Dr. Jeremy Sharp (00:12)
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Dr. Jeremy Sharp (00:36)
Hey folks, I am really glad to have NovoPsych Psychometric sponsoring the show. If you do structured assessment work, then you will likely love NovoPsych. NovoPsych brings 150 plus standardized measures into one platform. What I particularly like is the extra layer of psychometric interpretation. So it helps you understand what scores actually mean. So the results are easier to communicate. If you are interested in high quality measures for personality, disability, ADHD, or autism,
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Dr. Jeremy Sharp (01:20)
Hey folks, are back with another episode in the Autism mini series. Started a couple of episodes ago where we talked about the ADOS2 and Stan, current state of the research and specificity, sensitivity, validity with different populations. And now we are continuing with a discussion of the female autism phenotype.
If you didn’t listen to the first episode, I think it does lay some nice groundwork. So you could go back to that. It is just, I think, two episodes ago. And each episode in the Autism mini-series kind of builds on itself. So yeah, could be good to listen to the first one, though I think this can stand alone as well if you are super familiar with the ADAS and its strengths and limitations. So what are we talking about today? We’re talking about the female autism phenotype.
So we’re going to explore how autism manifests differently between males and females across multiple domains. We’re going to look at whether these differences reflect true phenotypic variation or measurement bias or both. So we’ll start with a discussion of prevalence. We’ll talk about social communication differences between males and females. Talk about something called the paradox of greater impairment required for diagnosis. Touch on restricted interests and repetitive behavior.
Psychiatric comorbidities and differences there, developmental trajectories, camouflaging. We’re going to introduce that concept before we explore it in depth in the next couple of episodes. there is a lot to take away from this. So stay tuned. Like I said at the beginning of the mini series, if you are not following or subscribing to the podcast, up to this point, now’s a great time to do it, just to make sure that you get notified and get those downloads whenever new episodes come out. And if you have been a long-time listener but haven’t shared the podcast with anyone recently, I would be super grateful if you did that and just help spread the word. If you find the podcast helpful and relevant for your work, share it with somebody else and bring somebody else on board and into the testing psychologist community.
So let’s jump to this conversation about the female autism phenotype.
Dr. Jeremy Sharp (03:47)
All right. Here we are. We’re back. We’re going to jump right in and start talking about prevalence. So prevalence is important here in this discussion. As many of you probably know, autism is diagnosed essentially like three to four times more often in males than females. So this is approximately a four to one ratio in clinic samples. This has been true since the original kind of conception of autism or Asperger’s.
The original descriptions like back in the 40s I think is when all this started. But is this ratio real or are we in fact missing women or females? So here’s some evidence for under diagnosis in the female population. One studies that are using pretty rigorous case ascertainment methods report lower ratios. OK. So that would be like three point seven percent in boys total prevalence versus one point five percent in girls.
which is actually more like a 2.5 to 1 ratio instead of that 4 to 1 ratio. So this suggests that current diagnostic procedures might be less sensitive to autism in females. So the gap between that clinic ratio 4 to 1 and the population ratio of 2.5 to 1 represents the quote unquote missing females. Okay. There is an issue with timing though, in terms of diagnosis.
Females are diagnosed later on average than males. There is one study that showed that females receiving assessments approximately six months later than males. And I think this delay compounds over time because later diagnosis means later intervention, later support, longer periods of struggling without understanding why, that kind of thing.
And there is certainly a resurgence, not resurgence, but… just a surge over the last few years of adult women seeking autism diagnoses or assessments for autism. think a lot of us have experienced that. There’s also a little bit of an intellectual disability paradox in this discussion though as well. in clinic samples, females are actually more likely to present with co-occurring intellectual disability and epilepsy in particular. So this suggests that girls without intellectual impairment or language delays may go unrecognized. So the implication is that females theoretically need to be more impaired to be identified.
So it’s a little bit just on prevalence and where we’re at here at the moment with diagnostic rates and so forth. But let’s talk about social communication and how this plays into things. So a great meta analysis of, I think 16 studies from recent years showed that females with autism had significantly better social interaction and communication skills than males did. So this mirrors the sex difference pattern seen in neurotypical individuals, which is interesting, in that females generally outperform males on social tasks.
