Girls with autism have long been misdiagnosed as their symptoms look quite different from those of their male peers on the spectrum. New research indicates that autism in girls is more common than previously thought as more is learned about the signs of autism in girls.

Are there fewer girls with autism or are they not being diagnosed?

People tend to think of boys when talking about high functioning autism, also known as Asperger’s syndrome.

The typical signs include:

• An obsessive desire to memorize facts and collect information on a particular subject
• The inability to have typical social interactions and maintain friendships
• Exceptional intelligence (often confused with savant syndrome)
• Autism spectrum disorder (ASD) affects 1 in 68 children in the United States and is four times as prevalent in boys than in girls. Girls with autism were considered to be more seriously affected and often also diagnosed with intellectual disabilities. Research now suggests that both these ideas are wrong. (Szalavitz, 2016)
  Disorders describes two trains of thought about autism in each gender. The first theory is that “being female confers protection against autism traits because of sex differences in neuroendocrine function,” due to higher levels of oxytocin, which “encourage nurturance and affiliation and provide protection in girls against the development of autistic traits.” (Solomon, Miller, Taylor, Hinshaw, & Carter, 2011)
  The second theory by Simon Baron-Cohen is that “high levels of fetal testosterone may cause boys to have ‘extreme male brains,’ characterized by phenotypes involving elevated ‘systematizing’ (focus on inanimate systems and details) versus ‘empathizing’ (focus on interpersonal orientation). A diagnosis may be missed because girls often show milder symptoms than their male peers. Girls are said to have “referral biases because they have better social skills than boys with and without ASD.” (Solomon, Miller, Taylor, Hinshaw, & Carter, 2011).

Signs of autism in girls and how they differ from boys with ASD

• Asperger’s in girls presents differently than in their male counterparts. While boys with ASD may collect information about topics that hold special meaning to them, girls with Asperger’s tend to align interests with those of their neurotypical peers, but in a “more focused way.” A teenage girl may collect makeup and study its application as done by a favorite makeup artist while a younger girl may learn the history of Barbie dolls or study her American Girlbooks. (Steward, 2014) 
  This makes it harder to recognize the signs of autism in girls. It becomes obvious during puberty when social interactions become more complex, and the pressure to conform is overwhelming.
  Young girls with autism might perform at an average to excellent level at school, even socializing at what appears to be an age-appropriate level. “Some girls with Asperger’s will manage to keep their difficulties under wraps at school, but might have ‘meltdowns’ at home, where they feel safe to relax and release the feelings that they have been squashing down all day.” (Steward, 2014)
  Robyn Steward compiled the following list for the BBC of typical difficulties that may be faced by someone with Asperger’s syndrome:
  • Understanding non-verbal communication, such as body language or tone
  • Interpreting the feelings, thoughts or motives of others
  • Relating to non-literal uses of language, such as idioms, jokes or irony
  • Following social conventions such as respecting another person’s physical space
  • Depending on familiar routines and feeling anxious if these are not adhered to
  • Experiencing sensory difficulties, for example being overpowered by visual, auditory or tactile stimuli
  • Limits to body awareness, for example, walking around obstacles or carrying out fine motor tasks. (Steward, 2014)

Are women and girls with autism being misdiagnosed?

• Boys and girls develop differently particularly throughout puberty. Girls are said to mature faster, develop social skills and emotional intelligence sooner. They also have a greater awareness of the world around them. These differences are often noticeable between neurotypical boys and girls.
  Girls with autism are less social than their neurotypical peers but do not seem to struggle as much as boys of the same age with autism. According to Maia Szalavitz, “females with autism may be closer to typically developing males in their social abilities than typical girl or boys with autism.” (Szalavitz, 2016) This gray area has left many women and girls with autism undiagnosed and unable to seek treatment.
  A 2014 study by psychologist Thomas Frazier of the Cleveland Clinic found that girl who was diagnosed with autism had lower IQs than their neurotypical peers as well as extreme behavior problems. The girls were also less likely to show signs of restricted interests (usually a diagnostic factor for Asperger’s syndrome). Current diagnostic tests typically focus on “male” interests and are not inclusive of restrictive interests with which a young girl or woman might have.
  Kevin Pelphrey, a researcher at Yale University’s Child Study Center, and father of two with autism told Szalavitz that current diagnostic tests are from studies (almost exclusively) of boys and that he believes this may be why so many girls and women are underdiagnosed/misdiagnosed. (Szalavitz, 2016)

Common co-occurring disorders associated with Asperger’s Syndrome in girls

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  Women and girls with Asperger’s syndrome often find themselves misdiagnosed. As a result, they are at a higher risk for co-occurring conditions which may be derived as coping skills or separate issues.  women and girls with Asperger’s syndrome are likely to have higher instances of depression, bipolar disorder, anxiety, obsessive-compulsive disorder, and attention deficit hyperactivity disorder (ADHD).

