By Dr. Michelle Garnett and Prof Tony Attwood
Most children referred for a diagnostic assessment for autism are males, and autistic males with fluent speech will likely be diagnosed, on average, by the time they are 8 years old. Autistic girls, by contrast, ‘fly under the radar’ and tend to be diagnosed during their teenage or adult years. In a recent research study, the male-to-female ratio of autism was 1:4 in 4–10-year-olds, leaping to 1:2 in adult women (Posserud et al, 2021). Our own clinical records for diagnostic assessments show the same pattern. Thus, young autistic girls and teenagers are not being identified and so are missing out on valuable, accurate and timely understanding and support. This article discusses how to recognise their profile at school.
Why do Autistic Girls often Fly Under the Radar?
Many autistic girls remain undiscovered because the signs of autism are less obvious than they are with boys. Why is this the case? In autism, understanding the social world does not happen innately or intuitively. Autistic children and adolescents cope with this difficulty in different ways. One strategy is to use ‘camouflaging’ to hide autistic characteristics. To successfully camouflage, the person will watch others closely to understand how to act and what to say in social situations. They will imitate others, develop scripts, practise at home, and adopt masks and personas to be able to manage social situations. Research suggests that autistic females camouflage more than males, and they camouflage to fit in socially at school and avoid being bullied (Cook et al, 2021).
Also, some autistic girls can be more motivated than autistic boys to conform and to fit in socially at school and are likely to be well-behaved, less disruptive, and so less likely to be noticed. They may have learned that if they are good, they will be left alone and if they are quiet, no one will see them, making it less likely they will come to the attention of their teachers.
Informed parents may consider that their daughter is autistic, but if the profile is not apparent either in the clinic during the diagnostic assessment, or at school, she is likely not to be diagnosed as being autistic. Additionally, teachers will not approach parents with concern that a girl may be autistic if they do not pick up the profile in the classroom. Research shows that autistic women often receive mental health diagnoses prior to a diagnosis of autism (Hamdani et al, 2023).
What to Know about Autistic Girls
Every autistic girl is unique, and her needs will be reflected differently. School staff should be cautious not to run the risk of overgeneralising since autistic students can be as different from each other as any other students. Despite this, there is a recognisable profile of autism in girls that we will describe here with the hope that increased recognition will lead to earlier support and understanding.
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, their responses may not come naturally or as quickly, making it difficult for them to keep up in group settings or with the conversation of many non-autistic girls. They may discover that boys are more like-minded friends since their friendship dynamics may be perceived as being easier to understand.
Rule Driven
Autistic girls are likely to strictly adhere to classroom rules and routines, these can be other’s rules and routines or their own. From an early age, autistic girls have applied their cognitive skills to analyse social interactions, and so they are much more likely than autistic boys to discuss the inconsistencies of social conventions and to be enforcers of social justice (e.g. fairness). If they are strongly motivated to abide by the classroom rules and also have a tendency to be shy, naïve and unassuming, they can easily be missed in a classroom of boisterous children. Autistic girls can also be very hesitant to ask for help for fear of drawing attention and strong perfectionism where she doesn’t want to get things wrong or be seen as ‘silly’ by teachers or peers.
Strong Interests
Because autistic girls may focus much of their intellectual energy on learning about their social world, their interests often centre on social topics, such as animals, especially cats and horses, psychology, friends, a particular person, including celebrities, also literature and fantasy. It is not so much the topic that differs from non-autistic girls; rather, it is the intensity of their interest. Often, she will have a rich imaginary world where she may engage in elaborate doll play using a script to re-enact real events, which may help decode social situations. Their tendency to follow scripts and their difficulties with social reciprocity may put them at odds with peers who may 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, autistic girls may have trouble recognising and managing conflict, affecting their ability to repair and maintain friendships.
High Levels of Anxiety
Despite their frequently better coping mechanism and ability to camouflage their social difficulties, these social difficulties are very real and cause enormous stress and confusion. The social challenges and sensory difficulties experienced by autistic girls can have a significant impact on their wellbeing, leading to high levels of anxiety in the classroom and playground. Signs of high anxiety at school include:
- school avoidance and refusal, choosing to visit the school health centre frequently.
- becoming overwhelmed (going quiet) in social situations; appearing shy.
- being reluctant to participate in class activities.
