Camouflaging Autistic Traits Questionnaire (CAT-Q)

The Camouflaging Autistic Traits Questionnaire (CAT-Q) is a 25-item self-report measure designed to assess camouflaging strategies in individuals aged 16 years and older (Hull et al., 2019). Camouflaging refers to strategies that people may use to adapt to or mask their autistic traits during social interactions, often to navigate a predominantly neurotypical social environment. The CAT-Q assesses the extent to which camouflaging strategies are used and is particularly relevant for identifying Autism in females and gender diverse people, who may be underdiagnosed or misdiagnosed due to their ability to mask autistic traits.

Example CAT-Q Items

The CAT-Q provides scores for overall camouflaging as well as three subscales:

• Compensation: Strategies for overcoming social challenges, such as using learned social scripts or imitating behaviours.
• Masking: Efforts to hide or suppress Autistic traits to appear more neurotypical.
• Assimilation: Attempts to fit into social situations, such as modifying behaviours to blend in.

The CAT-Q has useful clinical applications in addition to its utility in screening and assessment. Results can be integrated into formulation and treatment, help validate the experiences of Autistic people, and facilitate self-awareness. The nuanced understanding of camouflaging provided by the scale can assist with the identification of treatment targets and guide the development of coping strategies to help reduce negative impacts of camouflaging on well-being, while also recognising its adaptive aspects.

While the CAT-Q provides valuable insights into camouflaging strategies and can be a useful part of a comprehensive assessment for Autism, scores may also reflect phenomena other than, or co-occurring with, Autism (e.g., people with social anxiety may show greater use of camouflaging strategies). It is important to interpret the results within the context of the individual’s developmental history, personal characteristics, and social environment.

The Camouflaging Autistic Traits Questionnaire (CAT-Q) provides scores for overall camouflaging as well as three subscales, with higher scores indicating greater use of camouflaging strategies.

• Compensation (Items 1, 4, 5, 8, 11, 14, 17, 20, and 23). Strategies for overcoming social challenges, such as using learned social scripts or imitating behaviours.
• Masking (Items 2, 6, 9, 12, 15, 18, 21, and 24). Efforts to hide or suppress Autistic traits to appear more neurotypical.
• Assimilation (Items 3, 7, 10, 13, 16, 19, 22, and 25). Attempts to fit into social situations, such as modifying behaviours to blend in.

The respondent’s total and subscale scores are expressed as percentiles based on normative data for Non-Autistic adults of the same gender (e.g., male, female, or non-binary) (Baker et al., 2024; Hull et al., 2020). The percentiles contextualise the respondent’s scores relative to the typical scores of Non-Autistic adults. For example, the 50th percentile represents typical levels of camouflaging among Non-Autistic adults, while scores on the 90th percentile fall within the top 10% when compared to Non-Autistic adults.

The scoring approach uses qualitative descriptors to categorise CAT-Q scores (Baker et al., 2024). Each qualitative descriptor corresponds to a specific range of scores. The ranges for these descriptors were determined using percentiles derived from a Non-Autistic sample of 472 male, female, and non-binary adults obtained from a study by Hull and colleagues (2020). The ranges for the total CAT-Q score are as follows.

• Extremely Low (total score of 25 to 51) (less than or equal to the 5th percentile)
• Low (total score of 52 to 75) (percentile between 6 and 24)
• Moderate (total score of 76 to 112) (percentile between 25 and 75)
• High (total score of 113 to 136) (percentile between 76 and 94)
• Extremely High (total score of 137 to 175) (greater than or equal to the 95th percentile)

Graphs comparing the respondent’s total and subscale scores to the normative distribution of scores among Non-Autistic and Autistic individuals are presented, with shaded areas corresponding to scores between the 25th and 75th percentile. This graph contextualises the respondent’s scores relative to typical levels of camouflaging among Non-Autistic and Autistic adults.

