There is growing evidence of a camouflaging effect among females with autism spectrum disorder (ASD), particularly among those without intellectual disability, which may affect performance on gold-standard diagnostic measures. This study utilized an age- and IQ-matched sample of school-aged youth (n = 228) diagnosed with ASD to assess sex differences on the ADOS and ADI-R, parent-reported autistic traits, and adaptive skills. Although females and males were rated similarly on gold-standard diagnostic measures overall, females with higher IQs were less likely to meet criteria on the ADI-R. Females were also found to be significantly more impaired on parent reported autistic traits and adaptive skills. Overall, the findings suggest that some autistic females may be missed by current diagnostic procedures.
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Identity-first language rather than person-first language is used in this manuscript, consistent with practice among autistic self-advocates (Brown 2011).
Researchers and female self-advocates have used the terms “masking” and “camouflaging” to describe the phenomenon of autistic women and girls being missed by current diagnostic procedures. The authors chose the term camouflaging, and placed it in quotes for its initial use, to describe this phenomenon which can occur both when autistic women/girls actively seek to hide social communication difficulties, as well as when clinicians fail to accurately diagnose them, due to societal expectations that are believed by many to result in diagnostic bias.
American Psychiatric Association. (2000). Diagnostic and statistical manual of mental disorders (4th ed., text revision). Washington, DC: American Psychiatric Association.
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: American Psychiatric Publishing.
Andersson, G. W., Gillberg, C., & Miniscalco, C. (2013). Pre-school children with suspected autism spectrum disorders: Do girls and boys have the same profiles? Research in Developmental Disabilities, 34(1), 413–422. https://doi.org/10.1016/j.ridd.2012.08.025.
Auyeung, B., Baron-Cohen, S., Ashwin, E., Knickmeyer, R., Taylor, K., & Hackett, G. (2009). Fetal testosterone and autistic traits. British Journal of Psychology, 100(1), 1–22. https://doi.org/10.1348/000712608X311731.
Banach, R., Thompson, A., Szatmari, P., Goldberg, J., Tuff, L., Zwaigenbaum, L., & Mahoney, W. (2009). Brief report: Relationship between non-verbal IQ and Gender in Autism. Journal of Autism and Developmental Disorders, 39(1), 188–193. https://doi.org/10.1007/s10803-008-0612-4.
Bargiela, S., Steward, R., & Mandy, W. (2016). The experiences of late-diagnosed women with autism spectrum conditions: An investigation of the female autism phenotype. Journal of Autism and Developmental Disorders, 46(10), 3281–3294. https://doi.org/10.1007/s10803-016-2872-8.
Beatty, P. C., & Willis, G. B. (2007). Research synthesis: The practice of cognitive interviewing. Public Opinion Quarterly, 71(2), 287–311. https://doi.org/10.1093/poq/nfm006.
Begeer, S., Mandell, D., Wijnker-Holmes, B., Venderbosch, S., Rem, D., Stekelenburg, F., & Koot, H. M. (2013). Sex differences in the timing of identification among children and adults with autism spectrum disorders. Journal of Autism and Developmental Disorders, 43(5), 1151–1156. https://doi.org/10.1007/s10803-012-1656-z.
Bejerot, S., Eriksson, J. M., Bonde, S., Carlström, K., Humble, M. B., & Eriksson, E. (2012). The extreme male brain revisited: Gender coherence in adults with autism spectrum disorder. The British Journal of Psychiatry: The Journal of Mental Science, 201, 116–123. https://doi.org/10.1192/bjp.bp.111.097899.
Benjamini, Y., & Hochberg, Y. (1995). Controlling the false discovery rate: A practical and powerful approach to multiple testing. Journal of the Royal Statistical Society. Series B, 57(1), 289–300. Retrieved from http://www.jstor.org/stable/2346101.
Boat, T. F., & Wu, J. T. (Eds.). (2015). Prevalence of autism spectrum disorder. In Mental disorders and disabilities among low-income children (pp. 241–266). Washington, DC: The National Academies Press.
