The trend to stop hiding autistic symptoms and experiences — so-called “unmasking” — may help clinicians diagnose the condition, especially among teen girls and young women, experts say.

Celebrities are revealing their autistic tendencies. The Netflix series “Love on the Spectrum” has been renewed for a fifth season. And neurodivergence clubs are forming on high school and college campuses.

There are even influencers with autism. Their posts are fueling self-diagnosis and unmasking, and the content resonates with young females. Knowing this can help clinicians spot autism in a population that historically has been underdiagnosed. It can also provide a unique opportunity to help patients that goes beyond confirming or ruling out a diagnosis.

“All teens are looking for belonging. They’re looking for their people. That’s what adolescence is about — figuring out who you are and where you fit in,” said Ericka Wodka, PhD, ABPP-CN, a clinical neuropsychologist at Johns Hopkins and director of the Center for Autism Services, Science and Innovation at Kennedy Krieger Institute in Baltimore.

Regardless of labels, she said, “guiding people in the right direction toward the things that are going to be valuable and meaningful to them is really what our job is.”

Why Masking (and Unmasking) Should Be On Your Radar

Masking is when a person uses their “own understanding of what is expected of them” to hide their natural tendencies, said Joshua Rothman, MD, MS, an assistant clinical professor of pediatrics at UC San Diego. They might force themselves to make eye contact, suppress the urge to make repetitive motions, or ask how somebody’s feeling even if it makes them uncomfortable.

More people are choosing to drop the act.

Being themselves feels good, they say. On TikTok, people with autism talk about the relief unmasking brings them. They report a sense of authenticity after no longer pretending to be someone they’re not. They don’t feel burned out from trying to fit in. They feel at peace.

Girls with autism traditionally mask at higher rates than their male counterparts. In February, a study in The BMJ showed that the 4:1 male to female childhood autism diagnosis ratio equalizes to 1:1 by age 20 — meaning there are just as many females as males with autism, but female diagnosis is delayed.

“We need to identify some of those same signs earlier, so we can make the diagnosis earlier and so we can support those adolescent girls and young women earlier in life. And then they don’t get to the point where they’re feeling like they have to mask,” said Rothman.

How to Recognize Masking

Asking a patient about masking behavior can be a key diagnostic tool, some experts say. The key is to listen and ask patients about their experiences. Both patients and their parents can help you identify social adjustment behaviors.

“What’s really important is how much stress does that cause them?” said Wodka, whose research focuses on autism diagnosis and girls on the spectrum.

Keep in mind that everybody socially adjusts, such as during public speaking, she said.

But those with autism are “doing it so much, and it’s so effortful that it’s draining. They talk about burnout from it. And so then it has that additional impact of causing anxiety, causing stress, causing fatigue,” Wodka said.

Ask these questions to understand your patient’s experience:

• How much are you masking?
• What does masking look like for you?
• What does it feel like for you?

Ask parents whether their child role-plays before social events such as birthday parties or if the child is able to hold it together throughout the school day but turns irritable at home because they are in a safe space.

The Dx vs What Helps

Sometimes the patient isn’t the one seeking an autism diagnosis. It’s the parents, and they’re determined for you to make it official.

Parental awareness is higher than ever, said Rothman. His recent JAMA Network Open analysis showed a startling jump in off-label leucovorin prescribing for autism after CBS News and The White House separately raised awareness of the practice.

People respond when the media highlights a condition, Rothman said. “They start looking into it. They start sharing their own experiences. And we need to, as clinicians, be responsive to that situation. We need to come to them in a compassionate way and ask questions.”

Social media gets patients “through the door,” Rothman said. But it’s the clinician’s investigation that “really helps that family move forward.”

Take note when an autism diagnosis seems to be a goal. Find out what your patient is struggling with and identify ways to help.

Wodka often tells parents: “Diagnoses are like a box, and with kids, their arms pop out and they don’t always fit perfectly in these boxes. But we use these diagnoses to guide the next steps and what is going to help a person the most,” she said.

“To mislabel something as autism that is ADHD [attention-deficit/hyperactivity disorder], or vice versa, is not going to be in the person’s best interest,” she said.

This explanation — that the diagnostic process is imperfect — often resonates with parents, she said.

What About Those Who Want a Diagnosis but Don’t Get One?

Wodka reinforces what they can do for the symptoms the family considers problematic. She also tells them, “We can look at this again in a couple years to see if anything has changed.”

“Sometimes you see a patient and the anxiety is so prevalent that you can’t see anything past that, and so the discussion is, ‘Let’s address the anxiety, and then once we do that, let’s see what’s left.’ And maybe there aren’t other symptoms and really the anxiety is kind of the primary.”

This is tricky for clinicians when it comes to girls and young women, she said, because they also need to be alert to diagnostic overshadowing — when a symptom could fit multiple conditions, sometimes leading to a missed diagnosis.

“Girls are much more likely to first be diagnosed with a mood disorder like depression or anxiety and not have their autism identified,” she said. “That’s because, in general, mood disorders are more prevalently identified in females than [in] males, and so that will delay the autism diagnosis.”

Wodka advised staying aware of the potential for co-occurrence. “We do know that autism can often lead to mood concerns because they’re not getting the supports they need for the autism and don’t have effective coping strategies.”

The experts cited in this article reported no relevant disclosures.