Hiding in Plain Sight: Girls and Autism Spectrum Disorders
“Jenny” sits with three other adolescent girls at the lunch table. She is laughing at what they are saying. While she tends to be quiet, her friends chalk it up to her being somewhat shy. She frequently references lines from the show “Riverdale” and has watched the first five seasons twice. Her parents attribute her binge watching to the popularity of the show. Jenny’s favorite store is Sephora and she has a large collection of make-up, brushes, and other beauty products that she enjoys trying out after school. She often finds herself feeling exhausted after school and needing downtime by herself. While she describes herself as having friends, she has an ongoing feeling of awkwardness in being with others as well as social anxiety. She has a nagging sense that something is wrong with her.
The CDC reports that approximately 1 in 44 children in the U.S. is diagnosed with an autism spectrum disorder (ASD). Research highlights that boys are particularly vulnerable to developing the disorder, and are four times more likely to be diagnosed with autism than girls. We also know that individuals with ASD are at risk for other mental health concerns, including depression and anxiety. Of note, research has historically focused more on males than females given the base rates of diagnostic differences.
Are girls less vulnerable to developing ASD based on protective factors that may buffer the genetic loading or environmental variables that contribute to developing the disorder? Alternatively, does autism frankly look different in girls, making it harder to diagnose? Similar to a variety of developmental and mental health disorders, there are gender differences in the rate of autism in boys and girls. However, there is growing awareness that girls with ASD may in fact be hiding in plain sight. Such differences have been found as early as preschool. During that time period, girls are more likely to imitate other peers and strive to fit in with other children. Some studies suggest that girls may present with more meltdowns at home, with more irritability and lethargy compared to boys. At school they may be able to “hold it together” more, while boys with ASD may present with more hyperactivity or behavioral challenges which captures the attention of teachers. Females may be able to mask social challenges at school, making them look more typical. Stereotypes may get in the way of accurate diagnosis as well. For example, the restricted interests associated with an ASD diagnosis may look differently in girls, with girls perhaps developing more “socially appropriate” interests that, if closely looked at, take on an obsessive quality. Specifically, girls who have a restricted interest in unicorns may be dismissed by providers as having developmentally appropriate interests. Also, the repetitive behaviors associated with ASD may look differently in girls, with females showing more subtle symptoms. Many girls may be misdiagnosed with other neurodevelopmental conditions, such as ADHD. Girls may be able to “pass” as neurotypical for a while, but often their social challenges become more apparent in middle and high school. Adolescent girls on the spectrum may also be more vulnerable to sexual victimization given challenges with understanding non-verbal cues and understanding social boundaries. Overall, there is growing concern that a number of girls may be missed, resulting in delayed intervention or being diagnosed at all.
An important next step is for research to include girls as well as boys in psychological studies, as historically males have been over-represented in scientific studies. In particular, studying “high-functioning” individuals with ASD may help inform diagnostic tools used to make the diagnosis of ASD as well as inform treatments. Clinicians need to be informed about the potential differences in how males and females present in order to make appropriate diagnoses and help all children receive early intervention and ongoing supports. As a whole, we need to expand our lens to ensure that all individuals with symptoms of ASD are appropriately identified at early ages to ensure appropriate treatment, maximize their strengths, and mitigate the negative outcomes associated with missed diagnoses.