Boelte, S., & Poustka, F. (2000). Diagnosis of autism: The connection between current and historical information. Autism, 4(4), 382–390. https://doi.org/10.1177/1362361300004004004.
Bölte, S., Duketis, E., Poustka, F., & Holtmann, M. (2011). Sex differences in cognitive domains and their clinical correlates in higher-functioning autism spectrum disorders. Autism, 15(4), 497–511. https://doi.org/10.1177/1362361310391116.
Bölte, S., & Poustka, F. (2002). The relation between general cognitive level and adaptive behavior domains in individuals with autism with and without co-morbid mental retardation. Child Psychiatry and Human Development, 33(2), 165–172.
Brown, L. (2011). Identity-first language/autistic self advocacy network. Retrieved May 26, 2017, from http://autisticadvocacy.org/about-asan/identity-first-language/.
Carter, A. S., Black, D. O., Tewani, S., Connolly, C. E., Kadlec, M. B., & Tager-Flusberg, H. (2007). Sex differences in toddlers with autism spectrum disorders. Journal of Autism and Developmental Disorders, 37(1), 86–97. https://doi.org/10.1007/s10803-006-0331-7.
Chawarska, K., Paul, R., Klin, A., Hannigen, S., Dichtel, L. E., & Volkmar, F. (2007). Parental recognition of developmental problems in toddlers with autism spectrum disorders. Journal of Autism and Developmental Disorders, 37(1), 62–72. https://doi.org/10.1007/s10803-006-0330-8.
Cohen, J. (1988). Statistical power and analysis for the behavioral sciences (2nd ed.). Hillsdale: Lawrence Erlbaum Associates, Inc.
Constantino, J. N., & Gruber, C. (2012). The Social Responsiveness Scale Manual, Second Edition (SRS-2). Los Angeles: Western Psychological Services.
Constantino, J. N., & Gruber, C. P. (2005). Social responsiveness scale (SRS). Los Angeles: Western Psychological Services.
Cridland, E. K., Jones, S. C., Caputi, P., & Magee, C. A. (2014). Being a girl in a boys’ world: Investigating the experiences of girls with autism spectrum disorders during adolescence. Journal of Autism and Developmental Disorders, 44(6), 1261–1274. https://doi.org/10.1007/s10803-013-1985-6.
Daniels, A. M., & Mandell, D. S. (2014). Explaining differences in age at autism spectrum disorder diagnosis: A critical review. Autism: The International Journal of Research and Practice, 18(5), 583–597. https://doi.org/10.1177/1362361313480277.
Dworzynski, K., Ronald, A., Bolton, P., & Happé, F. (2012). How different are girls and boys above and below the diagnostic threshold for autism spectrum disorders? Journal of the American Academy of Child & Adolescent Psychiatry, 51(8), 788–797.
Elliot, C. D. (2007). Differential Ability Scales–Second Edition (DAS-II). San Antonio, TX: Harcourt Assessment.
Farley, M. A., McMahon, W. M., Fombonne, E., Jenson, W. R., Miller, J., Gardner, M., … Coon, H. (2009). Twenty-year outcome for individuals with autism and average or near-average cognitive abilities. Autism Research, 2(2), 109–118. https://doi.org/10.1002/aur.69.
Fombonne, E. (2009). Epidemiology of pervasive developmental disorders. Pediatric Research, 65(6), 591–598.
Frazier, T. W., Georgiades, S., Bishop, S. L., & Hardan, A. Y. (2014a). Behavioral and cognitive characteristics of females and males with autism in the simons simplex collection. Journal of the American Academy of Child & Adolescent Psychiatry, 53(3), 329–340. https://doi.org/10.1016/j.jaac.2013.12.004.
Frazier, T. W., Ratliff, K. R., Gruber, C., Zhang, Y., Law, P. A., & Constantino, J. N. (2014b). Confirmatory factor analytic structure and measurement invariance of quantitative autistic traits measured by the social responsiveness scale-2. Autism: The International Journal of Research and Practice, 18(1), 31–44. https://doi.org/10.1177/1362361313500382.
