.” 45 The shifting of identity across contexts draws upon attentional resources as we weigh up restrictions, internal (how we feel) and external (what is going on around us) input, and hierarchy (what aspects of our identity that we value). Currently, we know very little about the fluctuation of autistic identity with context. An important factor in this weighing up process is likely to be how safe persons feel in revealing aspects of their identity, particularly if their identity is stigmatized. Cage and Troxell-Whitman's 34 findings suggest that masking can fluctuate across contexts, but to develop a more meaningful understanding of this we might also want to ask which aspects of contextual fluctuation are not harmful to autistic people.

Many autistic people experience marginalization on several fronts, 46 in ways that intersect with other aspects of their identity. The impact of marginalized status on identity has long been explored by Black scholars. 47 , 48 Du Bois 47 wrote of the “double consciousness” of being Black in America: “It is a peculiar sensation, this double-consciousness, this sense of always looking at one's self through the eyes of others.” The nature of masking, of having to suppress aspects of one's identity, means having to see oneself through the lens of another. Du Bois stated the difficulty reconciling two competing ideals or aspects of the self, an idea that is drawn upon in the theory of cognitive dissonance. 49 Cognitive dissonance occurs when there is a discrepancy between two competing ideals held by an individual, that is, two contradictory beliefs or actions. This discrepancy causes stress, which an individual can attempt to resolve by changing or justifying one of the ideals. To survive as a marginalized person, the suppression of stigmatized aspects of identity may allow someone to walk in two (or more) worlds. However, continuing this suppression in the face of the cognitive dissonance can draw upon significant psychological resources. Cage and Troxell-Whitman 34 considered the intersection between stigmatized aspects of identity and masking, using Disconnect Theory 50 to examine costs and contexts of masking. They found that autistic adults reported masking across multiple contexts (i.e., at work, with romantic partners), for both conventional and relational reasons. Those who reported higher levels of masking or switching between masking/not masking also reported higher levels of stress, which is consistent with the idea that disconnection from one's identity causes psychological distress. This process of disconnection might be essential in understanding burnout, which has been described as the result of “chronic life stress and a mismatch of expectations and abilities without adequate supports.” 10

A potential relationship between masking and negative outcomes such as autistic burnout 10 and suicidality 9 means that it is important that we acknowledge masking as a self-protective mechanism rather than a necessarily conscious choice. Although masking has been defined as including both conscious and unconscious aspects, much of the research so far has focused on the conscious aspects (i.e., strategies that are externally visible to others). It is possible that the significant energy it takes to mask means that it is only sustainable for a period. To sustain masking long term, the person must find a way to resolve the cognitive dissonance and resulting distress. It stands to reason that the unconscious aspects of masking may be an attempt to resolve this dissonance, by distancing oneself from the process and minimizing the cognitive resources being dedicated toward maintenance. This process might also be compounded by the presence of alexithymia and interoceptive disconnection. Here we outline the potential relationship between these factors, and how they might lead to eventual burnout and exhaustion.

Alexithymia is defined as difficulty identifying one's own emotional states and distinguishing them from bodily states, and has a prevalence of around 50% in the autistic population. 51 Difficulty identifying one's own emotions can make it difficult to self-regulate, that is, not realizing that stress is increasing until you are at a breaking point. In addition, autistic people have reported that the energy put into masking can further detract from the already impacted ability to self-regulate, 52 placing strain on an already depleted system. This can be related back to Du Bois' 47 theory of double consciousness, whereby one aspect of identity is attempting to suppress and control the emotions experienced by the other to maintain safety. The further suppression of internal states and associated coping mechanisms (i.e., stimming 53 ) alongside an already present difficulty identifying one's own emotions could potentially be disastrous, leading to further long-term difficulties in mental health and well-being (i.e., burnout and suicidality).

We draw upon Hochschild's 54 theory of Emotional Labor as a useful framework for considering the emotionally suppressive side of masking, taking into account the cognitive, bodily, and expressive factors involved and what this might look like for an individual. Future investigation into the more unconscious and dissociative aspects of masking might draw upon Hochschild's theory of Emotional Labor to understand the pathway from masking to burnout, to provide a deeper understanding of how to support people in recovering from mental health issues. Figure 1 outlines the pathway that we are suggesting here; however, this should be considered alongside mediating factors, such as whether sensory needs are being identified and met, and the occurrence/frequency of shorter episodes of fatigue and burnout.

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Potential model for considering the relationship between masking and autistic burnout. The figure displays a linear relationship from stressor to masking response to presentation (which is effortful for a person to sustain). The masking response feeds separately into disconnection from internal cues, which then leads to an internal stress increase and difficulty regulating associated stress. In addition, the effortful presentation feeds directly into internal stress increase. Together, these flow into what we term “breaking point.” This includes a textual description of the image for those who are using screen-readers.

