The literature suggests that autism spectrum disorder (ASD) may go undiagnosed in females who do not have intellectual and/or language impairment (e.g., Mandy et al, 2012). Research on differences in ASD symptom presentation in females versus males is not yet well-developed and findings across studies are equivocal. The Diagnostic and Statistical Manual-5th Edition (DSM-5; American Psychiatric Association (APA), 2013) indicates that females may present with less impairment in social communication skills than their male counterparts (p. 57) and that for some individuals with ASD, impairments that do exist may not become an area of concern for self or others until contextual demands exceed compensatory strategies (e.g., camouflage; see Head, et al, 2014; APA, 2013). Clinical practice indicates that adolescent females may experience an increase in anxiety and/or develop depression in response to an increasing self-awareness that they are “different” than their peers. This can lead parents/self to pursue research on-line about symptoms and to discuss concerns with others. In some cases, this leads to the pursuit of a diagnostic assessment.
Assessing females for ASD should follow best-practice guidelines, the same as is the case for males. Best practice in ASD diagnostic assessment recommends using multiple methods and informants (e.g., Magyar & Pandolfi, 2012; Ozonoff et al., 2005). Practice considerations include:
- Record Review (for history of developmental levels: cognition, language, motor (previous testing information; psychiatric history; medical history; context: home, school/work, community))
- Interview (with parent: history of development, play and social behavior, emotions and behavior (temperament), psychiatric and medical; with teen: self-report of symptoms and experiences)
- ASD Questionnaires/Rating Scales: parent completed
- ASD Questionnaires/Rating Scales: individual completed
- Direct Assessment: Autism Specific Measure (e.g., Autism Diagnostic Observation Schedule-2, Childhood Autism Rating Scale-2)
Data obtained from the assessment should be analyzed for evidence of ASD core impairments using the DSM-5 symptom criteria as a guide. Differential diagnostic practice should be applied for ASD diagnosis with/without co-occurring behavioral health conditions. For females without a developmental history of delays or impairment, particular attention should be paid to:
- the individual’s social communication and interaction history (i.e., quality and nature of play, friendships, and co-worker relationships),
- the qualitative nature of speech forms used during interview (i.e., formal language, idiosyncratic),
- age-expected understanding of social relationships and social interactions
- if anxiety and/or depression is present, the areas related to the individual’s distress should be analyzed (e.g., social, performance, routines, rituals), and
- age-and-developmental appropriateness of the social communication and reciprocal social interaction during interview and upon direct assessment.
In addition to following the considerations in best-practice diagnostic assessment, there are a couple of other considerations that, if applied, may increase the likelihood of earlier identification of females at risk for ASD. One, increased awareness and knowledge of the risk factors associated with ASD and the myriad of ways these may present. ASD is a neurodevelopmental condition and early signs may be related to age-inappropriate behavioral reactions such shut-downs/meltdowns, avoidance of social situations (including school refusal); age-inappropriate and excessive/indiscriminate social approaches (e.g., poor peer choice, internet safety issues); developmental factors such as cognitive and language impairment(s); and the onset of behavioral health conditions (e.g., anxiety disorder, depression). The presence of one or more of these factors may moderate and/or overshadow the individual’s primary set of symptoms (i.e., ASD) and result in a delay in diagnosing ASD. Therefore, increasing awareness and knowledge of risk factors and how symptoms present is critical.
A second consideration is for those professionals on the “front lines” (i.e., pediatricians, school personnel, counselors). These professionals should consider adopting screening practices that can increase earlier identification. This can include the use of one or more methods of assessment such as record review, interview, and the administration of a valid and reliable rating scale. These considerations can be applied to any condition that warrants early (or earlier) identification such as behavioral health conditions in youth with ASD (e.g., Magyar & Pandolfi, 2009).
Dr. Magyar, a NYS Licensed Psychologist & NYS Board Certified Behavior Analyst in Rochester, NY, provides diagnostic assessment and treatment services to adolescents and adults with autism spectrum disorder (ASD). She focuses much of her practice on the assessment and treatment of females with ASD. Visit her website for information on her services and for contact information: www.magyarpsychservices.com.
American Psychiatric Association (2013). Diagnostic and statistical manual of mental disorders: 5th Edition. Washington, D.C.: Author.
Corsello, C., Spence, S., & Lord, C. (2012). The Autism Diagnostic Observation Schedule-2nd Edition. Western Psychological Services.
Head, A., M, McGillivray, J.A., & Stokes, M. A., (2014). Gender differences in emotionality and sociability in children with autism spectrum disorder. Molecular Autism, 5:19.
Magyar CI, Pandolfi V. (2009). Issues & Considerations in Assessment & Intervention of Mental Health Disorders in Children with Autism Spectrum Disorders. Autism Spectrum News, fall.
Magyar, C.I., & Pandolfi, V. (2012) Considerations for establishing a multi-tiered problem-solving model for students with autism and emotional-behavioral disorders. Psychology in the Schools, Special Edition; 49: 975-987.
Mandy, W, et al (2012). Sex differences in autism spectrum disorder: Evidence from a large sample of children and adolescents. Journal of Autism & Developmental Disorders, 42, 1304-1313.
Ozonoff, S., Goodlin-Jones, B.L., & Solomon, M. (2005). Evidence-based assessment of autism spectrum disorders in children and adolescents. Journal of Clinical Child and Adolescent Psychology, 34(3), 523-540.
Schopler, E., VanBourgondien, M.E., Wellman, G.J., & Love, S.R. (2010). The Childhood Autism Rating Scale-2nd Edition. Western Psychological Services.