The Autism Spectrum in Girls

A word of introduction 

In the 1970s, the British psychiatrist Lorna Wing observed that if a child exhibits various difficulties in three areas:

• social relationships (e.g. problems in interpersonal relationships),
• communication (e.g. language disorders, limited vocabulary),
• interests (e.g. restricted, rigid behaviours and interests),

then we can talk about autism. 

The Autism Spectrum

We are talking about the autism spectrum, which means that symptoms and the severity of difficulties can vary significantly from person to person. Some people with ASD may be able to function at a high level, experiencing only minor difficulties in everyday life, whilst others may require significant support.

For an autism spectrum disorder to be diagnosed, at least two of the three symptoms listed above must be present.

The autism spectrum means that the brain of a child – and later, an adult – functions differently from that of most people. Autistic behaviours are not pathological behaviours, but rather an atypical perception of the surrounding world. Such people, for example, spend more time observing objects and systems than other people; they are very precise in their perception of details, tend to follow their own desires and beliefs rather than being influenced by others; they are less interested in social interaction and group belonging; and they perceive things and phenomena as significant and important that are not perceived in this way by other people.

According to Simon Baron-Cohen, a psychologist at the University of Cambridge who has been conducting research into autism for several decades, the development of people with autism is neither better nor worse than typical development; it is simply different.

Why do most diagnoses concern boys?

Until recently, it was widely believed that there were significantly more men than women among those with autism spectrum disorders. However, the basis on which this conclusion was reached is increasingly being questioned. This is because when two scientists, Leo Kanner and Hans Asperger, observed and described autism in children in the 1940s, they limited their research to a group of boys. 

The boys exhibited similar behaviours, including isolating themselves, showing an interest in objects and a lack of interest in other children, and having difficulty communicating and forming relationships with others. However, none of these researchers included girls in their studies. Their research has so dominated the way we think about autism that the stereotypical image of a child on the spectrum is that of a boy.

Statistics show that 1 in 5 people with autism is a girl. Research carried out in Scotland in 2016 (which Ewa Furgał refers to in her book *A Girl on the Spectrum*) show that amongst young children, the gender ratio of diagnoses ranges from approximately 3:1 to around 4:1. However, it is highly likely that there are many more girls on the spectrum; it is simply more difficult to diagnose them. Autism spectrum disorders in girls simply manifest in a more subtle and less noticeable way. 

Why is autism diagnosed less frequently in girls?

The fact that autism is diagnosed less frequently in girls than in boys is a complex phenomenon. It may be due, amongst other things, to:

• differences in symptoms and behaviour between girls and boys, as girls with autism often display different, less obvious symptoms than boys. Their difficulties with social interaction may be less apparent, and their intense interests are often more socially acceptable, which makes it harder to diagnose autism (for example, they may be fascinated by books or animals, which is considered more ‘typical’ for girls);
• strong compensatory skills in girls, who may be better able to mimic social behaviours, learn appropriate social responses and put them into practice, which means that their difficulties with social interaction are not as apparent;
• stereotypes and a lack of awareness, as autism is often perceived as a condition that mainly affects boys, which can influence the awareness and expectations of both parents and professionals. This, in turn, can lead to the symptoms of autism in girls being overlooked;
• inappropriate diagnostic criteria and assessment tools, as there are no accurate diagnostic tools specifically designed to identify autism spectrum disorders in girls. Those used to identify autism are better suited to identifying the typical symptoms seen in boys. Girls who do not fit these patterns may be overlooked; 
• delays in the onset of symptoms, as in some girls the symptoms of autism may develop later or be less apparent at a younger age, leading to a later diagnosis;
• the presence of subtle social difficulties, as girls with autism may experience social difficulties, but these are often more subtle and may be perceived simply as shyness or introversion, rather than autism;
• social pressure and expectations, as girls often face greater social pressure to conform to behavioural expectations, which may lead them to conceal their difficulties more effectively.

As a result, many girls with autism are not diagnosed, or are diagnosed later. Raising awareness of how autism can present in girls is crucial to improving diagnosis and support.

How can autism be recognised in girls?

From a very young age, girls are told that they must not hit back when someone hits them, that they must not swear or show anger, or cause others distress, but rather that they should look after those who are weaker or younger, give way rather than stand up for themselves, and that certain things are simply ‘inappropriate’ for them to do. In short, they undergo a process of socialisation to become ‘proper girls’. As a result of this training, girls on the spectrum become highly attuned to others’ expectations of them and are more likely to want to conform to them. 

It is this ability to adapt that means girls on the autism spectrum are quite often not diagnosed at a young age, because… they function too well. They have a great ability to mimic a wide range of behaviours – they observe their surroundings and try to meet people’s expectations. Consequently, they are not diagnosed. A charming little girl who smiles beautifully, is neatly dressed, makes eye contact, follows instructions and does well at school – she does not raise any concerns, but rather inspires affection. That is why many girls do not receive a formal diagnosis until their teenage years or when they reach adulthood.

