• Autism Spectrum Disorders: Treatment, Services, Outcomes, and Community Functioning in Adolescents and Adults (ES Brodkin, Section Editor)
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Women and Autism Spectrum Disorder: Diagnosis and Implications for Treatment of Adolescents and Adults

Abstract

Purpose of Review

We review the recent literature regarding the implications of gender on the diagnosis and treatment of autism spectrum disorder (ASD) in women and adolescent females. We also discuss important clinical observations in treating this population.

Recent Findings

Growing research supports gender specificity in ASD symptom presentation. Differing phenotypes, psychiatric co-morbidities, and level of “camouflaging” (behavioral coping strategies to conceal symptoms for use in social situations) are thought to further contribute to the discrepancy in prevalence rates and resulting misdiagnosis or delayed diagnosis in adolescent females and women.

Summary

Both nosological and cultural factors appear to be contributing to differences in the diagnosis of ASD in women. These differences in presentation have important implications for late diagnosis, treatment of ASD, and the quality of life for women with autism.

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References

Papers of particular interest, published recently, have been highlighted as: • Of importance •• Of major importance

  1. 1.

    American Psychiatric Association, American Psychiatric Association, editor. Diagnostic and statistical manual of mental disorders: DSM-5. 5th ed. Washington, D.C: American Psychiatric Association; 2013.

    Google Scholar 

  2. 2.

    Asperger H. Die “autistichen psychopathen” im kindersalter [Autistic psychopathy in childhood]. Archive fur Psychiatrie und Nervenkrankheiten. 1944;117:76–136.

    Article  Google Scholar 

  3. 3.

    Kanner L. Autistic disturbances of affective contact. Nervous Child. 1943;2:217.

    Google Scholar 

  4. 4.

    Ritvo ER, Cantwell D, Johnson E, Clements M, Benbrook F, Slagle S, et al. Social class factors in autism. J Autism Dev Disord. 1971;1:297–310.

    CAS  Article  Google Scholar 

  5. 5.

    Rutter M, Lockyer L. A five to fifteen year follow-up study of infantile psychosis: I. Description of sample. Br J Psychiatry. 1967;113:1169–82.

    CAS  Article  Google Scholar 

  6. 6.

    Lotter V. Epidemiology of autistic conditions in young children. Soc Psychiatry. 1966;1:124–35.

    Article  Google Scholar 

  7. 7.

    Fombonne E. The changing epidemiology of autism. J Appl Res Intellect Disabil. 2005;18:281–94.

    Article  Google Scholar 

  8. 8.

    Baird G, Simonoff E, Pickles A, Chandler S, Loucas T, Meldrum D, et al. Prevalence of disorders of the autism spectrum in a population cohort of children in South Thames: the Special Needs and Autism Project (SNAP). Lancet. 2006;368:210–5.

    Article  Google Scholar 

  9. 9.

    World Health Organization. The ICD-10 classification of mental and behavioural disorders: clinical descriptions and diagnostic guidelines. Geneva: World Health Organization; 1992.

    Google Scholar 

  10. 10.

    • Baio J, Wiggins L, Christensen DL, Maenner MJ, Daniels J, Warren Z, et al. Prevalence of autism spectrum disorder among children aged 8 years - autism and developmental disabilities monitoring network, 11 Sites, United States, 2014. MMWR Surveill Summ. 2018;67:1–23 A very recent study examining the prevalence rate of ASD in a population cohort in London.

    Article  Google Scholar 

  11. 11.

    •• Loomes R, Hull L, Mandy WPL. What is the male-to-female ratio in autism Spectrum disorder? A systematic review and meta-analysis. J Am Acad Child Adolesc Psychiatry. 2017;56:466–74 A systematic review and meta-analysis of prevalence studies examining the male-to-female ratio in ASD.

    Article  Google Scholar 

  12. 12.

    Kreiser NL, White SW. ASD in females: are we overstating the gender difference in diagnosis? Clin Child Fam Psychol Rev. 2014;17:67–84.

    Article  Google Scholar 

  13. 13.

    Lai M-C, Baron-Cohen S. Identifying the lost generation of adults with autism spectrum conditions- ClinicalKey. Lancet Psychiatry. 2015;2:1013–27.

    Article  Google Scholar 

  14. 14.

