Autism in Girls: Why Signs of Neurodivergence are Overlooked

Autism in Girls Looks Different

About one in 36 children in the U.S. is autistic, a diagnosis that is four times more common in boys than in girls.¹ What explains this gender gap?

Science is working to determine factors that may explain autism’s diagnostic prevalence in males, but many clinicians who specialize in autism in girls and individuals assigned female at birth clearly see that gender bias — in referrals, diagnostic criteria, and tests — plays a role in diagnostic outcomes.

Autism is more readily identified in boys than in girls because, historically, the clinical and research focus has been on boys almost exclusively. Many clinicians who are trained in diagnosing autism are unaware how its traits can uniquely manifest in girls. Failing to realize that girls and women don’t always demonstrate the more stereotypical signs of autism, many clinicians end up overlooking behaviors that are indicative of autism. This is part of why girls and women are often diagnosed as autistic later in life than boys.

Signs of Autism in Girls

Social Motivation

Autism is characterized, in part, by difficulties and differences with social communication and interaction. Some autistic children may have trouble initiating or engaging in social interactions, which can result in them feeling left out or different. Some children, meanwhile, may prefer solitary activities.

Some children may struggle to understand when and how to join a conversation. An autistic child may follow up to a peer’s question with a brief response or with nothing at all, bringing the interaction to an end. Sometimes, conversations and interactions can become one-sided; an autistic child, for example, may not realize that others want to play differently and will continue to insist that everyone play a game according to very fixed rules. Autistic children may also show differences in use of eye contact, gestures, and facial expressions or misinterpret these cues from others.

[Take This Free Screening Test: Autism in Girls]

Autistic girls may experience all of the above. However, many demonstrate more social motivation — the drive to understand, connect, and enter relationships with others — than do autistic boys, which may make their social challenges less apparent and thus more likely to be overlooked.

• Autistic girls are more likely to want to fit in. As such, they are more likely to mask (i.e., hide or compensate for autistic traits) and mimic neurotypical behaviors.
• Autistic girls are more socially observant, which helps them pick up on details that allow them to better fit in and mask. It’s common for autistic girls to painstakingly study patterns in how people interact to reverse engineer “normal” behavior.
• Autistic girls are often perfectionists. The urge to fit in and flawlessly mask drives
  perfectionistic tendencies. Sensitivity to rejection is also common; when autistic girls stumble and experience social exclusion — despite their best efforts and desires to make and maintain
  friendships — the pain of rejection is profound.

Autism in Girls: The Consequences of Masking

We can’t talk about autism in girls without talking about masking. While masking often emerges as a coping strategy for socializing, especially for autistic girls without intellectual development disorder or who may not have observable behavioral or academic needs, it can create lots of issues, too.

• Masking is mentally taxing. Constantly trying to figure out others, understand unspoken
  social rules, and fit in with changing circumstances is highly exhausting.
• Masking interferes with self-understanding. Autistic girls often have trouble tuning into their own needs and emotions because masking has long forced them to suppress their authentic selves. Identity and self-esteem issues are common; some girls don’t even realize when they are masking. Masking can also interfere with friendships, as girls are unable to bring their full selves to these relationships or know what they want in a friend.
• Masking can impact clinical evaluations. Autistic girls who have become accustomed to hiding their traits may struggle to express and make sense of their behaviors and experiences, which can interfere with autism evaluations and lead to underdiagnosis or misdiagnosis. (This compounds the gender bias that causes girls’ autistic behaviors to be downplayed.)
• Masking can cause health issues. Constantly worrying about blending in with societal norms can turn into anxiety and other internalizing and physical issues. Many autistic girls tend to suppress their feelings, which causes more mental health challenges.

[Read: What Does Autism Spectrum Disorder Look Like in Children?]