Masking and Gender

Limited conceptualizations (i.e., a stereotypical idea of a White, male, and nonspeaking child 32 ) of what autism “looks like” have led to underdiagnosis in certain populations, notably people of color 55 and women. 56 The current diagnostic gap between men and women sits at around 4:1. 57 Attempts to remedy underdiagnosis in these populations have led to growth in understanding autistic heterogeneity 42 and how autistic characteristics might differ from person to person. However, the view of autism as a manifestation of “extremes” of the human condition has pervaded professional knowledge, leading to debate over whether diagnosis has become “diluted” through the inclusion of those who would not traditionally meet criteria specified in diagnostic measures. 58 This view sits in opposition to the acknowledgment that diagnostic criteria and understanding have been based upon external observations of limited samples of (i.e., mostly male) autistic people 31 , 59 .These external observations exclude the impact of other intersectional factors, 48 such as identified and unidentified co-occurring conditions, gender, race, sexuality, and cultural background: all of the factors that shape our identity.

Gender disparity in autism diagnosis is historically grounded in diagnostic criteria being based on observations of male children. 60 However, it has been strengthened by explanations such as the “extreme male brain” (EMB) theory of autism, 61 which posits that autism is a manifestation of cognitive traits associated with males (i.e., “systemizing,” logic), rather than those of females (i.e., empathizing). EMB proposes that fetal androgens may be responsible for the masculine cognitive profile in autistic people, and explain why men are more likely to receive a diagnosis. 61 An alternative explanation is the “female protective effect” 62 that posits that women are less likely to exhibit the same degree of behavioral autistic characteristics compared with male counterparts, and requires heightened genetic and environmental “risk” to do so. It is worth acknowledging here that there is very little evidence to support the idea of sexually dimorphic neurology in humans. 63

More recently, the disjoint between acknowledging limiting diagnostic criteria (and importantly, the interpretations of those criteria), while also acknowledging population-based underdiagnosis, has led to the proposal of the “Female Autism Phenotype,” 56 which posits that autistic women display a “female-specific” presentation of autism, of which masking may be a core aspect. Although much of the current research into masking does not state that masking is limited to females, 9 , 34 , 64 others do suggest that females may be more likely to mask. 65 , 66 Although it is important to recognize the different ways in which autism might present in intersection with other aspects of a person's identity and socialization, the labeling of this as “female autism” is likely to lead to more confusion in the future, which has a tangible impact outside of academia where these narratives might be perpetuated further. The idea of a female autism phenotype also fails to recognize the large number of autistic people who are outside of the gender binary, 67–69 potentially creating further barriers to diagnosis and support and the perpetuation of a stigmatizing narrative.

The idea of masking as a core trait of autistic women mostly comes from what Hull et al. 56 describe as a discrepancy approach to masking. Studies taking a discrepancy approach examine the difference between the self-reported internal characteristics of an autistic person and how they appear externally using behavioral assessments such as the autistic diagnostic observation schedule (ADOS). 70 Studies using this method have shown that autistic females tend to show a greater difference between self-reported autistic traits and observer reports than autistic males. 65 , 71 However, the discrepancy here may not lie with the person, but with how they are conceptualized and operationalized using the tools of measurement. In the introduction to this article, we briefly discussed the development of diagnostic tools that rely on the visibility of external behaviors and that, in turn, draw upon historical autistic stereotypes. Deconstruction of these tools from an autistic perspective 72 suggests that criteria used to measure how autistic a person appears is based on nonautistic ideas of appropriate social behavior. We can consider this issue through the lens of the double empathy problem. 73 Double empathy theory 73 explains communication differences between autistic and nonautistic people as a “mismatch of salience”; both groups draw upon different experiential knowledge, which may lead to bidirectional breakdowns in interpreting one another. Thus judging “how autistic” a person appears based on how well they are able to perform nonautistic behavior makes little sense. The presence (or lack of presence) of a decontextualized subjectively coded behavior is not necessarily an indicator of masking. In short, it is important to recognize that a discrepancy between self-reported “autistic traits” using clinical tools and how a person appears outwardly does not necessarily relate to masking. A reliance on stereotypical (nonautistic) expectations of what an autistic person might “look like” to an observer means that a person not fitting this stereotype may be coded as masking, as opposed to a recognition that autistic people vary in their behavioral expression as much as the nonautistic population.

Reflective approaches in contrast examine masking as a set of behaviors and strategies that individuals can implement, which leads to variation in the presentation of their autistic characteristics. 56 Studies using this approach have mostly found no difference between self-reported masking in males and females, 1 , 9 , 34 which reinforces our previous point about stereotype and expectation. Although this reflective approach is more aligned with the idea that autistic people are the experts in their own experience, there are some issues here to take into consideration. To reflect on masking, people must be aware that they are doing it that may make it difficult to measure both the conscious and unconscious aspects. Researchers might attempt to examine this by comparing the masking experiences of people who have received earlier diagnoses with those diagnosed more recently, as well as whether community involvement impacts on how people experience masking. 22

