The Hidden Face of Autism: Why Camouflaging Delays Diagnosis in Children

For some children with autism, the clearest sign of the condition is not what they show, but what they hide. A new retrospective study from Ege University in Türkiye has examined a group of 46 children and adolescents who received an autism spectrum disorder (ASD) diagnosis only after the age of six, some as late as 18, and found that camouflaging behaviors, co-occurring psychiatric conditions, and individual strengths may all conspire to keep core autistic features out of view. The findings, published in Frontiers in Child and Adolescent Psychiatry, offer one of the most detailed clinical portraits yet of a pediatric population that has long been overshadowed by research on autistic adults.

The research team, led by clinicians at the Department of Child and Adolescent Psychiatry at Ege University Faculty of Medicine in İzmir, reviewed the medical records of children and adolescents aged 6 to 21 who had been diagnosed with ASD after their sixth birthday. Every diagnosis had been confirmed using the Autism Diagnostic Observation Schedule, Second Edition (ADOS-2), a standardized observational assessment conducted by a senior child and adolescent psychiatrist with more than two decades of autism expertise. The team then extracted data using structured case report forms that drew on clinical records, parental reports, and a literature-informed checklist of camouflaging-related features, scoring masking, camouflaging, and compensatory strategies on a 0-to-10 visual analog scale.

The results paint a picture of striking diagnostic complexity. Attention-Deficit/Hyperactivity Disorder (ADHD) was by far the most common co-occurring psychiatric condition, present in 89.1 percent of the sample, followed by anxiety disorders at 26.1 percent, obsessive-compulsive disorder and major depressive disorder at 17.4 percent each, and specific learning disorder at 15.2 percent. This prevalence of ADHD is consistent with the concept of diagnostic overshadowing, in which the visible symptoms of one condition, such as hyperactivity and inattention, draw clinical attention away from the subtler social communication difficulties that define autism. Previous research has shown that children first diagnosed with ADHD experience longer delays before an eventual ASD recognition, and the new findings reinforce that pattern in a pediatric clinical setting.

Sex-related differences in presentation emerged as a central theme. Masking-related social adaptation behaviors, defined in the study as a child’s attempts to imitate peers in order to communicate and play, or to participate in social settings when invited even without intrinsic inclination, were the only camouflaging-related characteristic that differed significantly between girls and boys, and they were markedly more frequent among girls (p = 0.001). Giftedness and easy temperament, categorized as compensatory factors, were also observed more frequently in girls and were identified among the factors associated with delayed recognition. In contrast, boys showed significantly greater behavioral difficulties than girls, a pattern suggesting that more overt, externalizing symptoms may lead to earlier recognition in boys, while girls, who often display more subtle and internalized patterns, may face greater risk of delayed diagnosis.

The gendered nature of camouflaging strategies has been documented in prior research. Autistic girls are more likely to engage in socially oriented camouflaging, such as imitating peers’ gestures and facial expressions, memorizing conversational scripts, and closely observing social interactions to learn norms. Autistic boys, by contrast, tend to suppress atypical behaviors like stimming and limit social engagement rather than actively imitate. The new study’s finding that social adaptation behavior was the only masking-related factor differing between sexes aligns with the hypothesis that gendered socialization, which often encourages girls to appear more social and to model socially appropriate behaviors, may increase the risk that core autistic features in girls remain hidden, thereby delaying or obscuring diagnosis.

When families were asked directly about the reasons for the delayed diagnosis, the most frequently cited factors were the failure of consulted physicians to diagnose ASD (58.7 percent), high intelligence (43.5 percent), delayed referral to a psychiatrist (39.1 percent), difficulty accepting the diagnosis by families (34.8 percent), and having at least one family member with similar traits (30.4 percent). Camouflaging itself was identified as a reason for delay in 78.3 percent of cases. Only 39.1 percent of families had suspected ASD before the child turned six, and among those who had, 64.3 percent reported receiving a non-ASD diagnosis instead. These findings echo earlier work showing that delayed diagnoses can occur even when evaluations are carried out by multidisciplinary teams, underscoring the need for post-graduate education focused on less overt autism presentations.

