Autism in girls is often missed, with schools often not recognising that there are any issues, or attributing issues to the child being shy, anxious or awkward. Of those diagnosed with autism, females only make up around 20%.

Autism presentation in females is often less obvious due to a range of different factors and as many autistic girls wish to ‘blend in’, they are often keen to follow rules and do not present with behaviours that draw attention to them.

This, however, does not mean that they are not struggling in day-to-day life, especially life outside the home.

In this article, Jo Condon, our Director and Clinical lead, outlines the issues impacting autistic girls, the signs of autism and the benefits of a private autism assessment for girls. Jo has extensive knowledge and experience in the diagnosis of autism in females.

Why is Autism in Girls Often Missed?

Whilst some girls are diagnosed in early childhood, the more nuanced presentation in females means that those who are eventually identified are often not diagnosed until later childhood, adolescence or even adulthood.

Often females do not present with the obvious behaviours that have been traditionally associated with an autism presentation in males and are therefore not recognised by schools or frontline health professionals.

There are also many misconceptions about autism, such as “children with autism don’t give eye contact” or “people with autism don’t have empathy”, which also cause issues with girls being identified.

Parents often notice differences across different areas but do not realise that the pattern of behaviours they observe are associated with autism.

Autistic girls are more inclined to try to hide their differences and engage in behaviours that ‘mask’ or ‘camouflage’ their autistic traits.

Masking and Camouflaging

From an early age, autistic females learn to navigate social situations by hiding their differences or difficulties.

It is theorised that this could be because females generally tend to be more socially aware and motivated, with autistic females being more aware of their differences as well as being more motivated to conform socially. Masking and camouflaging could also be influenced by societal expectations of females.

Girls mask their difficulties in various ways, including avoiding interaction, copying others or taking control of the social situation.

Some autistic girls manage their difficulties with social interaction by avoiding interacting with others. This makes them appear ‘shy’ to those around them. When with parents, they may look toward them to respond on their behalf, in school they may rely on a close friend to interact for them. When not with someone who can support in this way, they may struggle to cope and girls who rely on friends in school may be reluctant to attend if their friend is not in school.

Another strategy used by autistic girls is to copy other’s behaviours. Girls often learn ‘accepted’ social behaviours from studying siblings, friends or characters on television. They may copy language, facial expression and gesture and / or the hobbies and interests of those around them.

Girls who use these passive behaviours tend to take a back seat in interactions, and prefer to be directed by others. They may follow along with others in play, which can hide the difficulties that they are experiencing.

Some autistic girls camouflage their differences by taking control of interactions, ensuring that the social situation is always predictable for them by creating rules and boundaries for others. Girls who try to control interactions can appear to be a little ‘bossy’ or overconfident when actually they are trying to manage their anxiety around unpredictable interactions. Girls who actively try to manage their difficulties tend to try and lead play, setting roles and rules for others. They will often take control of conversations, talking to others about their interests and leaving less opportunity for others to make comments or ask questions.

Masking and camouflaging get more difficult with age. As children grow, time spent with familiar adults in social situations decreases leading to more independent interactions. As children grow into adolescents, the social situations they are involved in become more complex and stressful. This, along with changes in friendship groups and the more chaotic environment, means that autistic girls’ difficulties often become more obvious in the first few years of secondary school. By this age, girls have usually learned a range of behaviours that help them to ‘fit in’ socially, but using their cognitive abilities to manage social interactions comes at the price of being completely exhausted after interaction

Misconceptions About Autism Which Impact the Identification of Autism in Girls

There are many misconceptions about how autism presents, and these misconceptions particularly impact the recognition of autism in girls.

Eye Contact

One misunderstood aspect of autism is eye contact, with many people incorrectly believing that autistic people do not give eye contact. Whilst many autistic people indeed find eye contact uncomfortable, this does not mean that all autistic people avoid eye contact. When assessing eye contact as part of the assessment of autism, clinicians look at how eye contact is used to regulate interaction. Many girls have learned how neurotypical people find eye contact in interaction important and use eye contact even when it is uncomfortable.

Empathy

Another misconception is that autistic people do not experience or demonstrate empathy. Whilst many autistic people identify with feeling decreased empathy towards others, many autistic people identify with being hyper-empathetic, often feeling other’s emotions so strongly that it causes them personal distress. Some autistic people find that they can empathise with those close to them or those with similar experiences to them but empathise less with people they are not so familiar with. It is not uncommon for autistic girls to feel a strong empathy for animals.

Pretend Play, Creativity and Imagination

It is often believed that autistic children cannot pretend and that autistic people do not have a creative imagination.

Some autistic children do not engage in pretend play, but girls often do have some engagement in pretend play, although this is often less flexible than their peers. They may mask their differences in play by setting rules for others to keep the play familiar to them or they may allow others to control the play and follow along with other’s instructions.  Some autistic children live in a pretend world and have difficulty separating their pretend activities from real life.

Autistic adolescents are often very creative, enjoying creative pursuits such as art, writing or music as hobbies.

Signs of Autism in Girls

All autistic children and young people have differences in social communication and interaction as well as restricted and repetitive behaviours, possibly including sensory differences.

