1. Understanding the presentation of females with autism
Alexandra Sturrock

2. 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

3. 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?

4. 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

5. Social bias arguement Original cases described: male dominant
Kanner: 3: 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)

6. 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)

7. 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

8. Current interest

9. “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)

10. 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

11. 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

12. 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)

13. 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

14. 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)

15. 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)

16. 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)

17. 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

18. 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)

19. 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

20. 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

21. Study

22. Who has supported this study?

23. Questions?