The invisibility of Autism in girls

I am always inspired after attending professional development workshops, however I was particularly so following Tony Attwood and Michelle Garnett’s “Girls and Women on the Spectrum” last October. Having worked with children and their families for 20 years, I have seen a huge shift in our understanding of the Autism Spectrum, but until recently, the emphasis in understanding, research and discussion has been on boys, with a ratio of males to females diagnosed being around 10:1. However, research for ASD now suggests that the ratio should be 3.5:1. Tony and Michelle beautifully explained why girls are less likely to be identified with ASD, and it is largely due to the condition being more ‘invisible’.

While girls have the same profile of abilities as boys, the expression is generally much subtler and less severe, meaning parents are less likely to seek help early, and clinicians may be hesitant to commit themselves to a diagnosis. I’ve seen this many times in my career and, sadly for the girls, it results in a missed opportunity for them to begin to understand their difficulties and receive early intervention.

Girls with autistic spectrum difficulties appear to have more advanced social skills, and rather than coping with negative emotions with physical aggression, they camouflage themselves by observing, analysing and imitating the skills of their neurotypical peers. This “child psychologist” approach in which these developing girls closely observe the behaviour of others is believed to begin at a young age and, although effective for a while, it becomes increasingly difficult (and exhausting) for girls to continue to mask their symptoms. Often due to this exhaustion, adolescent girls present to psychologists with depression or anxiety, resulting in later identification and diagnosis, and years of feeling different or weird with no explanation.

While their male counterparts tend towards strong ‘obsessive’ interests, such as with transportation or dinosaurs, girls tend to develop special interests in animals, music, art and literature. They also often seek out fiction in their reading and viewing in order to help them learn about the inner thoughts and feelings of others. Their play with dolls at a young age also tends to be more about decoding confusing social situations, than about imaginative play. As they get older, they tend to become expert mimics, who copy the mannerisms and character of socially successful peers. In fact, Tony stated they often make excellent psychologists due to their expert study of others. Girls and women with Autism also tend towards single friendships. This can go wrong when they eventually becoming smothering, resulting in rejection which they find incredibly confusing and hurtful, again often resulting in them being misdiagnosed with a personality disorder. Many girls with Autism also identify more with boys, or as gender neutral, finding stereotypically ‘female’ activities boring or trivial.

One of most important reasons for improving our identification of ASD in girls and adolescents is to prevent the long-term consequences of camouflaging, including anxiety, depression, loneliness and isolation. In addition, young women on the Spectrum are tragically over represented as victims of sexual assault due to a tendency to misinterpret social situations, and as experiencing substance abuse problems and eating disorders in order to manage their disabling anxiety.

However, thanks to the work of Tony, Michelle, and many other passionate researchers and clinicians world wide, girls and women with ASD are becoming more visible. The myths that all people with Autism “lack empathy” and “must have an obsessive interest” are gradually being dispelled, meaning parents who have “always known something was a little different” with their daughter can now be referred to a paediatrician, psychologist or speech pathologist by and understanding GP who understands the nuances of the female genotype of ASD.

If your daughter, niece, mother or aunt is a chameleon, appearing to wear different ‘masks’ for different situations, experiences sensory sensitivities, struggles with change, and often needs time out from social interactions due to exhaustion, let them know they are not alone, and that seeking help and potentially a diagnosis will open up pathways of understanding, strategies for coping, and hope for them to reach their own potential.