ADOS-2 Reliability workshop

Girls on the Autism Spectrum

Feb 6th 2014Regional ASD team:

Cork/KerryMaria Gleeson & Maeve

Feehan

Outline of session

9.30: Overview of girls on the Autism Spectrum

10.15: Video 1: Toddler module and scoring

11:00: BREAK11.15: discussion on scoring11.30: Video 2: module 312.15: Scoring and discussion1.00: Finish

Overview of girls on the Autism Spectrum

• Recent epidemiological studies on ASD report a male to female ratio of approximately : – 4:1 for children with Childhood Autism and 9:1 for

children with Asperger's/PDD-NOS Fombonne E. (2003),(Centers for Disease Control and Prevention [CDC] 2012).

• Sex differences are reported to be more pronounced when autism is not associated with learning disability.

• Among coexisting moderate to severe learning disability, the median male to female ratio is approximately 2:1, while within the normal range of intellectual functioning it is approximately 5–6:1.

Current Knowledge of girls and ASD

• Given this marked sex discrepancy, most ASD research has focused on boys. When girls with ASD are included in studies, sample sizes are often too small to allow for comparisons by sex.

• An understanding of sex differences in the presentation of ASD has important implications for tailoring assessment measures and interventions to the potentially unique presentations and needs of boys and girls.

Why the difference in ratio?

• One interpretation of this is that girls are simply much less prone to autism and that, compared with boys, they require greater disturbances in brain development, as seen by their intellectual disability, for any autism features to be visible.

• Genetic evidence of a possible female protective effect came in 2011, when two studies in Neuron showed that girls with autism are more likely to carry rare, spontaneous copy number variations (CNVs) — DNA deletions and duplications — than are boys with autism.

• What’s more, the CNVs that girls carry tend to be larger, suggesting that they only get autism when exposed to the most powerful genetic hits. Levy D. et al. (2011), Gilman S.R. et al. (2011)

there are hormonal and brain developmental differences

between typically developing children, adolescents, and adults:

These might also occur among girls and boys with developmental

disabilities.i.e. ASD might look differently

in boys than girls.

OR• There may be a distinct, female-

typical presentation of autism that the current diagnostic criteria and diagnostic tests miss, because those criteria were mainly derived from studying the disorder in males. What’s more, the female autism phenotype may be especially difficult to detect in those with average intelligence and above

OR• Some have proposed factors, such as

high levels of foetal testosterone, that might make boys particularly vulnerable.

OR• Others have suggested that girls

may be protected through a genetic mechanism related to their second X chromosome. (Skuse, 2000)

Assessment of girls on the AS

According to unpublished results presented at IMFAR, girls with Asperger syndrome are diagnosed on average at 10 years of age, two years older than the average age of diagnosis for boys.

Nice guidelines (2011) states “autism may be under-diagnosed in girls”

DSM-V

DSM-5 includes a brief subsection on ‘Gender-related diagnostic issues’ that says:“In clinic samples females tend to be more likely to show accompanying intellectual disability, which suggests that girls without accompanying intellectual disability or language delays may go unrecognized, perhaps because of subtler manifestation of social and communication difficulties.”

Questionnaires/clinical interviews to measure autism traits are based on ratings from parents, which are susceptible to cultural biases.

Many instruments used to assess autism and autism-like symptoms were designed and validated largely in groups of boys, who may manifest the symptoms of autism differently than girls do.

Possible issues with current assessments

What are the typical differences between boys

and girls?

Play and drawing• Boys prefer vehicles, building toys, and rough types of

physical play, whereas girls prefer dolls and social play

• differences in the motif, colour choice, figure composition, and use of motion in children’s pictures Girls draw flowers, butterflies, the sun, and human motifs significantly more often than do boys, who more often draw mobile objects such as trains and cars.

• Girls use colour more often and more diffusely; tend to arrange their figures in a row; and draw each figure equally. Boys tend to use blue and gray; draw three-dimensionally; and magnify or emphasize a central figure or theme more often than girls

• Although many studies on play do not control for social experiences that might contribute to gender specific play behaviour, there is evidence to suggest that these differences may be at least partially biological in nature. Play and other gender-specific behaviours are correlated with prenatal hormone exposure.

Problem Solving• Men and women show different patterns of intellectual

abilities even though there are no disparities in IQ or general intellectual functioning on standardized tests of intelligence such as the WISC and the WAIS (Kimura, 1992).

• Males outperform females on tasks that assess visuospatial and mathematical problem solving skills.

• On the other hand, women outperform men on tasks that assess verbal abilities and perceptual speed. Women have superior verbal episodic memory as measured by free recall and recognition of abstract words. Women also excel at facial recognition even when they are not using verbal strategies to facilitate performance, women are better than men at recalling emotional issues. They used magnetic resonance imaging to demonstrate that neural responses to emotional scenes were larger and more active in women than men.

Emotional well being and Mood

• Women experience higher rates of internalizing psychopathology such as anxiety, eating disorders, and mood disorders, while men engage in more externalized behaviour such as aggression.

• Although these differences are likely to be at least partially mediated by social factors such as gender-specific experiences, there is evidence to implicate biological factors as well. Many of these differences emerge after puberty; therefore, much research in this area has focused on the hormonal environment of the brain during the reproductive years as a possible explanation for such differences.