    •• Bargiela S, Steward R, Mandy W. The experiences of late-diagnosed women with autism spectrum conditions: an investigation of the female autism phenotype. J Autism Dev Disord. 2016;46:3281–94 A qualitative study examining the female ASD phenotype and its effect on diagnosis.

    Article  Google Scholar 

  15. 15.

    Howlin P, Moss P, Savage S, Rutter M. Social outcomes in mid- to later adulthood among individuals diagnosed with autism and average nonverbal IQ as children. J Am Acad Child Adolesc Psychiatry. 2013;52:572–581.e1.

    Article  Google Scholar 

  16. 16.

    • Hull L, Petrides KV, Allison C, Smith P, Baron-Cohen S, Lai M-C, et al. “Putting on my best normal”: social camouflaging in adults with autism spectrum conditions. J Autism Dev Disord. 2017;47:2519–34 Qualitative study using thematic analysis to examine social camouflaging in adults with ASD and focusing on the nature, motivations, and consequences of camouflaging.

    Article  Google Scholar 

  17. 17.

    •• Lai M-C, Lombardo MV, Ruigrok AN, Chakrabarti B, Auyeung B, Szatmari P, et al. Quantifying and exploring camouflaging in men and women with autism. Autism. 2017;21:690–702 A quantitative analysis of camouflaging in ASD confirms gender disparities with women reporting greater camouflaging.

    Article  Google Scholar 

  18. 18.

    • Lai M-C, Lombardo MV, Pasco G, Ruigrok ANV, Wheelwright SJ, Sadek SA, et al. A behavioral comparison of male and female adults with high functioning autism spectrum conditions. PLoS ONE. 2011 [cited 2018 Jul 3];6. Available from: http://ezp-prod1.hul.harvard.edu/login?url=http://search.ebscohost.com/login.aspx?direct=true&db=psyh&AN=2011-14242-001&site=ehost-live&scope=site. A behavioral comparison between sexes found women with high-functioning ASD to show more lifetime sensory symptoms, fewer socio-communication difficulties, and more self-reported autistic traits.

  19. 19.

    Lehnhardt F-G, Falter C, Gawronski A, Pfeiffer K, Tepest R, Franklin J, et al. Sex-related cognitive profile in autism spectrum disorders diagnosed late in life: implications for the female autistic phenotype. J Autism Dev Disord. 2016;46:139–54.

    Article  Google Scholar 

  20. 20.

    Koyama T, Kamio Y, Inada N, Kurita H. Sex Differences in WISC-III profiles of children with high-functioning pervasive developmental disorders. J Autism Dev Disord. 2009;39:135–41.

    Article  Google Scholar 

  21. 21.

    Bölte S, Duketis E, Poustka F, Holtmann M. Sex differences in cognitive domains and their clinical correlates in higher-functioning autism spectrum disorders. Autism. 2011;15:497–511.

    Article  Google Scholar 

  22. 22.

    • Kiep M, Spek AA. Executive functioning in men and women with an autism spectrum disorder. Autism Res. 2017;10:940–8 This study demonstrated differences in executive functioning between men and women with ASD and discussed possible implications.

    Article  Google Scholar 

  23. 23.

    Hill EL. Evaluating the theory of executive dysfunction in autism. Dev Rev. 2004;24:189–233.

    Article  Google Scholar 

  24. 24.

    Lai M-C, Lombardo MV, Suckling J, Ruigrok ANV, Chakrabarti B, Ecker C, et al. Biological sex affects the neurobiology of autism. Brain. 2013;136:2799–815.

    Article  Google Scholar 

  25. 25.

    Alaerts K, Swinnen SP, Wenderoth N. Sex differences in autism: a resting-state fMRI investigation of functional brain connectivity in males and females. Soc Cogn Affect Neurosci. 2016;11:1002–16.

    Article  Google Scholar 

  26. 26.

    Beacher FDCC, Radulescu E, Minati L, Baron-Cohen S, Lombardo MV, Lai M-C, et al. Sex differences and autism: brain function during verbal fluency and mental rotation. PLoS One; San Francisco. 2012;7:e38355.

    CAS  Article  Google Scholar 

  27. 27.

    Beacher FD, Minati L, Baron-Cohen S, Lombardo MV, Lai M-C, Gray MA, et al. Autism attenuates sex differences in brain structure: a combined voxel-based morphometry and diffusion tensor imaging study. Am J Neuroradiol. 2012;33:83–9.

