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A Systematic Review of Passing as Non-autistic in Autism Spectrum Disorder

Abstract

While long described in anecdotal accounts of the lived experiences of autistic individuals, the phenomenon of behaving in ways that appear inconsistent with the presence of autism (or passing as non-autistic; PAN) has recently seen a dramatic increase in scrutiny in the published scientific literature. Increased research attention has coincided with a proliferation of methods, definitions, measures, and population assumptions associated with PAN. To date, however, no review has sought to systematically identify and synthesize the literature on PAN. This systematic review reflects the state of the PAN literature as of May 2020. Ninety articles were screened, 66 were identified for evaluation, and 46 met inclusion criteria and were reliably coded for study characteristics and participant characteristics. Results reveal that the PAN literature includes a relatively even mix of qualitative, quantitative, and mixed-method studies, and that a variety of terms are used for PAN (with masking and camouflage being the most frequent). Sample sizes varied widely (from one to 832 participants), with 63.06% of participants being categorized as autistic. Nearly all studies reported methods for confirming autism diagnoses, with community and clinical diagnoses being most common. The majority of studies reported participant gender, with slightly more females included than males on average, but fewer than half of all studies compared PAN across genders. Nearly all studies reported participant age, demonstrating a wide range of 2 to 79 years, with a mean age of 23.85. Conversely, only 23.91% of studies provided participant race or ethnicity data. Nearly all studies formally or informally excluded participants with intellectual disability. Finally, measures of internalizing symptoms, which are often thought to be linked to PAN, were reported in only 17.4% of studies. Implications for gaps in understanding of PAN and future directions for the field are discussed.

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Fig. 1

Notes

  1. 1.

    To date, the vast majority of studies reporting on participant gender in this literature do not explicitly differentiate between biological sex and gender, often using the two terms interchangeably, and many theoretical models which hypothesize higher rates of PAN among females presume ‘female’ to mean ‘cisgender female’. Any deviations from this implicit pattern in the literature or here will be specifically noted.

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Funding

Support for this project was provided by the National Institute of Mental Health (NIMH) (R01MH110585). The NIMH was not involved in the study design, collection, analysis, or interpretation of data, writing of the manuscript, nor the decision to submit the article for publication.

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EJL: Conceptualization, Methodology, Investigation, Data curation, Validation, Formal analysis, Project Administration, Visualization, Writing—Original draft preparation. EGK: Conceptualization, Writing—Review and editing. CEF: Investigation, Data curation, Writing—Review and editing. JM: Investigation, Data curation, Writing—Review and editing. NI: Investigation, Data curation, Writing—Review and editing. DK: Investigation, Data curation, Writing—Review and editing. MDL: Conceptualization, Methodology, Validation, Resources, Supervision, Project Administration, Visualization, Writing—Review and editing, Funding acquisition.

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Correspondence to Erin J. Libsack or Matthew D. Lerner.

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Libsack, E.J., Keenan, E.G., Freden, C.E. et al. A Systematic Review of Passing as Non-autistic in Autism Spectrum Disorder. Clin Child Fam Psychol Rev 24, 783–812 (2021). https://doi.org/10.1007/s10567-021-00365-1

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Keywords

  • Autism spectrum disorder
  • Camouflage
  • Masking
  • Passing
  • PAN
  • Compensation