  While these issues may be co-occurring, they are often diagnosed as the only explanation for the symptoms presented by a girl with Asperger’s syndrome. Seeing the larger picture of how ASD fits with a co-occurring disorder is useful to give autistic girls the treatment they need.

  Anxiety-based disorders such as generalized anxiety, social anxiety, and obsessive-compulsive disorder (OCD) are reportedly seen in girls with Asperger’s syndrome than their neurotypical peers. According to the study mentioned above, 56% of people with Asperger’s syndrome meet the criteria of a diagnosis of anxiety with 22% diagnosed with social anxiety disorder, 22% diagnosed with generalized anxiety disorder, 13% diagnosed with panic disorder, 15% diagnosed with agoraphobia, and 7% diagnosed with obsessive-compulsive disorder. (Mazzone, Ruta, & Reale, 2012)

  Researchers are also finding that women and girls with autism have “striking similarities in the cognitive profiles” to women with anorexia nervosa, according to psychiatrist Janet Treasure of King’s College London. Treasure says that “both people with autism and those with anorexia tend to be rigid, detail-oriented and distressed by change[s].” A diagnosis of anorexia nervosa may explain away symptoms and therefore prevent girls from being diagnosed as having ASD.

  Treasure stressed that the majority of women with anorexia nervosa do not have autism, but women with anorexia have higher levels of autistic traits than typical women. (Szalavitz, 2016) Some women with autism who receive a diagnosis of anorexia nervosa may be eating restricted diets due to sensory issues surrounding food texture and other preferences, while other’s eating disorders may be triggered by the more typical stressors and pressure associated with anorexia nervosa. An estimated 23% of women diagnosed with anorexia nervosa also have an ASD. (Szalavitz, 2016)

  ADHD may be the most common diagnosis girls receive before, or in some cases instead of, Asperger’s syndrome. The overlap of symptoms can make it difficult to diagnose girls on the spectrum, especially with current diagnostic models focus on males. Many girls with autism keep their diagnosis of ADHD, but in conjunction with an ASD diagnosis.

  This gives them a greater explanation for their experiences and access to more resources to help them. Acknowledging this fuller picture is crucial to helping not only girls with Asperger’s syndrome but their families.

How can a diagnosis help a girl with autism?

• Just as with their male counterparts, women and girls with autism benefit from early intervention. An early diagnosis can mean earlier access to therapies and resources. It can also mean more time for the girl and her family to learn how to cope with an ASD diagnosis. Early intervention is key, but a diagnosis later in life is better than no diagnosis at all.
• Girls and women on the spectrum can take social skills classes. Here, they learn to cope with challenging social situations and form interpersonal relationships. Therapists can also help girls manage co-occurring conditions such as anxiety, depression, bipolar disorder, OCD, and anorexia.

What is the cost of not knowing?

• Seeking testing for ASD, especially for a girl, can be a daunting undertaking. As a parent, you might feel conflicted about whether a diagnosis is necessary for your daughter. It is important to keep in mind that people with autism can live fulfilling and beautiful lives. A diagnosis will open the door to further therapies and resources for you and your child.
  Even if your daughter is already well into adolescence, the skills she can develop through therapy are invaluable. Girls with autism who struggle with setting social boundaries or finding/maintaining meaningful relationships are at a higher risk for sexual exploitation. They are also more likely to stay in abusive relationships.
  A study by Baron-Cohen found that “66% of adults with the milder form of ASD (Asperger’s) reported suicidal thoughts, at a rate nearly 10 times higher than seen in the general population. The proportion was 71% among women, who made up the sample.” (Szalavitz, 2016). Girls with autism are also at a higher risk for affective (mood) disorders such as depression, anxiety, and bipolar disorder. (Solomon, Miller, Taylor, Hinshaw, & Carter, 2011).
  Finding a specialist who understands autism in girls and women is crucial to helping your daughter learn how to set boundaries and manage mental health.

What kinds of therapies can benefit autism in girls?

• Girls with autism have a variety of options for therapies. Applied Behavioral Analysis (ABA) is particularly helpful for young girls (under the age of five), but older girls can benefit as well. A method called talk therapy is said to help girls with autism. During psychotherapy, the therapist will present problems to the child, and they both work together to come up with a solution.
  A psychotherapy session is a place where clients are encouraged to ask questions, vent, and seek guidance. Occupational therapy (OT) is another option for children who need help establishing routines and carrying out daily tasks. An occupational therapist can help your daughter learn skills that will help her at home, school, or in the workplace.
  Girls and women with co-occurring disorders such as OCD, anorexia, or who are trauma survivors may need more specialists on their team. As more women and girls are receiving an ASD diagnosis, specialists are becoming more aware of the unique way females on the autism spectrum present and are developing new ways to help them thrive. Recognizing signs of autism in girls can happen earlier when parents are aware. If you are unsure where to begin, your daughter’s pediatrician or primary care doctor can connect you with resources in your area.