Understanding the presentation of females with autism Alexandra Sturrock

What is ASD? Autism Spectrum Disorder: a neuro-developmental disorder typified by difficulties with: Social and emotional understanding Social communication (language) Flexibility in thinking and behaviour Diagnosis achieved by identifying cluster of symptoms – professional opinion is critical in accurate identification

What is the male:female ratio? Female/Male prevalence ratings: 1:4 diagnosed (Frombonne et al, 2009) 2:1-7:1 depending on sample More females (IQ < 70) less females (IQ > 70) (Nicholas et al, 2008) Why?

Why the difference? Female protective effect? Extreme male brain? X-linked genetic involvement? Current definition of ASD based on male presentation of symptoms? - public/clinicians not recognising ASD in females FPE – oxytocin + estrogen = prosocial behaviours and reduced socal anxiety MBT – exposure to foetal testosterone leading to androgens and autistic traits

Social bias arguement Original cases described: male dominant Kanner: 3:11 Asperger: all male cases Current diagnostic tools based on research in male (Goldman, 2013) Public and clinician opinion based on historic models Same male bias in other disorders (ADHD, dyslexia etc) (Gardener et al, 2012)

What evidence is there? Females are being missed (Dworzynski et al, 2011; Giarelli et al, 2010; Kopp and Gillberg, 1992) Females are more likely to be diagnosed with another disorder (Giarelli et al, 2010); Kopp & Gillberg, 1992; Hiller et al, 2015) Language disorder, ADHD, anxiety, GDD Mental health diagnosis Later age of diagnosis (Wiggins et al, 2003, Shattuck et al, 2009, Goin-Kochel et al, 2014)

How could sex influence ASD diagnosis? Sex could affect ASD outcomes at different levels (Postova and Young, 2012) females>males symptoms muted or unexpressed Males and females have underlying difficulties at biological level. Social environment Females>males undiagnosed or receive other diagnosis Male> female express recognised ASD symptoms Diagnostic process Males>females Asd diagnosed Females: more verbal interactions, conversations, play engagement, eye gaze, reaction to emotion, attribution of emotion

Current interest

“So I cultivated an image, which I brought out to social situations” Self reports “So I cultivated an image, which I brought out to social situations” “I automatically mimic what other people are doing, what they are saying and how people say things” “it’s very draining trying to figure out everything all the time, everything is more like a manual, you’ve got to use one of those computers where you have to type in every command” (Bargiela et al 2016)

What do we know so far? Sparcity of evidence But growing! Early limitations of studies Few & small scale studies Studies have mixed IQ & ages No comparison to typical development Assessments are often limited to diagnostic tools, which might have male bias No specific language or communication assessments

What do we know so far? Different Social Skills (Kopp and Gillberg, 2011; Lai et al, 2011; Horovitz et al, 2011; Holtmann et al, 2007) More motivated to make friends and be sociable (Sedgewick et al, 2016) More likely to have a best friend (Dean, 2014) May have an older friend who will ‘mother’ her (Tierney, 2016) May have a younger or male friend (reduced social expectations) (Tierney 2016) Less friends overall (Dean 2014) and may become over reliant on one friend

What do we know so far? Different Social Skills More emotionally responsive to friends than males with asd, but less than females without asd (Head et al, 2014) Conversation more central to friendship bonding than males (Sedgewick et al, 2016)

What do we know so far? Different Social Skills Friendships in childhood facilitated by others (Tierney 2016) Difficulties with maintaining friends: Needing to take control of activities (Hiller et al, 2014) Difficulties interpreting others behaviour (Tierney, 2016) Less able to recognise aggressive social behaviour in friendship groups (Sedgewick et al, 2016) Social relationships become more difficult after adolescence: Development of sexual identity Changes in social groups following move to secondary school Different social expectations (Tierney et al, 2016) Getting it right is challenging – desire not to stand out Likely to mask and imitate Feelings of exhaustion. Meltdowns at home; covering up in school

What do we know so far? Different play: May do more pretend play (Knickmeyer et al, 2008) Prefer ‘female’-type play different social environments (Dean et al, 2014) More likely to choose ‘female’ toys (Harrop et al, 2016; Hiller et al, 2014) Boys and girls with autism will spend less time in play and symbolic play (Harrop et al, 2016)

What do we know so far? Different play: May show less repetitive behaviours (Mandy et al, 2012; Park et al, 2012; Szatmari et al, 2012) May have less restrictive interests but similar levels of routines, stereotyped movements and preoccupations (Hiller et al, 2014)

What do we know so far? Different behaviour: Internalising not externalising (Mandy et al, 2012; Amr et al, 2011; Cohen et al, 2010; Giarelli et al, 2010; Hiller et al, 2015)

Why Study differences in Language? Core feature in autism (ICD-10: WHO, 1993; Lord and Jones, 2012) Differences exist between typically developing females & males Enduring theory explaining difference between females & male presentation of autism (Wing, 1981) Differences in language centres of brain (Menon et al, 2015) Never been adequately tested

What do we know so far? Differences in Language & Communication More motivated to communicate (Horovitz et al, 2011) More likely to mimic voices (Kopp & Gillberg, 2011) Better non-verbal communication (Holtmann et al, 2007) but not interpret them (Hiller et al, 2014) Better able to maintain a reciprocal conversation (minimally) (Hiller et al, 2014) Better narrative memory – linked to better verbal fluency (Goddard and Howlin, 2014)

What do we know so far? Differences in Communicative experiences More integral to friendships (Sedgewick et al, 2016) Different profile across time (McLennan et al, 1993) Impact on social outcomes (Lai et al, 2011) Perceived difficulties (Holtmann et al, 2007; Lai et al, 2011) Degree of difficulty

Summary Less repetitive behaviours More pretend play Different types of preoccupations Coping strategies including masking and mimicking Female with autism Better ability to make but not maintain friends Better verbal skills in early years More socially motivated Better non-verbal skills Social interactions in childhood supported by others More likely to internalise difficulties Still struggle in comparison to typically developing girls! Increased social difficulties in adolescence and adult-hood

Study

Who has supported this study?

Questions?