Here are a few tips that may help you recognise autism in girls:

• Social interactions ÷ Girls with autism may find it difficult to make and maintain friendships, and may seem somewhat withdrawn or uninterested in their peers. They are less likely to play cooperatively with other children and more likely to play by taking on a strictly defined, assigned role. Very often, they choose one particular friend and want to spend time only with her. Sometimes they prefer to spend time with people who are older or much younger than themselves;
• communication ÷ they may have a distinctive communication style, which involves interpreting language literally, difficulties in understanding subtleties such as sarcasm or irony, and problems with using non-verbal communication;
• Interests and behaviours ÷ They may display intense, often narrow interests relating to socially acceptable areas, such as horses, literature or pop stars. They may also display repetitive behaviours or rituals, such as arranging objects in a specific way, always taking the same route to school, or being extremely attached to a single toy which they take with them everywhere;
• Sensory responses ÷ Girls with autism may be particularly sensitive to sensory aspects of their environment, such as loud noises, bright lights or the texture of clothing. They often prefer only certain types of clothing because of their sensory comfort; sometimes they dislike various personal care activities, as having their hair brushed or their nails cut causes them not only discomfort but actually pain;
• Emotions and behaviour ÷ may have difficulty with emotional regulation, leading to emotional outbursts or disproportionate reactions to seemingly minor problems. They often engage in stimming, which is a way of releasing emotions through repetitive body movements, such as rocking, flapping their arms or picking at their skin. There are also stims that are socially perceived as irritating and undesirable – clapping, repeating certain words or phrases, walking in circles; however, girls are much more likely to choose ways of releasing emotions that do not attract attention, such as twirling their hair around a finger, clicking a pen or biting their nails.

How girls cope with autism spectrum disorders

Girls with autism spectrum disorder often develop unique compensatory strategies to cope with their difficulties, particularly in the areas of social interaction and communication. They learn how not to stand out from the group and how to conform to social expectations, thereby masking their autistic traits. This masking of autistic symptoms occurs only in girls who are intellectually able-bodied.

Here are a few examples of how girls may compensate for autism spectrum disorders:

• Social imitation ÷ girls often practise facial expressions and gestures in front of a mirror, copying them from a classmate they like or who is the most popular. Or based on what they have seen in a film or read in a book. This imitation can help them appear more socially well-adjusted than they actually are;
• developing social scenarios ÷ they can mentally prepare scenarios for various social situations, practising what to say or how to behave. This may involve rehearsing conversations in front of a mirror or in their minds;
• concealing interests ÷ although they may have narrow or intense interests, typical of people with ASD, girls are more likely to learn to conceal these interests for fear of social exclusion or in order to fit in better with their peer group;
• reliance on routines and structures ÷ they may rely on established routines and structures to help them manage stress and uncertainty (for example, functioning well in small, familiar groups, but find it difficult in larger ones), in order to cope with the unpredictability of social interactions. They may demonstrate varying degrees of adaptability in different social contexts; 
• Use of verbal skills ÷ Girls with ASD often have well-developed verbal skills, which can help them to mask difficulties with non-verbal communication. They may use vocabulary and conversation to conceal their difficulties in understanding the more subtle aspects of social interaction;
• Seeking out individual, close friendships ÷ rather than trying to fit in with larger peer groups, girls with ASD may focus on forming deep, though often one-on-one, friendships. These close relationships can provide social support without the need to navigate complex group dynamics.

It is important to understand that these coping strategies, whilst helpful in some situations, can also be a burden for girls, as they require constant effort and may lead to exhaustion or problems with emotional wellbeing. 

The autism spectrum and puberty in girls

The most difficult time for girls on the autism spectrum is puberty, as it involves enormous, complex changes that take place during this period, affecting them physically, emotionally and socially.

Physical changes – which can be extremely difficult for people on the autism spectrum and may cause unpleasant feelings. The appearance of body hair, changes in body odour, menstruation and breast development – can be a source of discomfort for girls with ASD, particularly due to their heightened sensory sensitivity. Experiencing new physical sensations can lead to anxiety and uncertainty. For example, for sensory reasons (such as hypersensitivity to smells or certain materials), a girl on the autism spectrum may find it difficult to choose suitable sanitary products during her period.

