Camouflaging Autistic Traits Questionnaire: Cultural Adaptation,Reliability,and Validity in Autistic and Non-Autistic from Spain

Abstract

Background:

Researchers have proposed that camouflaging contributes to delayed or absent diagnosis and mental health problems in autistic individuals. Therefore, there is a need for validated measures of this construct. This study aimed to culturally adapt the Camouflaging Autistic Traits Questionnaire (CAT-Q) for the Spanish population (Spain) and assess its psychometric properties, addressing the need for camouflage assessment tools in Spain.

Methods:

We conducted a cultural adaptation process, which involved direct-back translation and pretest with autistic individuals. We tested internal consistency, test–retest reliability, construct validity, including structural validity (confirmatory factor analysis), measure invariance, and hypothesis testing for construct validity with a larger sample of 490 participants, including 379 non-autistic individuals and 111 autistic individuals. We assessed a subsample of 32 non-autistic participants for test–retest reliability.

Results:

The cultural adaptation process yielded the CAT-Q–Spanish version (ES), culturally adapted for the Spanish population. Autistic volunteers identified minor comprehension issues in three items and the researchers revised them. The CAT-Q-ES showed excellent internal consistency among non-autistic (McDonald’s omega [ω] = 0.95) and autistic individuals (ω = 0.89). The subscales (Compensation, Masking, Assimilation) demonstrated internal consistencies ranging from adequate to excellent. Test–retest reliability showed a strong relationship (r = 0.99, p < 0.001). Associations between CAT-Q-ES scores and related constructs, including autistic traits, and symptoms of anxiety and depression confirmed its validity, with autistic individuals scoring higher on the test.

Conclusion:

The CAT-Q-ES is conceptually and semantically equivalent to the original instrument, offering a valid and reliable measure of camouflage for Spanish adults. These findings enhance the assessment and understanding of camouflage within the Spanish context, addressing a crucial gap in the field.

Community Brief

Why is this an important issue?

Camouflaging means hiding or changing your behavior and part of who you are to “fit in.” Many autistic people camouflage their traits during social interactions to cope with social demands. When you feel the need to hide yourself, it becomes harder to understand what you need. This might lead to delays in autism diagnosis and/or cause mental health challenges. Measuring camouflaging is important for improving diagnosis and providing better support for autistic people. Right now, there is no tool available in Spain to assess camouflaging in autism.

What was the purpose of this study?

We wanted to adapt the Camouflaging Autistic Traits Questionnaire (CAT-Q) for Spanish people. The CAT-Q assesses three different strategies of camouflaging as follows: Compensation, Masking, and Assimilation. The original questionnaire focuses on British people, and we wanted to create a version that fits the Spanish culture.

What did the researchers do?

Our team carried out the following two steps to develop the CAT-Q-ES: a first step of translation and cultural adaptation and a second step focused on the reliability analysis of the CAT-Q-ES.

In the first step, a group of bilingual professionals took part in the CAT-Q translation. This ensures that the Spanish version measures the same as the original, without just being a word-for-word translation. Then, we asked autistic participants to read the questionnaire and give feedback to make it clearer. Based on their input, we revised the questions to create the CAT-Q-ES for Spanish people.

In the second step, we gave the CAT-Q-ES to 379 non-autistic and 111 autistic adults through an anonymous online survey. Their participation helped us check the reliability of the CAT-Q-ES to measure camouflaging over time. For example, we expected autistic participants to score higher than non-autistic participants. We also checked the relation between CAT-Q-ES scores, autistic traits, anxiety, and depression.

What were the results of the study?

The cultural adaptation process helped us to create a tool that was clear for Spanish autistic participants, called the CAT-Q-ES. We saw that the CAT-Q-ES measured camouflaging consistently over time. Autistic participants scored higher than non-autistic participants, and the CAT-Q-ES scores were related to autistic traits, as well as symptoms of anxiety and depression.

What are potential weaknesses in the study?

Weaknesses of the study include potential bias in recruiting online samples. Also, we could not ensure autism diagnoses, which may have impacted the generalization of the results to other samples. Future research must apply the CAT-Q-ES in larger and more gender-diverse samples.

How will these findings help autistic adults now or in the future?

The CAT-Q-ES can help clinicians, educators, and researchers better support autistic adults. By measuring camouflaging in clinical practice, we can uncover the psychological effects of camouflaging and late diagnosis, including issues like anxiety and depression. This questionnaire is also designed to be accessible for autistic individuals who want to understand their social behavior and masking strategies. It can encourage them to explore how they cope in social situations and identify and defend their own needs.

Background

Autism Spectrum Disorder (ASD) (“autism”) is an atypical and dimensional developmental condition with traits found in the general population.¹ Autism includes difficulties or differences in social interaction and communication, along with unusually narrow interests, restricted and repetitive behaviors, and atypical sensory processing.²

Clinicians diagnose autism more frequently in males, whereas autistic women, especially those without intellectual disabilities, may experience misdiagnosis or a lack of diagnosis,^3–6 with serious implications for their health and well-being.⁷ Research has partly attributed the late or misdiagnosis of autism, particularly in women without intellectual disability, to camouflaging.^8–10

Camouflaging involves using a set of conscious or unconscious strategies aimed at masking autistic characteristics and compensating for possible social difficulties.^11,12 Some of these strategies include innocuous engagement, non-autistic communication modeling, and active self-presentation.¹³ Although individuals develop camouflaging as a coping mechanism during social situations, it is associated with mental health issues.^11,14–17 Social expectations and gender roles make negative consequences more prevalent in autistic women.¹²

Researchers can quantify camouflaging behaviors in autistic individuals with various methods,¹⁶ including the development of the Camouflaging Autistic Traits Questionnaire (CAT-Q).¹⁸ However, there is currently no instrument in Spain to assess camouflage strategies in autistic people. Recent studies suggest that it is not clear whether camouflaging (as measured by the CAT-Q) is only associated with autism and autistic traits or whether it is a common experience across different neurotypes, including attention-deficit/hyperactivity disorder (ADHD),¹⁹ and those with stigma.^17,20 In addition, people with psychological symptoms of anxiety and depression tend to camouflage them.^9,12 This study aims to culturally adapt and evaluate the psychometric properties of the self-administered CAT-Q in the Spanish population. Following the hypotheses proposed in the original CAT-Q development,¹⁸ we expect that the scores obtained in CAT-Q-ES (Spanish version) will present a positive relationship with autistic traits, general anxiety, and depression. In addition, we expect diagnostic and gender differences in camouflaging scores.

