Compensatory Strategies Yield Mixed Outcomes in People With Autism

By Marilynn Larkin

August 03, 2019

NEW YORK (Reuters Health) - Compensatory strategies used by people with autism to disguise the condition have both positive and negative consequences, researchers say.

"Although autism is diagnosed based on behavior, clinicians should be more aware of underlying psychological difficulties - and compensatory strategies to overcome these difficulties - when seeing adults in clinic," Dr. Lucy Livingston of Kings College London told Reuters Health.

"To this end, explicitly asking about the use of compensatory strategies (e.g., do you copy others to fit in?) - and probing with further questions if required (e.g., do you find this tiring?) - will provide clinicians with greater insight about their clients," she said by email.

"The freely available compensation map in our paper may be a useful springboard for framing these questions in clinic," she noted.

"Our research shows that people with social difficulties who use compensatory strategies have good insight; therefore, clinicians would benefit from such information during their diagnostic procedures," she added. "And, most importantly, this should inform how they assist clients to manage their social difficulties, regardless of whether they meet criteria for autism."

Dr. Livingston and colleagues studied 136 adults who responded to an advertisement distributed globally through social media and the UK National Autistic Society. Participants self-reported via an online platform their use and experiences of compensatory strategies by completing a 10-item questionnaire and a series of open questions. They also rated how successful and tiring the strategies were, and whether they would recommend them to others having social difficulties.

As reported online July 23 in The Lancet Psychiatry, 58 participants (mean age, 35.8; 64% women) had a clinical diagnosis of autism (mean age at diagnosis, 30.1); 19 self-identified but were not formally diagnosed as autistic (mean age 40.2; 47% women); and 59 were not diagnosed or self-identified, but did report social difficulties (mean age, 33.9; 86% women).

Compensatory methods varied and included deep strategies such as planning and rehearsing conversations, as well as accommodation strategies such as going out of their way to be helpful. These types of strategies were used both by people with a formal diagnosis and by those without.

Shallow strategies, such as mimicking other people's gestures, were more common among those who had more autistic traits and were linked to negative consequences, such as anxiety or depression. Further, they were more difficult to use in stressful situations or when tired.

"The findings suggested that there are multiple compensatory strategies with distinct characteristics, individual and environmental factors that modulate compensatory strategy use and success; positive (social relationships, independence, employment) and negative (poor mental health, late diagnosis) outcomes associated with compensatory strategy use; and that individuals without a diagnosis use compensatory strategies that are qualitatively similar to individuals with a diagnosis," the authors conclude.

Dr. Julia Parrish-Morris of the University of Pennsylvania, author of a related editorial, commented by email, "This study highlights the importance of considering autistic people's inner experiences when making diagnoses and treatment recommendations."

"Currently, people's inner experiences, such as exhaustion or distress from trying to fit in socially, are not formally part of the autism diagnosis (DSM-V)," she told Reuters Health by email.

"Many of us - autistic and neurotypical - engage in behavioral compensation to support social interaction, but it can be really hard to sustain! Fully acknowledging this reality in research and clinical practice will improve our ability to understand and support individuals on the spectrum," she said.

"The next step in this process will be to explore how other life experiences - such as stigma due to race, sex/gender identity, or disability status - interact with autism to create unique stressors, resiliencies, and challenges for individuals," she added.

"As researchers and practitioners, it is critical to have nuanced conversations and tackle these complexities head on," she concluded.


Lancet Psychiatry 2019.