Why Females with Autism [level 1] Are Less Likely to Be Diagnosed

The vast majority of referrals for a diagnostic evaluation for ASD are boys. The ratio of males to females is roughly around 10:1; however, the epidemiological research for autism suggests that the ratio should be 4:1. Why are girls less likely to be identified as having the characteristics indicative of an autism spectrum disorder? 

Below are some possible reasons:

1. Each youngster with ASD develops his/her own techniques and strategies to learn how to acquire specific skills and develop coping mechanisms. One technique is to have practical guidance and moral support from one’s friends. Kids on the spectrum elicit from others either strong maternal or predatory behavior. If the youngster’s natural peer group is females, she is more likely to be supported and included by a greater majority of her friends.

Thus, females on the autism spectrum are often mothered by "normal" or neurotypical (NT) females, who may prompt the ASD youngster when she is unsure what to do or say in social situations - and comfort her when she is distressed. In contrast, “normal” males are notorious for their intolerance of kids who are different and are more prone to be predatory. 
This can have an unfortunate effect on the behavior of a boy with the disorder - and many complain of being teased, ignored and bullied by other males. In fact, some males with ASD actually prefer to play with females who are often kinder and more tolerant than their male friends.

2. Females are more likely to be enrolled in speech and drama lessons, and this provides a socially acceptable opportunity for coaching in body language. Many kids with autism have a prodigious memory, and this can include reciting the dialogue for all characters in a play and memorizing the dialogue or script of real life conversations. Knowing the script also means the youngster does not have to worry about what to say. Acting can subsequently become a successful career option (although there can be some confusion when grown-ups with the disorder act another persona in real life as this can be misconstrued as Multiple Personality Disorder rather than a constructive means of coping with an autism spectrum disorder).

3. Females are more motivated to learn - and quicker to understand key concepts - in comparison to males with ASD of equivalent intellectual ability. Thus, they may have a better long-term prognosis in terms of becoming more fluent in their social skills. This may explain why females with the disorder are often less conspicuous than males with the disorder and less likely to be referred for a diagnostic assessment. Moms with an autism spectrum disorder appear to have more maternal and empathic abilities with their own kids than dads with the disorder, who can have great difficulty understanding and relating to their kids.

4. It appears that many females on the spectrum have the same profile of abilities as males, but a subtler or less severe expression of the traits. Moms and dads may be reluctant to seek a diagnostic assessment if the youngster appears to be coping reasonably well, and therapists may be hesitant to commit themselves to a diagnosis unless the signs are conspicuously different to the normal range of behavior and abilities.

5. One must always consider the personality of the youngster with the disorder and how he/she copes with the difficulties he/she experiences in social reasoning, empathy and cognition. Some youngsters are overtly active participants in social situations. Their unusual profile of abilities in social situations is quite obvious. However, some are reluctant to socialize with others, and their personality can be described as passive. They can become quite adept at camouflaging their difficulties and clinical experience suggests that the passive personality is more common in females.

6. Some young people on the spectrum can be quite ingenious in using imitation and modeling to camouflage their difficulties in social situations. One strategy that has been used by many females is to observe individuals who are socially skilled and to copy their mannerisms, voice and persona. This is a form of “social echolalia” or mirroring where the person acquires a superficial social competence by acting the part of another person.

7. We have a stereotype of typical female and male behavior. Females are more able to verbalize their emotions and less likely to use physically violent acts in response to negative emotions (e.g., confusion, frustration and anger). We do not know whether this is a cultural or constitutional trait, but we recognize that kids who are violent are more likely to be referred for a diagnostic assessment to determine whether the behavior is due to a specific developmental disorder and for advice on behavior management.

Thus, males with the disorder are more often referred to a psychologists or psychiatrist because their violence has become a concern for their mom and dad, or teacher. A consequence of this referral bias is that not only are more males referred, therapists and academics can have a false impression of the incidence of violence in this population.

8. When a youngster would like more friends but clearly has little success in this area, one option is to create imaginary friends. This often occurs with young females who visualize friends in their solitary play or use dolls as a substitute for real individuals. Females with ASD can create imaginary friends and elaborate doll play, which superficially resembles the play of other females.

We need more studies to establish the true incidence of autism in females. In the meantime, these girls are likely to continue to be overlooked and not to receive the degree of understanding and resources they need.

Resources for parents of children and teens on the autism spectrum:

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