A sample of autistic and a sample of non-autistic participants tested the reliability and validity of the CAT-Q-ES. This controls for the possibility that the CAT-Q-ES may measure other social coping behaviors related to neurodivergence (such as impression management)²⁰ rather than specifically measuring camouflaging strategies related to autistic traits.

Methods

Instrument

The CAT-Q is a self-administered questionnaire that analyzes camouflaging strategies in individuals aged 16 years and older without intellectual disability. It consists of 25 items divided into three subscales as follows: Compensation (active behaviors aimed at overcoming social difficulties associated with autism), Masking (hiding autistic characteristics), and Assimilation (adoption of observed behaviors and attitudes to blend in with others in social situations). The items are scored on a 7-point Likert scale, where 1 is strongly disagree and 7 is strongly agree.

Participants

The research group recruited participants using online flyers with a link and a QR code through social network posts, autism association networks, research networks, health care professionals, and distribution during scientific events. The link and the QR code led to an online survey that included sociodemographic and clinical questions regarding autism diagnosis and associated conditions, the CAT-Q-ES, the Broad Autism Phenotype Questionnaire (BAPQ),²¹ the General Anxiety Disorder scale (GAD-7),²² and the Patient Health Questionnaire (PHQ-9).²³ All participants gave their informed consent to take part in the study and did not receive any compensation for participating in the study. The Ethics Committee of the University of Santiago de Compostela (Code: USC 26/2023) reviewed and approved the data collection through an anonymous online survey. We recruited a total of 490 participants, including 111 autistic and 379 non-autistic adults, for the psychometric analysis using an anonymous survey. Autistic adults reported their diagnosis of autism, diagnosis type (autism, Asperger’s, ASD, etc.), diagnosing professional, and age at diagnosis. We excluded 13 individuals who reported being self-diagnosed from the study to maintain sample consistency, minimize potential biases, and provide a clearer comparison between autistic and non-autistic individuals. Non-autistic adults reported that they did not have a formal diagnosis of autism or any other psychiatric condition. This responds to minimize potential biases and reduce diagnostic variability. All participants were 18 years of age or older, Spanish-born or living in Spain, and completed the CAT-Q-ES. The survey also asked participants to report their assigned sex and gender.

Exclusion criteria for autistic adults included self-reported intellectual disability. Exclusion criteria for the non-autistic group included reporting other diagnoses, including neurodevelopmental conditions (ADHD and intellectual disability, among others), psychiatric/psychological conditions, or other neurological conditions like epilepsy. We excluded non-autistic participants with self-reported neurodevelopmental or psychiatric/psychological conditions to ensure homogeneity in the non-autistic subsample and provide a clearer comparison between groups while minimizing potential biases.

The autistic group (age range 18–64; M = 35.82 years; standard deviation [SD] = 10.50) included 76 women (M = 36.41 years; SD = 10.75), 16 men (M = 39 years; SD = 7.98), and 19 non-binary people or people with other genders (i.e., people that report “non-binary gender,” “not sure,” or other genders [M = 31.11 years; SD = 9.93]). In addition, analyses also included 379 non-autistic adults (age range: 18–66 years; M = 32.45 years; SD = 11.12). This sample consisted of 293 women (M = 33.12 years; SD = 11.30), 76 men (M = 30.25 years; SD = 10.53), and 10 non-binary people or people with other genders (M = 27.10 years; SD = 4.28). Overall, the women subsample included 366 cisgender women, two intersexual women, and one woman that did not want to report her birth sex. Among the men’s subsample, there were 91 cisgender men and one transgender man. We conducted internal consistency and validation analyses on this sample. Table 1 presents the means and SDs of the scores for autistic and non-autistic participants across the studied variables. Readers can request participant data, subject to author approval. Seven autistic participants and 32 non-autistic individuals volunteered for the pretest and test–retest reliability, respectively. The Research Ethics Committee of Santiago-Lugo (2020/400) covered this process. We cannot provide the data of the participants in this analysis to protect their anonymity. Readers can find Supplementary Tables online.

Table 1.

Mean and Standard Deviation of Camouflaging, Autistic Traits, and Anxiety and Depression Scores for the Full Sample and Autistic and Non-Autistic Subsamples