Instead of using knowledge of atypical presentation of autism to acknowledge that autistic people are likely to present in a number of different ways, we risk simply shifting the goalposts to a different set of limiting criteria. This could potentially lead to further difficulties in recognizing men/nonbinary people who present a profile that is more aligned with what is labeled “female” autism, or excluding women/nonbinary people who do not fit the “female autism” profile. 74 The creation of subtypes and the language around them can also lead to additional forms of stigma manifesting. 75 , 76 Diagnosing women with “female autism” and men with “autism” proper lends credence to the suggestion that women are not really autistic, and do not experience or understand the challenges that real autistic people (i.e., men) experience. Similar discussion can be seen with regard to the former autism/Asperger syndrome differential diagnoses, and the harmful stereotypes that are associated (i.e., those with a diagnosis of Asperger syndrome being assumed to be simply “eccentric” and having low support needs vs. the idea of someone with a diagnosis of autism lacking capacity 77 ). Research has suggested that autistic women and girls may have a different set of challenges with regard to their social experiences, 78 but that these differences are most likely driven by social environment and gendered socialization rather than diagnosis, as Rose 27 points out “Autistic Women and girls don't experience different Autism, they experience different prejudice.” It is essential that we recognize the role that gender expectations and other intersectional aspects play in child development and how that impacts the development of one's sense of identity alongside the development of the mask. Again, we stress the need for the application of social theory to understanding the different ways in which an individual's autistic characteristics may present. Understanding gender prejudice, gender expectations, and gender norms experienced by an individual helps us to avoid victim blaming (i.e., shifting the spotlight away from the reliance on gendered stereotypes for diagnosis, and suggesting that those who do not fit with normative expectations have been missed because they are “better at hiding their autism”). We need to be clear when we examine masking that we are not conflating masking, and a person simply not fitting with a stereotyped idea of what autism should “look like.”

Beyond Gender: Future Directions in Masking Research

One possible consideration that might provide a more meaningful understanding of how autistic characteristics manifest across individuals is that of internalizing versus externalizing. Internalizing is characterized by the process of directing emotional experiences inward, that is, ruminating. Whereas externalizing is associated with the process of directing emotional experiences outward, that is, impulsivity. A person might display both internalizing and externalizing over the course of development, and across different contexts. Autistic people who are more prone to externalizing might appear to be easier to identify because of externally visible indicators, whereas autistic people who are more prone to internalizing might be more likely to “fly under the radar” for longer, or be diagnosed with things such as anxiety. 56 It is important to recognize how individual characteristics may impact on the perceived visibility of autism across different people, and not conflate this with masking.

It is also possible that internalized ableism and difficulty in identifying one's own autistic traits could impact on the ability to recognize and discuss one's own masking. Internalized ableism is the absorption of negative beliefs about a particular disability and an attempt to distance oneself from that “spoiled identity.” 79 , 80 Self-knowledge and reflection are essential for explicit discussions around masking, which leads to an unfortunate pitfall of masking research: we can only really learn about masking from the people who are aware they are doing it, when perhaps we stand to learn a lot more from those who are unaware. There are anecdotal reports from autistic people of those who, through self-acceptance, deep reflection, and working through trauma, have learnt to recognize some of the subconscious layers of masking. The impact of receiving a diagnosis later in life, in particular, can lead to the experience of reprocessing one's life history in the context of new information. 81 This can make it difficult to disentangle which parts of a person's identity are truly “them,” and which parts might be a result of masking. The term “unmasking” is common in community discussions, because it is the literal representation of autistic persons taking control of their mask and being more authentically themselves. This occurs by choice, after a long process of learning about themselves introspectively, spending time among other autistic people and learning from sharing relatable experiences through outrospection and therapizing themselves in various ways. 82 Botha 22 examined the importance of autistic community connectedness (ACC) in providing a buffer against the effects of minority stress. They found that ACC related to an improved sense of well-being, however, aspects of ACC impacted people in different ways. Political connectedness, for example, can help to reframe the way in which someone views themselves and reduces internalized stigma by showing individuals that they are not “alone.” Further work into how ACC impacts on “unmasking” is needed to expand our understanding of how autistic community involvement and support can help to mitigate the negative effects of masking and help people to minimize and move past internalized ableism.

It is also important that we are able to define what constitutes masking and related concepts clearly, particularly given the impact this could have on the diagnostic process as it currently stands. Diagnosis is still enshrined in the idea of being able to identify clinically defined autistic behavior during the diagnostic process. It is important to recognize that autistic persons expressing autistic characteristics in a way that intersects with their individual identity are not necessarily masking just because it does not fit with a stereotyped idea of what autism looks like to an external observer. This does not mean that they are expressing a different kind of autism, or that they are “hiding” their autistic traits under seemingly “normal” interests. Likewise, masking can impact on how a person might appear to observers, and differentiating these presentations is no easy job. Thus, clinicians need to be aware that (a) autism does not “look” like one thing and (b) that some people might mask during the diagnostic process, but also that (c) b is not always the cause of a. This is not an easy problem to solve (i.e., coming up with a standardized notion of masking that one might examine using a psychometric measure during the diagnostic process), but can be mitigated to some degree by ensuring that clinicians are aware of these issues and receive adequate training and continued professional development around autism from those who understand these concepts.

In addition to understanding how masking might look , the role of alexithymia should be considered in the discussion of how masking feels. What may appear to be an “if X then Y” statement (i.e., X happened, so I started to do Y as a response) might frame a trauma response 3 as a deliberate cognitive strategy due to difficulty in integrating the emotional aspect of experiences that led up to that point. Lawson 3 recently stressed the consideration of social threat in masking, and potential ways to investigate this without framing masking as a deceitful or deliberate process. This also highlights the importance of including autistic people at all stages of autism research. Differing tacit interpretations of a statement due to positionality (i.e., drawing on different experiential knowledge, which could lead to differing interpretations to an original intended meaning) may be impacted by the double empathy problem 31 , 73 and might be mitigated by including autistic people within a research team, particularly when working with qualitative data.

