In this Papers Podcast, Dr. Jiedi Lei discusses her JCPP paper ‘Understanding the relationship between social camouflaging in autism and safety behaviours in social anxiety in autistic and non-autistic adolescents’ (https://doi.org/10.1111/jcpp.13884). Jiedi is the first author of the paper.
There is an overview of the paper, methodology, key findings, and implications for practice.
Discussion points include:
- The definition of ‘social camouflaging’ and ‘masking’, how it typically manifests, and how it relates to social anxiety in autistic adolescents.
- Safety behaviours in social anxiety in autistic and non-autistic adolescents.
- How participants were recruited and engaged using cartoon-like stop-motion videos.
- Gender differences that emerged.
- Implications of the findings for CAMH professionals and how the findings could inform assessment and treatment of social anxiety disorder for autistic adolescents.
In this series, we speak to authors of papers published in one of ACAMH’s three journals. These are The Journal of Child Psychology and Psychiatry (JCPP); The Child and Adolescent Mental Health (CAMH) journal; and JCPP Advances.
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Dr. Jiedi Lei is a clinical psychologist and autism researcher currently completing a Research Fellowship at the University of Oxford, with a focus on Understanding Strengths-Based Approaches in Supporting Autistic Children and Young People (CYP). Jiedi’s research interests include understanding mechanisms that maintain anxiety disorders such as social anxiety in autistic CYP, with an aim of translating research to inform and improve clinical treatment for anxiety difficulties in this group. Jiedi is currently examining ways of assessing and incorporating character strengths to embody strength-based approach when supporting autistic CYP and their families in mental health settings and beyond. Jiedi has been awarded NIHR Oxford Senior Research Fellowship for her translational research to improve mental health for autistic CYP under the Oxford Health BRC Mental Health in Development Theme.
Other resources
- Open Access paper from Autism ‘Exploring the association between social camouflaging and self- versus caregiver-report discrepancies in anxiety and depressive symptoms in autistic and non-autistic socially anxious adolescents’, (March 2024), Jiedi Lei, Eleanor Leigh, Tony Charman, Ailsa Russell, and Matthew J Hollocks
- Example stop-motion video from the project
Transcript
[00:00:01.360] Jo Carlowe: Hello, welcome to the Papers Podcast series for the Association for Child and Adolescent Mental Health, or ACAMH for short. I’m Jo Carlowe, a Freelance Journalist, with a specialism in psychology. In this series, we speak to authors of papers published in one of ACAMH’s three journals. These are the Journal of Child Psychology and Psychiatry, commonly known as JCPP, the Child and Adolescent Mental Health, known as CAMH, and JCPP Advances.
Today, I’m interviewing Clinical Psychologist, Dr. Jiedi Lei, Paul Foundation Clinical Research Fellow at the Department of Psychiatry at the University of Oxford. Jiedi is the first author of the paper, “Understanding the Relationship Between Social Camouflaging in Autism and Safety Behaviours in Social Anxiety in Autistic and Non-Autistic Adolescents,” recently published in the JCPP. This paper will be the focus of today’s podcast. If you’re a fan of our Papers Podcast series, please subscribe on your preferred streaming platform, let us know how we did, with a rating or review, and do share with friends and colleagues.
Jiedi, welcome, thank you for joining me. Can you start with an introduction about who you are and what you do?
[00:01:17.992] Dr. Jiedi Lei: Thank you for having me. So, my name’s Jiedi, I’m a Clinical Psychologist, and also Autism Researcher. So, my primary focus is working with autistic children and young people and supporting their families. And I’ve wrote this paper as part of my clinical psychology doctorate when I was studying at King’s.
[00:01:37.640] Jo Carlowe: Thank you. So, we’re going to look at your JCPP paper today, this is, “Understanding the Relationship Between Social Camouflaging in Autism and Safety Behaviours in Social Anxiety in Autistic and Non-Autistic Adolescents.” I’d like to start with some definitions, so beginning with ‘social camouflaging,’ including masking, can you define this for us and explain how it typically manifests, and how it relates to social anxiety in autistic adolescents?