	Full sample								ASD subsample								Non-autistic subsample
	All		Women		Men		GD		All		Women		Men		GD		All		Women		Men		GD
	N	M SD	N	M SD	N	M SD	N	M SD	N	M SD	N	M SD	N	M SD	N	M SD	N	M SD	N	M SD	N	M SD	N	M SD
CAT-Q-ES
Total	490	98.3	369	96.7	92	96.0	29	127.3	111	132.3	76	134.9	16	122.4	19	130.2	379	88.4	293	86.7	76	90.4	10	121.9
		33.4		33.8		30.1		22.8		21.4		19.2		28.5		21.5		29.5		29.5		27.5		25.3
Compensation	490	30.8	369	29.7	92	30.9	29	44.7	111	46.6	76	47.2	16	43.6	19	46.6	379	26.2	293	25.2	76	28.2	10	41.0
		14.8		14.7		13.7		12.1		10.7		10.5		11.2		11.13		12.4		12.0		12.7		13.5
Masking	490	34.8	369	34.8	92	33.4	29	40.4	111	40.8	76	42.1	16	36.1	19	39.8	379	33.1	293	32.9	76	32.8	10	41.4
		9.5		9.6		8.8		8.6		8.11		6.7		10.9		9.4		9.2		9.4		8.2		7.3
Assimilation	490	32.7	369	32.1	92	31.7	29	42.3	111	44.9	76	45.7	16	42.8	19	43.7	379	29.1	293	28.6	76	29.4	10	39.5
		12.3		13.0		11.8		8.1		7.4		7.0		8.6		7.6		11.7		11.9		11.0		8.5
BAPQ
Total	440	121.1	328	118.1	86	123.7	26	150.0	103	160.2	70	162.1	16	155.2	17	157.2	337	109.1	258	106.1	70	116.5	9	136.2
		37.1		38.2		30.9		28.4		21.4		20.8		24.1		21.4		32.4		32.8		27.7		35.6
Aloof	440	41.7	328	40.8	86	42.4	26	51.3	103	54.5	70	55.1	16	53.2	17	53.2	337	37.9	258	36.9	70	40.0	9	47.8
		14.2		14.5		12.6		11.2		8.8		8.4		9.8		9.5		13.2		13.4		11.9		13.8
Pragmatics	440	37.6	328	36.5	86	38.6	26	48.0	103	50.7	70	51.1	16	48.6	17	50.6	337	33.6	258	32.5	70	36.3	9	43.1
		12.2		12.4		10.7		9.7		8.4		8.3		9.3		8.1		10.3		10.2		9.6		11.0
Rigidity	440	41.7	328	40.8	86	42.7	26	50.6	103	55.1	70	55.9	16	53.4	17	53.4	337	37.7	258	36.7	70	40.2	9	45.3
		14.0		14.5		11.6		11.5		9.9		10.1		10.2		9.1		12.4		12.6		10.5		14.2
GAD-7
Total	430	9.2	322	9.3	83	8.2	25	12.0	101	14.1	69	14.6	16	13.1	16	12.6	329	7.7	253	7.8	67	7.0	9	10.8
		5.7		5.7		5.5		5.6		5.2		5.0		5.9		5.4		4.9		4.9		4.7		5.9
PHQ-9
Total	425	9.9	319	9.7	81	9.6	25	13.5	99	16.1	67	17.2	16	12.4	16	15.2	326	8.1	252	7.8	65	8.9	9	10.4
		6.8		6.9		6.1		7.2		6.8		6.3		7.4		7.1		5.7		5.6		5.5		6.8

ASD, Autism Spectrum Disorder; BAPQ, Broad Autism Phenotype Questionnaire; CAT-Q-ES, Camouflaging Autistic Traits Questionnaire–Spanish version; GAD-7, General Anxiety Disorder scale; GD, non-binary people or people with other genders people; M, mean; PHQ-9, Patient Health Questionnaire; SD, standard deviation.

Procedure

This study includes the cultural adaptation of the CAT-Q that follows the process proposed by the American Educational Research Association, American Psychological Association, and the International Test Commission in 2021.^24,25 This investigation also followed COnsensus-based Standards for the selection of health Measurement INstruments guidelines for measurement properties. Thus, we performed direct and back translation, pretest with autistic volunteers, reliability analysis (internal consistency and test–retest reliability), and construct validity (structural validity, measurement invariance, and hypothesis testing).^24–28

Cultural adaptation of the CAT-Q

Direct and back translation

Before translating the CAT-Q items, the research team reviewed the original English version to ensure its suitability for reproduction within the cultural context of Spain.²⁹ Two Spanish bilingual translators (one psychologist and one educational psychologist) independently conducted direct translations of the questionnaire from English to Spanish, with subsequent expert committee review (three members of this research team and one author of the original questionnaire CAT-Q). We used a structured approach to review the CAT-Q-ES translation and resolve discrepancies. We accepted the item if the two translations fully coincided. When they differed, the committee analyzed both versions and the original item, prioritizing construct equivalence over literal accuracy. If one translation maintained construct equivalence, the committee chose it; otherwise, we created a new version by combining accurate elements from each translation. The committee retranslated the items that lacked construct equivalence. We conducted a back translation process to ensure that the translated items retained the construct equivalence of the original ones. Different bilingual translators (an expert psychologist in autistic camouflaging and a translator with dual nationality) independently performed the back translation from Spanish to English. The expert committee assessed equivalence between the original and back-translated English versions, proposing alternative translations for items lacking equivalence. All individuals involved in the translation and expert consensus processes were bilingual, and in every step, at least one person had resided in the United Kingdom for at least one year. In addition, as the author of the original CAT-Q instrument is a member of the research team who reviewed the cultural adaptation process, we had the opportunity to receive feedback on specific cultural considerations for the questionnaire.

Pretest with autistic volunteers

The research team requested feedback from seven autistic volunteers (two women, two men, two non-binary persons, and one selected “no response”) to test the feasibility and applicability and to improve the comprehensibility of the text. The group of volunteers evaluated the clarity of the items, suggested improvements, and completed all questionnaire items. During the pretest with autistic volunteers, we asked participants to indicate any issues with item comprehension and to suggest ways to rephrase unclear items to improve clarity. If they could not suggest a rephrasing, the instructions encouraged them to indicate which parts were difficult to understand. The researchers reviewed items that presented difficulty for two or more participants. All participants had Spanish nationality, were Spanish-born, or living in Spain.

A linguistic expert reviewed the cultural adaptation of CAT-Q to Spain to ensure that the final items are linguistic and semantically adapted to the target language and population.