Future research may want to examine the relationship between masking, identification of one's own “autistic traits,” and alexithymia to understand how complex interactions between the three might impact on how masking manifests. It is also important to explore trauma that can arise from lifelong stigma experienced by autistic people, and how this can contribute to the development of masking across the lifespan from childhood through to adulthood in relation to additional intersecting factors (e.g., co-occurring identified and unidentified disabilities/neurodivergence, race, and socioeconomic status), which produce and interact with the stigma that they have experienced.

We might also want to consider the developmental aspects of masking in greater detail, particularly in relation to the internalized ableism and stigma previously discussed. Researchers have started to examine masking in adolescents, 83 , 84 adding to our understanding of masking across the lifespan. We may also want to consider the experiences of parents. Many parents of autistic children only realize that they are themselves autistic once their child has gone through the diagnostic process. 31 , 85 , 86 It is possible that masking in these families might also constitute a learned behavior, passed from parent to child. Researchers may want to examine whether parents of autistic children report engaging in masking (or similar identity management behavior), and what the motivations behind this might be.

Finally, researchers may want to examine whether there are aspects of masking that autistic people feel are beneficial or have an overall positive impact on their well-being. Although we have mostly focused on the negative side of masking in this article, it is possible that many people view masking as part of a viable social strategy.

We suggest that future research considers masking as a multidimensional fully interactive construct. To start, masking research needs to be fully grounded in social theory that acknowledges the role that the social environment and collective norms have upon the autistic person. Applying a social lens acknowledges that autistic people are social beings that do not develop in a vacuum. Moreover, masking should be considered in terms of its process; we might think of masking like the process of rock formation. What we see is the rock face, akin to the externally visible strategies that one might use to mask, for example, making eye contact and mimicking facial expressions. But these strategies have been molded over time, transformed by pressure, building up layer upon layer to create what is seen by the observer. Future research should consider the role of environment and context in masking, the outside pressures that led to the initial development, and the impact that this has had upon the individual. It should also take into account the developmental trajectory of masking, and the role that time and trauma play in the development of the mask, as well as the intersection between autism and other aspects of a person's identity (such as gender or race/ethnicity). The interaction between these processes and outcomes is likely to be an essential factor in understanding what can be done to provide better support for those whose mental health is negatively impacted by masking.

Authorship Confirmation Statement

A.P. and K.R. conceptualized and wrote this article. Both authors have reviewed and approved this article submission. The article has been submitted solely to Autism in Adulthood .

Author Disclosure Statement

No competing financial interests exist.

Funding Information

The authors did not receive any funding for this study.

Analysis of Autistic Adolescents’ Essays Using Computer Techniques

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Published: 27 July 2024

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Izabela Chojnicka ORCID: orcid.org/0000-0001-8723-6873 1 &
Aleksander Wawer ORCID: orcid.org/0000-0002-7081-9797 2

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Challenges associated with narrative discourse remain consistently observable across the entire spectrum of autism. We analyzed written narratives by autistic and non-autistic adolescents and aimed to investigate narrative writing using quantitative computational methods.

We employed Natural Language Processing techniques to compare 333 essays from students in the final eighth grade of primary school: 195 written by autistic and 138 by non-autistic participants.

Autistic students used words with a positive emotional polarity statistically less frequently ( p < .001), and their stories were less abstract ( p < .001) than those written by peers from the non-autistic group. However, autistic adolescents wrote more complex stories in terms of readability than participants from the non-autistic group ( p < .001). The writing competencies assessed by teachers did not differ significantly between the two groups.

Findings suggest that written narratives by autistic individuals may exhibit characteristics similar to those detected by computational methods in spoken narratives. Collecting data from national exams and its potential usefulness in distinguishing autistic individuals could pave the way for future large-scale and cost-effective epidemiological studies on autism.

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Introduction

Autistic individuals comprise a very heterogeneous group regarding language capacity, ranging from non-speaking to fluently speaking individuals (World Health Organization, 2021 ). Challenges related to the pragmatic use of language are observed across the entire autism spectrum in individuals with varying levels of intellectual and linguistic abilities, including those individuals who display structural language skills within the typical range (Schaeffer et al., 2023 ). Difficulties with pragmatic language in autism include narrative discourse (Baixauli et al., 2016 ). Narrative skills develop from the early stages of life, being an important way of sharing experiences among children and a tool for understanding the world, as well as incorporating experiences into the sense of one’s self (Fivush et al., 2011 ). In this study, we use quantitative computational methods to investigate the narrative writing of autistic adolescents, which remains under-researched in comparison to spoken narrative abilities (Finnegan & Accardo, 2018 ).