[00:02:07.579] Dr. Jiedi Lei: Social camouflaging is, kind of, an umbrella term, and it’s used to describe a range of behaviours used to hide autism traits, and sometimes it’s referred to as ‘masking.’ So, in this particular paper we used the self-report questionnaire, called the Camouflaging Autism Traits Questionnaire, to look at slightly different aspects of social camouflaging behaviour. So, this included masking, which is around hiding aspects of somebody’s autistic presentation, or presenting a non-autistic persona to other people.
[00:02:40.160] Jo Carlowe: Hmmm hmm.
[00:02:41.160] Dr. Jiedi Lei: It also included compensation, so that’s finding ways around, kind of, the social and communication difficulties you might experience that’s associated with having autism. And then the last aspect of camouflaging was assimilation, and this is attempts to try to blend into a social situation where you might feel uncomfortable, so you’re trying to not let other people see the discomfort that you might be in.
So, how it relates to social anxiety, well, what we know is that when we’re thinking about what maintains social anxiety in anybody is that, you know, when you are feeling worried about how you’re going to come across to other people in a social situation or how might other people perceive you, what people often do is they try to engage in behaviours that they believe will keep themselves safe and away from negative perceptions from other people. So, these safety behaviours can include things like avoidance, so trying to avoid eye contact, staying on the edge of the group, or they could be behaviours known as, kind of, impression management behaviours. So this is when you’re trying to actively come across well, and trying to prevent the things that you’re worried about from happening.
In this particular paper, what we’re interested in is camouflaging in some aspects looks very similar to these impression management behaviours, in the sense that, you know, you’re trying to manage how you present yourself in a social situation, and you’re trying to come across well. In particular, we’re interested in how this might present itself during adolescence, because what we know is that the adolescent brain, it’s really attuned and very sensitive to peer evaluations. And so, during adolescence, when you’re making a decision, you’re very much influenced by what peers might think or react to your response, and that desire to fit in and come across well is very strong during adolescence.
So, we’re really interested in how those, kind of, social worries you might experience about not wanting to come across weird might be really relevant during this developmental phase. And we also know that adolescence is one of the peak periods for people to experience social anxiety, as well.
[00:04:41.360] Jo Carlowe: That’s really helpful. Just sticking with safety behaviours, in the paper, I think you talk about how this relates both to – well, to social anxiety, but in both autistic and non-autistic adolescents. Can you say something about that, and perhaps about the difference between the two group?
[00:04:57.220] Dr. Jiedi Lei: Safety behaviours is often referred to in the clinical language used around social anxiety. So, these refer to different types of behaviours people might do to keep them safe when they are worried about coming across badly in a social situation. So, the motivation there really is to come across well, or not to embarrass yourself in a particular social situation. So, examples of safety behaviours can include things like avoidance, so trying not to attract attention, avoiding eye contact, staying on the edge of the groups. But they can also include things like impression management. So these are things like making an effort to get your words right, maybe rehearsing what you’re going to say in your mind, trying to fit in and act normal.
And I think it is underneath this kind of impression management behaviours that got me really interested in thinking about how this might look really similar to camouflaging behaviours. Because parts of that camouflaging, when you are thinking about it purely from an autism literature, is that ability to, kind of, disguise any social communication differences, and also trying to fit in and act normal in a social situation.
So, in this particular paper, I was quite interested in, you know, we have these two sets of behaviours, which, when you’re just looking at it from the outset, might have some similarities, but from the autism and social anxiety literature, they stem from different, kind of, mechanisms and motivations. Are we actually able to distinguish the two when you’re looking at autistic adolescents in particular, who have high levels of social anxiety?
