Abstract
Restricted and repetitive behaviors and interests (RRBI) have garnered attention for their presenting sex differences in Autism Spectrum Disorder (ASD). Specifically, previous works have claimed that RRBI are less predictive of an ASD diagnosis for females relative to males. Previous reports have demonstrated mixed findings: females present with greater RRBI (e.g., compulsive behaviors), females present with fewer RRBI (e.g., restricted interests), and females are not distinguishable from males based on overall RRBI profiles. The following review details behavioral and neurophysiological RRBI findings to argue that female presentations are qualitatively and quantitatively unique and should be taken into consideration for diagnostic measures. Future directions will be suggested in under-explored areas including functional imaging, sensory profiles, and typically developing control groups.
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Abbott, A. E., Linke, A. C., Nair, A., Jahedi, A., Alba, L. A., Keown, C. L., et al. (2018). Repetitive behaviors in autism are linked to imbalance of corticostriatal connectivity: a functional connectivity MRI study. Social Cognitive and Affective Neuroscience, 13(1), 32–42. https://doi.org/10.1093/scan/nsx129.
American Psychiatric Association (APA). (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Arlington: American Psychiatric Publishing.
Antezana, L., Factor, R. S., Condy, E. E., Strege, M. V., Scarpa, A., & Richey, J. (2018). Gender differences in restricted and repetitive behaviors and interests in youth with autism. Autism Research, 12, 274–283. https://doi.org/10.1002/aur.2049.
Anthony, L. G., Kenworthy, L., Yerys, B. E., Jankowski, K. F., James, J. D., Harms, M. B., et al. (2013). Interests in high-functioning autism are more intense, interfering, and idiosyncratic than those in neurotypical development. Development and Psychopathology, 25(03), 643–652. https://doi.org/10.1017/S0954579413000072.
Attwood, T., & Grandin, T. (2006). Aspergers and girls. Arlington: Future Horizons.
Attwood, T., Grandin, T., Bolick, T., Faherty, C., Iland, K., Myers, J. M., & Wroble, M. (2006). Asperger’s and girls. Texas: Future Horizons.
Baghdadli, A., Pascal, C., Grisi, S., & Aussilloux, C. (2003). Risk factors for self-injurious behaviours among 222 young children with autistic disorders. Journal of Intellectual Disability Research, 47, 622–627. https://doi.org/10.1046/j.1365-2788.2003.00507.x.
Banach, R., Thompson, A., 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, 188–193.
Baio, J., Wiggins, L., Christensen, D. L., Maenner, M. J., Daniels, J., Warren, Z., et al. (2018). Prevalence of autism spectrum disorder among children aged 8 years — Autism and Developmental Disabilities Monitoring Network, 11 Sites, United States, 2014. MMWR Surveillance Summaries, 67(6), 1–23. https://doi.org/10.15585/mmwr.ss6706a1.
Beggiato, A., Peyre, H., Maruani, A., Scheid, I., Rastam, M., Amsellem, F., et al. (2016). Gender differences in autism spectrum disorders: divergence among specific core symptoms. Autism Research, 10, 680–689. https://doi.org/10.1002/aur.1715.
Bishop, S. L., Hus, V., Duncan, A., Huerta, M., Gotham, K., Pickles, A., et al. (2013). Subcategories of restricted and repetitive behaviors in children with autism spectrum disorders. Journal of Autism and Developmental Disorders, 43, 1287–1297. https://doi.org/10.1007/s10803-012-1671-0.
Bitsika, V., Sharpley, C. F., & Mills, R. (2018). Sex differences in sensory features between boys and girls with autism spectrum disorder. Research in Autism Spectrum Disorders, 51, 49–55. https://doi.org/10.1016/j.rasd.2018.04.002.
Bodfish, J. W., Symons, F. J., Parker, D. E., & Lewis, M. H. (2000). Varieties of repetitive behavior in autism: comparisons to mental retardation. Journal of Autism and Developmental Disorders, 30, 237–243.
Bodfish, J. W., Symons, F. W., & Lewis, M. H. (1999). The repetitive behavior scale. Western Carolina Center Research Reports.
Bresin, K., & Shoenleber, M. (2015). Gender differences in the prevalence of nonsuicidal self-injury: a meta-analysis. Clinical Psychological Reviews, 38. https://doi.org/10.1016/j.cpr.2015.02.009.