    CAS  Article  Google Scholar 

  28. 28.

    Baron-Cohen S. The extreme male brain theory of autism. Trends Cogn Sci. 2002;6:248–54.

    Article  Google Scholar 

  29. 29.

    Joshi G, Wozniak J, Petty C, Martelon MK, Fried R, Bolfek A, et al. Psychiatric comorbidity and functioning in a clinically referred population of adults with autism Spectrum disorders: a comparative study. J Autism Dev Disord. 2013;43:1314–25.

    Article  Google Scholar 

  30. 30.

    Lugnegård T, Hallerbäck MU, Gillberg C. Psychiatric comorbidity in young adults with a clinical diagnosis of Asperger syndrome. Res Dev Disabil. 2011;32:1910–7.

    Article  Google Scholar 

  31. 31.

    Nolen-Hoeksema S, Girgus JS. The emergence of gender differences in depression during adolescence. Psychol Bull. 1994;115:424–43.

    CAS  Article  Google Scholar 

  32. 32.

    Sukhodolsky DG, Scahill L, Gadow KD, Arnold LE, Aman MG, McDougle CJ, et al. Parent-rated anxiety symptoms in children with pervasive developmental disorders: frequency and association with core autism symptoms and cognitive functioning. J Abnorm Child Psychol. 2008;36:117–28.

    Article  Google Scholar 

  33. 33.

    May T, Cornish K, Rinehart N. Does gender matter? A one year follow-up of autistic, attention and anxiety symptoms in high-functioning children with autism Spectrum disorder. J Autism Dev Disord. 2014;44:1077–86.

    Article  Google Scholar 

  34. 34.

    Mandy W, Chilvers R, Chowdhury U, Salter G, Seigal A, Skuse D. Sex Differences in autism spectrum disorder: evidence from a large sample of children and adolescents. J Autism Dev Disord. 2012;42:1304–13.

    Article  Google Scholar 

  35. 35.

    Solomon M, Miller M, Taylor SL, Hinshaw SP, Carter CS. Autism symptoms and internalizing psychopathology in girls and boys with autism spectrum disorders. J Autism Dev Disord. 2012;42:48–59.

    Article  Google Scholar 

  36. 36.

    Larson R, Richards MH. Introduction: the changing life space of early adolescence. J Youth Adolesc. 1989;18:501–9.

    CAS  Article  Google Scholar 

  37. 37.

    Mahalik JR, Morray EB, Coonerty-Femiano A, Ludlow LH, Slattery SM, Smiler A. Development of the conformity to feminine norms inventory. Sex Roles. 2005;52:417–35.

    Article  Google Scholar 

  38. 38.

    Barrett AE, Raskin WH. Trajectories of gender role orientations in adolescence and early adulthood: a prospective study of the mental health effects of masculinity and femininity. J Health Soc Behav. 2002;43:451–68.

    Article  Google Scholar 

  39. 39.

    Broderick PC, Korteland C. Coping style and depression in early adolescence: relationships to gender, gender role, and implicit beliefs. Sex Roles. 2002;46:201–13.

    Article  Google Scholar 

  40. 40.

    Fiese BH, Skillman G. Gender differences in family stories: moderating influence of parent gender role and child gender. Sex Roles. 2000;43:267–83.

    Article  Google Scholar 

  41. 41.

    Danielsson UE, Bengs C, Samuelsson E, Johansson EE. “My greatest dream is to be normal”: the impact of gender on the depression narratives of young Swedish men and women. Qual Health Res. 2011;21:612–24.

    Article  Google Scholar 

  42. 42.

    Tolman DL, Impett EA, Tracy AJ, Michael A. Looking good, sounding good: femininity ideology and adolescent girls’ mental health. Psychol Women Q. 2006;30:85–95.

    Article  Google Scholar 

  43. 43.

    Tjaden P, Thoennes N. Prevalence and consequences of male-to-female and female-to-male intimate partner violence as measured by the National Violence Against Women Survey. Violence Against Women. 2000;6:142–61.

    Article  Google Scholar 

  44. 44.

    Safety Skills for Asperger Women: How to Save a Perfectly Good Female Life by Liane Holliday Willey [Internet]. [cited 2018 Jul 31]. Available from: https://www.goodreads.com/book/show/11187137-safety-skills-for-asperger-women.