Below are some of the characteristics of autism seen in girls of different age ranges. Children presenting with these patterns of differences should be screened for autism and referred for an assessment if necessary.

Signs of Autism in Girls in the Early Years

• Differences in language development, delayed language or language that appears advanced for their age
• Repeating words and language, not using language socially
• Often playing in the same way, repeating actions or only playing a few familiar games
• Being controlling in play, directing parents’ behaviours or preferring they just watch
• Appearing more interested in ordering or setting out toys and objects rather than playing with them
• Lack of, or reduced range of, pretend play activities
• Dislike of, or distress around unfamiliar people or certain familiar people
• Not showing an interest in joining in shared activities, such as action songs
• Struggling in busy places or unfamiliar places
• Not making direct requests for help
• Reduced gestures to compensate for language, for example, not initiating pointing, waving, clapping or head nodding
• Moving body repetitively, for example, spinning self around, jumping and bouncing or making unusual movements with hands or fingers
• Distress in response to certain noises such as hairdryers, hand dryers, sirens or motorbikes
• Eating difficulties, eating a limited range of food, reluctance to try new things or not liking food touching on the plate
• Sensory-seeking behaviours, wanting to touch, smell or mouth objects in the environment

Signs of autism in Girls as Children

• Repeating phrases that have been heard on television or are used by others
• Using stock phrases to respond to questions, such as always saying, “I’m fine, thank you” or “It was good”
• Only talking about own interests or experiences rather than sharing the experiences of others or asking about others
• Avoiding interaction with less familiar or unfamiliar people, hiding away or looking to others to respond for them
• Not having an equal role in play with others, taking control or taking a passive role in interaction
• Reduced interest in friendships, such as only wanting a single friend, a lack of interest in seeing friends outside of school or frequent breakdowns of friendships
• Preferring to spend time alone rather than with others
• Becoming very focused on interests or hobbies, wanting to pursue hobbies intensely and/or liking to know facts and details about particular topics
• Enjoying collecting, organising and ordering toys or objects
• Needing reassurance about daily and weekly activities, struggling when things are not planned in advance or when things change
• Moving body repetitively, for example, spinning self around, jumping and bouncing or making unusual movements with hands or fingers
• Sensory differences such as finding certain noises unpleasant, having issues with certain textures, being a fussy eater

Signs of Autism in Adolescent Females

• Difficulties understanding, making and/or maintaining friendships
• Struggling in unfamiliar social situations, feeling anxious about meeting new people
• Feeling anxious about or avoiding social activities involving groups of friends or family
• Finding some of the non-academic aspects of school difficult or experiencing school-based anxiety
• Exhaustion after school
• Difficult to engage in social conversation or chit chat, or can only engage in conversation around certain topics
• Thinks in a ‘black and white’ way, can sometimes appear blunt unintentionally
• Prefers to spend time alone
• Reluctance to try new things, join new clubs or try new activities
• Likes rules, struggles when others do not follow the rules
• Much of their spare time is spent engaging in the same particular interest or activity
• Enjoying collecting, organising and ordering items
• Struggling when things don’t go to plan, such as when people are late, somebody changes the plans or appointments don’t run on time
• Needing reassurance about daily and weekly activities, struggling when things are not planned in advance or when things change
• Needing a daily routine to manage, feeling ‘out of sorts’ if their morning or evening routine (or specific part of the routine) cannot be followed
• Feeling irritated by noises made by other people such as chewing, sniffing, coughing or tapping
• Hearing noises or smelling things, that others do not, or being bothered by noises and smells that others are not affected by
• Repetitive movements of hands or fingers, often seen fidgeting with objects, picking skin or cracking joints

Benefits of a Private Autism Assessment for Girls

Undiagnosed autistic girls can experience low self-esteem as a result of feeling that they do not quite fit in, feeling exhausted by social interaction and being misunderstood by others.

Receiving an autism diagnosis is very empowering, and helps girls begin to be able to understand themselves and begin to reduce their masking behaviours.

An autism diagnosis also helps others to understand differences. If school are not recognising a girl’s differences the autism diagnostic report can help them to understand their autism and how it impacts them.

Educational establishments have a legal duty to make reasonable adjustments for those with an autism diagnosis. Schools must ensure that a child is not disadvantaged because of their autism.

With 212,964 people waiting for an NHS autism assessment in England and over 10,000 children alone waiting more than a year for an autism assessment in Wales, children are facing years on a waiting list for an NHS autism assessment. By choosing a private autism assessment, the waiting times are reduced to as little as two weeks.

Private autism assessment services offer a more personalised approach to your child’s assessment. You will be able to speak to an expert ahead of arranging an assessment to make sure an assessment is the right thing for your child.

From start to finish, your assessment will be coordinated with you, and the team will take your preferences into account. You will feel listened to and will be able to get your queries answered in a timely way.

Many people have concerns before the assessment, for example, about how the process works or what happens if a child does not engage. You can discuss concerns with the team before your assessment sessions and your assessment will be planned in line with your specific circumstances.

An autism assessment not only provides a diagnostic outcome but also provides you with sources of information and support and provides recommendations for addressing your child’s specific needs.