Giarelli, E., Wiggins, L. D., Rice, C. E., Levy, S. E., Kirby, R. S., Pinto-Martin, J., & Mandell, D. (2010). Sex differences in the evaluation and diagnosis of autism spectrum disorders among children. Disability and Health Journal, 3(2), 107–116. https://doi.org/10.1016/j.dhjo.2009.07.001.
Gilman, S. R., Iossifov, I., Levy, D., Ronemus, M., Wigler, M., & Vitkup, D. (2011). Rare de novo variants associated with autism implicate a large functional network of genes involved in formation and function of synapses. Neuron, 70(5), 898–907. https://doi.org/10.1016/j.neuron.2011.05.021.
Halladay, A. K., Bishop, S., Constantino, J. N., Daniels, A. M., Koenig, K., Palmer, K., … Szatmari, P. (2015). Sex and gender differences in autism spectrum disorder: Summarizing evidence gaps and identifying emerging areas of priority. Molecular Autism, 6(1), 36. https://doi.org/10.1186/s13229-015-0019-y.
Hartley, S. L., & Sikora, D. M. (2009). Sex differences in autism spectrum disorder: An examination of developmental functioning, autistic symptoms, and coexisting behavior problems in toddlers. Journal of Autism and Developmental Disorders, 39(12), 1715–1722. https://doi.org/10.1007/s10803-009-0810-8.
Hiller, R. M., Young, R. L., & Weber, N. (2016). Sex differences in pre-diagnosis concerns for children later diagnosed with autism spectrum disorder. Autism, 20(1), 75–84. https://doi.org/10.1177/1362361314568899.
Holtmann, M., Bölte, S., & Poustka, F. (2007). Autism spectrum disorders: Sex differences in autistic behaviour domains and coexisting psychopathology. Developmental Medicine & Child Neurology, 49(5), 361–366. https://doi.org/10.1111/j.1469-8749.2007.00361.x.
Howe, Y. J., O’Rourke, J. A., Yatchmink, Y., Viscidi, E. W., Jones, R. N., & Morrow, E. M. (2015). Female autism phenotypes investigated at different levels of language and developmental abilities. Journal of Autism and Developmental Disorders, 45(11), 3537–3549. https://doi.org/10.1007/s10803-015-2501-y.
Jacquemont, S., Coe, B. P., Hersch, M., Duyzend, M. H., Krumm, N., Bergmann, S., … Eichler, E. E. (2014). A higher mutational burden in females supports a “female protective model” in neurodevelopmental disorders. American Journal of Human Genetics, 94(3), 415–425. https://doi.org/10.1016/j.ajhg.2014.02.001.
Kanne, S. M., Gerber, A. J., Quirmbach, L. M., Sparrow, S. S., Cicchetti, D. V., & Saulnier, C. A. (2011). The role of adaptive behavior in autism spectrum disorders: Implications for functional outcome. Journal of Autism and Developmental Disorders, 41(8), 1007–1018. https://doi.org/10.1007/s10803-010-1126-4.
Kataoka, S., Takuma, K., Hara, Y., Maeda, Y., Ago, Y., & Matsuda, T. (2013). Autism-like behaviours with transient histone hyperacetylation in mice treated prenatally with valproic acid. The International Journal of Neuropsychopharmacology, 16(1), 91–103. https://doi.org/10.1017/S1461145711001714.
Kirkovski, M., Enticott, P. G., & Fitzgerald, P. B. (2013). A review of the role of female gender in autism spectrum disorders. Journal of Autism and Developmental Disorders, 43(11), 2584–2603. https://doi.org/10.1007/s10803-013-1811-1.
Klin, A., Saulnier, C. A., Sparrow, S. S., Cicchetti, D. V., Volkmar, F. R., & Lord, C. (2007). Social and communication abilities and disabilities in higher functioning individuals with autism spectrum disorders: The Vineland and the ADOS. Journal of Autism and Developmental Disorders, 37(4), 748–759. https://doi.org/10.1007/s10803-006-0229-4.