The clinical stakes of late diagnosis are considerable. Early identification of autism is closely linked to access to appropriate support services, educational resources, and community programs, and it reduces parental stress while enhancing adult independence. Missed diagnoses restrict access to crucial early interventions during critical developmental periods. In the new study, the initiation of appropriate treatment and interventions following the late ASD diagnosis was associated with a significant decrease in Clinical Global Impression severity scores, from 4.45 to 2.80, and a significant increase in Global Assessment Scale functioning scores, from 52.71 to 73.04 (p < 0.001 for both). These retrospective changes suggest potential clinical benefits associated with accurate diagnosis and appropriate management, even when recognition comes years after the first referral.

One of the more technically intriguing results concerns the relationship between camouflaging and post-diagnosis functioning. Clinician-rated camouflaging scores demonstrated a moderate positive correlation with post-diagnosis Global Assessment Scale scores (r = 0.38, p = 0.009), a finding that contrasts with adult literature linking camouflaging to increased psychological burden and autistic burnout. However, this association was no longer statistically significant after controlling for baseline GAS using partial correlation, suggesting that the observed relationship may partly reflect pre-existing differences in functioning rather than a direct effect of camouflaging itself. Camouflaging rate was also correlated with follow-up CGI score (r = -0.36), CARS score (r = 0.43), and baseline CGI score (r = 0.33). In a multiple linear regression model predicting follow-up CGI scores, camouflaging rate, CARS score, and age at ASD diagnosis were all significantly associated with the outcome, while baseline CGI was not.

The study also documented the broader mental health context of this late-diagnosed group. Nine cases (19.6 percent) had a history of non-suicidal self-injury, most commonly self-cutting, two cases had a history of suicide attempts, and 17.3 percent reported passive suicidal thoughts. Previous research has shown that autistic individuals are at markedly increased risk of self-injury and suicidality compared to the general population, and such behaviors are often under-recognized in individuals with late or overshadowed diagnoses, where emotional and behavioral difficulties may mask core autistic features. The authors suggest that ASD screening is critical for cases presenting with self-harm and suicide attempts. Sensory sensitivities were present in 78.3 percent of participants, spanning visual, auditory, olfactory, gustatory, and tactile domains, a rate consistent with prior estimates ranging from 45 to 95 percent and a potential clinical clue during the diagnostic process.

The authors are careful to frame these findings as exploratory. The retrospective design, the small sample size of 46 participants, the single cultural context, and the use of a clinician-developed case report form rather than a standardized pediatric camouflaging instrument all limit generalizability. The gender imbalance in the sample, with 23.9 percent female and 76.1 percent male, may also have constrained the ability to detect sex-related differences in age at diagnosis. Notably, no significant difference was found between the diagnosis ages of girls and boys in this sample, a result that contrasts with previous findings of longer delays in females and may reflect the younger age of the cohort or the sample’s gender imbalance. The authors call for further prospective research using developmentally appropriate pediatric measures of camouflaging to clarify how these behaviors unfold across childhood and adolescence, and whether targeted assessment tools could capture the nuances of less overt autism presentations to improve diagnostic equity for all children on the spectrum.

Subject of Research: Clinical characteristics and camouflaging behaviors in children and adolescents with late-diagnosed autism spectrum disorder: a retrospective descriptive study

Article Title: Clinical characteristics and camouflaging behaviors in children and adolescents with late-diagnosed autism spectrum disorder: a retrospective descriptive study

Article References: Özbaran, N. B., Şener, Z. İ., Sarı, S., & Korkmaz Şahin, G. (2026). Clinical characteristics and camouflaging behaviors in children and adolescents with late-diagnosed autism spectrum disorder: a retrospective descriptive study. Frontiers in Child and Adolescent Psychiatry, 5, Article 1910194. https://doi.org/10.3389/frcha.2026.1910194

Image Credits: AI Generated

DOI: 10.3389/frcha.2026.1910194

Keywords: Clinical, characteristics, camouflaging, behaviors, children, adolescents, late-diagnosed, autism, spectrum, disorder, retrospective, descriptive