Lara Schaeffer

Why Smart Girls with ASD are Underdiagnosed

Girls and women are diagnosed with autism significantly less often than boys and men, but many psychologists believe that the reality of the difference in autism occurrence between female and male patients is much smaller than diagnosis rates would seem to indicate.

As you may know, two criteria are at play in an autism diagnosis: social communication and interaction deficits, and restricted, repetitive patterns in behavior, interests, or activities. For girls on the spectrum relative to the first criteria, some are socially motivated, but unsure how to maintain relationships and navigate conflict. Others simply have less motivation to seek out and maintain social relationships. In terms of the second criteria, in girls, repetitive behaviors and interests are often milder or less obvious than in boys. Finally, girls have the same tendencies as boys for sensory sensitivities that are common with ASD, but they may be less likely to speak up about their discomforts. In general, there seems to be a more subtle presentation of autism symptoms in girls than in boys.

Psychologists have found that girls are also more likely to control their behaviors in public, or to internalize their differences so as not to stand out. In addition, it’s also thought that girls might be given less societal leeway and be provided with more feedback and correction when their behavior is atypical. All of this together result in a more typical appearance or affect for girls on the spectrum than for boys.

Researchers have determined that girls have strong abilities to understand how others are interacting with each other, both verbally and nonverbally; they also have greater tendencies and abilities to mirror those interactions than boys seem to. However, once they break into social situations, autistic females face challenges understanding new and unexpected dynamics including conflict and misunderstandings. Additionally, it’s important to note that difficulty with social communication in autistics increases with the age of the patient and the complexity of the relationship involved.

In sum, greater tendency toward social adaptability, greater societal correction and mimicry, and greater self-control keep autistic girls from being identified as early and as often as boys. This is especially true when higher IQs and higher verbal skills are at play, as those traits can lead to further masking of ASD symptoms.

I have been following the work of several current autism researchers, and I am happy to report that several of them are now insisting that their sample groups for their studies are more proportionately female than in the past. Still, in recent decades, almost everything we know about autism comes from studying boys. It’s good that is beginning to change.

The bottom line seems to be that assumptions about autism often work against female diagnosis. Misdiagnosis is also a contributing factor in the underdiagnoses of females, with common misdiagnoses including depression, anxiety, and ADHD. Separately, since those conditions can also be co-occurring with autism, a diagnosis of one of them could provide false security that a patient's challenges have been fully discovered. If undiagnosed, autistic females miss out on important supports and the opportunity to understand their differences and how those differences affect them.

In my mind, both society and practitioners really need a wake-up call in terms of females and autism. While we work toward that, it’s important to stay strong, to keep learning, and to keep sharing. We can do this together.

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