Knickmeyer, R. C., & Baron-Cohen, S. (2006). Fetal testosterone and sex differences in typical social development and in autism. Journal of Child Neurology, 21(10), 825–845. https://doi.org/10.1177/08830738060210101601.
Knickmeyer, R. C., Wheelwright, S., & Baron-Cohen, S. B. (2008). Sex-typical play: Masculinization/defeminization in girls with an autism spectrum condition. Journal of Autism and Developmental Disorders, 38(6), 1028–1035. https://doi.org/10.1007/s10803-007-0475-0.
Kreiser, N., & White, S. (2014). ASD in females: Are we overstating the gender difference in diagnosis? Clinical Child and Family Psychology Review. Retrieved from http://link.springer.com/article/https://doi.org/10.1007/s10567-013-0148-9.
Lai, M.-C., Baron-Cohen, S., & Buxbaum, J. D. (2015). Understanding autism in the light of sex/gender. Molecular Autism, 6(1). https://doi.org/10.1186/s13229-015-0021-4.
Lai, M.-C., Lombardo, M. V., Ruigrok, A. N., Chakrabarti, B., Auyeung, B., Szatmari, P. … MRC AIMS Consortium. (2016). Quantifying and exploring camouflaging in men and women with autism. Autism. https://doi.org/10.1177/1362361316671012.
Little, L. M., Wallisch, A., Salley, B., & Jamison, R. (2016). Do early caregiver concerns differ for girls with autism spectrum disorders? Autism. https://doi.org/10.1177/1362361316664188.
Loomes, R., Hull, L., & Mandy, W. P. L. (2017). What is the male-to-female ratio in autism spectrum disorder? A systematic review and meta-analysis. Journal of the American Academy of Child & Adolescent Psychiatry. https://doi.org/10.1016/j.jaac.2017.03.013.
Lord, C., Rutter, M., DiLavore, P., Risi, S., Gotham, K., & Bishop, S. (2012). Autism Diagnostic Observation Schedule–2nd Edition (ADOS-2). Los Angeles: Western Psychological Corporation.
Lord, C., Rutter, M., DiLavore, P. C., & Risi, S. S. (2001). Autism Diagnostic Observation Schedule: Manual. Los Angeles: Western Psychological Services.
Lord, C., & Schopler, E. (1985). Brief report: Differences in sex ratios in autism as a function of measured intelligence. Journal of Autism and Developmental Disorders, 15(2), 185–193. https://doi.org/10.1007/BF01531604.
Lord, C., Schopler, E., & Revicki, D. (1982). Sex differences in autism. Journal of Autism and Developmental Disorders, 12(4), 317–330. https://doi.org/10.1007/BF01538320.
Mandic-Maravic, V., Pejovic-Milovancevic, M., Mitkovic-Voncina, M., Kostic, M., Aleksic-Hil, O., Radosavljev-Kircanski, J., … Lecic-Tosevski, D. (2015). Sex differences in autism spectrum disorders: Does sex moderate the pathway from clinical symptoms to adaptive behavior? Scientific Reports, 5, 10418. https://doi.org/10.1038/srep10418.
Mandy, W., Chilvers, R., Chowdhury, U., Salter, G., Seigal, A., & Skuse, D. (2012). Sex differences in autism spectrum disorder: Evidence from a large sample of children and adolescents. Journal of Autism and Developmental Disorders, 42(7), 1304–1313. https://doi.org/10.1007/s10803-011-1356-0.
McLennan, J. D., Lord, C., & Schopler, E. (1993). Sex differences in higher functioning people with autism. Journal of Autism and Developmental Disorders, 23(2), 217–227. https://doi.org/10.1007/BF01046216.
Messinger, D. S., Young, G. S., Webb, S. J., Ozonoff, S., Bryson, S. E., Carter, A., … Zwaigenbaum, L. (2015). Early sex differences are not autism-specific: A Baby Siblings Research Consortium (BSRC) study. Molecular Autism, 6(1). https://doi.org/10.1186/s13229-015-0027-y.
