Social Camouflaging in the Presentation of Suspected Autism Spectrum Disorder in Toddler Girls

Background: Autism spectrum disorder (ASD) is more frequently diagnosed in males than in females, with ratios varying from 2:1 to 12:1 (e.g., Frazier & Harden, 2016; Whiteley et al., 2010). This imbalance could stem, in part, from a heightened tendency for girls with ASD to engage in “social camouflaging,” or compensatory behaviors that mask their symptoms relative to their male counterparts (Kreiser & White, 2013), including staying close to peers, jointly engaging with peers, and weaving in and out of peer groups (Dean, Harwood, & Kasari, 2017). Girls with ASD may also engage more than their male peers in social initiation behaviors that conceal complex difficulties forming and maintaining relationships, such as making eye contact, appropriately production of facial expressions, initiating social interactions, and making requests (Harrop et al., 2015; Oien et al., 2016; Spies et al., 2011). Limited research, however, has compared these discrete social communication behaviors between boys and girls using validated ASD assessment measures.

Objectives: The current study investigated sex differences in social communication behaviors assessed by the ADOS-2 Toddler Module. We hypothesized that toddler girls referred for an ASD evaluation would exhibit better and more frequent social initiation behaviors (eye contact, facial expression, social overtures, and requesting) than would their male counterparts.

Methods: We tested hypotheses using data from a diverse sample of toddlers (n=214; 26% female, Mean age=25 months, 47% White) referred for an ASD evaluation at an outpatient autism center where research-reliable clinicians administered the ADOS-2 Toddler Module (Lord et al., 2012).

Results: As predicted, girls initiated significantly more social overtures with parents than did boys in both univariate (t = -2.66; p < .01) and multivariate analyses (F = 7.09, p < .01). However, no significant sex differences were evident for eye contact, facial expressions, or requesting.

Conclusions: Findings suggest that among the ADOS-2 Toddler Module social communication items, it may primarily be those measuring the tendency to extend social overtures that differentiate girls referred for an ASD evaluation from boys. Other behaviors that prior research has shown to differ between girls and boys with ASD (eye contact, facial expressions, requesting) did not show sex differences in the present study. Girls with ASD often engage in “social camouflaging” behaviors, which may reflect gendered socialization patterns (Dean et al., 2017). For instance, girls with ASD more often situate themselves near peer groups and report wanting to be socially involved with others than do boys (Attwood, 2006). However, once girls initiate social interactions, they may have difficulties sustaining them, much like their male peers (Cridland et al., 2014). These findings raise the possibility that the social overture item may not be an optimal indicator of ASD in toddler girls. Thus, identifying specific items, such as social overtures toward parents/caregivers, where girls and boys differ, may suggest areas of sex-specific strengths or weaknesses that could facilitate early diagnosis.