Differences in Restricted and Repetitive Behaviors

Autism is characterized by restrictive, repetitive patterns of behavior, interests, or activities as demonstrated by the following signs:

• hand flapping, finger flicking, rocking, and other stereotyped behaviors (or “stims”)
• lining up, stacking, spinning, sorting and/or categorizing toys and objects
• echolalia and other forms of repetitive speech
• a strong preference for routine; resistance to change
• rigid, perseverative thinking; insistence on adherence to rules
• highly restricted, fixated interests (i.e., special interests)
• hyper- or hyporeactivity to sensory input

While autistic girls can show the above signs, these behaviors may manifest differently.

• Autistic girls are less likely to demonstrate repetitive movements. When they do, they are more likely to demonstrate different types of repetitive movements than boys, like tapping their fingers or twirling their hair, which can be easily overlooked.
• Autistic girls’ special interests are more likely to center on animals, celebrities, or fictional characters, which can seem more socially acceptable and thus less likely to be flagged as a sign of autism.

Autism in Girls: How to Support Neurodivergent Youth

Know the Signs — and Myths

Early detection is key for autistic girls to receive the support they need so they can develop self-
understanding without shame. Parents, educators, and clinicians should be aware of the above signs of
autism in girls and these common autism myths:

Clinicians: Peel Back the Layers

Clinicians overlook autism in girls, especially in those without intellectual or language disorders, because these girls can be adept at camouflaging. Their symptoms tend to be more internalizing, and they may have trouble verbalizing their experiences and what they need. Even when girls do show signs of autism, to the untrained eye, these girls can appear “not autistic enough.”

• Dig deep. Ask about relationships when evaluating girls for autism. How does your patient experience friendships and connecting with others? How does your patient feel about their ability to make friends and maintain them? How does this experience connect to her self-esteem? What is the toll of social interactions on your patient? Watch for cues that your patient finds social interactions exhausting and effortful. You may need to carry out longer assessments and observe your female patients over time so you can dive deep into their experiences. If they do not show signs of or report impairment across settings, watch for signs of subjective distress.
• Screen for comorbid conditions. Autism and ADHD co-occur at high rates, and the symptom overlap cannot be overstated. Anxiety and specific learning disorders are also common.
• Actively educate yourself on autism in girls. Seek out training and review the latest literature. Listen and learn from patients with lived experience.

More Ways to Support Autistic Girls

• Seek interventions and supports. From speech, physical, and occupational therapy to IEPs or 504 plans, secure the services that support your child’s individual needs. Medications are available to help support mood and reactivity. Talk to an autism specialist about the best interventions for your child and seek a second opinion if your provider makes you feel disrespected or unheard.
• Provide structure and routine. Stability and predictability reduce anxiety, stress, and overwhelm in autistic children, who often struggle with rigidity, inflexibility, and stress during transitions.
• Support executive functions. The cognitive skills that allow us to plan, prioritize, organize, manage time, start tasks, and self-regulate are often impaired in autistic individuals and can significantly impact daily functioning. Scaffolding in the classroom and at home can help.
• Teach healthy coping skills. Emotional dysregulation is very much a part of autism. What’s more, girls are socialized to suppress their emotions, which can accumulate and lead to intense emotional outbursts. Autistic girls must be taught emotional awareness, including how to monitor, label, and understand their emotions. Breathing exercises, mindfulness, muscle relaxation techniques, and other strategies can help improve emotional regulation.
• Talk about autism from a neurodiversity-affirming standpoint. Viewing autism from a strengths-based perspective can help young girls accept themselves, refrain from masking, and gain the confidence to advocate for themselves throughout their lives.

Autism in Girls: Next Steps

• Get This Free Download: The ADHD-Autism Link in Children
• Read: ADHD, Autism, and Neurodivergence Are Coming Into Focus
• Read: 4 Autism Myths — Dispelled
  

The content for this article was derived from the ADDitude ADHD Experts webinar titled, “AuDHD Guidance: Why Autism is So Difficult to Diagnose in Women and Girls with ADHD” [Video Replay & Podcast #511] with Karen Saporito, Ph.D., which was broadcast on June 27, 2024.

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