In this post, general health psychologist and clinical neuropsychologist Raquel Hernández Becerra discusses the problem faced by girls diagnosed with Autism Spectrum Disorder (ASD) level 1.

Throughout my professional career, I have observed how difficult it is for many psychology professionals to reach a diagnosis of Autism Spectrum Disorder (ASD) when the child has level 1 autism. But if it is a girl who presents symptoms of level 1 autism, the invisibility is almost total unless you are an expert in the field. Therefore, the families of these girls go through endless journeys with different professionals in the healthcare system, receiving different incorrect diagnoses or simply being told that “nothing is wrong”.

Autistic symptoms in women

When we talk about autism, we usually have an image of a boy rather than a girl since there is a higher number of boys diagnosed with autism compared to girls, as autistic symptoms are much more evident in boys than in girls. When we talk about autistic symptoms, we must consider the difficulties in social skills, communication, restricted interests, and/or repetitive or stereotyped movements. There are different studies that have clearly shown the differences in autistic symptoms within level 1 between women and men.

Social skills

Girls and women with autism are better at using social gestures and social smiles, and they are more effective in establishing social relationships with their peers when compared to boys with ASD because the interests and play activities of girls with autism are similar to those of typically developing girls. This social mimicry makes their disorder much more invisible compared to the social behavior of boys with autism, whose play is more solitary, repetitive, and peculiar than that of their typically developing male peers.

Similarly, some studies have observed that empathy and understanding of friendship relationships in girls with autism is deficient compared to typically developing girls, although it is similar to that of typically developing boys. In fact, it has been documented how girls and adolescents with autism maintain a higher social motivation and greater intimacy in their social relationships than boys with autism.

Communication

It has been shown that girls, adolescents, and women with autism, compared to their typically developing female peers, are similar in terms of expressive and receptive vocabulary. There is also similarity between them in expressing emotions.

However, deficiencies are observed in the pragmatics and semantics of language, which cause them to fail in social situations where the communicative message is important, such as the use of pauses, word selection, metaphors, idioms, etc. Therefore, women with autism, in their search for communicative strategies to compensate for their deficiencies, use imitation and absence of response, which leads to misunderstandings in the recipient of the message and, as a result, negative social interactions.

There is also evidence that females with autism can describe internal processes related to physiological sensations through language better and more frequently than males with autism.

Restricted interests and/or repetitive or stereotyped movements

In most cases, girls with autism have interests that are more socially accepted since they are more common among their female peers. These interests include fashion, celebrities, or sports, for example.

However, some studies have revealed that the most common interests in females with autism fall into two categories: television (movies, series, YouTube videos…) and psychology (role-playing games, imagination, relationships…).

Nevertheless, during adolescence, typically developing girls’ interests tend to expand extensively, which does not happen to the same extent in adolescent girls with autism. The difference is that these girls usually remain focused on the same interest and have difficulties in opening up to new interests, which leads to considering adolescent girls with ASD as childish and results in social failure.

Still, different studies have shown that girls and adolescents with autism, in the majority of cases, have fewer restricted interests and repetitive movements than boys with autism, resulting in fewer diagnoses of females with autism.

Another difference has been observed compared to boys with autism. While girls with ASD show restricted interests mainly related to animals or people, boys are mainly focused on objects such as vehicles.

Comorbidity in girls and adolescent girls with autism

There is a wide variety of studies that show that although women with autism tend to have fewer comorbidities compared to men with autism, when comorbidity is present, it tends to be internalizing disorders such as depression, anxiety, sleep problems, or somatic symptoms. However, men tend to commonly present externalizing behaviors, so comorbidity with attention-deficit/hyperactivity disorder (ADHD) or behavioral problems is usually observed.

What should we look for to detect a possible ASD in women?

There are two types of profiles that we should observe:

1. Externalizing: They may appear sociable because they tend to talk non-stop and usually have people around them. However, if you observe the quality of their social interaction, you will notice pragmatic and semantic deficiencies.
2. Internalizing: Quieter and more timid girls who are mainly focused on individualistic activities such as painting or reading, for example. This type of profile is often confused with attention deficit.

We can also observe the following symptoms in different stages of development:

1. Preschool and school stage:

• Symbolic play: They may play with miniatures and dolls, but if you observe their play, you will notice that it is not very imaginative or creative, rather repetitive.

• “Guide” peers: Girls with autism tend to seek out other girls who can help them understand different social situations, becoming their behavioral models to imitate.

• Inflexibility: They may have a great interest in school materials, taking utmost care of them and not allowing their peers to use them. They may even have a tantrum if they lose an eraser or pencil sharpener.

• Restricted or repetitive interests: These can be observed in activities such as drawing or collecting objects (plush toys, dolls, hairbands…). The difference in these activities compared to their typically developing peers is the intensity with which they engage in these actions.

2. Adolescence and youth: They may display perfectionistic behavior and have greater social difficulties because the complexity of social messages and the importance of pragmatics at this age make them feel overwhelmed and have more difficulty blending in with their peers. Mild self-harming behaviors (hair-pulling, lip-biting) may occur, and symptoms of depression, anxiety, or sleep problems may be present, as they feel that they struggle to fit in with others and end up feeling blocked without the tools to manage it all.

Early detection

In light of all this, it is crucial to increase knowledge about the autistic profile in girls, adolescents, and women to enable early detection of the disorder, allowing girls to receive social and communication tools as early as possible.

In my professional experience, in most cases, when I have made late diagnoses in adolescence and, after the appropriate intervention, the teenager learns that they have ASD, they typically feel relieved as they finally understand themselves, detect their deficits, and can act on them.

References

• Romo Pluma, R. and Hernández Arteaga, E. (2023). Autism Spectrum Disorder in women: An outstanding area for research in education. INTEGRA2 Journal of Special Education and Family, 14(2), 60-73.

• Cedano, Y. M., Rivera-Caquías, N., Alvarez-Alvarez, M., and Vega-Carrero, M. (2024). Autism Spectrum Disorder in Females. Puerto Rican Journal of Psychology, 25(1), 1-22.

• Pérez Estrada, K. A. (2023). Unique Perspectives: The autistic spectrum in women. Digital University Journal, 24(6), 1-12.

• Montagut Asunción, M., Mas Romero, R. M., Fernández Andrés, M. I., and Pastor Cerezuela, G. (2018). Influence of gender bias on the diagnosis of autism spectrum disorder: A review. Psychosocial Intervention, 27(1), 42-54.

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