In the United States, one out of every 54 children, is suspected of being autistic (1). This rate has increased each time that the CDC performs studies to explore the rate. One of the reasons is our increased understanding of autism and how we define autism. Our ability to detect and label early signs of autism is improving and this allows for early intervention strategies to be employed during key developmental growth time-windows.
Rates of autism vary around the world, and this may be a factor of access to resources, parental feelings about diagnostic labels, and growth in the prevalence of autism in general. Males outnumber females at a ratio of 4.5:1. (6) In the past 10 years there has been a renewed exploration of girls and autism – to see why autism is less prevalence among females. We are discovering that our diagnostic criteria and approach to girls may mean that many girls have been missed. This has significant impact. Girls do not get access to early intervention which would benefit them. Additionally, they may be labelled as having other disorders that are an element of their autistic traits, rather than a diagnosis on their own. (6)
How is autism in girls missed?
When researchers explore clinicians and school records of autistic girls, it seems that they were missed because they ‘fly under the radar” (8). One reason is that girls need to be bimodal- diagnosed – early and late (9) because of preferential diagnosis towards boys. Practitioners have been using indications of social isolation as a method to identify ASD (Autism Spectrum Disorder) and girls simply do not play alone as much as boys (9).
This inability to see autism, and label it as such, seems to happen at all the stages that typically identify a child as being autistic. These stages include when a) their parent thinks something is different and of concern with their own child, b) if teachers or another significant adult in the child’s life has concerns or has suspicions that this child is different from other kids, c) if the family doctor believes that this child’s agrees with the suspicions of those adults, and that then, d) a psychologist observes and conducts appraisals that might be decisive that this girl child is different from other children and that autism may be the cause of those differences (8) .
In describing how it is that girls look different and get missed (7) , Carpenter and his colleagues write, “Many autistic girls have a desire to fit in with their peers. It appears that, to a greater extent than most autistic boys, many girls use protective and compensatory factors to give the appearance of social conformity and integration with their peer group. They may use observational learning to interpret and imitate facial expressions, create scripts for social interaction and apply rules by rote to social-emotional situations and friendships”. (7)
Girls with autism can use compensatory behaviours such as staying in close proximity to pears, weaving in and out of activities, which appear to mask their social challenges (9). Girls can even learn to “linguistically camouflage” using “Um” and “Uh” appropriately to create pauses in conversations (10). We call these compensatory behaviours camouflaging. It includes the skills of Blending and Masking (11).
It appears that girls are flying under the diagnostic radar in terms of being labelled autistic. It’s important to understand that when autistic girls act in a manner that looks normal, it doesn’t mean that they are typical. It is exhausting to mask. But girls do it because they seem to want friendships (11, 12). And there are consequences to this.
Firstly, girls are being diagnosed in a manner that Professor Francesca Happé , from Kings College in London, describes as diagnostic over-shadowing. In this process by which these girls are brought to the attention of psychologists struggling with other problems, or an educational or mental health nature. Happé comments, “Autistic girls seem more likely to conceal and internalise difficulties. Over time this imposes a detrimental psychological burden, making autistic girls vulnerable to emotional difficulties and mental health disorders such as anxiety, self-harm, depressive, personality and eating diseases. There are a growing indications that autism may be an underlying case of a significant number of undiagnosed girls experiencing those difficulties”(7).
From my personal perspective I meet teen girls that come for help, presenting with learning profiles such as dyspraxia, and anxiety together with communication challenges, or with ADHD, depression and signs of OCD, that are quite possibly autistic. Autism is the core component of their experience and these other challenges, are manifestations of living with autism and masking. Identifying that autism is part of the profile is a mental health, and learning therapy, game-changer.
We need to support autistic girls. Whilst they may look like they can manage friendships, and their cleverness to blend may distract from an autism diagnosis, research indicates that they also have trouble within those friendships. When compared to typical girls, autistic girls encounter more social and communication challenges and can find friendships much more difficult and stressful to manage than their neurotypical peers (12,13).
These problems include troubles with bullying, difficulties with conflict in friendships, understanding flexibility in friendships, understanding who they are versus playing personas, and understanding social rules (12,13). Indeed, it seems that whilst these girls are doing really well, we need to help them do better.
For too long girls’ abilities to fit in may have dismissed their need for support for their autism. Just because you can hide it, doesn’t mean it doesn’t exist. These autistic girls are the potential poster children of accomplishment, and we need to support them as such, not wait until they are overwhelmed and need help because they present to psychologists with another mental problem.
About the author: Angela Watkins is a counsellor and psychologist working our of the RED DOOR Counselling practice in Hong Kong. In addition to her work with teens dealing with issues such as depression, learning styles, anxiety and perception of self, Angela is SEN educator working with teens with a variety of Special Educational Needs. Angela is the proud mum of Alex – an autistic teen girl.
References and Resources
- Australian Bureau of Statistics survey of Disability, Aging and Careers (2015)
- US CDC figures
- US census data 2019
- National Autistic Society UK
- Epidemiology and Research Committee, Child Assessment Service, Department of Health, Hong Kong. https://www.dhcas.gov.hk/file/caser/CASER3.pdf
- Naguy, A; and Alamiri, B (2018). Girls and Autism – Any sex-based peculiarities? The Journal of Nervous and Mental Disease. Vol 206(7) page 579.
- Carpenter, B; Happé, F, and Egerton, J. (2019) Girls and Autism: Educational, Family and Personal Perspectives. Routledge. Quotation from Chapter 1: Where are all the autistic girls?
- Happé, F. (2019). What does research tell us about girls on the autism spectrum. Chapter 2 of Carpenter, B; Happé, F, and Egerton, J. (2019) Girls and Autism: Educational, Family and Personal Perspectives. Routledge.
- Dean, M; Harwood, R; and Karsari, C. (2016). The art of camouflage: Gender differences in the social behaviours of girls and boys with autism spectrum disorder. Autism. Vol 21(6), 678-689.
- Parish-Morris, J; Liberman, MY; Cieri, C; Herrington, JD; Yerys, BE; Bateman, L; Donaher, J; Ferguson, E; Pandey, J; Schultz, RT. (2017) Linguistic camouflage in girls with autism spectrum disorder. Molecular Autism. Vol 8(48).
- Ryan, C; Coughlan, M; Maher, J; Vicario, P; and Garvey (2020). Perceptions of friendships among girls with autism spectrum disorders. The European Journal of Special Needs Education. April.
- Cook, A; Ogden, J; and Winstone, N. (2018). Friendship motivations, challenges and the role of masking for girls with autism in contrasting school settings. European Journal of Special Needs Education. Volume 33(3), page 302-315.
- Sedgewick, F; Hill, V; and Pellicano, E (2018). It’s different for girls: Gender differences in the friendships and conflicts of autistic and neurotypical adolescents. Autism. Vol 23(5).