People with autism use a variety of strategies to ‘pass’ as neurotypical in social situations, a near-constant effort that can help them build relationships, but can also take a toll on mental health, concludes a new study published in The Lancet Psychiatry.

Neurotypical describes the majority of the world’s population — people who don’t display characteristics of autism or other atypical patterns of thought, behavior or mental processing.

Researchers say these compensation efforts might help explain why autism has been linked to mood disorders like depression, and why some people on the spectrum, especially girls and women, fly under the radar of clinicians and receive either a delayed diagnosis or none at all.

Autism is a neurodevelopmental disorder characterized by repetitive behaviors and difficulty with social interaction, language and communication skills. The condition exists on a spectrum, which means two different people with autism might have widely different abilities across each of these areas. The study involved 136 adults, with an average age of 36, primarily located in Europe and North America. They were divided into three groups: people who had been diagnosed with autism; people who self-identified as autistic, but had no formal diagnosis; and people who neither had an autism diagnosis nor self-identified as autistic, but who identified as ‘socially awkward.’

Compensation describes any effort that allows a person with autism to navigate successfully a world unsuited to their way of processing. Its goal is to generate new social behaviors that allow the person with autism to fit into neurotypical expectations. Some compensation strategies are superficial, such as mimicking others’ gestures, and consequently only go so far. More complex compensation strategies use intellect and executive function to adapt to real-time situations — adhering to social patterns like making eye contact; preplanning small talk, such as planning ahead of time questions to ask people; and switching between social norms depending on one’s environment — for instance, between the workplace and a friend’s birthday party.

“I think I observe patterns in behavior and then try to transfer this. So if a person is behaving x/y/z types of ways, they could be feeling or thinking what so and so people had felt. It’s almost a case of systematically storing little patterns in each person and the context, so I can refer to it in future,” reported one diagnosed female study participant. For a neurotypical person, this might be more understandable in the analogy researchers offer — as constant mental math for a person not great at math to begin with: “gesture + facial expression + context = particular mental state.” Another way to describe it? As a kind of social codeswitching.

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Many of the participants adopted these methods of social compensation out of a desire for relationships. “I strongly desire friendship,” reported one diagnosed female participant, “but am aware that I am not very good at initiating it and even worse at maintaining it…despite my awareness, my ability to counteract my poor social skills lags behind. In short, now I know that I am the problem, but I still don’t know how to fix myself very well.”

At the same time, compensation efforts essentially boil down to putting on a performance, which can undermine the very relationships they’re meant to foster. “The inability to mask or compensate beyond the initial stages of a relationship has meant I have never developed the social capital which all people need to succeed,” reported one diagnosed male participant.

The performance of neurotypical behavior can also keep autistic people from accessing the support they need; for instance, many study participants said busy, bright environments can overload their senses leaving them with no energy to compensate, yet workplaces may still hold their autistic employees to a neurotypical standard of social behavior. The same reasons, researchers posit, could keep some people with autism from getting a diagnosis: participants report that it’s easier to compensate socially and ‘pass’ for neurotypical in one-on-one, soothing settings, with few distractions — the typical doctor’s exam room.

With such constant, necessary, behind-the-scenes social effort that runs the risk of backfiring in several ways, little wonder that compensation takes a toll on mental health. Among study participants, social compensation was linked to anxiety, depression and suicidal ideation.

“I have little energy left at the end of the workday, I can’t keep up with the cleaning of my house or feed myself. It’s hard to imagine myself as a mother … it’s not because I’m not competent,” reported one female diagnosed participant.

“I have planned three methods for my own suicide,” reported a male, diagnosed participant. “I have lost great people in my life and destroyed previous careers and relationships. All of this, I put down to compensating.”

“I think I’m f***ed either way…because people think that I can take more of their s*** if I compensate than I actually can,” reported another female diagnosed participant.

If there’s anything neurotypical society should take from the study, it’s this: People who saw their atypicality as a strength, rather than a weakness, were better at achieving a balance — of compensating and reaping the related social benefits, amid taking breaks to be themselves and seeking out environments conducive to their abilities — and thus protecting their mental health. While the world should work toward accepting autistic behaviors as they are, with no social judgment, it should also work toward changing the narrative around the condition — to one focused on strengths, rather than weaknesses.