Initial Observations of Girls’ Social Presentation in a Clinical Setting

Background:

Autism spectrum disorder (ASD) is estimated to be almost 5 times more common in boys than girls (Baio, 2014).What we know about profiles of ASD in girls lags behind what is known about boys, but research has shown inconsistencies in profiles of girls and boys. Greater cognitive impairment in girls (Frazier et al, 2014) and later age of diagnosis has been found, which can delay the start of intervention (Kavanagh et al., 2013; Rynkiewicz et al., 2012), while others have shown comparable developmental profiles between girls and boys (Zwaigenbaum et al., 2012). Clinicians in our diagnostic clinic often report different social presentations in girls that make diagnosis and case conceptualization difficult. In particular, clinicians note that many girls seem to initially present with strengths in eye contact, directed affect and play skills though weaknesses in these areas become more apparent over the course of the evaluation. 

Objectives:

The purpose of this study is to analyze initial behavioral observations of girls who went on to receive ASD diagnoses in a clinical setting.

Methods:

A detailed record review was conducted of diagnostic evaluations for children ages 0-48 months between 1/1/2016 and 10/12/2016 in an autism center serving a diverse population. Children who were clinically referred received an initial diagnostic interview (DI) with a psychologist, neurologist or nurse practitioner. Those who were determined to have red flags for autism were referred on to receive diagnostic evaluations. Assessments each included a developmental/cognitive measure, adaptive measure and the ADOS-2.

Results:

84 girls (24% of total referrals) ages16-47 months were referred for a diagnostic assessment for ASD. Each patient received a diagnostic interview, after which autism was ruled out for 28% of the girls (compared to 15% for boys). The remaining 61 girls returned to assess for ASD, and of these 47 (78%) received an ASD diagnosis (compared to 88% for boys). Record review for those 47 girls, from initial behavioral observations during the diagnostic interview, revealed the following: 14 (30%) girls were noted to have “good” or “excellent” eye contact and an additional 14 (30%) were noted to have “inconsistent eye contact” or “moments of good eye contact.” In addition, thirteen (28%) girls were noted to have appropriate directed/shared affect and 7 (15%) girls were noted to engage in appropriate pretend play.

Conclusions:

These findings highlight the importance of comprehensive evaluations to assess for ASD in girls, especially given that initial clinical impressions noted strengths in key symptom areas (e.g., eye contact and directed facial expressions) in 30% of girls who went on to meet full behavioral criteria for ASD. Furthermore, these findings point to potential reasons for low referral rates of girls to autism specialty clinics; many providers may not recognize social vulnerabilities when initial impressions are that of good eye contact and directed affect. This underscores the importance of continued focus on symptom profiles of girls with ASD and translation of these findings to current clinical practices in screening and diagnosis of ASD in girls.