Now, in terms of specific differences, though, when we compare males with autism, females might have better reciprocal communication, be more likely to share interests with others, integrate verbal and nonverbal behavior more effectively, modify their behavior by situation, show better eye contact, and respond more appropriately to joint attention. These are a lot of things that overlap, obviously, with the criteria that we’re looking at in considering an autism diagnosis. There is a critical caveat, though.
So, that looks like, despite better observable social skills, females have similar underlying social understanding difficulties as males. So they may not intuitively understand social rules, but females have learned to follow them better than males have. And similarly, they may not naturally read social cues, but they’ve developed workarounds. So the surface looks different, but the underlying neurology may be the same as far as we think at this point, there is a little, little issue with measurement bias as well. We kind of alluded to this in the first episode in the mini series, but on the ADOS, you know, females were rated as less impaired in eye contact. Their response to joint attention and quality of social overtures was associated with less underlying social communication difficulties compared to males. And yet the diagnostic threshold does not account for these sex differences, you know, in the general population.
So lots to consider here, especially in the social communication realm, but we’re going to talk about some more aspects of this dilemma here as we go along. I’m going to talk about, like I said, the paradox of greater impairment for diagnosis. So what does this mean? means that some studies are reporting that young girls diagnosed with autism display greater social communication deficits than boys, actually.
And this is particularly true in toddler age kids from clinician ratings and preschool aged kids, which is similar to toddler as far as parent ratings. So what does this mean? This likely means that females require more severe impairment to be recognized and diagnosed. Girls with milder presentations are missed. Only those with obvious difficulties are identified. And this is consistent with that intellectual disability finding as well that females in clinic samples are more impaired because less impaired females aren’t making it to clinics.
There is a little bit of a diagnostic overshadowing problem as well, where females who do present for evaluation often have prominent co-occurring conditions like anxiety or depression or eating disorders or self-harm. And these conditions might overshadow the underlying autism and clinicians may treat that presenting problem without recognizing the neurodevelopmental foundation. So I’m going to pause here. mean, there’s a lot to continue to discuss, we’re gonna move into a discussion of restricted interests and repetitive behaviors and the sex differences there. But if you are finding yourself, like seeing yourself in this discussion a little bit in the sense that as a clinician, you’re kind of wrestling with how to integrate this, you’re not alone.
Dr. Jeremy Sharp (10:11)
I think this is a big discussion point in the field right now is, what degree can we interpret these behaviors and characteristics if they are not sort of like classic quote unquote symptoms of autism. The DSM has not necessarily caught up to account for differences in female presentations that we know about. And so it puts us in an interesting place from a clinical standpoint. So just a note on that. And we wrestle with this a lot in our practice as well.
But I do want to talk about restricted interests and repetitive behaviors a bit. So in terms of quantitative findings, males with autism show higher levels of stereotype behaviors and restricted interests compared to females. There’s a meta-analysis that also showed, like I said, kind of bore this out.
Now, that said, No significant sex differences for sensory experiences or insistence on saneness emerged from this meta-analysis though. let’s repeat that just for a second. in this meta-analysis, recently, males with autism showed higher levels of stereotype behaviors and restricted interests compared to females, but there were no significant sex differences for sensory experiences or insistence on sameness.
What about though, when we dig into the types of repetitive behaviors? Well, females showed higher levels of compulsive behaviors, insistence on sameness, and self injurious behaviors. Whereas males showed more stereotype motor movements and restricted interests. There’s some really large scale data showing that males were also more associated with higher severity of repetitive motor behaviors and restricted interests, but lower severity of compulsions and self injurious behaviors. Okay, so that’s all the, that’s the quantitative difference. Well, let’s talk about the qualitative difference, and the content of the interest.
So special interests in females may have a more social focus, like a singer or an actor or a fictional character. They may also have like a more normative focus, like horses or animals or art or fashion. So the intensity is unusual, but the topic is not necessarily.
OK, so this is that really digging into that sort of classic conceptualization of like a boy who’s kind of obsessed with, say, train schedules and is easily flagged, whereas a girl that is obsessed with horses is seen as relatively typical. All right. So folks out there, mean, Donna Henderson comes to mind. She’s been talking about this stuff for a long time. There are many others as well. But the research is certainly supporting these claims. As far as clinical implications, though, clinicians have to look beyond the content of interest to the intensity, and exclusivity and functional impact. Does the interest dominate conversation to the exclusion of other topics? That’s still going to be present. Does it interfere with other activities or relationships? Is the depth of knowledge unusual for the person’s age?