Psychometric analysis

Reliability

Internal consistency

We determined the reliability of the entire CAT-Q-ES scale and its subscales using the concepts of internal consistency (McDonald’s omega [ω]). McDonald’s omega is considered more accurate than Cronbach’s alpha for ordinal test items.^30,31 A value ω > 0.7 indicates acceptable internal consistency, whereas a value ω > 0.8 indicates good internal consistency. We conducted internal consistency analyses using RStudio with the “lavaan” package.^32,33

Test–retest reliability

A sample of 32 non-autistic and bilingual participants (English-Spanish) who were not part of the internal consistency analysis evaluated test–retest reliability. We chose bilingual test–retest technique as an important method to assess the accuracy, adequacy, and stability of the translation of an instrument.^34,35 This process helped ensure that we assessed the tool’s stability, focusing on content equivalence rather than linguistic differences. The bilingual participants’ proficiency in both allowed them to capture the nuances of the language, which was crucial for testing the content equivalence between the Spanish-adapted version and the original version. Therefore, we chose a convenience sample of non-autistic bilingual individuals following Ramada-Rodilla et al.’s guidelines.²⁷ The participants completed both the CAT-Q-ES and the original CAT-Q with a 2- to 3-week interval between assessments. The methodology suggests that a time interval of 15 to 20 days between administrations is necessary to prevent responses from being influenced by changes in the participants’ conditions or the learning effect.^27,36 We computed the stability of the measurements using Pearson correlations and two-way random single measures ICC (intraclass correlation coefficient). Correlation coefficient between 0.90 and 1.00 indicated very high correlation, 0.70 and 0.90 high, 0.50 and 0.70 moderate, and 0.30 and 0.50 low correlation.³⁷ We considered ICC values within the range of 0.50 to 0.75 moderate, those between 0.75 and 0.90 good, and values exceeding 0.90 indicated excellent reliability. We used IBM Statistical Package for Social Sciences (SPSS), version 29 for Windows (IBM Inc.) to carry out test–retest reliability analyses.

Validity

Structural validity

Confirmatory factor analysis (CFA) examined the adequacy of the original 3-factor structure (compensation, masking, assimilation).¹⁸ We used DWLS (diagonally weighted least squares) estimators due to their suitability for ordinal data, such as Likert-scale responses.^38,39 Model fit indicators encompass the Comparative Fit Index (CFI), with values of 0.95 or higher considered indicative of a good fit; the root mean square error of approximation (RMSEA), where values below 0.06 suggest a good fit and values below 0.08 indicate an acceptable fit; and the standardized root mean square residual (SRMR), with values equal to or below 0.08 reflecting an acceptable fit and values below 0.100 suggest a mediocre fit.⁴⁰ We used RStudio with the “lavaan” package to conduct CFA analyses.^32,33

Measurement invariance analysis

This research tested measurement invariance to guarantee that we measured the same latent variables across autistic and non-autistic samples. We also analyzed measurement invariance between binary genders (men and women), including both autistic and non-autistic participants. Furthermore, we conducted separate measurement invariance analyses between binary genders within the non-autistic sample. Measurement invariance analyses across genders excluded non-binary people or people with other genders due to the small sample size. We did not perform measurement invariance analysis across genders in the autistic group given the small sample size. This study assesses configurational, metric, and scalar invariance because invariance at these three levels is the prerequisite for examining differences in means.⁴¹ We used DWLS estimators and standardized factor loadings for these analyses. We used RStudio with the “lavaan” package to conduct this analysis, and we determined measurement invariance by a ΔCFI < 0.01.^32,33,41

Hypothesis testing for construct validity

Comparator instruments

This study analyzed the construct validity of the Spanish cultural adaptation of the CAT-Q-ES with the BAPQ to measure autistic-like traits, GAD-7 to measure general anxiety, and PHQ-9 to measure depression by Spearman correlations. We selected these tools based on the original CAT-Q development study.

We conducted non-parametric tests because the scores of any instrument (CAT-Q-ES, BAPQ, GAD-7, and PHQ-9) did not follow the normal distribution within the full sample. We used IBM Statistical Package for Social Sciences (SPSS), version 29 for Windows (IBM Inc.) to carry out these validity analyses.

Known-groups validity

When the tests of invariance supported the ability to perform between-group analyses, we examined the differences in the total score and subscales of the CAT-Q-ES between diagnostic groups using the Mann–Whitney U test. This study explored gender differences between men, women, and non-binary people or people with other genders within diagnostic groups through Kruskal–Wallis test and post hoc analysis using Dunn’s test. We used Bonferroni corrections and set a p value threshold, considering p values below 0.05 as significant. We carried out non-parametric tests because CAT-Q-ES scores did not follow the normal distribution within the full sample or within diagnostic groups. In gender groups, the CAT-Q-ES scores for women did not follow the normal distribution in any variable. Men’s scores followed the normal distribution in all variables except for Compensation. Non-binary people or people with other genders had scores that followed the normal distribution in all variables except for the CAT-Q-ES total score. We used RStudio to carry out known-groups validity analyses with the exception of Mann–Whitney U test (IBM SPSS, version 29 for Windows [IBM Inc]).³²

Results

Cultural adaptation of the CAT-Q

The direct translation analysis (English-Spanish) found that only 1 item of the CAT-Q-ES has not shown full equivalence between the two translations. Specifically, Item 1, “When I am interacting with someone, I deliberately copy their body language or facial expressions,” had highly similar Spanish translations, except for the omission of the word “deliberately” in one version. The expert committee included this word in the Spanish adaptation to keep close alignment with the original text, resulting in the following Spanish version: “Cuando interactúo con alguien, copio intencionadamente su lenguaje o sus expresiones faciales.”

The back translation analysis reported all items to show adequate equivalence with the original English version. Supplementary Table S1 shows the process of direct and back translation of the CAT-Q into Spanish.

As reported in Supplementary Table S2, the autistic volunteers found comprehension issues in 3 of the 25 items (items 3, 12, and 25), while we applied the suggested changes for 12 other items. They mainly encountered difficulties in comprehension due to the use of double meaning or ambiguous words and negative items. Some participants found the term “normal” inappropriate, yet the research group decided not to accept this comment. Ultimately, the research team made revisions for the 3 problematic items (3, 12, and 25) and accepted for items 7, 11, and 18, enhancing cultural adaptation and equivalence with the original version (see Supplementary Table S2).

The linguistic expert primarily noted minor grammar and orthographic corrections and concluded that the translated text was culturally adapted to the Spanish language and culture.

