With roughly one percent of the population reported to fall somewhere on the autism spectrum, and with this number ever steadily rising, how come the ratio of boys to girls with autism remains at around four to one?
The fundamental question is, what are little girls made of? In the nursery rhyme, boys are made of slugs, snails and puppy dogs’ tails, whereas girls are made of sugar and spice and all things nice. Whilst this might seem like a light-hearted poem, it is important to consider how this might translate onto societal norms and consequently, how that might lead to a misdiagnosis or missed diagnosis of autism in girls.
1. Diagnostic bias
Autism was first coined in the 1940s by two men, Kanner and Asperger. Kanner (1943) studied four times as many boys as girls whilst creating the autism phenotype and Asperger (1944) originally believed that no girls with autism existed. More recent research (Szalavitz, 2016) suggests that girls with autism process social information differently to girls without autism, but also to boys with autism. This would suggest that the diagnostic criteria so heavily relied upon by health professionals is largely weighted towards the male presentation of autism, whilst the female presentation remains largely unresearched.
2. Gender stereotypes Through social cognitive theory, we understand that children learn via a mix of modelling and direct tuition; that is, children imitate what they are exposed to (Bandura, Ross & Ross, 1961) as well as what they are told. Many studies have demonstrated that adults and older children are naturally inclined to promote gender stereotypical play. Boys’ toys might include cars, ride-on tricycles and robots, whereas girls’ toys might include teddy bears, home role play and dolls. Through these gender stereotyped toys, children are learning specific skill sets. Generally, boys’ toys teach spatial awareness, logic and mechanics and gross motor skills. In comparison, girls’ toys teach compassion, nurture and language skills. This means that girls are often greater exposed to play (and therefore learning) situations that promote the social skills considered to be impaired (Wing & Gould, 1979) by autism, increasing their opportunity to practice such skills. 3. Masking
A combination of reduced understanding of the female autism phenotype, plus increased practice of the skills required to demonstrate social competence means that girls with autism are often able to ‘mask’ their difficulties. This happens more as the child becomes older and learns through real life and role play scenarios that being ‘different’ can lead to negative consequences e.g. bullying. Instead, girls with autism have gained enough practice of what a ‘typical’ interaction should encompass that they are able to follow the script and blend in. However, the social understanding remains minimal – this is just a script after all – and this can lead to increased feelings of depression, stress and anxiety. To remove the mask, there needs to be an increased awareness of the female autism phenotype, alongside increased acceptance of neurodiversity within society.
It is positive to see that research is beginning to turn its focus onto the female population and explore the nuances of autism within girls and women. However, as suggested within Happé and Frith’s (2020) annual research review, there are still many questions to be answered in order to gain a better understanding of autism and girls.
Keen to read more about this topic? Please find below a list of useful resources including books for adults and children, interventions and online resources.
Useful resources
Books for Adults
‘Autism and girls: Flying under the radar’ by NASEN - an easy-to-read guide to autism in girls, key issues and practical strategies from an educational perspective.
‘Girls and autism’ by Barry Carpenter, Francesca Happé and Jo Egerton – a combination of the latest research and lived experiences provides essential information to help support and teacher girls with autism.
‘NeuroTribes’ by Steve Silberman - this book covers the history of autism and some of the key people who have influential in our understanding of the condition over the years.
‘The independent woman’s handbook for super safe living on the autistic spectrum’ by Robyn Steward - written by an autistic woman, this ‘handbook’ can be used as a guide to life, covering everything from relationships to drugs to money to the internet (and much more).
Books for Children
‘I’m a bunny who knows what it’s like to have autism’ by Sherry Haley - this beautifully illustrated book started life as a shop window display. It contains pictures of rabbits describing various features of autism and strategies for support.
‘It’s raining cats and dogs’ by Michael Barton - autistic author Michael Barton uses simple drawings to illustrate the confusion caused by idioms, metaphors and day-to-day phrases.
‘Can you see me?’ by Libby Scott and Rebecca Westcott – a personal perspective of living with autism, written as a narrative, by 11 year old Libby.
‘M is for Autism’ and ‘M in the Middle’ by The Students of Limpsfield Grange School and Vicky Martin - both resources have been produced by the students of Limpsfield Grange School, a secondary school for girls with communication and interaction difficulties.
Interventions
‘The ASD Girls’ Wellbeing Toolkit’ by Tina Rae and Amy Such - a 30 week intervention programme aimed at girls with social communication difficulties, aged 10 and up. The programme covers aspects of self-identity, managing relationships and planning for the future.
Online Resources
Purple Ella - an autistic female blogger with two autistic daughters
Curly Hair Project - a social enterprising providing a bank of resources including blogs, training and merchandise to support people with autism and those around them.
‘Women and Girls’ by the National Autistic Society - an online training course focused on promoting awareness of autism in the female population.
'Supporting ASD Girls in the Early Years' - on demand webinar hosted by Learning & Wellbeing Psychology (coming soon)
References
Asperger, H. (1944). Die “Autistischen Psychopathen” im Kindesalter. Archiv für Psychiatrie und Nervenkrankheiten, 117(1), 76 – 136.
Bandura, A., Ross, D. & Ross, S.A. (1961). Transmission of aggression through imitation of aggressive models. Journal of Abnormal and Social Psychology, 63, 575-82.
Happé, F. & Frith, U. (2020). Annual research review: Looking back to look forward – changes in the concept of autism and implications for future research. The Journal of Child Psychology and Psychiatry, 61(3), 218 – 232.
Kanner, L. (1943). Autistic disturbances of affective contact. Nervous Child, 2, 217 – 250.
Szalavitz, M. (2016). The invisible girls. Scientific American Mind. March/April, 48 – 55.
Wing, L., & Gould, J. (1979). Severe impairments of social interaction and associated abnormalities in children. Journal of Autism and Developmental Disorders, 9(1), 11 – 29.