• Pubertal stage (rather than chronological age) seems to be a stronger predictor for mood disorders. Thus, depression, anxiety disorders may result from a biological vulnerability that heightens sensitivity to environmental stressors.

Social skills (in general!)

• Girls: – more emotional sensitivity in helping a

newcomer to join a group– show more sharing of toys– more communication, – use fewer direct commands– less aggression – from teens onward, strive for greater

emotional depth and intimacy than males.

(Geary, 1998, Kimura, 1999)

• Boys: – More concerned re social rank and

competition– Emphasis on doing things rather than

on communication for it’s own sake (Caplan et al, 1997)

Gender differences in Autism Spectrum Disorder: what the

research says

• Girls are more likely to have intellectual disability, particularly in the severe and profound range, than boys (CDC 2007); Lord et al. 1982; Lord and Schopler 1985; Tsai and Beisler 1983; Tsi et al. 1981; Volkmar et al. 1993; Wing 1981).

• In a sample of 22 girls and 68 boys with ASD aged 18–33 months using the Mullen Scales of Early Learning (MSEL; Mullen 1995),Carter et al. (2007) found that boys had better developed language and fine motor skills than girls. In contrast, girls had better developed visual reception abilities than boys.

• However, some studies suggest that young boys and girls with ASD evidence a similar pattern of developmental strengths and weaknesses. Both boys and girls perform better on visual reception and fine motor tasks than gross motor and language tasks (Carter et al. 2007; Joseph et al. 2002; Lincoln et al. 1995).

• Holtmann et. al (2007).

Found no differences in the sample of high-functioning participants with ASD, independent of confounding effects of IQ and age

Found no difference concerning the core triad of ASD

• On the other hand, in several domains of coexisting psychopathy, females exhibited significantly more symptoms than males: – Social– Attention– Thought problems(On CBCl)

Scales reflect difficulties in:

•Peer relations

•Social immaturity

•Social dependency

•Inattentive, Impulsive, Hyperactive, Compulsive, Bizarre behaviour

Play

• games that did not require pretence, girls with an ASD did not show a preference for female-typical items

• girls with an ASD had higher scores on game involving pretence than males with an ASD. Girls with an ASD showed a significant preference for female pretence items as opposed to male pretence items.

(Knickmeyer et al. 2007)

• researchers noted that girls with ASD had more appropriate interests than boys (Kopp and Gillberg 1992; Wolff and McGuire 1995).

• Girls tended to "avoid demands" at a significantly higher level than boys. Girls may be more likely to avoid demands passively, by ignoring them, rather than acting out like boys.

• parents of a girl are more likely to report that their daughter "interacts mostly with younger children" than are parents of boys

Specific “red flags” for a possible ASD in girls/young women

• Social immaturity• Preservative interests- the intensity of them• Different eye contact• Poor handwriting• Poor gross motor co-ordination• Isolation or teasing by peers• Lowering grades• Viewed as “odd” by teachers• Disorganised• Passive and lack of interest in classroom activities• Lack of empathy• Repetitive questioning

Useful reading*in the RASD drop box

• Middletown Centre for Autism: Autism Spectrum Disorder and Girls. Research Bulletin no .4 (2010).

• http://femaleasd.wordpress.com• *Hartley & Sikora. (2009). Sex differences in Autism Spectrum

Disorders: An examination of Developmental Functioning, Autistic Symptoms and Coexisting Behaviour problems in Toddlers. Journal of Autism & Developmental Disorders. Vol. 39(12) pp1715-1722.

• *Werling & Geschwind. (2013). Understanding sex bias in autism spectrum disorder. Proceedings of the National Academy of Sciences. Vol. 110, no 13.

• *Holtmann, Bolte & Poustka. (2007). Autism Spectrum disorders: sex differences in Autistic behaviour domains and coexisting psychopathology. Developmental medicine & Child Neurology, Vol. 49: pp 31-36.

• *Stacy et al. (2013). Sex differences in co-occurring conditions of children with autism spectrum disorders. Autism.

• *Thompson et. al. (2003). Sex matters in Autism and other developmental disabilities. Journal of Learning Disabilities. Vol. 7(4).

• *Lai et al. (2011). A Behavioural Comparison of Male and Female Adults with High Functioning Autism Spectrum Conditions. PLoS, Vol. 6(6).

• *Lai et al. (2013). Biological sex affects the neurology of Autism. Brain: a journal of Neurology. Vol. 136.

• *Ingudomnukul et. al. (2006). Elevated rates of testosterone-related spectrum conditions disorders in women with autism. Hormones and Behaviour.

• Fombanne. (2003). Epidemiological Surveys of Autism and Other Pervasive Developmental Disorders: An Update. Journal of Autism and Developmental Disorders, Vol. 33 (4).

• Carter et al. (2007). Sex differences in toddlers with Autism Spectrum Disorders. Journal of Autism and Developmental Disorders, Vol 37.

• *Begeer et al. (2012). Sex differences in the timing of Identification among children and adults with Autism Spectrum Disorders. Journal of Autism and Developmental Disorders.

• *Knickmeyer et al. (2007). Sex-typical Play: Masculinization/Defeminization in Girls with an Autism Spectrum Condition. Journal of Autism and Developmental Disorders.