Many previous studies on narration in autism have focused on examining spoken narratives, mainly storytelling. According to the meta-analysis by Baixauli et al. ( 2016 ), spoken narratives by autistic participants were shorter and less diverse (measured by the number of different words) than narratives produced by typically developing children and adolescents. In terms of narrative macrostructure, spoken narratives of autistic children were less causally connected and considerably less coherent than those of typically developing peers. Additionally, autistic individuals used significantly fewer internal state terms than neurotypical participants. Internal state language (ISL) refers to the vocabulary that describes character perceptions, emotions, and mental states. A study by Siller et al. ( 2014 ) revealed a relationship between the presence of ISL vocabulary in narratives and theory of mind. Based on the findings of the aforementioned meta-analysis (Baixauli et al., 2016 ), autistic individuals with higher intelligence levels encounter significant difficulties compared to their peers in verbally describing internal states. The authors argued that this might indicate an asynchrony in the development of cognitive and linguistic aspects with socioemotional meaning.

Yet, spoken discourse differs from written discourse. The former typically occurs in interaction, inherently involving reciprocity, the experience and perception of affect, and encompassing broad non-verbal and paralinguistic features. The latter may be more deliberate, allowing time to think through the narrative and revise it if the writer decides to do so. Writing, particularly handwriting, is a perceptual-motor activity that requires the coordination of multiple simultaneous tasks: the mechanics of writing, content, and organization (Finnegan & Accardo, 2018 ; Shevchuk-Hill et al., 2022 ). However, similar to spoken discourse, it may involve the theory of mind abilities, as the story gains if the writer is able to adopt the reader’s perspective. Some authors have analyzed narrative writing in autism (e.g., Baixauli et al., 2021 ; Price et al., 2019 ). Shevchuk-Hill et al. ( 2022 ) compared stories by autistic ( n = 19) and non-autistic ( n = 23) university students using automated methods. Authors concluded that writing may be a strength for autistic students whose stories were rated at a higher reading level, contained fewer grammatical errors, and had more positive writing affect (Shevchuk-Hill et al., 2022 ). In contrast, a study of autistic adolescents indicated difficulties with writing skills, specifically in terms of productivity, lexical diversity, and overall coherence of the story (Baixauli et al., 2021 ), similar to results reported for spoken narratives. Therefore, it seems that there is no clear consensus regarding written narrative skills in autism.

In this study, we aimed to build on prior research on narrative in autism by investigating the utility of natural language processing techniques (NLP) for quantifying the narrative abilities in the writing of autistic adolescents. According to our knowledge, this is the first study utilizing sentiment and linguistic abstraction analyses to examine narratives written by autistic individuals. Sentiment analysis extracts subjective information in terms of the positive and negative emotional tones of the text. With the development of social media, it has become a frequently utilized NLP technique (Denecke & Reichenpfader, 2023 ). Sentiment analysis considers various types of words, not only those that explicitly describe emotions (e.g., ‘happy’, ‘sadness’) but also other words that carry positive or negative connotations (e.g., ‘good’, ‘wise’, ‘home’; Wawer, 2019 ). Thus, sentiment analysis is broader than the analysis of words that refer to internal emotional states.

Linguistic abstraction was assessed using the linguistic category model (LCM), a model of interpersonal language that provides means to investigate linguistic devices used to represent social events (Semin, 2012 ). The LCM typology classifies words based on their degree of abstraction, with the principal distinction established among three categories of verbs: Descriptive Action Verbs (DAVs), Interpretative Action Verbs (IAVs), and State Verbs (SVs) (for the Polish version we used see Wawer & Sarzyńska, 2018 ). DAVs represent the most concrete verbs used to depict a singular and observable event (e.g., ‘A kicks B’). IAVs describe specific observable events (e.g., ‘A hurts B’), and they are more abstract than DAVs as they omit the perceptual aspects of an action. The most abstract category encompasses State Verbs, which pertain to mental states (e.g., ‘to think,’ ‘to understand’) and emotional states (e.g., ‘to admire’) or changes thereof. The model also considers adjectives (ADJ) as the abstract end of the continuum. Therefore, in addition to enabling the analysis of the level of abstraction, LCM also allows assessing the number of words describing the mental and emotional states of the person (Beukeboom et al., 2013 ).

Combining both methods, sentiment analysis and LCM, may be a useful automated alternative to analyzing the internal state language of narratives using hand-coding methods. However, it should be noted that the two methods do not analyze exactly the same words as the hand-coding approach to ISL. Additionally, we calculated a readability index as a lexical complexity metric.

We obtained essays written and evaluated in a standardized manner as part of a nationwide exam. It allowed for the comparison of autistic adolescents with peers from the population, including both neurotypical individuals and those with possible other neurodevelopmental and psychiatric conditions. In our previous research, where we employed NLP techniques and machine learning, we analyzed differences in spoken narratives between autistic individuals and typically developing peers (e.g., Wawer & Chojnicka, 2022 ). Here, we compared autistic adolescents with a more diverse group from the population. We hypothesized that stories written by autistic adolescents contain fewer words with emotional polarity and exhibit lower levels of linguistic abstraction than stories written by their peers, similar to differences detected for spoken narratives (Chojnicka & Wawer, 2020 ).