Øien, R. A., Hart, L., Schjølberg, S., Wall, C. A., Kim, E. S., Nordahl-Hansen, A., … Shic, F. (2017). Parent-endorsed sex differences in toddlers with and without ASD: Utilizing the M-CHAT. Journal of Autism and Developmental Disorders, 47(1), 126–134. https://doi.org/10.1007/s10803-016-2945-8.
Pilowsky, T., Yirmiya, N., Shulman, C., & Dover, R. (1998). The autism diagnostic interview-revised and the childhood autism rating scale: Differences Between diagnostic systems and comparison between genders. Journal of Autism and Developmental Disorders, 28(2), 143–151. https://doi.org/10.1023/A:1026092632466.
Pine, D. S., Guyer, A. E., Goldwin, M., Towbin, K. A., & Leibenluft, E. (2008). Autism spectrum disorder scale scores in pediatric mood and anxiety disorders. Journal of the American Academy of Child and Adolescent Psychiatry, 47(6), 652–661. https://doi.org/10.1097/CHI.0b013e31816bffa5.
Pugliese, C. E., Anthony, L., Strang, J. F., Dudley, K., Wallace, G. L., & Kenworthy, L. (2015). Increasing adaptive behavior skill deficits from childhood to adolescence in autism spectrum disorder: Role of executive function. Journal of Autism and Developmental Disorders, 45, 1579–1587. https://doi.org/10.1007/s10803-014-2309-1.
Reinhardt, V. P., Wetherby, A. M., Schatschneider, C., & Lord, C. (2015). Examination of sex differences in a large sample of young children with autism spectrum disorder and typical development. Journal of Autism and Developmental Disorders, 45(3), 697–706. https://doi.org/10.1007/s10803-014-2223-6.
Robinson, E. B., Lichtenstein, P., Anckarsater, H., Happé, F., & Ronald, A. (2013). Examining and interpreting the female protective effect against autistic behavior. Proceedings of the National Academy of Sciences, 110(13), 5258–5262. https://doi.org/10.1073/pnas.1211070110.
Rutter, M., Le Couteur, A., & Lord, C. (2003). Autism diagnostic interview-revised (Vol. 29, p. 30). Los Angeles: Western Psychological Services.
Schoch, H., Kreibich, A. S., Ferri, S. L., White, R. S., Bohorquez, D., Banerjee, A., … Brodkin, E. S. (2017). Sociability deficits and altered amygdala circuits in mice lacking Pcdh10, an autism associated gene. Biological Psychiatry, 81(3), 193–202. https://doi.org/10.1016/j.biopsych.2016.06.008.
Shattuck, P. T., Durkin, M., Maenner, M., Newschaffer, C., Mandell, D. S., Wiggins, L., … Cuniff, C. (2009). Timing of identification among children with an autism spectrum disorder: Findings from a population-based surveillance study. Journal of the American Academy of Child & Adolescent Psychiatry, 48(5), 474–483. https://doi.org/10.1097/CHI.0b013e31819b3848.
Siklos, S., & Kerns, K. A. (2007). Assessing the diagnostic experiences of a small sample of parents of children with autism spectrum disorders. Research in Developmental Disabilities, 28(1), 9–22. https://doi.org/10.1016/j.ridd.2005.09.003.
Sparrow, S. S., Balla, D. A., & Cicchetti, D. V. (2005). Vineland-II adaptive behavior scales. Circle Pines: AGS Publishing.
Strang, J. F., Kenworthy, L., Dominska, A., Sokoloff, J., Kenealy, L. E., Berl, M., … Wallace, G. L. (2014). Increased gender variance in autism spectrum disorders and attention deficit hyperactivity disorder. Archives of Sexual Behavior, 43(8), 1525–1533. https://doi.org/10.1007/s10508-014-0285-3.