Changes in group communication and relationships – shifts occur in peer hierarchies and group communication, which people on the autism spectrum may not fully understand. Consequently, they begin to stand out from their peer group. They may become the subject of ridicule and, in extreme cases, online abuse – due to a failure to conform to the rules, differences in vocabulary, youth slang or other areas of interest. Many girls then begin to take an interest in boys, fashion and beauty treatments, and these topics largely dominate their conversations. It becomes increasingly difficult for girls on the autism spectrum to ‘fit in’, simply because they are not interested in these topics. People on the autism spectrum are very often bullied at school and experience psychological and physical abuse. As a result, many experience immense stress, which can manifest as aggression, self-harm or increased repetitive movements. 

Rejection by a group within which they had previously managed to function to some extent may result in a serious mental health crisis. And yet, during adolescence, belonging to a peer group becomes a marker of social status. This can cause them to experience a deepening sense of loneliness, rejection and even a mental health crisis; 

Changes in puberty hormones and emotional regulation – the effects of sex hormones during puberty can cause significant mood swings, emotional hypersensitivity and intense reactions, yet for people on the autism spectrum, recognising and regulating emotions is a huge challenge. During adolescence, therefore, people on the autism spectrum may experience more frequent outbursts of anger or emotional reactions that are incomprehensible to those around them. Emotional problems, which are common amongst adolescent girls and women with ASD, can lead to the development of anxiety disorders, depression or anorexia. 

Researchers have observed that a significant proportion of girls diagnosed with anorexia show signs of autism, such as an excessive focus on detail. This suggests that a large proportion of women with anorexia may be struggling with undiagnosed autism. Some researchers even claim that as many as 23 per cent of women with anorexia also have autism.

Changes in the process of discovering one’s identity – adolescence is a time when one’s personality takes shape and one discovers one’s identity, including gender identity and sexual orientation. This is a process that may take longer than for peers. The topic of sexuality can prove challenging, as girls on the spectrum often struggle to recognise intentions and interpret non-verbal cues (which can even lead to sexual abuse). They may also find it difficult to recognise boundaries, both their own and those of others. Girls on the autism spectrum are therefore particularly vulnerable to emotional abuse in relationships and to sexual violence. Teenagers on the spectrum often find it difficult to understand a lack of reciprocity, and their expressions of sexual interest may breach boundaries and take violent forms, such as stalking.

Girls with ASD may also face difficulties with issues such as self-esteem, body image and coping with expectations regarding femininity. These issues can be particularly complex in the context of social and cultural norms.

Support for girls with ASD during adolescence should be comprehensive and include not only education about physical changes but also emotional support and the development of social skills. It is important that the people around these girls – parents, carers, teachers and therapists – are aware of these challenges and prepared to provide the necessary support, which may include behavioural therapy, emotional support and sex education tailored to their individual needs and level of understanding.

Ultimately, adolescence for girls on the autism spectrum is a time full of challenges, but also of opportunities. Providing them with the right support can make a significant contribution to their development and independence in adult life.

Less obvious symptoms of autism in girls

The less obvious symptoms of autism in girls often make the condition more difficult to diagnose than in their male peers. Here are a few examples of these more subtle symptoms.

Social masking – girls with autism are often better at masking their social difficulties by imitating the behaviour of others. They may observe and imitate their peers or figures in the media, learning how to behave in various social situations. This means that their difficulties may be less apparent to outsiders.

Subtle communication difficulties – these may include trouble understanding implied meanings, irony or sarcasm. Girls with autism may also find it difficult to maintain an appropriate pace of conversation or to recognise the significance of body language and other non-verbal cues.

Socially acceptable interests – girls with autism may have obsessive interests, but these are often more socially acceptable than typical ‘masculine’ obsessions, such as trains or sports statistics. Their passions may centre on literature, art, animals or celebrities.

Strong empathy and emotionality – contrary to stereotypes, some girls with autism may display deep empathy and strong emotional reactions, often more intense than those of their peers who are not on the spectrum. They may be very sensitive to the emotions of others, but find it difficult to properly understand and respond to those emotions.

Perfectionism and fear of making mistakes – some girls with autism may display a strong tendency towards perfectionism and fear making mistakes, which can lead them to avoid situations in which they feel insecure.

Variable social skills – they may demonstrate varying degrees of adaptability in different social contexts. For example, they may function well in small, familiar groups, but struggle in larger, less structured social environments.

Internal experience of the world – girls with autism may have a rich inner mental life, which is sometimes difficult for outsiders to observe. They may have complex internal monologues, imaginary worlds or detailed scenarios that they act out in their minds.

Recognising these subtle symptoms requires careful observation and an understanding of the specific characteristics of autism in girls. 

Summary

We hope this article has provided you with valuable information on the diagnosis of ASD in girls.

Diagnosing and treating this condition requires a comprehensive approach and collaboration between a range of specialists. 

At Senso Senso, we provide comprehensive support for the diagnosis and treatment of difficulties arising from the autism spectrum.

If you have any questions or need support, the Senso Senso advice centre is always here to help.

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