Dr. Jeremy Sharp (13:12)
So we still have to ask these questions when we’re evaluating the intensity of these interests, even if they appear more socially appropriate.
There’s also a component that we need to discuss around psychiatric comorbidities and sort of the burden that, or the outsize burden that females tend to carry here.
Dr. Jeremy Sharp (14:51)
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Dr. Jeremy Sharp (15:55)
So just as a statistic, a reference point, by age 25, 77 of 100 autistic females versus 62 of 100 autistic males received at least one psychiatric diagnosis. OK, this comes from a.
Swedish study or Swedish population study with pretty rigorous methodology. So in terms of specifics there, like autistic females consistently showed like significantly higher rates of anxiety and depression and sleep disorders. The cumulative incidence of anxiety was higher in females, among individuals with autism and among neurotypical folks. I think we are well aware of this. Depression is also prominent.
So, you know, among individuals with autism. Males initially show higher cumulative incidence of depression before 15, but that reverses in later adolescence when females pass the males in terms of incidence of depression. So something happens in adolescence that particularly affects autistic females. So that’s something to look out for with adults, adult women or female presenting individuals.
There are a lot of comorbidities, know, autistic individuals with comorbidities are more likely to meet criteria for multiple psychiatric conditions. There are, think it’s like 55 % of folks with, you know, two or more comorbid diagnoses versus like 45 % in control subjects. So the burden is not just having like one psychiatric concern, but many or multiple. So you might be asking the question, why?
Of course, I’m always wondering why. Possible explanations include greater camouflaging or masking efforts that lead to exhaustion and burnout, later diagnosis, meaning longer periods without support, hormonal factors that affect mood regulation, greater social awareness, leading to greater awareness of social failure, quote unquote, or struggles, and potentially internalization of difficulties rather than externalization.
Dr. Jeremy Sharp (18:03)
I’m going to dig a little bit deeper into the developmental trajectories here as well. So in early childhood, diagnosed young girls are more likely to have better cognitive development, less intense autistic symptoms, reduction of symptoms over time. This might reflect that only the most obviously affected girls are diagnosed early, of course. But adolescence is a little bit of an inflection point.
So, difficulties in adaptive functioning and social challenges may emerge more prominently for females and adolescents. Social demands increase dramatically in middle school and high school. Friendships get to be more complex. They require skills that might have been adequate in childhood but are insufficient for adolescent social navigation. And this is when many females first come to clinical attention. Now, as we move into adulthood though, know, older girls tend to show fewer restricted interests and repetitive behaviors over time. It’s important to keep in mind, and certainly an argument to gather a really strong developmental history from caregivers if you can. This might reflect learning to suppress though, rather than true reduction. We’ll talk about camouflaging and masking in just a second.
Dr. Jeremy Sharp (19:14)
But adult females may have developed more sophisticated compensation strategies that kind of mask those underlines, difficulties. And so with that, I’m to do a brief transition into camouflaging and talk more about this in episode three here of the miniseries. females do consistently report more camouflaging across all three cat Q subscales. So the cat Q is a self-report measure that looks at it’s called the camouflaging autistic traits questionnaire. The three subscales are assimilation, compensation, and masking.
So females do consistently report more camouflaging compared to males. There is a meta analysis that confirmed that females use more compensation and masking strategy than males in general. in the new DSM, new-ish, the DSM-5TR, it does explicitly explicitly state that attempting to hide or mask autistic behavior may also make diagnosis harder in some females. OK.
So there’s a little bit of a nod there to the idea that women may be masking more. This is, guess, official recognition that our diagnostic criteria may be systematically biased.
OK, so a little bit of a cycle gets created here where females may camouflage more. They appear less impaired. They’re less likely to be diagnosed. They don’t receive support. They have to camouflage more to cope. This leads to mental health issues. They present with more anxiety and depression than the autism is overshadowed. And so a bit of a vicious cycle could be happening for many of these female individuals.
Dr. Jeremy Sharp (20:53)
That’s just a little teaser. Like I said, I’m going to go much deeper into camouflaging and masking in episode three of the mini series where, you know, we’re going to talk about camouflaging is clearly central to understanding the female autism phenotype. What exactly is it though? How do we measure it? And is it unique to autism?
These are the important questions that we are wrestling with right now. So in the next episode, we’ll take a deeper dive into camouflaging and masking. Like I said, make sure to subscribe, follow, and tune in next time for episode three in the Autism miniseries.
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