Trubanova, A., Donlon, K., Kreiser, N. L., Ollendick, T. H., & White, S. W. (2014). Under-identification of ASD in females: A case series illustrating the unique presentation of ASD in young adult females. Scandinavian Journal of Child and Adolescent Psychiatry and Psychology, 2(2), 66–76.
Tsai, L. Y., & Beisler, J. M. (1983). The development of sex differences in infantile autism. The British Journal of Psychiatry, 142(4), 373–378. https://doi.org/10.1192/bjp.142.4.373.
Van Wijngaarden-Cremers, P. J. M., van Eeten, E., Groen, W. B., Van Deurzen, P. A., Oosterling, I. J., & Van der Gaag, R. J. (2014). Gender and age differences in the core triad of impairments in autism spectrum disorders: A systematic review and meta-analysis. Journal of Autism and Developmental Disorders, 44(3), 627–635. https://doi.org/10.1007/s10803-013-1913-9.
Volkmar, F., Sparrow, S. S., Goudreau, D., Cicchetti, D. V., Paul, R., & Cohen, D. J. (1987). Social deficits in autism: An operational approach using the Vineland Adaptive Behavior Scales. Journal of the American Academy of Child & Adolescent Psychiatry, 26(2), 156–161. https://doi.org/10.1097/00004583-198703000-00005.
Volkmar, F. R., Szatmari, P., & Sparrow, S. S. (1993). Sex differences in pervasive developmental disorders. Journal of Autism and Developmental Disorders, 23(4), 579–591. https://doi.org/10.1007/BF01046103.
Wechsler, D. (2003). Wechsler Intelligence Scale for Children–Fourth Edition (WISC-IV). San Antonio, TX: The Psychological Corporation.
Wechsler, D. (2008). Wechsler Adult Intelligence Scale-Fourth Edition (WAIS-IV). San Antonio, TX: The Psychological Corporation-Pearson.
Wechsler, D. (2011). Wechsler abbreviated scale of intelligence–Second edition (WASI-II). San Antonio, TX: NCS Pearson.
Wechsler, D. (2014). WPPSI-IV: Wechsler Preschool and Primary Scale of Intelligence-Fourth Edition technical and interpretive manual. San Antonio, TX: Pearson.
Wechsler, D. (2014). Wechsler Intelligence Scale for Children–Fifth Edition (WISC-V). Bloomington, MN: The Psychological Corporation.
Wechsler, D., & Hsiao-pin, C. (2011). WASI-II: Wechsler abbreviated scale of intelligence. Bloomington: Pearson.
Wilson, C. E., Murphy, C. M., McAlonan, G., Robertson, D. M., Spain, D., Hayward, H., … Zinkstok, J. (2016). Does sex influence the diagnostic evaluation of autism spectrum disorder in adults? Autism, 20:808–819.
Yerys, B. E., Wallace, G. L., Sokoloff, J. L., Shook, D. A., James, J. D., & Kenworthy, L. (2009). Attention deficit/hyperactivity disorder symptoms moderate cognition and behavior in children with autism spectrum disorders. Autism Research: Official Journal of the International Society for Autism Research, 2(6), 322–333. https://doi.org/10.1002/aur.103.
Funding for this project was provided by grants and financial support through several institutions, including: The Isadore and Bertha Gudelsky Family Foundation, Children’s National Health Institute IDDRC P30 HD040677, Pennsylvania State Department of Health, The Philadelphia Foundation, Pfizer, Robert Wood Johnson Foundation, Virginia Tech Center for Autism Research, and the National Institute of Child Health and Human Development (R03HD081070). We are grateful to the children and families who participated in this study.
Conflict of interest
All authors declare no conflict of interest.
All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards. Informed consent was obtained from all individual participants included in the study.
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Ratto, A.B., Kenworthy, L., Yerys, B.E. et al. What About the Girls? Sex-Based Differences in Autistic Traits and Adaptive Skills. J Autism Dev Disord 48, 1698–1711 (2018). https://doi.org/10.1007/s10803-017-3413-9
- Autism spectrum disorder
- Sex differences
- Adaptive skills