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Urgent Need for an Autism Screening Tool which is not Male-Biased

Clare Allely's latest blog entry

[Posted on 9 May, 2017 by Clare Allely]

Compared to males, females with autism spectrum disorder (ASD) are frequently identified and diagnosed much later. Females with ASD also tend to receive a diagnosis only when the autistic symptomology is more severe and/or have more co-existing behavioural and/or cognitive problems. The under-identification of this disorder in females has resulted in a male-biased understanding of ASD which has obvious significant implications on our clinical and scientific understanding of the disorder. The clinical assessments that are currently available and widely used are predominantly based on the phenotype which is presented by the majority of males with ASD. For instance, the Autism Diagnostic Observation Schedule Second Edition (ADOS-2, Lord, Rutter, DiLavorne, Risi, Gotham, & Bishop, 2012); the Autism Spectrum Quotient (AQ, Baron-Cohen, Wheelwright, Skinner, Martin, & Clubley, 2001) and the Social Communication Questionnaire (SCQ, Rutter, Bailey, & Lord, 2010).

There are a number of reasons why many females are not identified. One of the key explanations is that females with ASD frequently take more steps to camouflage their impairments given that they tend to have more self-awareness and better expressive behaviours (e.g., reciprocal conversation, sharing interests) and exhibit less repetitive use of objects and different types of restricted interests compared to males with ASD. Such ability to camouflage impairments can occur irrespective of the presence of similar social understanding impairments exhibited in males with ASD (Head, McGillivray, & Stokes, 2014). Studies have also shown that the phenotype of the disorder can be different in females compared to males with ASD. On average, it has been suggested that females with ASD exhibit less restricted, repetitive behaviours, and interests (RRBI). These findings are really important to consider because if RRBIs are used as key diagnostic criteria, many females with ASD will potentially not be referred for assessment and diagnosed (Rynkiewicz et al., 2016).

There is an urgent need to investigate and identify a wide range of behaviours which go beyond those included in the potentially male-biased ASD screening instruments and diagnostic assessments (Lai, Lombardo, Auyeung, Chakrabarti, & Baron-Cohen, 2015) in order to prevent females with ASD from being overlooked and to ensure that they are integrated into our understanding of the disorder.

Baron-Cohen, S., Wheelwright, S., Skinner, R., Martin, J., & Clubley, E. (2001). The autism-spectrum quotient (AQ): Evidence from asperger syndrome/high-functioning autism, males and females, scientists and mathematicians. Journal of Autism and Developmental Disorders, 31, 5-17.

Head, A. M., McGillivray, J. A., & Stokes, M. A. (2014). Gender differences in emotionality and sociability in children with autism spectrum disorders. Molecular Autism, 5, 19.

Lai, M. C., Lombardo, M. V., Auyeung, B., Chakrabarti, B., & Baron-Cohen, S. (2015). Sex/gender differences and autism: setting the scene for future research. Journal of the American Academy of Child and Adolescent Psychiatry, 54, 11-24.

Lord, C., Rutter, M., DiLavorne, P. C., Risi, S., Gotham, K., & Bishop, S. L. (2012). Autism Diagnostic Observation Schedule, Second Edition (ADOS-2) Manual (Part I): Modules 1-4. Torrance, CA: Western Psychological Services.

Rutter, M., Bailey, A., & Lord, C. (2010). SCQ: Social Communication Questionnaire. Manual. Los Angeles, CA: Western Psychological Services.

Rynkiewicz, A., Schuller, B., Marchi, E., Piana, S., Camurri, A., Lassalle, A., & Baron-Cohen, S. (2016). An investigation of the ‘female camouflage effect’ in autism using a computerized ADOS-2 and a test of sex/gender differences. Molecular Autism, 7,10.

This is a blog. The purpose of the blog is to provide information and raise awareness concerning important issues. All views and opinions expressed are those of the writer and not necessarily shared by the GNC.