Cohen, I. L., Tsiouris, J. A., Flory, M. J., Kim, S-Y., Freedland, R., Heaney, G., Pettinger, J., & Brown, W. T. (2010). A Large scale study of the psychometric characteristics of the IBR modified overt aggression scale: Findings and evidence for increased self-destructive behaviors in adult females with autism spectrum disorder. Journal of Autism and Developmental Disorders, 40(5):599–609.
Condy, E. E., Scarpa, A., & Friedman, B. H. (2017). Respiratory sinus arrhythmia predicts restricted repetitive behavior severity. Journal of Autism and Developmental Disorders, 47(9), 2795–2804. https://doi.org/10.1007/s10803-017-3193-2.
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, 86–97.
Dichter, G. S., Felder, J. N., Green, S. R., Rittenberg, A. M., Sasson, N. J., & Bodfish, J. W. (2010). Reward circuitry function in autism spectrum disorders. Social Cognitive and Affective Neuroscience, 7(2), 160–172. https://doi.org/10.1093/scan/nsq095.
Duerden, E. G., Oatley, H. K., Mak-Fan, K. M., McGrath, P. A., Taylor, M. J., Szatmari, P., & Roberts, S. W. (2012). Risk factors associated with self-injurious behaviors in children and adolescents with autism spectrum disorders. Journal of Autism and Developmental Disorders, 42, 2460–2470. https://doi.org/10.1007/s10803-012-1497-9.
Duvekot, J., van der Ende, J., Verhulst, F. C., Slappendel, G., van Daalen, E., Maras, A., & Greaves-Lord, K. (2016). Factors influencing the probability of a diagnosis of autism spectrum disorder in girls versus boys. Autism, 21, 646–658.
Frazier, T. W., Georgiades, S., Bishop, S. L., & Hardan, A. Y. (2014). Behavioral and cognitive characteristics of females and males with autism in the Simons simplex collection. Journal of the American Academy of Child and Adolescent Psychiatry, 53, 329–340.
Fulceri, F., Narzisi, A., Apicella, F., Balboni, G., Baldini, S., Brocchini, J., et al. (2016). Application of the repetitive behavior scale-revised – Italian version – in preschoolers with autism spectrum disorder. Research in Developmental Disabilities, 48, 43–52. https://doi.org/10.1016/j.ridd.2015.10.015.
Gotham, K., Risi, S., Pickles, A., & Lord, C. (2007). The autism diagnostic observation schedule: revised algorithms for improved diagnostic validity. Journal of Autism and Developmental Disorders, 37, 613–627. https://doi.org/10.1007/s10803-006-0280-1.
Halladay, A. H., Bishop, S., Constantino, J. N., Daniels, A. M., Koenig, K., Palmer, K., et al. (2015). Sex and gender differences in autism spectrum disorder: Summarizing evidence gaps and identifying emerging areas of priority. Molecular Autism, 6. https://doi.org/10.1186/s13229-015-0019-y.
Harrop, C., Gulsrud, A., & Kasari, C. (2015). Does gender moderate core deficits in ASD? An investigation into restricted and repetitive behaviors in girls and boys with ASD. Journal of Autism and Developmental Disorders, 45, 3644–3655.
Harrop, C., Jones, D., Zheng, S., Nowell, S., Boyd, B. A., & Sasson, N. (2018). Circumscribed interests and attention in autism: the role of biological sex. Journal of Autism and Developmental Disorders, 48(10), 3449–3459.https://doi.org/10.1007/s10803-018-3612-z.
Hattier, M. A., Matson, J. L., Tureck, K., & Horovitz, M. (2011). The effects of gender and age on repetitive and/or restricted behaviors and interests in adults with autism spectrum disorders and intellectual disability. Research in Developmental Disabilities, 32, 2346–2351. https://doi.org/10.1016/j.ridd.2011.07.028.
Hiller, R. M., Young, R. L., & Weber, N. (2014). Sex differences in autism spectrum disorder based on DSM-5 criteria: evidence from clinician and teacher reporting. Journal of Abnormal Child Psychology, 42, 1381–1393. https://doi.org/10.1007/s10802-014-9881-x.
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, 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, 361–366.
Hull, L., Mandy, W., & Petrides, K. (2017). Behavioural and cognitive sex/gender differences in autism spectrum condition and typically developing males and females. Autism, 21(6), 706–727. https://doi.org/10.1177/1362361316669087.
