Hello. Why is autism under-diagnosed or missed in girls?
Autism is a disorder of the development and functioning of the brain.
It causes problems with social interaction and communication
and difficulties with behaviour, interests and activities.
Children with autism also have sensory processing issues.
Boys are four times more likely to be diagnosed with autism than girls.
Is that because the prevalence rates are higher? A study
in UCL in 2017 by Loomes et al showed that the true male to
female ratio of people with autism is closer to 3:1 than 4:1.
Recent research has shown that it's
difficult to identify symptoms of autism in girls and women.
This has led to delayed diagnosis, misdiagnoses
and some people not being diagnosed at all.
As a result of this, many girls and women feel unsupported
and do not understand themselves. This can lead to
mental health problems. Indeed, in the teenage years,
girls with autism are more likely to suffer from anxiety and depression
than boys with autism, and also typically developing girls. So why are we
not picking up these girls with autism? I will discuss
some of the reasons for this in this video. I'm Dr Beth Colby,a
psychiatrist in London. Two of the reasons for under-diagnosis
in girls are diagnostic gender bias and gender
stereotypes. Ever since the first published reports
and descriptions of autism in boys in the
1940s by Hans Asperger and Kanner,
it was thought that autism predominantly affected boys.
Asperger initially believed that autism only affected boys.
All four participants in Hans Asperger's study were boys,
and eight out of 11 participants in Kanner's study
were boys, and all of Asperger's students were male.
Thus the model we have for classic autism is a male model,
the diagnostic tests were developed with boys in mind
and they may fail to detect symptoms in girls
as they may not fit the stereotypical profile
of a person with autistic spectrum disorder.
This is even more likely if the girl does not have
a behaviour or learning problem. Since the diagnostic criteria for autism
is based on research, and girls are under- represented in clinical samples, the
actual diagnostic criteria themselves are biased. A general lack of
understanding about autism may mean that healthcare professionals, teachers,
parents or caregivers can miss symptoms in girls. These include
stereotypes about autism, such that somebody who is autistic
has a keen interest in maths and science and that autistic people are unable to
form friendships. Researchers have also speculated
a gender bias in parental reporting, due to the
expectations and socialization of gender roles in society.
The presence of repetitive behaviour and special interests
is a key diagnostic criterion and clinicians
often look for stereotypically male interests, such as
train time tables and numbers during the diagnostic process.
However, girls with autism do not necessarily have the same kind of
special interests as typical autistic boys, and their
interests are similar to typically developing
girls, such as dolls, unicorns, pop stars, Disney, etc, and these are all
socially accepted. They may become passionately and
obsessively interested in these areas but may not gravitate
towards the more 'geeky' areas of technology or maths.
However, it's not about the particular thing or subject
that somebody's obsessed about, it's about the
level of interest which is the important thing.
Stereotypes about typical male and female behaviours can also get in the
way of diagnosis for girls with autism. If boys isolate themselves and played
alone and didn't speak much there'd be more concern, but if it's
girls, people think oh they're naturally
quieter anyway and more content to play alone. However, speaking
less and preferring to be alone are symptoms of autism. As autism
is more common in boys than girls, parents, caregivers, healthcare providers
and people involved in education may be less likely to look for symptoms in
girls. Another reason why a diagnosis of autism
may be missing girls is that boys and girls can
present differently. This is because boys are more likely to
react to stress outwardly, for example they're becoming
angry or misbehaving, and the behaviour is more visible and may
flag up autism sooner. However, girls with autism are
less likely to be aggressive but may become
withdrawn and passive, and girls are more likely to react to stress
with behaviours that are not noticed immediately, such as self-harm.
They may be referred to professionals because of internalizing
symptoms such as anxiety, depression and eating disorders,
but the health care professionals may may miss the
social dysfunction underneath all this caused by the autism.
Sometimes girls may be misdiagnosed with ADHD,
attention deficit hyperactivity disorder, as they may have hyperactivity without
the social and communication difficulties
so autism is missed. Many autistic women are not diagnosed because of their
ability to camouflage or mask their symptoms by copying socially
appropriate behaviour. Girls with autism tend to be more
sociable and able to make friendships than boys with autism. From a
young age, girls may not understand what's going on
in a social situation, but they're able to get by by copying what
things around them and imitating what they see.
Whilst they can do this in primary school, when it gets to secondary school,
where relationships and social situations are
more complex, they are they're not able to do this.
Girls with autism may become exhausted with the effort of
trying to appear similar to other people and to fit in,
and some may not actually be aware that they're masking in the first place.
Many autistic girls may share a smile or give better eye contact and appear more
socially motivated, so the diagnosis of autism may not cross
somebody's mind. Undiagnosed autistic girls may end up
wondering what's wrong with them, and this can lead to low self-esteem,
anxiety and depression. Some symptoms of autism may be less
common in girls than boys, or maybe milder, for example repetitive behaviours such as
lining up toys, a fascination with swirling wheels
or parts of objects, obsessions with trains or video games or mechanical
objects are more common in boys, and these
symptoms are easier to spot than difficulties with communication or
socializing. Girls with autism may have milder
symptoms or simply different ones. Their intense interests may appear
more normal and less repetitive. Some researchers
wonder if girls' obsessions and rituals might not
show up on autism screenings or be flagged by
parents because they seem neither odd nor unmanageable.
Girls control their emotions much better at school than boys do,
and they act far differently at school than they do at home.
Teachers are less likely to voice concern about girls than boys,
and this is possibly because boys are more disruptive. However, often girls
manage to hold their emotions and behaviour in when they're at school,
but when they get home then they implode and
have a meltdown. Trying to blend in at school
is difficult for children, but also it may hinder diagnosis,
as the teacher may not be aware that the child has difficulties.
It may be that there are different autism profiles for
boys and girls, that is, they may differ in the ways that they
exhibit the strengths and the challenges of autism.
Boys with autism tend to have a very repetitive and limited areas of play,
whereas girls with autism are less repetitive and have broader areas of
play. Girls with autism are more likely than
boys to be able to respond to non-verbal
communication such as pointing or gaze-following. They
are also less prone to be distracted and they're more focused. Research into
how the symptoms of autism may differ in boys and girls
may help in the development of diagnostic criteria that pick up the
symptoms of autism present in girls. An understanding of how autism presents
differently in girls will also help in understanding their
different needs and providing them with the right supports and interventions.
Thank you for listening. I hope this has been of interest. 'Bye for now.