The essays were written as part of the nationwide eighth-grade Polish language time-limited exam, conducted upon the completion of primary school education, simultaneously undertaken by all students throughout the country, under standardized conditions, and with standardized examination sheets. There were ten versions of exam sheets tailored to accommodate the special needs of some students: (1) for students without disabilities and those with specific learning disorders (OPOP-100); (2) for students with autism, including Asperger’s syndrome (OPOP-200); (3) for students with visual impairments font size 16 pt (OPOP-400); (4) for students with visual impairments font size 24 pt (OPOP-500); (5) for deaf and hard of hearing students (OPOP-700); (6) for students with mild intellectual disability (OPOP-800); (7) for students with aphasia (developmental language disorder; OPOP-900); (8) for students with motor disabilities caused by cerebral palsy (OPOP-Q00); (9) for students whose limited knowledge of Polish makes it difficult to understand the text being read (OPOP-C00); (10) for students who are citizens of Ukraine (OPOU-C00). Students who used type (2) exam sheets, based on a clinical diagnosis of Autism Spectrum Disorder confirmed by a psychiatrist and a commission responsible for making decisions regarding the need for special education, were assigned to the Autistic Group. The Non-autistic Group comprised students who took exams on type (1) sheets.

One of the tasks on the exam was to handwrite an essay on a given topic. Autistic students were allowed to opt out of handwriting and type their essays in case of handwriting legibility issues. In this paper, we use the term essay as a written composition. The students chose one of two types of essays: an opinion essay or a short story. The instruction for the task was: “ Choose one of the given topics and write an essay. • Remember to maintain the discourse style indicated in the topic: write an opinion essay or a short story. • In your essay , refer to the selected compulsory reading. The list of compulsory readings is on page 3 of this examination paper. • Your work should be at least 200 words long. • Write the essay in the designated place. Do not write in the margin. ” We only analyzed essays of the short story type. In the section designated for students from the general population (OPOP-100), the topic for the story was: “ Write a story about meeting one of the characters from the selected compulsory reading. A shared adventure prompted you to reflect that it was worth moving to the world depicted in this reading. The essay should demonstrate that you are familiar with the selected compulsory reading. ” In the section designated for students within the autism spectrum (OPOP-200), the topic was formulated slightly differently: “ Imagine you have the opportunity to travel back in time to the world of one of the compulsory readings. Write a story about your adventure in this world. The essay should demonstrate that you are familiar with the selected compulsory reading. ”

As part of the exam, stories written by students were subject to assessment conducted by teachers trained to follow standardized examination guidelines. It included the following categories: Topic Development, Creative Elements, Literary Skills, Text Composition, Style, Language, Spelling, and Punctuation. The total score for the task was determined by summing the points in each category.

We received data from the District Examination Boards responsible for storing documentation from the nationwide eighth-grade examination. We asked the Examination Boards to select essays in a way that there were roughly equal proportions of students who achieved high and low exam results in both groups, with a majority of students obtaining average scores; apart from that, sampling was conducted in a random fashion. Anonymized scans of the essays, presented as .pdf files, were provided, accompanied by information on each student’s sex, year of birth, and ASD diagnosis (or lack thereof). Optical character recognition for converting scans into text was not effective for our data. Therefore, the essays were manually transcribed by two trained students into .txt files, preserving the original spelling, paragraph structure, punctuation, and other aspects such as capitalization while omitting portions of the text that were crossed out by a student. A third person (one of the authors, IC) revised 30% of the prepared transcripts.

Participants

We collected 333 stories from students in the final, eighth grade of primary school: 195 stories written by autistic students (Autistic Group; average age 14.85 years; 25% girls); and 138 written by students from the general population (Non-autistic Group; average age 14.64 years; 25% girls). The latter included neurotypical adolescents as well as, most likely, undiagnosed adolescents with neurodevelopmental or psychiatric conditions present in the population. The Non-autistic Group specifically included adolescents with developmental learning disorders (often referred to as dyslexia, dysorthographia, or dyscalculia), as students with developmental learning disorders took the exams on the same exam sheets as students from the general population. Despite having a similar average age, the groups exhibited statistically significant differences ( p = .006; Table 1 ). Within the Autistic Group, some students were 16 ( n = 18) and 17 years old ( n = 1). The Non-autistic Group consisted solely of students aged 14 and 15.

Sentiment Analysis, Linguistic Abstraction, and Readability

We employed a manually created dictionary of 5421 positive and negative words, representing the sentiment of the most frequent sense of a word and therefore requiring no word sense disambiguation. The level of language abstraction was calculated according to the weighted summation formula: DAV + IAV*2 + SV*3 + ADJ*4. Applied computational methods are described in Chojnicka & Wawer ( 2020 ). To evaluate the readability of an essay, we calculated the Gunning Fog Index (Gunning, 1952 ), which estimates the years of formal education necessary for a person to comprehend the text upon their initial reading. We used the textstat library Footnote 1 to perform the computations.

Essay Length and Scores

The essays did not differ significantly between the two groups regarding the linguistic and literary categories, and the total score assigned by teachers. Therefore, it appears that the writing competencies assessed in a school-oriented manner by teachers were similar in both groups. We also assessed whether the number of tokens (words) differentiates both groups. Essays by autistic adolescents were shorter compared to those by peers from the control group ( U = 11108.50, Z = -2.711, p = .007, r = -.149; Table 2 ). Since a statistically significant difference was detected, we carried out subsequent dictionary-based analyses (sentiment, LCM) using normalized values, wherein each parameter was divided by the number of tokens.

