Autism Spectrum Disorders (ASD) in women is often, less spoken about and less identified, but that isn’t a testament to its general prevalence or presentation. Historically, it is said, that the prevalence of ASD in males is higher than in females, in the ratio of 1:4. This leads to the gender bias that ASD is only seen in males. Additionally, many professionals have been trained to easily recognize typical Asperger’s /autism spectrum traits in males than in females.
Gender Bias in diagnosing
Many mistake women on the spectrum as having a dual personality; one outside where she is odd but still in control to one when she is home when the mask is removed. Due to this gender bias, professionals are less likely to diagnose women with ASD even if the signs are present. Lately, however, in our clinics and practise we do see an increasing number of referrals being made for women with suspected ASD. Research by Kanner in 1971 described 3 girls & 5 boys with ASD symptoms, and most of the data on Asperger’s has come from research on males.
There is also this common thinking that males think logically and are more precise in their thought process, whereas, the female thought process is more emotional and attached to feelings. It is also a common misconception that ASD traits become more prevalent in women after puberty. Women have often been observed to mask the symptoms of ASD by forcing themselves to have good eye contact, preparing jokes and phrases ahead of conversations, able to mimic the social behaviours of others and able to imitate gestures.
How do females often mask their ASD?
ASD is diagnosed when three are consistent deficits in core areas of social interaction, social communication, rigidities, repetitive behaviours and sensory features interfere with everyday functioning. Social interactions in women are usually masked as they often follow things by delayed imitation. They observe other children and imitate the social norms. They are usually on the periphery of social activities. Girls are also, often, more aware and have a strong urge to interact socially. When involved with social play instead of leading the games they usually follow others, masking the features further. Girls with social communication difficulties can come across as more immature and passive than their peers. Usually girls are mothered by other girls in primary schools but also have a history of often being bullied in secondary schools due to difficulties with fitting in with the norms.
Social Communication & Social Imagination
Social Communication is an area which deals with the ability to comprehend and express using language as a tool. There has been little difference in girls or boys acquiring speech. Also research has shown that girls, in general, have superior linguistic abilities as compared to boys of similar cognitive levels. During social conversations, girls are expected to make and participate in social conversations, however, girls with ASD may not chit chat or make small talk to make conversations. Autistic girls may also have poor understanding of the social hierarchy and how to make conversations in public.
Social imagination is an area where elaborate sequences of ideas are spun together and elaborate pretend play scenes can be played with peers. Girls are good at imagination and can engage with pretend play. Many girls engage with rich fantasy play and spin elaborate sequence of fantasy which may be far away from reality. Girls can engage in fictional play and can actually get in solitary learnt scenes and interactions when playing with dolls or pretend play. Girls play usually lacks social reciprocity and can be dominating in play controlling the play situations.
What’s the difference?
Special interest and routines are again seen to be prominent stereotypes for males with ASD compared to girls. Boys are usually aggressive and hyperactive with interest in technical items and facts about certain things. Girls can be more passive and can collect information on people rather than things. Girls have similar interests like other girls such as soaps, animals, shopping & fashion. Unlike males the stereotype is that they do not have an interest in transportation, sports, computers and astronomy. What really stands as a differentiating factor in the quality and intensity of the interest that girls on the spectrum have compared to typically developing peers.
Also it has been recorded that autistic girls may have one or a few friends. They might appear naive or immature, as she is out of sync with the trends or the social norms. Girls on the spectrum are also reported to be perfectionist at work and things they do. Unusual Responses to Sensory Input over and under reaction to sensory input is an important feature for all on the autism spectrum, common in females.
How can diagnosis be improved?
The current diagnostic system does not give enough examples of characteristics in women warranting a thorough investigation to give the diagnosis of ASD to someone. There is a need to ask the right questions and also improve our observation skills. The definitions of core characteristics which have deficits in ASD needs to be broadened. Questions in the Diagnostic Interview for Social and Communication Disorders (DISCO) Wing et al 2002 highlight the differences in the girls for all aspects of the Triad and routines / interests.
Usually girls/ women on the spectrum are referred for mental health issues, Obsessive Compulsive disorders, anxiety and depression and selective mutism, eating disorders, rather than considering ASD, making the presentation and clinical diagnosis to be skewed. But a detailed case history and parental interview would often present features of ASD spectrum. These cases are often misdiagnosed and treated for the presenting symptoms with medications and behaviour therapies often leaving the women with great stresses and difficulties. Anxiety is common in women with autism often leading to passive personalities and ability to let others lead the situations and make decisions.
The Importance of the right diagnosis is the starting point in providing appropriate support to women on the spectrum. A timely diagnosis can avoid the difficulties women and girls experience throughout their lives. Diagnosis can lead to assessment of needs in education, leisure, housing, social relationships and employment
Milind Sonawane, Sr.SLT ASD