[00:06:26.039] Jo Carlowe: Hmmm. You’ve already gone into some of the details of the paper…
[00:06:29.170] Dr. Jiedi Lei: Yeah.
[00:06:30.170] Jo Carlowe: …can you give us a, kind of, overview of what you looked at, and why, just to set the scene for us?
[00:06:34.790] Dr. Jiedi Lei: Of course, yeah. So, in this paper, our primary aim is to understand how camouflaging behaviours and safety behaviours might be differentially related to social anxiety and autism traits in a sample of autistic and non-autistic adolescents. And because of, you know, the overlaps in impression management behaviours and camouflaging behaviours we just talked about, and we know that there’s a high level of social anxiety symptoms amongst autistic children and young people, what really got me interested is in trying to understand, can we actually distinguish between these two sets of behaviours, in terms of why people might be doing them? Is it purely related to hiding autism traits? Is it also related to co-occurring levels of social anxiety? And how unique is this to autistic adolescents, or do we also perceive this in non-autistic adolescents, as well? So, that was, kind of, the main aim of our particular study.
[00:07:30.550] Jo Carlowe: And can you tell us a little about the methodology used for this study?
[00:07:34.110] Dr. Jiedi Lei: We decided to recruit lots of autistic and non-autistic young people to complete some self-report questionnaires, looking at things like autism traits, social anxiety symptoms, and also, safety behaviours and camouflaging. So, overall, we recruited 115 young people, mostly coming from child and adolescent mental health services, and that included 61 autistic young people, and 54 non-autistic adolescents.
A main design aspect of this study is because we anticipated autistic young people to have higher levels of social anxiety, what we wanted to know is, you know, we wanted to be sure that the relationships we’re seeing, it’s down to differences in autism traits, and not because the non-autistic adolescents also have, kind of, lower levels of social anxiety. So, what we tried to screen for is we asked non-autistic young people to answer a few short questions on their self-reported levels of social anxiety, to try to screen for young people that experienced higher levels of social anxiety, in a way that, kind of, matched the two groups, in terms of social anxiety symptom severity.
We just asked young people to complete these different questionnaires online, and then we took their self-report measures and inputted all of that data into one, kind of, model that allowed us to simultaneously look at all of these associations between all of the different constructs, to try to understand how behaviour is measured under the camouflaging questionnaire, and the safety behaviour questionnaire might differentially relate to autism traits and social anxiety across the two groups.
Because, you know, most of the young people from our study came from a clinical sample, we wanted to also make sure that the relationships we’re seeing are not due to other mental health symptoms, such as, generalised anxiety or depression. So we asked young people to also complete those questionnaires, and we were able to control for those different types of symptom severities when looking at these particular relationships, as well.
[00:09:27.430] Jo Carlowe: I think I noticed that with the recruitment, you used a rather nice, very accessible video, to attract participants.
[00:09:34.519] Dr. Jiedi Lei: Yeah.
[00:09:35.519] Jo Carlowe: Just describe that.
[00:09:36.709] Dr. Jiedi Lei: This is something I picked up actually during my PhD studies, and I was talking to someone around how do we engage young people, especially autistic young people, who often have quite concrete ways of understanding information, and can be a little bit harder to reach.
[00:09:53.800] Jo Carlowe: Hmmm hmm.
[00:09:54.800] Dr. Jiedi Lei: And just engage them in a more fun way, to tell them what the study is about? And I was talking to someone who used to produce some documentaries for the BBC actually, and…
[00:10:02.760] Jo Carlowe: Wow.
[00:10:03.760] Dr. Jiedi Lei: …he said, “Have you ever thought about making a short video?” And I thought, wow, that’s really interesting, to produce some really easy, kind of, cartoon-like, stop motion videos.
[00:10:13.029] Jo Carlowe: Hmmm.