  45. 45.

    • Wood JJ, Klebanoff S, Renno P, Fujii C, Danial J. Chapter 7 - Individual CBT for anxiety and related symptoms in children with autism spectrum disorders. In: Kerns CM, Renno P, Storch EA, Kendall PC, Wood JJ, editors. Anxiety in Children and Adolescents with Autism Spectrum Disorder [Internet]. Academic Press; 2017 [cited 2018 Jul 31]. p. 123–41. Available from: http://www.sciencedirect.com/science/article/pii/B9780128051221000077 A chapter reviewing the effectiveness of CBT therapy in treating both children and adults with ASD.

  46. 46.

    Spain D, Blainey SH, Vaillancourt K. Group cognitive behaviour therapy (CBT) for social interaction anxiety in adults with autism spectrum disorders (ASD). Res Autism Spectr Disord. 2017;41–42:20–30.

    Article  Google Scholar 

  47. 47.

    Spek AA, van Ham NC, Nyklíček I. Mindfulness-based therapy in adults with an autism spectrum disorder: a randomized controlled trial. Res Dev Disabil. 2013;34:246–53.

    Article  Google Scholar 

  48. 48.

    Jones RM, Wheelwright S, Farrell K, Martin E, Green R, Di Ceglie D, et al. Brief report: female-to-male transsexual people and autistic traits. J Autism Dev Disord. 2012;42:301–6.

    Article  Google Scholar 

  49. 49.

    • Accordino RE, Kidd C, Politte LC, Henry CA, McDougle CJ. Psychopharmacological interventions in autism spectrum disorder. Expert Opin Pharmacother. 2016;17:937–52 Opinion piece on psychopharmacological treatment of core and associated symptoms of ASD.

    CAS  Article  Google Scholar 

  50. 50.

    McCracken JT, McGough J, Shah B, Cronin P, Hong D, Aman MG, et al. Risperidone in children with autism and serious behavioral problems. N Engl J Med. 2002;347:314–21.

    CAS  Article  Google Scholar 

  51. 51.

    Owen R, Sikich L, Marcus RN, Corey-Lisle P, Manos G, McQuade RD, et al. Aripiprazole in the treatment of irritability in children and adolescents with autistic disorder. Pediatrics. 2009;124:1533–40.

    Article  Google Scholar 

  52. 52.

    Pasquali R, Stener-Victorin E, Yildiz BO, Duleba AJ, Hoeger K, Mason H, et al. PCOS Forum: research in polycystic ovary syndrome today and tomorrow. Clin Endocrinol. 2011;74:424–33.

    Article  Google Scholar 

  53. 53.

    Oswald TM, Winder-Patel B, Ruder S, Xing G, Stahmer A, Solomon M. A pilot randomized controlled trial of the ACCESS program: a group intervention to improve social, adaptive functioning, stress coping, and self-determination outcomes in young adults with autism spectrum disorder. J Autism Dev Disord. 2018;48:1742–60.

    Article  Google Scholar 

  54. 54.

    Farley M, Cottle KJ, Bilder D, Viskochil J, Coon H, McMahon W. Mid-life social outcomes for a population-based sample of adults with ASD. Autism Res. 2018;11:142–52.

    Article  Google Scholar 

  55. 55.

    Kamio Y, Inada N, Koyama T. A nationwide survey on quality of life and associated factors of adults with high-functioning autism spectrum disorders. Autism. 2013;17:15–26.

    Article  Google Scholar 

  56. 56.

    • Mason D, McConachie H, Garland D, Petrou A, Rodgers J, Parr JR. Predictors of quality of life for autistic adults. Autism Research [Internet]. [cited 2018 Sep 23];0. Available from: http://onlinelibrary.wiley.com/doi/abs/10.1002/aur.1965 This study includes the largest study sample to date examining the quality of life of individuals with ASD and examines gender differences.

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Correspondence to Renée M. Green.

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Green, R.M., Travers, A.M., Howe, Y. et al. Women and Autism Spectrum Disorder: Diagnosis and Implications for Treatment of Adolescents and Adults. Curr Psychiatry Rep 21, 22 (2019). https://doi.org/10.1007/s11920-019-1006-3

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Keywords

  • Autism spectrum disorder
  • ASD
  • Women
  • Female
  • Adults