CAT-Q Validity for Autism Assessment
The CAT-Q (Camouflaging Autistic Traits Questionnaire) is NOT a diagnostic tool for autism and should not be used to assess for autism spectrum disorder itself—it is specifically designed to measure social camouflaging behaviors in individuals who are already known or suspected to have autism. 1
What the CAT-Q Actually Measures
The CAT-Q is a 25-item self-report questionnaire that measures social camouflaging strategies—the compensatory behaviors autistic individuals use to mask or hide their autistic characteristics during social interactions. 1 It comprises three subscales:
- Compensation: Strategies to actively compensate for difficulties in social situations 1
- Masking: Behaviors used to hide autistic characteristics from others 1
- Assimilation: Efforts to fit in with non-autistic social norms 1
Psychometric Properties for Its Intended Purpose
The CAT-Q demonstrates robust validity and reliability as a measure of camouflaging behaviors, not as a diagnostic instrument:
- Internal consistency is excellent (α = 0.94) 1
- Test-retest reliability is acceptable (r = 0.77) 1
- Convergent validity has been established through correlations with measures of autistic traits, wellbeing, anxiety, and depression 1
- Construct validity has been supported, showing that CAT-Q items are distinguishable from (though related to) social anxiety, fear of negative evaluation, and autistic social traits 2
- The measure has been validated across multiple languages including Italian, demonstrating cross-cultural applicability 3
Critical Limitations for Autism Assessment
The CAT-Q cannot and should not replace established autism diagnostic procedures. The American Academy of Child and Adolescent Psychiatry guidelines emphasize that autism diagnosis requires comprehensive clinical evaluation including direct observation, developmental history, and use of validated diagnostic instruments like the ADOS and ADI-R. 4
Why the CAT-Q Is Not a Diagnostic Tool:
- It was developed to measure a specific phenomenon (camouflaging) rather than core autism symptoms 1
- It does not assess the DSM-5 diagnostic criteria for autism spectrum disorder 4
- The Assimilation subscale shows problematic cross-loading with autistic social traits items, raising questions about what exactly it measures 2
- No studies have examined its sensitivity, specificity, positive predictive value, or negative predictive value for autism diagnosis
Appropriate Clinical Use
Use the CAT-Q only after autism has been diagnosed or is strongly suspected, to understand the extent of camouflaging behaviors that may:
- Mask symptom severity and complicate clinical presentation 1
- Contribute to mental health burden (anxiety, depression, burnout) 1
- Inform therapeutic interventions targeting the psychological costs of camouflaging 1
Recommended Diagnostic Approach for Autism
For actual autism assessment, follow established guidelines:
- Ages 18-30 months: Use M-CHAT-R/F with structured follow-up interview (score ≥3 initial, ≥2 after follow-up indicates risk) 5
- All ages: Comprehensive diagnostic evaluation must include clinical interview, developmental history, direct observation, and consideration of DSM-5 criteria 4
- Standardized diagnostic tools: ADOS (Autism Diagnostic Observation Schedule) and ADI-R (Autism Diagnostic Interview-Revised) remain gold standards 4
- Medical workup: Include chromosomal microarray (24% diagnostic yield), fragile X testing, and other genetic evaluations as indicated 4
Important Caveat About Self-Report Screening Tools
Research on the Autism-Spectrum Quotient (AQ), another self-report measure, found it had poor specificity (0.29) and negative predictive value (0.36) for predicting autism diagnosis in adults referred for assessment, with 64% false negatives. 6 This underscores that self-report questionnaires alone are inadequate for autism diagnosis and can miss a substantial proportion of autistic individuals.