Tuesday, December 12, 2017

There has been a significant increase in reported cases of autism over the past
decade. Prevalence rates have risen steadily, from one in 150, to one in
110, and now to one in every 54 children (18.5
per 1,000 children aged 8 years).
According to the CDC's Autism and Developmental Disabilities
Monitoring (ADDM) Network, autism is 4 times more common among boys (1
in 34) than among girls (1 in 144). Statistics also indicate that
referrals for evaluation of boys are nearly ten times higher than for
girls. Moreover, girls are diagnosed with autism at later
ages compared to boys. This gender “gap” raises serious questions because many female students with
ASD are being overlooked and will not receive the appropriate educational
supports and services.

Why are fewer girls being identified? Why do
parents of girls experience a delay in receiving a diagnosis? Are there
gender differences in the expression of the disorder? Answers to these
questions have practical implications in that gender specific variations may
have a significant impact on identification practices and the provision of
clinical and educational services. Although few studies have examined gender
differences in the expression of autism spectrum disorders, we do have several
tentative explanations for the underdiagnosis and late identification of girls
with ASD. They include the following.

Social communication and pragmatic deficits
may not be readily apparent in girls because of a non-externalizing
behavioral profile, passivity, and lack of initiative. Girls who have
difficulty making sustained eye contact and appear socially withdrawn may
also be perceived as “shy,” “naive,” or “sweet” rather than
having the social impairment associated with an autism spectrum disorder.

The diagnosis of another disorder often
diverts attention from autism-related symptomatology. In many cases, girls
tend to receive unspecified diagnoses such as a learning disability,
processing problem, or internalizing disorder. A recent survey of women
with Asperger syndrome indicated that most received a diagnosis of anxiety
or depression prior being identified with an autism spectrum disorder.

The perseverative and circumscribed interests
of girls with autism spectrum disorders may appear to be age-typical.
Girls who are not successful in social relationships and developing
friendships might create imaginary friends and elaborate doll play that
superficially resembles the neurotypical girl.

Although Students with ASD are more likely to
be the target of bullying than typical peers, this may not be recognized
in girls due to gender differences in preferred modes of aggression. For
example, girls may use covert verbal, social, and psychological forms of
aggression while boys tend to rely on confrontational and direct modes of
bullying. As a result, the more subtle nature of relational and indirect
aggression (social exclusion and rejection) used by girls may be taken less
seriously than the more obvious, direct aggression exhibited by boys.

Although girls may appear less symptomatic
than boys, the genders do share similar profiles. Research suggests that
when IQ is controlled, the main gender difference is a higher frequency of
idiosyncratic and unusual visual interests and lower levels of appropriate
play in males compared to females. As a result, the behavior and
educational needs of boys are much more difficult to ignore and are
frequently seen by teachers and parents as being more urgent, further
contributing to a referral bias.

Over reliance on the male model with regard to
diagnostic criteria might contribute to a gender “bias” and underdiagnosis
of girls. Clinical instruments also tend to exclude symptoms and behaviors
that may be more typical of females with ASD. For example, assessment
instruments such as the Autism Spectrum Rating Scales (ASRS) and Social
Responsiveness Scale (SRS) have generally reported higher mean scores for
boys than girls. The lower symptom scores for girls may reflect gender
differences and expression of the phenotype. Recent research suggests that
certain single test items may be more typical of girls than of boys with
ASD, and examining symptom gender differences at the individual level
might lead to a better understanding of the gender difference in ASD.

Apart from biases in reporting or diagnosis,
there is significant evidence to suggest that multiple biological factors
contribute to the sex differences seen in autism. These include genetic
and hormonal differences between males and females that may provide a
“protective” mechanism for girls and lead to differences in symptoms and
vulnerability to the disorder.

If girls do process
language and social information differently than boys, then clinical and
educational interventions based largely on research with boys may be
inappropriate. As a result, girls may receive less than optimal academic and
behavioral interventions. If gender specific variations do exist, then the
predictive validity of the diagnosis and developmental course may well differ
between the sexes. Unfortunately, the consequences of a missed or late
diagnosis can result in social isolation, peer rejection, lowered grades, and a
greater risk for mental health and behavioral distress such as anxiety and
depression during adolescence and adulthood. As a result, there is an
urgent need for research to compare girls with ASD to typical boys and girls to
more fully comprehend the implications of being a girl on the autism spectrum. Best
practice recommends that when a girl presents with a combination of social
immaturity, restricted interests, limited eye gaze, repetitive behaviors,
social isolation, and is viewed as “unusual” or “different” by parents, teachers and
peers, the possibility of an ASD should be given consideration. Clinicians and school-based professionals might also question the presence of ASD in girls referred for internalizing disorders such as anxiety or depression. Best practice
assessment and intervention guidelines are available from: A Best Practice Guide to Assessment
and Intervention for Autism Spectrum Disorder in Schools (2nd Edition.) and Autism Spectrum Disorder in Children
and Adolescents: Evidence-Based Assessment and Intervention in Schools.

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