Sentiment and Language Abstraction Analyses

Autistic students used words with a positive evaluative meaning statistically less frequently in their stories compared to participants from the Non-autistic Group ( U = 8611.00, Z = -5.597, p < .001, r = -.307). We found no such difference for words with a negative evaluative meaning ( p = .857).

We observed statistically significant differences for mental and emotional State Verbs (SVs), Adjectives (ADJs), and the overall level of Language Abstraction. Autistic students used SVs ( U = 10655.5, Z = -3.235, p = .001, r = -.177) and ADJs ( U = 11009.50, Z = -2.826, p = .028, r = -.155) less frequently in their essays than peers from the control group (Table 2 ). The calculated language abstraction for the entire essays was lower in the ASD in comparison to the Non-Autistic Group ( U = 9666.50, Z = -4.378, p < .001, r = -.240). We did not find statistically significant differences for less abstract verb categories.

Essays’ Readability

To evaluate the readability of an essay, we calculated the Gunning Fog Index, obtaining statistically significant differences ( U = 10129.50, Z = -3.843, p < .001, r = -.211). Then, we excluded three outliers from the Autistic Group who scored significantly higher than all other participants in the study, indicating the use of an unusually difficult and complex language. After removing the outliers, the differences remained statistically significant ( U = 10129.50, Z = -3.648, p < .001, r = -.200). Autistic students wrote more complex stories in terms of readability ( M = 9.85, SD = 5.49) than peers from the Non-autistic Group ( M = 7.93, SD = 1.99, Table 2 ).

Previous studies on narrative skills in autism have primarily focused on spoken narratives. In this study, we present results pertaining to written narrations, offering a novel perspective in several ways: (1) written narrations by autistic individuals exhibit similarities in certain characteristics to spoken narrations, (2) these characteristics can be detected using automated, quantifiable, and objective computer measures, and (3) we utilized data from standardized nationwide exams, enabling the study of large groups.

Previous studies on internal state language in autism have mostly focused on verbs and adjectives relating to characters’ emotional (e.g., ‘laugh’, ‘happy’) and cognitive states (e.g., ‘know’, ‘confused’). The results of the meta-analysis conducted by Baixauli et al. ( 2016 ) indicate that autistic children use fewer ISL terms than neurotypical peers in spoken narratives. In our study, written narratives by autistic adolescents were similar to spoken narratives in terms of sentiment and the level of linguistic abstraction. In the stories, students from both groups included more words with a positive emotional tone than words with a negative emotional tone. However, autistic students used fewer words with positive emotional polarity than students from the Non-autistic Group with a moderate effect size. This finding aligns with our previous research on spoken narratives produced during the ADOS-2 (Lord et al., 2012 ) Picture Book task (Chojnicka & Wawer, 2020 ). The results we have obtained using the same NLP techniques (sentiment analysis and Linguistic Category Model) suggest that autistic individuals not only use fewer direct expressions and descriptions of positive emotions but also fewer other emotionally positively related words (such as ‘trust’, ‘home’).

Another result consistent with our prior research on spoken narratives is the lower level of abstraction of the essays of autistic adolescents. We found statistically significant differences in the overall level of an essay’s abstraction, the number of LCM Adjectives, and State Verbs related to mental and emotional states or changes therein. Autistic students used fewer Adjectives and State Verbs, and their essays were less abstract than those written by non-autistic peers. The current results indicate that the narratives of autistic students were more concrete, consisting primarily of direct (e.g., “They built a sandcastle on the beach”) rather than subjective descriptions related to cognitive and emotional states (e.g., “They knew that honesty was the best option”). In the article on spoken narratives produced by autistic individuals during the ADOS-2 Picture Book task (Chojnicka & Wawer, 2020 ), we demonstrated less frequent use of DAVs and SVs, as well as a lower overall level of abstraction in the Autistic Group.

In our previous studies (Chojnicka & Wawer, 2020 ; Wawer & Chojnicka, 2022 ) on spoken narratives, participants in the autistic and comparison groups were matched for age, sex, and non-verbal and verbal intelligence quotients. In the current project, we did not have access to data regarding the intellectual functioning of the participants. However, the groups did not differ significantly in writing skills measured by the number of points awarded by teacher-examiners in the categories: Topic Development , Creative Elements , Literary Skills , Style , Language , Text Composition , Spelling , Punctuation , and the Total score. Nonetheless, autistic students wrote shorter essays than non-autistic peers. This aligns with previous studies pointing to lower productivity of spoken narratives from autistic individuals (Baixauli et al., 2016 ).

