The most common autistic spectrum disorders (ASD) seen by health and education services are autistic disorder, also called childhood or classic autism, and Asperger’s syndrome*. Autistic disorder is characterised by speech delay and signs of impaired social interaction, communication and imagination.
Lorna Wing’s research found a ratio of two to one male to female prevalence of autistic disorder and fifteen to one for Asperger’s syndrome, suggesting that girls were less prone to the more subtle forms of ASD (Wing, 1981). Certainly, males are more susceptible to organic conditions (where there is measurable disease) such as autism which is a neurological developmental condition. In addition, girls appear to have some protection from the genetic variants that are thought to cause autism.
However, it is becoming clear that girls simply may be under-represented in Asperger figures because the history of research into ASD, from its inception with Kanner’s and Asperger’s work in the mid 1940s onwards, is based on males. Diagnostic tools – using interviews, specific tasks and categorisation of behaviours resulting in quantitative scores for analysis – were developed according to male phenotypes (Gould and Ashton-Smith, 2011). The ways in which Asperger’s syndrome manifests in girls have not been adequately investigated and only in the last five to ten years has attention been focused on females.
Diagnosis of ASD is based on the triad of impairments, identified by Wing and Gould in 1979. With Asperger's syndrome, girls can present differently to boys in each of these areas of impairment.
(Holtman et al., 2007)
It seems that girls on the autistic spectrum may be less noticeable than boys because they are less disruptive and have an ability to mimic behaviours (Attwood, 2012.) However, they lack social understanding and any deep knowledge of language. This becomes increasingly obvious at secondary school level, when there are no younger children to associate with, when peer groups are more mixed and any “protection” may have dissolved. Additionally, multiple stimuli (such as crowds in corridors or screams in playgrounds) and changes to routines which occur at secondary education can increase individual anxiety greatly. Adolescence, involving unstoppable changes, such as menstruation and the growth of breasts and body hair, can profoundly affect girls with ASD, heightening anxieties due to lack of control over what is happening.
Anorexia nervosa has been called “female Asperger’s” because around one fifth of girls who present with anorexia have traits which are peculiar to the autistic spectrum; around 20 to 30 per cent of anorexic patients are perfectionists and demonstrate rigid modes of thinking and behaviour, which are common autistic traits. Anorexia offers girls with ASD what they perceive to be a positive outcome because lack of nutrition prevents menstruation and physical development.
It is not until puberty that girls’ social difficulties become more obvious, particularly as they enter secondary school when they can become the subject of bullying or can be generally marginalised and perceived as strange. Unlike boys, they become withdrawn, depressed and quiet, rather than aggressive.
Profound anxieties may be demonstrated in altered behaviours, lower grades at school, poor sleep patterns, low mood/depression and obsessive behaviour.
Research from 2011 found that many women who were later diagnosed as being on the autistic spectrum initially were thought to have learning difficulties, personality disorders, obsessive compulsive disorder or eating disorders (Rivet and Matson, 2011). This differential diagnosis could be related to lack of awareness of how ASD present in females.
More research is essential to identify features of ASD, particularly Asperger's syndrome, in girls and to train health and teaching staff about presentations in females. Diagnostic tools must be adapted to incorporate gender differences and ensure that scores attributed to behaviours include the range of symptoms in girls. Observation of girls in the social setting of school, paying close attention to friendships, is vital for diagnosis. Seeing how girls manage during unstructured time is also telling, since those with Asperger's have difficulty identifying how to fill the time and do not enjoy the freedom but are lost and anxious.
The earlier diagnosis is made, the sooner intervention can be implemented. Within a school, this might mean:
All research suggests that an early diagnosis of ASD, followed by appropriate interventions, will optimise the person’s life chances by increasing independence, understanding and accumulation of language and social abilities. To date, the ways in which females present with Asperger’s have not been thoroughly examined or used as the basis for diagnostic tools, which continue to be male dominated.
The All Party Parliamentary Group on Autism is recommending that there is a lead teacher for autism in every school who has relevant expertise and training. This follows a survey which found that 80 per cent of respondents thought that teachers were not given sufficient training to support children with autism. Any such training should, of course, include gender issues. After all, teachers are in a unique position to be able to identify the signs of ASD in girls and implement strategies to help them to develop to their full potential.
Kate Reynolds is a registered general nurse, counsellor and trainer of health professionals with 18 years’ NHS experience. She is the mother of an autistic child and the author of Party Planning for Children and Teens on the Autism Spectrum. Kate blogs at:
* The term “Asperger’s syndrome” is used also to refer to higher functioning autism (HFA) for the purposes of this article, since the only difference in presentation is that HFA involves clinical speech delay in childhood.