Autism Spectrum Disorder (ASD) is a neurodevelopmental condition that affects how someone thinks, feels, interacts with others, and experiences their environment. Every person with autism presents differently, which is why we refer to autism as a ‘spectrum’.
Data suggests that boys are 4 times more likely to have autism than girls. However, this figure may hide the true prevalence of autism in females due to biases in their presentation, assessment and diagnosis rates.
The current standardised measures used for diagnosis of ASD often have false negative results for females. The DSM-5 has been criticised for its inability to truly capture the psychopathology of females with ASD. There is increasing evidence that highlights the differing presentation of ASD in males and females, particularly those without intellectual disability. Many individuals with ASD, learn to adapt using social coping strategies and attempts to fit in, compensating and masking their ASD symptoms. Females are naturally more social and therefore girls on the autism spectrum may learn to mimic other socially skilled peers making it much more difficult to pick up their social deficits.
For the affected person, these camouflaging behaviours can be cognitively exhausting, often leading to greater stress, anxiety, and depression – which might be how they present and are treated in the clinical setting. Girls might manage to ‘keep it together’ at school and appear fairly well to their teachers, but decompensate and become very emotional at home. Their obsessive interests in make-up, art, music, games or dolls might appear fairly ‘normal’.
These findings suggest that females require exaggerated observable characteristics to be diagnosed with the existing criteria. It might also explain why those higher functioning females, presenting with more subtle ASD behaviours, are less likely to be referred for a clinical assessment and are not accurately diagnosed when they do.
ASD can often be misdiagnosed as borderline personality disorder in girls. Common overlapping symptoms are emotional dysregulation, impulsivity, poor self-concept, self-harming behaviours, social difficulties and attachment anxiety. Generally, emotion dysregulation in BPD occurs within the relational context, whilst in ASD it is more often associated with the need for sameness, rigidity and changes to routines.
Other presentations in girls with an underlying ASD diagnosis, include ‘odd, difficult or stubborn’ behaviour, OCD, obsessive traits, eating disorders, picky eating, overwhelming emotions and poor executive functioning (planning, organising and monitoring).
Girls who present with the triad of social challenges, sensory-aversive or sensory seeking-behaviour and rigidity or obsessiveness, might warrant an ASD assessment.
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