- being unable to communicate verbally (situational mutism).
- feeling they are consistently judged negatively by their peers.
- withdrawal from social interaction and sitting in the library at lunchtime instead.
- somatic complaints including low energy, headache, stomach-ache, chest pain and tiredness.
Dr Jekyl and Mr Hyde
Due to camouflaging, the autistic girl’s socialising appears normative to non-autistic girls and teachers, and she can successfully ‘keep it together’ at school. An autistic girl may be able to do such a great job at wearing the mask and fitting in that nobody apart from her parents would believe she is autistic. However, the toll that this effort takes on her energy levels and emotions is high. Girls will often come home feeling exhausted, irritable, and overly emotional. She can ‘meltdown’ or ‘shutdown’ the moment she is out of the school situation and parents are at a loss as to how to assist their daughter, where afternoons after school are characterised by tears, tantrums, “rude behaviour,” social avoidance, and arguments. It is not uncommon for parents to experience blame from professionals because the visible challenges occur only in the home situation.
The Profile of the Autistic Girl in the Classroom
Below is an outline of some of the common difficulties autistic girls face at school to assist teachers to recognise the profile:
- May have slower information processing for social and emotional information, resulting in a time delay in their responses.
- Shows difficulty putting their thoughts and feelings into words and difficulty expressing their wants and needs.
- Has executive function challenges, e.g. difficulties with planning and organising their time, belongings and behaviour.
- Has sensory issues, e.g. for bright lights, certain noises, odours such as perfume. These may not be overtly apparent due to masking.
- Social difficulties are apparent in subtle ways, for e.g. dislikes group projects, will not ask for help, goes to the library at lunchtime, does not have a best friend or only has one friend and is lost if that friend is not at school or moves between groups of friends but does seem to belong to one group, prefers boys as friends.
- Seems more stressed during transitions between classes and at the start and end of the day.
- Is overly reactive for seemingly small things, e.g. change in familiar classroom routines.
- Is very good at art, singing, languages and/or reading.
- Has a strong sense of social justice.
- Maybe perfectionistic but disorganised for some tasks.
- Tends toward black and white thinking.
- May be gender fluid or dysphoric.
- May be a tomboy.
- May appear shy, rude, lazy or ‘odd.’
- Can have a literal interpretation of language.
- Is extremely empathic and sensitive.
Where to from here?
Our online course Autistic Girls and Women is for parents and carers as well as educationalists and health practitioners. It celebrates the unique presentation of autistic girls and women and is thus suitable for autistic adolescent girls 14 years old and older to watch. The course aims to increase awareness and knowledge of the autistic female presentation and share strategies we find useful in clinical practice. We address key challenges, including self-understanding, adolescence, relationships and expressing and managing emotions. We also provide strategies to maximise the possibility of successful outcomes.
*NB: Wherever gender is referred to, we are referring to the gender assigned at birth.
Resources
Our website: www.attwoodandgarnettevents.com
Relevant Books:
Spectrum Women: Walking to the Beat of Autism edited by Barb Cook and Michelle Garnett, published by Jessica Kingsley Publishers.
Autism and Girls, by Temple Grandin, Tony Attwood, Michelle Garnett and others, published by Future Horizons Inc.
References
Cook J, Hull L, Crane L, Mandy W. Camouflaging in autism: A systematic review. Clin Psychol Rev. 2021 Nov;89:102080. doi: 10.1016/j.cpr.2021.102080. Epub 2021 Sep 6. PMID: 34563942.
Hamdani Y, Kassee C, Walker M, Lunsky Y, Gladstone B, Sawyer A, Ameis SH, Desarkar P, Szatmari P, Lai MC. Roadblocks and detours on pathways to a clinical diagnosis of autism for girls and women: A qualitative secondary analysis. Womens Health (Lond). 2023 Jan-Dec;19:17455057231163761. doi: 10.1177/17455057231163761. PMID: 36999318; PMCID: PMC10071154.
Posserud, M-B, Skretting Solberg, B, Engeland, A, Haavik, J, Klungsøyr, K. Male to female ratios in autism spectrum disorders by age, intellectual disability and attention-deficit/hyperactivity disorder. Acta Psychiatr Scand. 2021; 144: 635– 646. https://doi.org/10.1111/acps.13368