Reliability

Internal consistency

The internal consistency of the total CAT-Q-ES scale was good in the full sample (ω = 0.95) and in the subsamples of individuals with autism (ω = 0.89) and non-autistic (ω = 0.94). The subscales showed acceptable-good levels of internal consistency across the full sample and the respective subsamples. Specifically, the Compensation subscale exhibited good internal consistency in the full sample (ω = 0.93), non-autistic subsample (ω = 0.91), and autism subsample (ω = 0.85). The Masking subscale demonstrated good internal consistency in the full sample (ω = 0.82) and the non-autistic group (ω = 0.81), while maintaining an acceptable level in the autism subsample (ω = 0.74). Similarly, the Assimilation subscale showed good internal consistency in the full sample (ω = 0.92) and the non-autistic group (ω = 0.90), but an acceptable level in the autism subsample (ω = 0.77).

Test–retest reliability

Thirty-two non-autistic adults aged 22–49 years participated in test–retest reliability analysis. Of this sample, 26 were women (M = 32.75 years; SD = 7.06) and 6 were men (M = 32.2 years; SD = 7.56).

The CAT-Q-ES demonstrated strong test–retest reliability across different measures. Specifically, the total score showed a high correlation between the test and retest administrations (r = 0.99; p < 0.001), indicating a strong and significant association. The ICC also showed a high level of agreement between the test and retest scores (ICC = 0.97; p < 0.05), further supporting the test–retest reliability of the total score. We found similar results for the individual subscales as follows: Compensation (r = 0.97; p < 0.001; ICC = 0.92; p < 0.05), Masking (r = 0.98; p < 0.001; ICC = 0.96; p < 0.05), and Assimilation (r = 0.99; p < 0.001; ICC = 0.97; p < 0.05).

Construct validity

Structural validity

Confirmatory factor analysis

The results show the original three-factor structure (Compensation, Masking, and Assimilation)¹⁸ for the whole sample and for non-autistic individuals. Analysis conducted in the full sample showed a good fit (CFI = 0.991; SRMR = 0.049). The non-autistic sample obtained similar results (CFI = 0.991; SRMR = 0.057). For the autistic sample, while the CFI value indicates an acceptable model fit (CFI = 0.944), a value of SRMR = 0.106 and RMSEA = 0.105 indicate a mediocre fit. Table 2 shows the CFA fit indices for the non-autistic and autistic subsamples and the combined sample.

Table 2.

Fit Indices of the Original Three Factor Structure Using Confirmatory Factor Analysis

	χ²	Df	CFI	RMSEA	SRMR
ASD subsample	600.389^*	272	0.944	0.105 (0.093–0.116)	0.106
Non-autistic subsample	856.637^*	272	0.991	0.075 (0.070–0.081)	0.057
Total sample	918.739^*	272	0.994	0.070 (0.065–0.075)	0.049

p < 0.001.

χ², chi squared; CFI, Comparative Fit Index; Df, degrees of freedom; RMSEA, root mean square error of approximation; SRMR, standardized root mean square residual.

Measurement invariance analysis

Despite the fact that the model fit shows some issues by the SRMR and RMSEA indices in the autistic sample, we decided to proceed with the measurement invariance analyses between diagnostic groups. The research team made this decision based on the satisfactory fit indicated by the CFI and the understanding that both SRMR and RMSEA may tend to increase in small and unbalanced samples.^42,43 The results showed measurement invariance between diagnostic groups, as indicated by a ΔCFI below 0.01, for both item loadings (metric invariance) and intercepts (scalar invariance) when comparing the autistic and non-autistic groups. SRMR fits were below 0.08 in all models, showing a good fit (Table 3). We can conclude that scores from the CAT-Q-ES reliably compare across diagnostic groups.

Table 3.

Measurement Invariance Model Comparison by Diagnosis (ASD = 111, non-Autistic = 379)

Model	χ²	Δχ²	Df	CFI	ΔCFI
1. Configural invariance	668.081		588	0.996
2. Metric invariance	593.077	75	566	0.999	0.003
3. Scalar invariance	668.081	75	588	0.996	0.003

Δχ², chi square difference; ΔCFI, CFI difference.

Regarding measurement invariance across genders, ΔCFI values below 0.01 for Metric and Scalar invariance indicated measurement invariance when comparing women and men, both when including autistic and non-autistic participants (see Supplementary Table S3) and within the non-autistic subsample (see Supplementary Table S4).

Hypothesis testing for construct validity

Comparator instruments

Some participants that completed the CAT-Q-ES did not complete the rest of the instruments (n = 50 in case of BAPQ, n = 60 in case of GAD-7, and n = 64 in case of PHQ-9). Thus, these validity analyses included a total of 440 participants (n = 103 ASD; n = 337 non-autistic) aged 18–64 years (M = 33.26 years; SD = 10.88). The non-autistic sample consists of 258 women (M = 33.26 years; SD = 11.01), 70 men (M = 30.53 years; SD = 10.72), and 9 non-binary people or people with other genders (M = 27.33 years; SD = 4.47). Autistic group included 70 women (M = 36.23 years; SD = 10.94); 16 men (M = 38 years; SD = 9.34); and 17 non-binary people or people with other genders (M = 30.82 years; SD = 9.34). In the entire sample, as well as in the autistic and non-autistic samples individually, results show significant positive correlations between the total CAT-Q-ES score, as well as all CAT-Q-ES factors, with autistic-like traits, general anxiety, and depression. However, the Masking factor did not show a significant relationship with either autistic-like traits or with depressive and anxious symptoms in the autistic sample (Table 4).

Table 4.

