5 Reasons Why Girls' Autism Symptoms Are Often Missed

“No one diagnosed my daughter with ASD because she talked,” said some parents of girls who discussed this problem with me. The more that I work with families of girls with autism spectrum disorder (ASD), the better I understand their plight. Many of these girls were diagnosed with ASD in elementary school and after receiving diagnoses for other mental health conditions, along with being placed on psychotropic medication. In talking to parents, I discovered five commonalities in their stories about the misdiagnoses:

1. Speech and Communication Skills

• Girls with ASD may exhibit more subtle symptoms compared to boys, making their condition less noticeable or easily overlooked.
• They tend to have better verbal abilities than boys on average and may use language to compensate for social challenges, allowing them to engage in conversations and navigate social situations more effectively. This can make their autism less apparent, as their verbal skills may mask other symptoms.
• While boys with autism often have more stereotypical interests (e.g., trains and dinosaurs), girls may have interests that are more socially acceptable or align with typical female interests. This can make their conversations seem more typical and less indicative of autism.

2. Social Behaviors

• “In some cases, autistic girls may understand more nuanced social expressions, such as accents or styles of dress, which camouflages their symptoms,” says Charles Rohr III, licensed clinical psychologist, and they often develop coping mechanisms, such as imitating social behaviors they observe in others. This masking can make their symptoms less apparent or hide their underlying difficulties in social communication and interaction and may lead to underdiagnoses or a misdiagnosis.
• Girls are often more socially inclined than boys, and those with autism may intensely observe and mimic their peers' social behaviors. This mimicry can make them appear more socially adept than they actually are, masking their underlying difficulties with social interaction.

3. Misdiagnoses

• Girls with ASD are often diagnosed with other mental health conditions (i.e., anxiety, bipolar, and attention-deficit/hyperactivity disorder [ADHD]). Some clinicians may not be fully aware of the varied presentation of autism in girls or may not have received adequate training on how to recognize it.
• Historically, autism has been studied and diagnosed primarily in boys, leading to a bias in diagnostic criteria. Many diagnostic tools were initially developed based on observations of autistic traits in boys, which may not fully capture the presentation of autism in girls.
• Practitioners may not ask questions about restricted and repetitive behavior (RRB; i.e., motor stereotypies, restricted interests). RRBs are only specific to ASD. Learning if girls exhibit these behaviors is a part of the diagnostic criteria for ASD, according to the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, and must be questioned during diagnostic interviews.
• Parents may accept diagnoses by professionals despite their observations of their daughter’s behaviors. You are your daughter’s best advocate. If a provider tells you no to ASD although you believe that your daughter does have ASD, then continue to advocate on her behalf. Find another practitioner that you believe will assist you with determining whether your daughter’s behaviors and social communication deficits are due to ASD. Rohr recounted an initial IEP meeting with his daughter’s school psychologist, who disregarded his concerns about the impacts of her autistic symptoms in the classroom. “It wasn’t until I told her that I am a licensed clinical psychologist who works exclusively assessing children for autism and throwing around clinical terms like central coherence and theory of mind, that she took my concerns seriously. I recall her laughingly stating, 'I’ve never heard a regular parent use the term theory of mind before!'”

4. Societal Expectations for Behaviors

• “There are broad cultural and societal expectations regarding how girls and boys 'should' behave. Girls are often expected to be more socially adept and emotionally expressive, which may hide their autistic traits or lead to them being attributed to other causes" says Rohr. “Further, in patriarchal cultures in which subservience is expected of children, particularly girls, sitting quietly in one’s own internal world may be considered culturally appropriate and even expected, and therefore may not present any obvious cause for concern for parents and caregivers.”
• Girls are often expected to be more emotionally expressive than boys, and those with autism may learn to mimic appropriate emotional responses. This can make it difficult for others to recognize their challenges with understanding and expressing emotions.
• Girls are often socialized to be more compliant and to adhere to social norms. This pressure to conform can lead girls with autism to work harder to fit in, even if it means suppressing or hiding their autistic traits.

5. Minimizing Parental Concerns

• This is huge. I tell parents under my care daily, “You are the experts on your daughter’s behavior.” We need to believe parents and respect their feelings. Most parents will not discuss possible symptoms of ASD with professionals responsible for their daughter’s care unless they truly believe that she may have ASD.

How to Help Girls With Autism Spectrum Disorder

Girls are underdiagnosed with ASD, though many need timely and accurate diagnoses, especially in early childhood. This leads to better outcomes and improved access to the support and services they need. The general public needs to become educated about the unique presentation of autism in girls. Opportunities to learn and recognize the signs of autism in girls, including the subtle differences in presentation compared to boys will help with sensitivity to the diverse ways that ASD presents in girls. Parents of girls with ASD need more support and resources to learn about the early signs of autism, how to navigate the diagnostic process, and strategies for accessing services and support. Lastly, health care professionals and educators need to be aware of these differences and consider the broader range of autistic traits that may manifest in girls, beyond just social communication difficulties. Early recognition and intervention are key to providing appropriate support and resources for girls with autism.

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