The invisibility of autism in girls, adolescents, and women

In this post, health psychologist and clinical neuropsychologist Raquel Hernández Becerra describes the problem faced by girls diagnosed with level 1 autism spectrum disorder (ASD).

Autism spectrum disorder (ASD) in girls, especially level 1, has clinical characteristics that make it hard to detect, which leads to underdiagnosis and late diagnosis. Unlike boys, girls with autism often show better apparent social adaptation, use camouflaging strategies, and have more typical patterns of interest, which can hide their real difficulties.

Understanding this is key for assessment and neurorehabilitation professionals to identify autism early and design better-tailored, more effective interventions.

Throughout my career, I have seen how difficult it is for many psychology professionals to reach a diagnosis of autism spectrum disorder (ASD) when a child has level 1 autism. And if the child with level 1 autism symptoms is a girl, she is almost completely invisible unless you are an expert in the field. As a result, the families of these girls go through endless journeys with different healthcare professionals, receiving different misdiagnoses or simply being told that “nothing is wrong.”

Autism symptoms in women

When we talk about autism, we tend to picture a boy rather than a girl, since many more males than females are diagnosed with autism, because autism symptoms are much more evident in males. When we talk about autism symptoms, we need to keep in mind that there must be difficulties in social skills, communication, and restricted interests and/or repetitive or stereotyped movements. Several studies have clearly shown the differences in autism symptoms within level 1 between women and men.

Social skills

Girls and women with autism are better at using social gestures and social smiling, and more effective at forming social relationships with their peers compared with males with ASD, since the interests and games of girls with autism resemble those of typically developing girls. This social mimicry makes their disorder much more invisible compared with the social behavior of boys with autism, whose play is more solitary, repetitive, and unusual than that of typically developing boys.

Likewise, some studies have found that empathy and understanding of friendships in girls with autism are poorer than in typically developing girls, although they are similar to those of typically developing boys. In fact, research has documented that girls and adolescents with autism have greater social motivation and more intimacy in their social relationships than males with autism.

Communication

Research has shown that girls, adolescents, and women with autism are similar to their typically developing female peers in acquiring expressive and receptive vocabulary. They are also similar in how they express emotions.

However, deficits in pragmatics and semantics are observed, which cause them to struggle in social situations where the communicative message matters, that is, the use of pauses, word choice, metaphors, idioms, and so on. As a result, when women with autism look for communication strategies to make up for these gaps, they rely on imitation and not responding, which leads to misunderstandings on the part of the listener and, in turn, to negative social interactions.

There is also evidence that females with autism can describe internal processes linked to physiological sensations through language better and more often 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, such as fashion, celebrities, or sports.

In any case, some studies have found that the most common interests among females with autism fall into two categories: television (movies, series, YouTube videos, etc.) and psychology (role-playing games, imagination, relationships, etc.).

However, in adolescence, interests typically broaden considerably, which doesn’t happen in the same way in adolescent girls with autism. The difference is that they tend to stick with the same interest and find it hard to open up to new ones, which leads to adolescent girls with ASD being seen as childish, resulting in social failure.

Even so, various studies have shown that most girls and adolescents with autism have fewer restricted interests and repetitive movements than males with autism, which leads to fewer females being diagnosed with autism.

Another difference from males with autism has also been observed. While girls with ASD show restricted interests mostly related to animals or people, boys tend to focus on objects, such as vehicles.

Comorbidity in girls and adolescents with autism

Many studies show that although women with autism tend to have less comorbidity than males with autism, when comorbidity is present, it usually involves internalizing disorders such as depression, anxiety, sleep problems, or somatic symptoms. Males, on the other hand, commonly show externalizing behaviors, so comorbidity with attention-deficit/hyperactivity disorder (ADHD) or behavioral problems is often observed.

What should we look for to flag possible ASD in women?

There are two types of profiles to watch for:

1. Externalizing: They seem sociable because they tend to talk nonstop and usually have people around them. However, if you look at the quality of their social interactions, you will notice pragmatic and semantic deficits.
2. Internalizing: Quieter, shyer girls whose interests focus mainly on solitary activities, such as painting or reading. This type of profile is often mistaken for attention deficit.

We may also see the following symptoms at different stages of development:

1. Preschool and school age:
   • Symbolic play: They may play with miniatures and dolls, but if you watch their play, you will notice that it is not very imaginative or creative and tends to be rather repetitive.
   • “Guide” friends: Girls with autism often look for other girls who help them understand different social situations and who become behavioral models for them to imitate.
   • Inflexibility: They may be very interested in school supplies, taking great care of them and not letting classmates use them. They may even have a tantrum if they lose an eraser or a pencil sharpener.
   • Restricted or repetitive interests: These can be seen in activities such as drawing or collecting objects (stuffed animals, dolls, hair ties, etc.). What sets these activities apart from those of their typically developing peers is the intensity with which they do them.
2. Adolescence and young adulthood: They may show perfectionist behavior and more social difficulties, since the complexity of social messages and the importance of pragmatics at this age make them feel overwhelmed and make it harder for them to blend in with their peers. Mild self-harming behaviors (pulling their hair, biting their lips, etc.) may appear at this stage, as well as symptoms of depression and anxiety or sleep problems, since they feel they struggle to fit in with others and end up shutting down because they lack the tools to manage everything.

Early detection

Given all this, it is essential to increase awareness of the autism profile in girls, adolescents, and women, since it allows for early detection of the disorder so that girls can be given social and communication tools as early as possible. 

In my professional experience, in most cases where I have made a late diagnosis in adolescence and, after the appropriate intervention, the adolescent has learned that she has ASD, she usually feels relieved that, at last, she can understand herself, identify her deficits, and do something about them.

References

• Romo Pluma, R. y Hernández Arteaga, E. (2023). Trastorno del espectro autista en mujeres: Un área pendiente para la investigación en educación. INTEGRA2 Revista Electrónica de Educación Especial y Familia, 14(2), 60-73.
• Cedano, Y. M., Rivera-Caquías, N., Alvarez-Alvarez, M. y Vega-Carrero, M. (2024). Trastorno del Espectro Autista en Féminas. Revista Puertorriqueña de Psicología, 25(1), 1-22.
• Pérez Estrada, K. A. (2023). Perspectivas únicas: el espectro autista en mujeres. Revista Digital Universitaria, 24(6), 1-12.
• Montagut Asunción, M., Mas Romero, R. M., Fernández Andrés, M. I. y Pastor Cerezuela, G. (2018). Influencia del sesgo de género en el diagnóstico de trastorno de espectro autista: una revisión. Psychosocial Intervention, 27(1), 42-54.

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“This article has been translated. Link to the original article in Spanish:”
La invisibilidad del autismo en niñas, adolescentes y mujeres