Spearman Correlations of the Camouflaging Autistic Traits Questionnaire–Spanish Version Scores with Related Measures

	BAPQ-Total	BAPQ-Aloof	BAPQ-Pragmatic language	BAPQ-Rigidity	GAD-7-Total	PHQ-9-Total
Full sample	n = 440				n = 430	n = 425
CAT-Q-ES total	0.82^**	0.77^**	0.79^**	0.72^**	0.55^**	0.64^**
Compensation	0.76^**	0.68^**	0.76^**	0.67^**	0.49^**	0.56^**
Masking	0.54^**	0.52^**	0.53^**	0.46^**	0.43^**	0.52^**
Assimilation	0.88^**	0.85^**	0.80^**	0.78^**	0.54^**	0.64^**
ASD	n = 103				n = 101	n = 99
CAT-Q-ES total	0.37^**	0.29^*	0.30^*	0.31^*	0.36^**	0.37^**
Compensation	0.31^*	0.21^*	0.30^*	0.26^*	0.27^*	0.27^*
Masking	−0.02	0.08	−0.07	−0.04	0.15	0.17
Assimilation	0.57^**	0.42^**	0.41^**	0.53^**	0.44^**	0.47^**
Non-autistic	n = 337				n = 329	n = 326
CAT-Q-ES total	0.77^**	0.73^**	0.73^**	0.62^**	0.38^**	0.54^**
Compensation	0.67^**	0.59^**	0.69^**	0.55^**	0.30^**	0.44^**
Masking	0.47^**	0.45^**	0.48^**	0.36^**	0.33^**	0.45^**
Assimilation	0.84^**	0.84^**	0.74^**	0.70^**	0.38^**	0.53^**

p < 0.05.

^**

p < 0.001.

Known-groups validity

After checking measurement invariance between diagnostic groups and between binary genders (men and women), including both autistic and non-autistic participants, this study evaluated the effect of diagnosis and gender on the CAT-Q-ES scores. The mean difference (MD) between the autistic and non-autistic groups (Table 5) was significant on the CAT-Q-ES total score and all its subscales, with the autistic group scoring higher in all cases as follows: CAT-Q-ES total (MD = 43.91; p < 0.001), Compensation (MD = 20.33; p < 0.001), Masking (MD = 7.73; p < 0.001), and Assimilation (MD = 15.85; p < 0.001).

Table 5.

Mann–Whitney U Between Diagnostic Groups and Kruskal–Wallis Test with Post Hoc Dunn’s Test Gender Comparisons Within Groups

Scales	Group	Mean (SD)	Mean difference (MD)	U
CAT-Q-ES Total	ASD	132.32 (21.37)	43.91	5067.50^**
	Non-ASD	88.41 (29.49)
Comp	ASD	46.58 (10.67)	20.33	5060.50^**
	Non-ASD	26.25 (12.44)
Masking	ASD	40.82 (8.11)	7.73	10137.50^**
	Non-ASD	33.09 (9.19)
Assim	ASD	44.92 (7.38)	15.85	5873.00^**
	Non-ASD	29.07 (11.73)

Gender differences within groups
	Mean (SD)	Post hoc	χ²
CAT-Q-ES Total
ASD			3.22
Women	134.92 (19.16)	ASD W > ASD GD > ASD M
Men	122.44 (28.47)
GD	130.21 (21.54)
Non-ASD			12.40^*
Women	86.74 (29.48)	Non-ASD GD > Non-ASD W^* Non-ASD GD > Non-ASD M^*
Men	90.43 (27.53)
GD	121.90 (25.34)
Comp
ASD			1.77
Women	47.20 (10.48)	ASD W > ASD GD > ASD M
Men	43.56 (11.25)
GD	46.63 (11.13)
Non-ASD			13.79^*
Women	25.23 (11.98)	Non-ASD GD > Non-ASD W^** Non-ASD GD > Non-ASD M^*
Men	28.25 (12.73)
GD	41.00 (13.47)
Masking
ASD			4.56
Women	42.07 (6.71)	ASD W > ASD GD > ASD M
Men	36.06 (10.88)
GD	39.84 (9.39)
Non-ASD			7.61^*
Women	32.87 (9.37)	Non-ASD GD > Non-ASD W^* Non-ASD GD > Non-ASD M^*
Men	32.83 (8.24)
GD	41.40 (7.29)
Assim
ASD			2.88
Women	45.66 (7.02)	ASD W > ASD GD > ASD M
Men	42.81 (8.61)
GD	43.74 (7.61)
Non-ASD
Women	28.64 (11.86)	Non-ASD GD > Non-ASD W^* Non-ASD GD > Non-ASD M^*	8.47^*
Men	29.36 (11.04)
GD	39.50 (8.53)

p < 0.05.

^**

p < 0.001.

Assim, Assimilation; Comp, Compensation; M, men; non-ASD, non-autistic subsample; U, Mann–Whitney U; W, women.

Regarding gender differences within groups, Kruskal–Wallis test (Table 5) did not show significant gender differences in the CAT-Q-ES total score in the autistic sample [χ²(2) = 3.22, p = 0.200], Compensation [H(2) = 1.77, p = 0.412], Masking [χ²(2) = 4.56, p = 0.102], or Assimilation [χ²(2) = 2.88, p = 0.237]. In contrast, the results found significant gender differences for CAT-Q-ES total score [χ²(2) = 12.40, p = 0.002], Compensation [χ²(2) = 13.79, p = 0.001], Masking [χ²(2) = 7.61, p = 0.022], and Assimilation [χ²(2) = 8.47, p = 0.014] in the non-autistic sample. Bonferroni-adjusted pairwise comparisons revealed that non-binary people or people with other genders scored significantly higher than both women and men across all variables. For CAT-Q-ES Total, non-binary people or people with other genders had significantly higher scores compared with women (Z = −3.45, p = 0.002) and men (Z = −2.93, p = 0.010). We observed similar patterns for Compensation (Z = −3.38, p = 0.002 for women; Z = −2.53, p = 0.034 for men), Masking (Z = −2.75, p = 0.018 for women; Z = −2.64, p = 0.025 for men), and Assimilation (Z = −2.89, p = 0.012 for women; Z = −2.54, p = 0.033 for men). The analyses did not find significant differences between women and men across any of the variables within the non-autistic sample.

Discussion

The CAT-Q is an instrument widely used in research, with great utility for clinical practice as it may help identify camouflaging within the diagnostic process. Given the increasing prevalence of autism diagnoses due to changes in definitions,⁴⁴ social awareness, and improving primary care resources,⁵ there is a need for tools that help women to receive an early diagnosis on par with men.

