Girls with high-functioning autism are diagnosed about a half-year later than boys, a large new study finds. But subtle, early signs -- like having trouble picking up on social cues -- may point to an autism diagnosis. If so, a type of therapy called social skills training can help girls make friends and meet their full potential.
On Tuesday, Dr. Paul Lipkin, director of medical informatics at Kennedy Krieger Institute in Baltimore, presented new findings on nearly 10,000 children with autism, using data from the Interactive Autism Network registry. On average, boys were diagnosed with Asperger's syndrome, an autism spectrum disorder, at about 7.1 years old, while girls were diagnosed at 7.6 years.
Digging deeper, the researchers also compared types of symptoms for about 5,100 of these children. Girls were more likely to have problems with social cognition -- the ability to recognize and interpret social cues, says Lipkin, the director of IAN. What other kids learn by experience doesn't come as naturally to them.
Boys were more likely to exhibit obvious mannerisms, such as hand flapping and other repetitive behaviors, and to have narrowly restricted interests. Autism is much more common in boys. In the IAN registry, the ratio of enrolled boys to girls was about 4.5 to 1.
The gender gap only held for higher-functioning children, with a slightly narrower gap for pervasive developmental disorder, a moderate diagnosis on the autism spectrum. However, "in those with frank autistic disorder, there was no difference in age of diagnosis" Lipkin says. "Those children's problems are quite overt and easily recognizable, even to the general public. So when girls are having those severe problems, they probably aren't looking much different than the boys."
Fitting In or Faking It?
The new findings come as no surprise to clinical psychologist Shana Nichols, owner of the Aspire Center for Learning and Development in Melville, New York. Nichols says many girls arrive at the Center between ages 10 and 12. Until then, they've been able to get by with their peers. But even earlier, she says, "parents often say they've noticed their daughters aren't quite as attuned to the social nuances -- although they're good at faking it."
By sharing common activities and nodding and smiling during conversations, girls with autism may look like they're participating well, Nichols says. But in reality, she continues, there's "a more surface-level, almost an intellectual understanding of the social interaction."
Amy Keefer, a clinical psychologist with Kennedy Krieger's Center for Autism and Related Disorders, starts seeing patients around age 8. With autism, she says, "boys' interests tend to stand out more." For example, boys may have a deep fascination with city sewer systems, while girls may be really into the movie "Frozen."
Intense focus on their area of interest is what sets girls with autism apart, Nichols says. Being a girl who "really, really loves horses" is not the same as "being a girl who really loves horses and also knows a million different facts about all the different breeds, and that becomes an exclusive interest."
Keefer says when kids with autism play with others, it's different. "Maybe the girl tells her friends what to do," she says. "It has to fit her rules and be exactly her way."
Rising Social Demands
As preteens, Nichols says, girls with autism "hit that age at which the demands of social relationships exceed their skill sets" and expectations for friendship change. Now, she says, the attitude becomes, "'We're going to have more conversations and begin to talk on the phone.' There are more emotions involved."
Still, many young girls who don't have autism find it hard to breeze through social interactions. "A lot of girls struggle with fitting in and wanting to be with the popular crowd -- it's very difficult for girls in general," Nichols says.
What distinguishes girls with autism is that "their core social understanding and social perspective-taking abilities are impaired," she says. "Whereas girls who are more shy and awkward wouldn't show the same kinds of deficits in social understanding and interactions that our girls on the spectrum show." Standardized tools, like the Social Responsiveness Scale used in the Kennedy Krieger study, are one way clinicians pinpoint social impairment.
Social Skills Training
Social skills training -- with a therapist who acts as a coach to help children learn to understand and respond to social cues -- can help girls navigate the complexities of adolescent language and behavior. Nichols says her center uses a "multisensory, experiential intervention," including presentations, work sheets and team activities, like planning parties.
Girls role play and analyze videos, allowing them to watch, dissect and act out social interactions. "It's really important to have a lot of those interventions happen within the context of a group of peers -- other girls who are experiencing the same difficulties" in a safe environment, Nichols says.
And there's the simple opportunity for girls to hang out together, have fun and make friends, she adds: "When you're a girl on the spectrum, and a lot of other girls haven't been friendly, you often feel pretty lonely."
Keefer says therapists can help girls learn conversational nuances like how to give compliments, because that's such a common way for girls to break the ice. Some therapists may even get involved with helping girls with fashion -- as tricky as that can be -- because it's so important for fitting in. And girls can learn skills that will help them live independently, later in college and as young adults.
Not Just Social Issues
With autism, social deficits are only part of the picture. High sensitivity to noise, lights and tactile sensations -- like the fabric of clothing -- is another core symptom, Nichols notes, along with distress when dealing with change.
In girls who come to her center, prior diagnoses of anxiety disorder and depression, along with issues with attention, can represent "a little bit of a red flag" for autism, she says. Girls may exhibit resistance to change, along with mood instability and fluctuations.
Academic challenges can affect even high-functioning kids. There might be problems with language and motor skills, including fine motor skills used for handwriting, Keefer says. Unfortunately, she adds, when symptoms are subtle, schools may not accept the diagnosis of autism. With better support, she says, children could get needed help for learning difficulties.
If you have concerns as a parent, "Believe in and act on your instincts," Keefer says. "You will never regret having your child evaluated."
Nichols says that while it's wonderful to see the kids make strides in therapy, what happens in the outside world matters most. It could be feedback from parents that kids are showing new insight at home, like saying, "Oh, I'm being one-sided," if they catch themselves talking nonstop about their own interests.
It's really great when friendships blossom. "The play dates, the birthdays, the invites -- when we start to see that, it's amazing," Nichols says. "Not only will the group members start inviting each other, but we hear about classmates who are now inviting them."
Treatment is not about changing who the girls are, Nichols says. "It's about teaching them to be more flexible, more aware of others and more able to regulate and control their emotions. Not to get so upset over small things; but to go with the flow a bit."