[00:10:14.029] Dr. Jiedi Lei: That gives young people a couple of scenarios of what it’s like to have social anxiety experiences that they might be able to relate to. And through that, kind of, telling a story about somebody who experiences social anxiety and the worries they have, hopefully, young people can watch that, relate to some aspects of the video, and think, okay, well, this could potentially be something that I can help with, or something I’m interested in learning more about. So, that was, kind of, the intention of conveying the study in a slightly more fun way to…
[00:10:41.779] Jo Carlowe: Hmmm hmm.
[00:10:42.779] Dr. Jiedi Lei: …recruit and engage young people from more diverse backgrounds, as well.
[00:10:46.040] Jo Carlowe: Fantastic, and we can include a link to that. Let’s return to the findings, what key findings from the paper would you like to highlight?
[00:10:55.820] Dr. Jiedi Lei: I think this was the first time that we looked at a sample of autistic and non-autistic young people, to look at this potential overlap between camouflaging and safety behaviours, in relation to both autism and social anxiety. So, I think it was interesting that we found, you know, masking behaviours. So those aspects of trying to hide autism related traits, and impression management behaviours, both showed a very strong positive relationship, suggesting that, you know, the two are, at least at face value, young people reported them to be quite similar, and they were more associated with social anxiety rather than autism traits.
This was particularly interesting because I think, often, we think about camouflaging is something that’s specific to masking autism related traits…
[00:11:41.029] Jo Carlowe: Hmmm.
[00:11:42.029] Dr. Jiedi Lei: …and impression management is very much spoken about in a social anxiety maintenance context. But, actually, what this study is suggesting is that both aspects actually require you, if you are doing them well, they require you to pay lots of attention to yourself, during that social situation, to really self-monitor what’s happening, turning that focus of attention inwards, to be able to know, you know, this is how I think I’m presenting myself, and this is how I would like to present myself.
And so, what this study is suggesting is that, you know, if a young person experiencing high levels of social anxiety, and they are increasing that attention inwards, to focus on how they might be coming across, then that same mechanism potentially operates for camouflaging. And, inadvertently, if you are trying to hide some aspects of yourself during a social situation, you might actually be inadvertently reinforcing that pattern of social anxiety as well, ‘cause you’re not focusing on how other people are actually, kind of, responding to you in the moment. But you’re too worried about, you know, I just don’t want to accidently do anything that might embarrass myself.
I guess it’s also interesting that this is the first time we recruited lots of young people largely from a child and adolescent mental health setting. So we know these are young people who are struggling in some aspects of their mental health and seeking support. And so, it also allowed us to have a think about, you know, is that camouflaging really specific to just autism traits? Or are young people who potentially have mental health difficulties, are they engaging in some aspects of trying to hide those difficulties away from their peers, in that particular age group, as well?
[00:13:10.210] Jo Carlowe: Were there any gender differences that emerged in the study?
[00:13:13.570] Dr. Jiedi Lei: Yeah, so this is a really popular question. Because our sample size was still quite small, so it was not really possible to make very conclusive decisions around gender differences. But we did find that – you know, we asked young people actually to report gender identity, rather than biological sex. So when looking at gender identity, what we did find is that this relationship between safety behaviours and social anxiety was stronger in young people who self-identified as male, compared to those who are self-identified as female. So, perhaps that relationship, you know, between self – safety behaviours and social anxiety rather than autism traits is more significant in those who self-identify as male.
[00:13:53.870] Jo Carlowe: I was interested in the idea from your paper that aspects of camouflaging, such as masking and compensation, could be conceptualised as coping strategies in social situations that are not unique to autism. Was that finding unexpected?
[00:14:07.610] Dr. Jiedi Lei: I think, to some extent, what we know is that, you know – so, impression management behaviours, in general, it’s a very human trait, because we all enter a social situation wanting to put our best foot forward and wanting to present the best version of ourselves. But I think, you know, the pressure of feeling like you have to conform to the social norm you’re in might not be the same for everybody. So, sometimes that could be influenced by your own beliefs around how you might come across or how other people might perceive you, but lots of times, these internal factors really interact with the external or wider societal beliefs, as well.