This research is the first to provide a reliable and validated cultural adaptation of a camouflaging assessment for the Spanish population. The study followed a replicable and internationally accepted methodology for the cultural adaptation of assessment instruments that included direct-back translation, pretest with autistic participants, and process of psychometric analysis.^24–28

Different cultural adaptations of the CAT-Q carried out similar initial methods to our study (direct-back translation), but they did not disclose the sample used for the final version of the instrument.^30,39,40,45 In addition, none of these adaptations reported the feedback from the autistic community. Following other Spanish adaptations,^36,46 the present study carried out a pretest to examine comprehension and feasibility.^24,28

The Spanish adaptation of the CAT-Q resulted in a suitable instrument for autistic individuals with the most items (88%) perceived as clear and understandable (refer to Supplementary Table S2). Autistic volunteers revealed comprehension difficulties on three items (3, 12, and 25), with comprehension issues mainly due to double-meaning or ambiguous words and negative phrasing. Based on participants’ comments, the research team modified these items and three others to ensure better understanding without compromising literalness. In addition, some participants found the term “normal” inappropriate, yet the research group decided to retain it for its importance in understanding one motivation underlying autism social camouflaging.⁴⁷

Relating to psychometric properties, the present results demonstrate acceptable-excellent internal consistency and high stability in both subscales and the overall score of the CAT-Q-ES, congruent with other versions of CAT-Q.^{30,39,40,45,48}

Regarding structural validity, the present findings conformed to the original factor structure for the entire sample and the non-autistic group. Nevertheless, the model fit indices (RMSEA and SRMR) for the autistic sample suggest a mediocre fit mean, whereas the CFI implies an acceptable fit, showing discrepancies in the model fit for this group (Table 2), likely attributed to the limited sample size.^42,43

In line with the initial study,¹⁸ the present research also found measurement invariance across diagnostic groups (Table 3), despite autistic group overscoring on all CAT-Q-ES subscales. This implies that the measured construct is psychometrically equivalent between groups.⁴¹ In addition, the present investigation found measure invariance in binary genders in the non-autistic subsample and in the whole sample (see Supplementary Tables S3 and S4). In conclusion, the factorial structure of the CAT-Q-ES remains consistent across diagnostic groups. Although there are discrepancies in the model fit for the autistic sample, conducting invariance analyses (metric and scalar) strengthens this conclusion by showing that the measurement is equivalent across diagnostic groups. Other CAT-Q validations found noninvariance of the measure between diagnostic groups.^28,40 Cultural specificities, differences in study design (i.e., including an autistic group for advice), and sample characteristics like participant’s age may have influenced these differences between studies.³⁹

The CAT-Q-ES scores correlated positively with autistic-like traits, depression, and anxiety (Table 4), consistent with prior validations.^18,30,45 In the present study, the Masking factor was not related with autistic-like traits in the ASD sample, possibly because masking relates more to self-identification as autistic than to the presentation of specific characteristics.¹⁸ Furthermore, while the total sample and non-autistic group showed positive correlations between the Masking factor and general anxiety or depression, no direct relationship appeared in the ASD sample. These results support the theory that autistic people, especially women, may camouflage depressive symptoms.^9,12 In contrast, the French version of the CAT-Q found positive and significant correlations with measures of depression hinting at potential cultural differences.³⁰ Anxiety has been positively associated with camouflage in most of the evidence.¹³ However, some studies have not found this association.^9,16

Although the findings in the literature are diverse, a recent work indicates the high prevalence of autistic people that report a transgender identity, as well as a notable prevalence of transgender individuals with an autism diagnosis.⁴⁹ The current study established known-groups validity of CAT-Q-ES through varying scores across groups and genders (women, men, non-binary people, or people with other genders; see Table 5). Some studies have not found consistent differences between autistic and non-autistic camouflaging behaviors using the CAT-Q.^20,50,51 Researchers have theorized that camouflaging is a coping response related to any type of stigmatization, such as those related to sexuality, ethnicity, mental illness, invisible disabilities, and more. Therefore, many people can relate to these strategies.²⁰ However, the present study found significant differences using a sample of non-autistic individuals while controlling for other neurodevelopmental, psychological, and psychiatric conditions.

Autistic women scored higher than autistic men on the overall CAT-Q-ES. In line with other research, these results are not extrapolated to the non-autistic group, where men scored higher than women, except for the Masking factor.¹¹ These outcomes further support the questionnaire’s construct validity, as it effectively discriminates between diagnostic groups. In line with other studies,²⁸ the Masking factor displayed the smallest mean difference between the ASD and non-autistic groups in the present study.

Researchers have theorized that a combination of neurobiological, developmental, and cognitive factors, as well as gendered social expectations, may lead autistic women to engage more in camouflaging behaviors and, therefore, not receive ASD diagnoses as often as men.^11,12 Furthermore, other investigations have suggested that autistic women may show behavioral traits, such as masking autistic traits, in a manner that differs from autistic men. This could be one of the reasons why autism is underdiagnosed in women.^14,52,53

A novel aspect of the present study was the inclusion of a small group of non-binary people or people with other genders. While autistic non-binary people or people with other genders did not surpass autistic women, in the non-autistic sample they scored significantly higher than both women and men in the total CAT-Q-ES, Compensation, Masking, and Assimilation (see Table 5). Other validations of the CAT-Q reflect contradictory results on gender differences. Some have reported that autistic females obtained higher total scores than autistic males, but non-autistic females do not exhibit more camouflaging behaviors than males.^39,40 While other studies found that autistic females scored higher on Assimilation than males,⁵⁴ other investigations did not find gender differences when applying their adapted versions of the CAT-Q.^30,48 One study suggested that autistic females reported more camouflaging behaviors than men and non-binary individuals, but gender differences in the non-autistic group were minimal.¹¹ Given these findings, researchers need to conduct future studies with a larger gender-representative sample to better understand gender differences in social camouflage in both autistic and non-autistic individuals.

