Autism is comparatively more frequently diagnosed in males than it is in females. A widely accepted explanation is the ‘female protective effect’ – that there is something inherent in being biologically female that reduces that probability of developing autism. However, present research suggests that autism could be underdiagnosed in females because the diagnostic criteria – restricted and repetitive interest, social and communication impairments and sensory issues – do not often fit squarely with how females typically express their autism. Other overlapping diagnoses such as depression, anxiety and anorexia further complicate the issue. This article discusses why diagnosing autism in girls can be a thorny process and some female-typical autism presentation.
Challenges in Diagnosing Autism in Girls
A study (Szalavitz, 2016) compared the incidences of (observable) autism traits and formal autism diagnoses in a sample of more than 15,000 twins – they found that if girls and boys had comparable autism traits, the girls needed to have either a significant intellectual disability or severe behavioural problems, or both, for them to be formally diagnosed. This finding suggests that clinicians are overlooking many girls who are on the less severe end of the spectrum, previously known as Asperger’s syndrome.
Another paper (ibid.) also found evidence corroborating such a claim. Their findings showed that girls who were formally diagnosed were more likely to have more severe intellectual disability and extreme behavioural problems. However, in addition, the study revealed that these girls also had lesser (or more indeterminate) signs of having restricted interests, like having intense fixations on a particular topic such as vehicles that were characteristic of autistic children. These interests are often a key diagnostic factor for those on the less disabling end of the autism spectrum, and since girls do not seem to exhibit those behaviours, it would be challenging to formally diagnose them.
Female-Typical Autism Presentation
Autistic girls and autistic boys differ in several regards. Their difficulties are considered to be categorically different – meaning that their autism is not simply a matter of gradation (i.e. where they are placed along the spectrum), but that their differences are conceptually distinct. Girls with autism experience a different challenge in social relationships, the nature of their special interests differ and they are prone to internalising problems. These female-typical autism presentations will be elaborated here in that order.
Some research suggests that girls with autism may have lesser social-communication impairments than males, and while is it true that autistic females tend to have higher levels of social motivation (i.e. the intent and desire to form friendships with other people) than males on average (Head et al., 2014) they may find it harder to maintain long-term relationships or friendships than autistic males – even if they have similar levels of social motivation compared to non-autistic females (ibid.). In addition, conflict in social relationships may be more difficult for autistic females to cope with when compared with non-autistic females and even autistic males (Sedgewick et al., 2019).
In a similar vein, there is some research into gender differences in restricted and repetitive interests, suggesting that females with autism have lower levels of these special interests than males (Lai et al., 2015). However, others have argued the contrary, which is that the special interests of autistic females might be in different areas than in autistic males and may have thus been underestimated (Mandy et al., 2012). Studies have found that autistic males’ interest tend to be in more mechanical domains such as computers, vehicles or physics while autistic females’ interest appear to focus more on areas with a relational intent, such as fictional characters or animals (ibid.). The type of special interests may be considered more age appropriate for autistic females than autistic males, so it may have been missed by parents, educators and clinicians.
The final characteristic to be elaborated here, namely internalising problems, do not represent the core features of autism but may form part of the typical clinical presentation such as anxiety, depression, self-harming and eating disorders. Internalising problems describe the inward expression of emotional difficulties, and this stands in contrast to externalising problems, where difficulties are turned outwards resulting in aggression or behavioural problems. Autistic females are significantly more likely to have co-occurring internalising disorders (e.g. depression, eating disorders) than males, and autistic males are significantly more likely to have co-occurring externalising disorders such as inattention or behavioural problems (Hiller et al., 2014).
All in all, findings demonstrate that autistic traits in females are presented in subtle variations that are not currently captured by diagnostic tools and criteria, making the process of getting a formal diagnosis as an autistic female long and arduous. Parents, educators and also clinicians should be more attuned to the female-typical autism presentation and take them into consideration when looking for signs of autism in girls.
Written by Jacelyn Lee.
References
Szalavitz, M. (2016, March 01). Autism - It's Different in Girls. Retrieved November 08, 2020, from https://www.scientificamerican.com/article/autism-it-s-different-in-girls/
Head, A. M., McGillivray, J. A., & Stokes, M. A. (2014). Gender differences in emotionality and sociability in children with autism spectrum disorders. Molecular Autism, 5(19). https://doi.org/10.1186/2040-2392-5-19.
Sedgewick, F., Hill, V., & Pellicano, E. (2019). ‘It’s different for girls’: Gender differences in the friendships and conflict of autistic and neurotypical adolescents. Autism, 23(5), 1119–1132. https://doi.org/10.1177/1362361318794930.
Lai, M.-C., Lombardo, M. V., Auyeung, B., Chakrabarti, B., & Baron-Cohen, S. (2015). Sex/gender differences and autism: Setting the scene for future research. Journal of the American Academy of Child and Adolescent Psychiatry, 54(1), 11–24. https://doi.org/10.1016/j.jaac.2014.10.003.
Mandy, W., Chilvers, R., Chowdhury, U., Salter, G., Seigal, A., & Skuse, D. (2012). Sex differences in autism spectrum disorder: Evidence from a large sample of children and adolescents. Journal of Autism and Developmental Disorders, 42(7), 1304–1313. https://doi.org/10.1007/s10803-011-1356-0.
Hiller, R. M., Young, R. L., & Weber, N. (2014). Sex differences in autism spectrum disorder based on DSM-5 criteria: Evidence from clinician and teacher reporting. Journal of Abnormal Child Psychology, 42(8), 1381–1393. https://doi.org/10.1007/s10802-014-9881-x.
Hull, L., Petrides, K. V., & Mandy, W. (2020). The Female Autism Phenotype and Camouflaging: A Narrative Review. Review Journal of Autism and Developmental Disorders. doi:10.1007/s40489-020-00197-9