Knutsen, J., Crossman, M., Perrin, J., Shui, A., & Kuhlthau, K. (2018). Sex differences in restricted repetitive behaviors and interests in children with autism spectrum disorder: an autism treatment network study. Autism. https://doi.org/10.1177/1362361318786490.
Kohls, G., Antezana, L., Mosner, M. G., Schultz, R. T., & Yerys, B. E. (2018). Altered reward system reactivity for personalized circumscribed interests in autism. Molecular Autism, 9, 9. https://doi.org/10.1186/s13229-018-0195-7.
Lai, M. C., Lombardo, M. V., Auyeung, B., et al. (2015). Sex/sex differences and autism: setting the scene for future research. Journal of the American Academy of Child and Adolescent Psychiatry, 54, 11–24.
Lam, K. S. L., & Aman, M. G. (2007). The repetitive behavior scale-revised: independent validation in individuals with autism spectrum disorders. Journal of Autism and Developmental Disorders, 37, 855–866.
Langen, M., Durston, S., Kas, M. J. H., van Engeland, H., & Staal, W. G. (2011a). The neurobiology of repetitive behavior: …and men. Neuroscience & Biobehavioral Reviews, 35(3), 356–365. https://doi.org/10.1016/j.neubiorev.2010.02.005.
Langen, M., Kas, M. J. H., Staal, W. G., van Engeland, H., & Durston, S. (2011b). The neurobiology of repetitive behavior: of mice…. Neuroscience and Biobehavioral Reviews, 35(3), 345–355. https://doi.org/10.1016/j.neubiorev.2010.02.004.
Lawson, L. P., Joshi, R., Barbaro, J., & Dissanayake, C. (2018). Gender differences during toddlerhood in autism spectrum disorder: a prospective community-based longitudinal follow-up study. Journal of Autism and Developmental Disorders, 48, 2619–2628. https://doi.org/10.1007/s10803-018-3516-y.
Lehnhardt, F.-G., Falter, C. M., Gawronski, A., Pfeiffer, K., Tepest, R., Franklin, J., & Vogeley, K. (2016). Sex-related cognitive profile in autism spectrum disorders diagnosed late in life: implications for the female autistic phenotype. Journal of Autism and Developmental Disorders, 46(1), 139–154. https://doi.org/10.1007/s10803-015-2558-7.
Lord, C., Rutter, M., & Le Couteur, A. (1994). Autism diagnostic interview-revised: a revised version of a diagnostic interview for caregivers of individuals with possible pervasive developmental disorders. Journal of Autism and Developmental Disorders, 24, 659–685 https://doi.org/7814313.
Lord, C., Rutter, M., DiLavore, P. C., Risi, S., Gotham, K., & Bishop, S. (2012). Autism diagnostic observation schedule (2). Western Psychological Services: Edition. Torrance.
Lord, C., Schopler, E., & Revicki, D. (1982). Sex differences in autism. Journal of Autism and Developmental Disorders, 12, 317–330.
Maddox, B. B., Trubanova, A., & White, S. W. (2016). Untended wounds: non-suicidal self-injury in adults with autism spectrum disorder. Autism, 1362361316644731, 412–422. https://doi.org/10.1177/1362361316644731.
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, 1304–1313. https://doi.org/10.1007/s10803-011-1356-0.
May, T., Cornish, K., & Rinehart, N. J. (2016). Gender profiles of behavioral attention in children with autism spectrum disorder. Journal of Attention Disorders, 20, 627–635. https://doi.org/10.1177/1087054712455502.
McFayden, T. C., Albright, J. A., Muskett, A. E., & Scarpa, A. (2018). The sex discrepancy in an ASD diagnosis: an in depth look at restricted interests and repetitive behaviors. Journal of Autism and Developmental Disorders, 49, 1693–1699. https://doi.org/10.1007/s10803-018-3839-9.
Messinger, D. S., Young, G. S., Webb, S. J., Ozonoff, S., Bryson, S. E., Carter, A., et al. (2015). Early sex differences are not autism-specific: a baby siblings research consortium (BSRC) study. Molecular Autism, 6. https://doi.org/10.1186/s13229-015-0027-y.