Implications for clinical practice

The development of the CAT-Q-ES has important implications for clinical practice in Spain. The total score of the CAT-Q-ES can help clinicians in identifying if patients are masking some of their difficulties and to what degree. A higher score is linked to symptoms of generalized anxiety, depression, and social anxiety, but this association exists throughout the entire range of camouflaging.⁵⁵ Therefore, a more thorough evaluation of autistic traits and potential psychological/psychiatric co-occurring conditions is necessary. In addition, the CAT-Q-ES tool classifies camouflaging behavior into three subscales, enabling clinicians to identify different strategies and find where to focus their attention.

Moreover, future research could use CAT-Q-ES to evaluate the hypothesis that camouflaging is a dimensional experience across different neurotypes, by applying it to a more neurodiverse sample. In this context, CAT-Q-ES could serve as a screening tool to assess autistic traits, anxiety, and depression symptoms in neurodivergent individuals.

Limitations

The use of online communication methods has shown significant benefits in autism research, enhancing accessibility and communication within the autistic population.^56–58 Online methods offer advantages such as recruiting larger samples, overcoming geographical limitations, promoting inclusivity, minimizing human errors, and improving participant comfort.^59–62 However, despite these advantages, there are limitations associated with online data collection that affect the present study.

One primary limitation of online studies is the potential for biased samples, as they may attract individuals with specific interests, higher cognitive abilities, and moderate-to-high socioeconomic status.^63–65 The study focuses on the cultural adaptation and validation of a tool that promotes the diagnosis process of autism, thereby improving the quality of life of the Spanish autistic population, particularly adult autistic women. The current sample is limited by an overrepresentation of women, which results in a lack of representativeness of the autistic population due to the inverted gender ratio. A limitation of this study is the inability to verify the accuracy of self-reported diagnoses of autism, which could potentially impact the reliability of the results. Like other online studies, the current online survey required information about the diagnostic process to control for “scammer” participants.^18,30,48,54 However, it is still possible that some self-reported clinical diagnoses may not be truthful.

Another limitation comes from recent research that argues against back translation for not considering it sufficient to ensure that the translated text is linguistically and culturally adapted to the target population.⁶⁶ The present study has implemented a pretest stage to determine that the items of the CAT-Q-ES are comprehensible and a linguistic expert revised the text to check that the text is adapted to the target language and population. Although we have used this methodology, there are different procedures for culturally adapting measures. For instance, DuBay et al. proposed some guidelines for translating and culturally adapting parent-report tools that involve a multidisciplinary team with translators trained in different types of equivalence, assessing the quality of the reproduction of the test (including back translation and cognitive interviews/pretesting) and a pretest stage within the target population.²⁹

It should be noted that the test–retest analyses did not include autistic participants. While the questionnaire is applicable to both autistic and non-autistic individuals, not including autistic participants in this analysis is a limitation for the generalization of the results. However, this analysis aimed to ensure linguistic equivalence and stability, not to assess specific validity in the autistic population. Future studies could replicate this analysis in an autistic sample to fully validate the temporal stability of the questionnaire.

We need to address some limitations about the instruments used to compare the CAT-Q-ES score. The BAPQ version used in this study was an online version from which we could not find out the translation process. Originally developed for relatives of autistic individuals, this brings into question its validity when measuring autistic traits.⁶⁷ In contrast, the BAPQ has shown its validity to assess autistic traits in both autistic and non-autistic populations.⁶⁸ Future research could benefit from a culturally validated measure of autistic traits that has been explicitly developed for use in autistic populations to improve the robustness of the results. Regarding the PHQ-9 and GAD-7, these widely used screening tools assess criteria for major depressive and generalized anxiety disorders, respectively. However, they are not diagnostic instruments and may not capture the full range of anxiety and depression symptomatology, which should be considered when interpreting the results.

This study focuses on the cultural adaptation of the CAT-Q for the Spanish population. However, it is important to note that using this tool in Spanish-speaking populations from Latin American countries may require further revisions to ensure that the text is culturally appropriate for the specific context of each country and understandable to its population.

Conclusion

This study highly suggests that the Spanish version of the CAT-Q is a suitable tool that analyzes camouflaging in autistic people in Spain. The CAT-Q-ES has adequate reliability and validity data, offering Spanish clinicians and researchers a psychometrically sound measure. However, as we did not conduct the test–retest in autistic individuals, we cannot generalize the test–retest results to the autistic population. This research supports the idea that camouflage may be more associated with women than men in autism. However, future research with a larger gender-diverse sample is required to investigate measurement invariance between genders. Finally, this research adapts a tool for European Spanish speakers. Cultural adaptations for other Spanish speaking countries are needed to address potential cultural differences.

Footnotes

Acknowledgments

The authors thank those involved in translation and questionnaire review, specially to the autistic individuals who participated in the study. Fundación María José Jove supported this work.

Authorship Confirmation Statement

S.C.-P.Z.: Conceptualization, methodology, formal analysis, data curation, investigation, writing—original draft, and writing—review and editing; M.L.-M.: Conceptualization, methodology, formal analysis, investigation, and writing—original draft; M.T.-F.: Conceptualization, methodology, formal analysis, data curation, investigation, and writing—review and editing; M.A.-N.: Investigation and writing—review and editing; L.H.: Conceptualization and writing—review and editing; A.C.: Supervision, project administration, and funding acquisition; B.G.-G.: Conceptualization; methodology, investigation, writing—original draft, and writing—review and editing; M.F.-P.: Conceptualization, project administration, methodology, investigation, supervision, and writing—review and editing. The article has been submitted solely to Autism in Adulthood.

Author Disclosure Statement

The authors declare that they conducted the research without any commercial or financial relationships that could be construed as a potential conflict of interest.

Funding Information

This work received funding from Instituto de Salud Carlos III (PI22/00208). The Xunta de Galicia supported S.C.-P.Z. by a predoctoral fellowship.

Supplementary Material

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