So, we know that, you know, for some groups that might be more prone to being perceived with social stigma, or perhaps have more negative bias perceptions from other people. They might also be engaging in impression management behaviours for slightly different reasons, as well. I think when you look at these two aspects of behaviours, camouflaging and safety behaviours, especially impression management behaviours, when you just look at the questions, at face value, there is quite a bit of overlap in terms of the observable behaviours they might be measuring. But I think it’s – so, you know, from that aspect, I don’t think it’s too surprising that we found the findings in the particular paper, beca – and young people are interpreting them in a very similar way.
But, yeah, what is interesting is these same behaviours actually measured in one context might also be maintaining inadvertently mental health difficulties in a slightly different context. And so, it was more interesting to think about the broader impact of some of these behaviours, which might go beyond hiding one particular aspect of yourself, but might also influence maintenance and development of mental health difficulties in particular.
[00:15:53.290] Jo Carlowe: We’ll look at the implications of that in a moment, but I just wondered if there was anything else in the paper that you would like to highlight?
[00:15:58.699] Dr. Jiedi Lei: One thing that really struck me is, you know, when you’re purely looking at one questionnaire, taken at face value, and you might be using that in isolation, or interpreting the results from that in isolation, it might not always give you the full picture. So, you know, the questionnaire looking at camouflaging often is framed in the context of autism, and looking at autism traits, but, actually, when you look at it together with mental health difficulties, that same questionnaire might tap into behaviours that serve a slightly different function.
And so, I think it’s quite important for Researchers, when using either the camouflaging or measuring mental health difficulties to think about how does that same questionnaire operate under different conditions, as well, and what other measures are you trying to capture within that particular study?
[00:16:42.680] Jo Carlowe: So, what are the implications of your findings for CAMH professionals? So, for example, how might your findings inform assessment and treatment of social anxiety disorder for autistic adolescents?
[00:16:56.339] Dr. Jiedi Lei: I think that, holding in mind some of the limitations of using these questionnaires in isolation, I think it’s really important for Clinicians to keep that open mind that, you know, interpreting any single assessment measure is not going to give you the full picture. And I think, as a Clinician, you are trained in doing very careful assessments and very careful formulations of what’s happening with that young person. So I think it is very much maintaining that perspective, and to work together with that young person to really understand, from their perspective, how are they making sense of these behaviours? Behaviours that when you’re just reporting on paper might look really similar, but they might have slightly different, from the young person’s perspective, slightly different motivations…
[00:17:36.590] Jo Carlowe: Hmmm hmm.
[00:17:37.590] Dr. Jiedi Lei: …behind that. So, I think it’s helpful for Clinicians to hold in mind that the same behaviour which might look really similar, some young people might think, I’m doing that to hide autism related difficulties. But, actually, helping the young person to scaffold that thinking a little bit more and explain, you know, maybe through psychoeducation, some of that behaviour we know can also maintain social anxiety.
So, can we help that young person to understand, really weigh up, you know, the pros and cons of that behaviour, in different settings, so they’re better able to make a decision around what sorts of behaviour experiments they might want to do in social anxiety treatment, and what they’re willing to, kind of, change or adapt or drop in a social situation, as well.
[00:18:16.910] Jo Carlowe: Any thoughts about the types of interventions or treatments that are useful and from what you’ve discovered from the research?
[00:18:22.610] Dr. Jiedi Lei: Yeah, so what we know is that, you know, this particular model, and thinking about safety behaviours, in general, refers a lot to the Clark and Wells social anxiety model, and that’s what informs, kind of, the cognitive therapy in adults with social anxiety. So, a lot of those is constructing, kind of, behavioural experiments with the individual, to think about what might happen if you were to drop the safety behaviours that you are now more aware of in a social situation, and can we test it out? Does your worst, kind of, predictions that people will find you embarrassing and make these negative remarks, does that really come true, when you’re not doing some of the safety behaviours?