Miller, M., Bales, K., Taylor, S. L., Yoon, J., Hostetler, C. M., Carter, C. S., & Solomon, M. (2013). Oxytocin and vasopressin in children and adolescents with autism spectrum disorders: sex differences and associations with symptoms. Autism Research, 6, 91–102.
Murphy, O., Healy, O., & Leader, G. (2009). Risk factors for challenging behaviors among 157 children with autism spectrum disorder in Ireland. Research in Autism Spectrum Disorders, 3, 474–482.
Nicholas, J. S., Charles, J. M., Carpenter, L. A., King, L. B., Jenner, W., & Spratt, E. G. (2008). Prevalence and characteristics of children with autism-spectrum disorders. Annals of Epidemiology, 18, 130–136.
Parish-Morris, J., Liberman, M. Y., Cieri, C., Herrington, J. D., Yerys, B. E., Bateman, L., et al. (2017). Linguistic camouflage in girls with autism spectrum disorder. Molecular Autism, 8(1), 48. https://doi.org/10.1186/s13229-017-0164-6.
Ratto, A. B., Kenworthy, L., Yerys, B. E., Bascom, J., Wieckowski, A. T., White, S. W., et al. (2017). What about the girls? Sex-based differences in autistic traits and adaptive skills. Journal of Autism and Developmental Disorders, 48, 1698–1711. https://doi.org/10.1007/s10803-017-3413-9.
Rojahn, J., Barnard-Brak, L., Medeiros, K., & Schroeder, S. R. (2016). Stereotyped behaviours as precursors of self-injurious behaviours: a longitudinal study with infants and toddlers at risk for developmental delay. Journal of Intellectual Disability Research, 60, 156–166. https://doi.org/10.1111/jir.12224.
Rubenstein, E., Wiggins, L. D., & Lee, L.-C. (2015). A review of the differences in developmental, psychiatric, and medical endophenotypes between males and females with autism spectrum disorder. Journal of Developmental and Physical Disabilities, 27, 119–139. https://doi.org/10.1007/s10882-014-9397-x.
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. https://doi.org/10.1186/s13229-016-0073-0.
Sasson, N. J., Dichter, G. S., & Bodfish, J. W. (2012). Affective responses by adults with autism are reduced to social images but elevated to images related to circumscribed interests. PLoS One, 7, e42457. https://doi.org/10.1371/journal.pone.0042457.
Schroeder, S. R., Marquis, J. G., Reese, R. M., Richman, D. M., Mayo-Ortega, L., Oyama-Ganiko, R., et al. (2014). Risk factors for self-injury, aggression, and stereotyped behavior among young children at risk for intellectual and developmental disabilities. American Journal on Intellectual and Developmental Disabilities, 119, 351–370. https://doi.org/10.1352/1944-7558-119.4.351.
Solomon, M., Miller, M., Taylor, S. L., Hinshaw, S. P., & Carter, C. S. (2012). Autism symptoms and internalizing psychopathology in girls and boys with autism spectrum disorders. Journal of Autism and Developmental Disorders, 42, 48–59. https://doi.org/10.1007/s10803-011-1215-z.
Supekar, K., & Menon, V. (2015). Sex differences in structural organization of motor systems and their dissociable links with repetitive/restricted behaviors in children with autism. Molecular Autism, 6. https://doi.org/10.1186/s13229-015-0042-z.
Van Wijngaarden-Cremers, P. J. M., van Eeten, E., Groen, W. B., Deurzen, P. A. V., Oosterling, I. J., & Gaag, R. J. V. d. (2014). Gender and age differences in the core triad of impairments in autism spectrum disorders: a systematic review and metaanalysis. Journal of Autism and Developmental Disorders, 44, 627–635. https://doi.org/10.1007/s10803-013-1913-9.
Westeinde, A. V., Cauvet, E., Toro, R., Kuja-Halkola, R., Neufeld, J., Mevel, K., & Bolte, S. (2018). Sex differences in brain structure: an autism twin study on restricted and repetitive behaviors. BioRxIV. https://doi.org/10.1101/334367.
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McFayden, T.C., Antezana, L., Albright, J. et al. Sex Differences in an Autism Spectrum Disorder Diagnosis: Are Restricted Repetitive Behaviors and Interests the Key?. Rev J Autism Dev Disord 7, 119–126 (2020). https://doi.org/10.1007/s40489-019-00183-w
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DOI: https://doi.org/10.1007/s40489-019-00183-w