By Dr Michelle Garnett and Professor Tony Attwood
Many autistic girls remain undiagnosed because the signs of autism are less obvious than they are in boys. The main reason for “flying under the radar” of a diagnosis is the use of camouflaging as a coping mechanism. Camouflaging means to pretend to know how to socialise by using observation, imitation and adopting a persona or wearing a mask to meet social demands. An autistic girl does not intuitively know what to do or say in a social situation. From a very young age she will closely observe and analyse her peers before making the first step. She will use imitation and acting to be able to conceal her confusion when socialising with peers.
She is generally more motivated to conform and to fit in socially than an autistic boy. She is likely to be well behaved and less disruptive at school, and so is less likely to be noticed. She may have learned that if she is very very good, she will be left alone and if she is quiet, no one will see her, making it less likely that she will come to the attention of her teacher. Often parents can see that there are problems because their daughter “melts down” the moment she is picked up from school, i.e. the mask comes off and all the physical tension and exhaustion of the day is shed via shouting, crying and self-isolation. Unfortunately, when parents bring these matters to the attention of school staff or a health professional, they may be blamed because the problems are occurring at home rather than school.
Missing out on an early diagnosis of autism means not only missing out on early intervention and support for the whole family, but also the autistic girl feels that something is “wrong” with her and incorrectly assumes that she is defective, leading to mental health problems in the teenage years. In this article we describe what you need to know about autistic girls at school, how to recognise female autistic signs, and the important next steps to take.
What to Know About Autistic Girls at School
Unlike most autistic boys, girls are more likely to be able to accurately interpret and answer questions about social interactions, social situations and friendship. However, slower processing speed for social information due to a necessary reliance on intellect rather than intuition, means that their responses will likely be slower, making it difficult for them to keep up in a group setting or with very socially skilled girls. Consequently, girls tend to choose single close friendships rather than being part of a group. They often find males more appealing as friends because male friendship dynamics may be perceived as being easier to understand.
Willingness to follow the rules, a natural tendency to shyness, and social naivety are often present. Such qualities can mean that they are easily missed in a classroom where louder children gain the teacher’s attention. Autistic girls are usually very hesitant to ask for help. They may fear drawing attention and are often self-directed and perfectionistic, so do not wish to be seen as stupid or making a mistake.
Autistic girls can focus much of their intellectual energy on learning about their social world, hence special interest topics may have more of a social focus, such as mental health, self, friendships, animals, celebrities, literature and fantasy. Sometimes it is not the topic that differentiates them from their peers so much as the intensity of their focus on it. Often an autistic girl will have a rich imaginary world within which they engage in elaborate doll play to re-enact real events, helping them decode social situations. Their tendency to follow scripts (i.e. be rule abiding), and lack of social reciprocity in play and conversation may put them at odds with peers who may be unaware or not want to follow her script and find her too controlling. She will not easily read social cues to know what to do, or to know how to predict people’s behaviour. Thus, girls may have trouble recognising and managing conflict, affecting their ability to repair and maintain friendships.
Despite their frequently better coping mechanisms and ability to camouflage their social difficulties, their social difficulties are very real, on a par with those of autistic boys, and cause enormous stress, confusion and exhaustion. In addition, autistic girls experience sensory processing challenges at the same level or more than autistic boys. Social and sensory challenges generally lead to high levels of anxiety in the classroom and playground. When this occurs, you may observe an autistic girl:
- become overwhelmed in social situations
- be reluctant to participate in class activities
- be unable to communicate verbally (situational mutism)
- feel judged negatively by their peers
- withdraw from social interaction
During primary school autistic girls can appear to be neurotypical, successfully ‘keeping it together’ at school. In fact, an autistic girl may be able to do such a great job at “wearing a mask” and fitting in that nobody would believe she has autism. However, the toll on their energy levels and emotions can be high. Girls will often come home feeling exhausted, irritable, and overly emotional, following a day processing both the academic and social curriculum. Over time secondary mental health concerns often develop including anxiety and depressive disorders, self-harm, eating disorders and suicidality. The average age of diagnosis for autistic girls around the world is 12-13 years old, coinciding with the first year of high school, when the social world suddenly becomes far more complex, and hormonal changes that increase anxiety and exacerbate autistic features.
How to Recognise the Signs of Autism in Females
Below, we describe signs of autism to look for in autistic girls:
- She may show lower information processing speed for social and emotional information. The girl takes slightly longer to answer in social situations, may avoid answering questions in class and/or may avoid speaking in groups. She may “hide” in groups, but always seems on the outer periphery of the group.
- Look out for signs that she is ‘too quiet’ or ‘too good.’ She may be internally struggling with social confusion, sensory issues, and executive functioning problems. She may need help but be unable to ask for it.
- Does she show situational mutism? Situation mutism refers to an involuntary and temporary loss of the ability to speak in certain situations, typically with new people or people in authority. Mutism is indicative of very high anxiety.
- She may show occasional difficulties with reading the body language and facial expressions of teachers and peers. She may respond inappropriately at times because it is difficult to mask and camouflage 100% of the time.
- She may have difficulty verbally describing her thoughts and emotions, even though her vocabulary for other topics may be superior. For example, she cannot answer a question about what she thinks or feels, and she uses less words than expected for emotions, “It feels bad” instead of “I feel embarrassed.”
- She has difficulty expressing her wants and needs.
- She has executive function challenges, i.e. difficulties with planning, organising, prioritising and initiating action.
- She has sensory issues. For example, lights are too bright, or certain noises or odours are stressful or overwhelming.
- Look out for evidence of distractibility, exhaustion, shutdown and irritability, for example, being on a ‘short fuse.’
- She may be triggered to very high levels of stress by transitions and change.
- She may cope well in structured social experiences but appears ‘lost’ during unstructured times such as recess and lunch breaks.
- Her parents are concerned with her moods, temper tantrums, depression or school refusal, even though teachers see no evidence of this in class.
You Have Noticed Female Signs of Autism, What Next?
So now you know the signs, you have a girl in mind, what to do next? If you are a teacher, you may approach the parents and ask them how their daughter is going at home. Mention the signs that concern you and share this article with them. Acknowledge that you are not a diagnostician, and you may be wrong, but that you are concerned and wish to do all that you can to assist their daughter. If you are a parent who is concerned, approach your daughter’s teacher. Share this article and discuss what they have observed. We have developed a screening questionnaire that is still in development and will give qualitative data. Please follow this link* to access the free questionnaire and scoring information. Teachers and parents can complete the questionnaire.
To take the next step to obtain a formal diagnosis, carefully consider the level of experience of the Clinical Psychologist, Paediatrician or Psychiatrist you choose. The field of understanding the female presentation of autism is an emerging one and many health professionals did not receive training as part of their degree. Approach your local autism association for names of diagnosticians who are experienced in the diagnosis of autism for girls and women.
Where to Now?
We have been working with the female presentation of autism for over 80 years and have distilled our own knowledge from clinical experience and research into a 2-day Masterclass which we will be presenting in London on the 19th and 20th January 2023. You can view the recording for 60 days beyond the event. If you cannot attend in London, the event will be a live webcast. The training is for parents, professionals and autistic adult women.