I guess what this paper is highlighting is that some of the camouflaging behaviours might also have a similar effect, in terms of maintaining social anxiety. So, if you’re working with an autistic young person and thinking about structuring those behavioural experiments around what’s a safety behaviour, what should you test for? Maybe part of that, clarifying young person’s predictions, you might want to touch on, “Do you think any aspect of this might be related to having autism?” Or, “Is any aspect of the safety behaviour you’re trying to, kind of, hide your autism traits? And can we think about that, in addition to thinking about the social anxiety aspect of the social situation, as well?”
So, I think it’s helping Clinicians to think a little bit more broadly, and bring autism into the conversation when you’re structuring those behaviour experiments, and think about, what’s the function of that behaviour in a particular context?
[00:19:49.460] Jo Carlowe: Very helpful, thank you. Jiedi, are you planning any follow-up research, or is there anything else in the pipeline that you would like to share with us?
[00:19:56.780] Dr. Jiedi Lei: Yeah, so I think one thing we’re also interested in is whether camouflaging behaviours might be related to, kind of, hiding or compensating for differences for other, kind of, co-occurring mental health difficulties, not just for autism traits. So, we’re particularly interested in, you know, often when you have young people coming into CAMHS, you ask the young person and their parent and caregivers to give parallel ratings on the young person’s, kind of, mental health symptoms. And what we’re interested in is in whether, if young people potentially might be engaging in camouflaging or hiding aspects of their mental health difficulties beyond autism traits, whether that might be associated with how parents and caregivers might perceive the young person’s mental health, and how the young person’s rating those symptoms themselves.
So, one of the studies in the pipeline is to look at those caregiver and young person discrepancy ratings on mental health symptoms, and look at how that might be associated with young person’s reported camouflaging behaviours, when accounting for autism traits.
[00:20:56.950] Jo Carlowe: That’ll be really interesting. Are you at the recruitment stage? Where are you?
[00:21:01.900] Dr. Jiedi Lei: So, that paper is actually under review, so, fingers crossed that it might have a smooth journey and come out soon.
[00:21:07.510] Jo Carlowe: Right, good luck. Finally, what is your take home message for our listeners?
[00:21:12.760] Dr. Jiedi Lei: Yeah, I think the message here is just to highlight that behaviours are really multifaceted constructs. So, two people who have a very similar behavioural profile might have very different underlying motivations and, you know, as to why they’re behaving in that way, or, at least, a very different understanding of why they think they’re behaving in that way. So, I think when you’re working with a young person, in particular, especially autistic young people, to just really, really get to the bottom of, you know, helping them understand why they’re doing a particular behaviour, and what are they hoping to change through that intervention, as well.
I think when it comes to this camouflaging paper, because, you know, everything was done online and young people only gave these self-report ratings, we weren’t really able to have those one-on-one conversations, or through a more of a qualitative aspect, as to why young people might be answering questions in a particular way.
So, I think, you know, for Clinicians trying to translate this into their practice, it’d be really helpful to have more of those conversations and help young people, whether, you know, that’s from social anxiety aspect or from autism aspect, to really fully understand motivations that young person might have in terms of doing a particular behaviour, and have, you know, very clear predictions of what the young person believes might happen. Whether due to their social anxiety, or due to having autism in a social situation, before you go about manipulating any of these behaviours through intervention.
[00:22:38.200] Jo Carlowe: Brilliant, Jiedi, thank you ever so much. For more details on Dr. Jiedi Lei, please visit the ACAMH website, www.acamh.org, and Twitter @ACAMH. ACAMH is spelt A-C-A-M-H, and don’t forget to follow us on your preferred streaming platform, let us know if you enjoy the podcast, with a rating or review, and do share with friends and colleagues.