To assess the readability of an essay, we computed the Gunning Fog Index (Gunning, 1952 ), which estimates the years of formal education necessary for an individual to comprehend the text upon their initial reading. The higher the index value for a given text, the more years of education are needed for complete understanding. The Gunning Fog Index takes into account the length of sentences and the number of “complex” words with four or more syllables (for the Polish language; in English, words with three syllables or more are considered complex words; Świeczkowski & Kułacz, 2021 ). The outcomes of our study suggest that autistic adolescents wrote more complex essays in terms of readability than non-autistic peers. This aligns with the results obtained in the study of written stories by university students (Shevchuk-Hill et al., 2022 ). The authors used the Dale-Chall readability formula and suggested a higher reading level for stories written by autistic young adults. This result may be related to the tendency of some autistic individuals to use pedantic, encyclopedic vocabulary and overly formal and adult-like language (Luyster et al., 2022 ). An interesting finding, despite higher essay complexity as measured by the number of syllables, is that people with autism produced less abstract essays as measured by the LCM. The connection between LCM and the Gunning-Fog index is not explored, examining it, especially in the case of morphologically rich languages such as Polish, is an interesting subject of future research.

However, the obtained results should be treated with caution as the Autistic Group included several older students than the Non-autistic group. In Poland, finishing primary school at a later age often results from postponing compulsory schooling, usually by a year, in the case of children considered not developmentally ready to start school, which might be the case for autistic students. It may also result from not being promoted to the next class due to insufficient mastery of the educational material at a given level. However, in both cases, all students completed the same number of years of formal education.

We would like to address the limitations of the current study that suggest directions for future research. The strength of the study was the relatively large number of collected essays, but we had limited clinical characteristics of participants, and as discussed earlier, we did not have data on IQ scores. The second limitation was the slightly different task instructions received by participants from the two groups. One aspect that draws attention is that the instruction for the Non-autistic Group included the phrase “shared adventure”, whereas the instruction for the Autistic Group used the wording “your adventure”. The first implies interpersonal experiences, while the second does not. It could have an impact on the results we obtained. However, analyses involving human raters indicate that both instructions did not differentiate the essays in an evident manner. In another project using the same data, human raters, psychologists experienced in autism diagnosis, were tasked with assigning participants to groups after reading their stories. The raters’ effectiveness was close to random (unpublished data). Hence, the essays from both groups did not differ in a way that would be noticed by human raters.

Another limitation is related to the assumptions underlying the computational methods used. The meaning of certain words, as they occur in the text, depends on their neighboring words. This could be captured using an approach based on Construction Grammar (Goldberg, 1995 , 2006 ). When applied to dialogic engagement, using the notions of lexical and syntactic resonance, Tantucci and Wang ( 2023 ) identified differences in creativity and intersubjective engagement in children with ASD in contrast with the neurotypical population. However, in our approach, the measures of sentiment and the LCM model use the most frequent sense of a word. We argue that this is a strong baseline approach, outperforming automated word sense disambiguation tools available in Polish. Rare senses and usages contribute less to the overall error. Moreover, this contribution is unlikely to have a significant influence on comparisons between groups that we make. On the one hand, the advantage of our approach is full automation and no annotation inconsistencies introduced by inter-annotator disagreements. On the other hand, the method proposed by Tantucci and Wang ( 2023 ) offers a more fine-grained analysis, and better handling of word senses.

We would like to draw the reader’s attention to another aspect. Most of the essays were handwritten, but in the case of the Autistic Group, there were also essays written using a keyboard. This is a technical difference between the groups that may also affect the written stories, although we do not propose a hypothesis regarding the direction of this influence.

Our study indicates that automated, quantitative computational methods are effective means for analyzing written narratives in autism. A significant conclusion drawn from our study is that written narratives by autistic individuals proved similar to spoken narratives in terms of characteristics detected by computational methods. Autistic adolescents used fewer words with positive emotional polarity and verbs describing the mental and emotional states of the characters, and their essays were less abstract but more complex in terms of readability than the narratives of non-autistic peers. Collecting data from national exams and its potential usefulness in distinguishing autistic individuals could pave the way for future large-scale and cost-effective epidemiological studies on autism.

Data Availability

Data is available upon request from the corresponding author.

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Acknowledgements

We would like to express our gratitude to the Polish District Examination Boards. In particular, we would like to thank: Dr. Maria Krystyna Szmigel , the Deputy Director of the District Examination Board in Krakow; Mrs. Joanna Peter and Mrs. Anna Rappe from the District Examination Board in Krakow; Mrs. Grażyna Klimuszko , the Deputy Director of the District Examination Board in Łomża; and Mr. Grzegorz Dudzicki from the District Examination Board in Łomża; Mrs. Ragna Ślęzakowska , the Head of the General Education Examinations Department of the District Examination Board in Warsaw; We would like to thank the students who prepared essays for computer analysis: Patrycja Jaworska and Paweł Zubrzycki.

The project was supported by grants from the Polish National Science Centre (grant no. 2020/39/D/HS6/00809 and from the funds awarded by the Ministry of Science and Higher Education in the form of a subsidy for the maintenance and development of research potential in 2023 and 2024 (501-D125-01-1250000 zlec.5011000231; 5011000228). The funders had no role in study design, data collection and analysis, decision to publish, or manuscript preparation.

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Conceptualization, methodology, writing, review, and editing; analyzing and discussing the results: IC, AW; design, data collecting, and project administration: IC; computational analyses: AW. All authors have read and agreed to the published version of the manuscript.

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Correspondence to Izabela Chojnicka .

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Chojnicka, I., Wawer, A. Analysis of Autistic Adolescents’ Essays Using Computer Techniques. J Autism Dev Disord (2024). https://doi.org/10.1007/s10803-024-06482-4

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