If administered more than once, a meaningful change in camouflaging is defined as a change of 13 or more points in the total score based on a Minimally Important Difference (MID) calculation.

It is recommended to interpret CAT-Q scores in light of the following considerations.

• Firstly, sex and gender differences exist in camouflaging, with Autistic females and non-binary and gender-diverse Autistic people typically scoring higher than Autistic males (Cook et al., 2021; Hull et al., 2020). Considering camouflaging is particularly important when assessing Autism in these groups, as greater use of camouflaging strategies may result in lower scores on measures of autistic traits (Cook et al., 2021, 2024).
• Secondly, while camouflaging strategies are often associated with Autism — particularly among females and non-binary and gender-diverse individuals — they are not an inherent feature of, or specific to, Autism (Lai et al., 2020). Camouflaging represents strategies used by both Autistic and Non-Autistic people to adapt to and navigate social environments. The CAT-Q does not fully differentiate camouflaging strategies used by Autistic people from similar strategies used by Non-Autistic people.
• Thirdly, some items on the CAT-Q may conflate autistic camouflaging with similar strategies arising from social anxiety or other mental health challenges (Fombonne, 2020). High scores may therefore reflect efforts to manage social anxiety or neurodivergence more broadly (e.g., ADHD).
• Lastly, greater use of camouflaging is associated with increased mental health challenges among Autistic adults (Cook et al., 2021). Although the direction of this relationship is not yet understood, it underscores the importance of considering mental health challenges when interpreting CAT-Q scores.

The Camouflaging Autistic Traits Questionnaire (CAT-Q) demonstrates robust psychometric properties (Hull et al., 2019). It shows high internal consistency for the total scale (Cronbach’s alpha = 0.94) and subscales: Compensation (0.91), Masking (0.85), and Assimilation (0.92). It also shows good test-retest reliability for the total scale and subscales over a three-month interval (rs = 0.77, 0.78, 0.70, and 0.73, respectively).

The CAT-Q was validated on an age- and gender-diverse sample of 306 Autistic and 472 Non-Autistic adults (mean age = 34.56 years, SD = 14.89 years), allowing for meaningful interpretation of a respondent’s total score and subscale scores relative to both Autistic and Non-Autistic adults of the same gender (Hull et al., 2020). The means and standard deviations for the total score and subscale scores among key groups are as follows:

Autistic:

• Total: Male 109.64 (26.50); Female 124.35 (23.27); Non-binary 122.00 (17.12)
• Compensation: Male 36.81 (12.14); Female 41.85 (11.11); Non-binary 43.50 (9.89)
• Masking: Male 32.90 (10.57); Female 37.87 (10.54); Non-binary 36.06 (8.78)
• Assimilation: Male 39.93 (11.26); Female 44.63 (7.82); Non-binary 39.88 (6.43)

Non-Autistic:

• Total: Male 96.89 (24.22); Female 90.87 (27.67); Non-binary 109.44 (27.20)
• Compensation: Male 30.06 (10.92); Female 27.18 (11.5); Non-binary 35.48 (11.32)
• Masking: Male 36.34 (8.13); Female 34.69 (9.05); Non-binary 38.70 (7.61)
• Assimilation: Male 30.48 (10.33); Female 29.00 (11.73); Non-binary 35.26 (12.11)

The above means and standard deviations are used to convert the respondent’s score to percentiles, providing useful information about their use of camouflaging strategies relative to Autistic and Non-Autistic adults of the same gender (Baker et al., 2024). For respondents whose gender is unspecified, percentiles are based on the pooled means and standard deviations for males, females, and non-binary individuals.

While the CAT-Q demonstrates robust psychometric properties, concerns about construct validity remain, particularly regarding its overlap with similar constructs and strategies related to adapting to social norms, social anxiety and other mental health challenges, or neurodivergence more broadly (e.g., ADHD) (Fombonne, 2020; Lai et al., 2020).

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