The Gender Gap in Asperger Syndrome: Where are the Girls?

The Gender Gap in Asperger Syndrome: Where are the Girls?

Lee A. Wilkinson

A Case Study Published in

TEACHING Exceptional Children Plus

Volume 4, Issue 4, March 2008

Copyright ? 2008 by the author. This work is licensed to the public under the Creative Commons Attribution License

The Gender Gap in Asperger Syndrome: Where are the Girls?

Lee A. Wilkinson

Abstract Although there has been a dramatic increase in the recognition of autism spectrum disorders over the past decade, a significant gender gap has emerged in the diagnosis of milder forms, such as high functioning autism and Asperger syndrome. Statistics indicate that while boys are being referred and identified in greater numbers, this is not the case for girls. Girls are also diagnosed at later ages compared to boys. In this article, the author discusses possible explanations for the underidentification of girls with high functioning autism and Asperger syndrome. A case vignette is used to illustrate the gender differences relevant to the understanding and timely diagnosis of girls with this autism spectrum condition.

Keywords Asperger syndrome, autism spectrum, diagnosis, gender differences, social skills

SUGGESTED CITATION: Wilkinson, L. A. (2008). The gender gap in Asperger Syndrome: Where are the girls?. TEACHING Exceptional Children Plus, 4(4) Article 3. Retrieved [date] from

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Asperger syndrome is an autism spec-

Why are fewer girls being identified?

trum disorder characterized by problems in Why do parents of girls experience a delay in

social relatedness, empathic communication receiving a diagnosis? Are there gender dif-

and understanding, and circumscribed inter- ferences in the expression of the disorder?

ests in the presence of generally age- Answers to these questions have practical im-

appropriate language acquisition and cogni- plications in that gender specific variations

tive functioning (Volkmar & Klin, 2000). may have a significant impact on identifica-

Students with Asperger syndrome often expe- tion practices and the provision of educational

rience problems related to their social deficits services for children with autism spectrum

and are at risk for academic underachieve- disorders (Thompson, Caruso, & Ellerbeck,

ment, school drop-out, peer rejection and in- 2003). Although few studies have examined

ternalizing problems such as anxiety and de- gender differences in the expression of

pression (Safran, 2002; Wilkinson, 2005). Al- autism, we do have several tentative explana-

though there has been a dramatic increase in tions for the underidentification and late di-

the number of children diagnosed with autism agnosis of girls with Asperger syndrome. This

spectrum disorders over the past

article discusses these possibili-

decade, a significant gender gap has emerged in the identification of milder forms, such as high functioning autism and Asperger syndrome. Statistics indicate that while boys are being referred and identified in greater numbers, this is not the

When I think of my earliest years, I recall an overwhelming desire to be away from my peers. I much preferred the company of my imaginary friends-

ties and provides a case vignette to illustrate the gender differences relevant to the understanding and timely diagnosis of girls with Asperger syndrome.

Gender Roles

case for girls (Attwood, 2006; Ehlers & Gillberg, 1993; Wagner, 2006). For example,

-Liane Holliday Willey (1999)

Gender role socialization is critical to understanding why girls with Asperger syn-

referrals for evaluation of boys

drome are being underidenti-

are ten times higher than for girls

fied (Faherty, 2006). Since fe-

(Attwood, 2006). Girls are also diagnosed males are socialized differently, autism spec-

with autism spectrum disorders at later ages trum disorders may not manifest in the same

relative to boys (Goin-Kochel, Mackintosh, & way as typical male behavioral patterns

Meyers, 2006). This gender gap raises serious (Bashe & Kirby, 2005). For example, girls

questions because many female students with might not come to the attention of parents and

Asperger syndrome are being overlooked and teachers because of better coping mechanisms

may not receive the appropriate educational and the ability to "disappear" in large groups

supports and services. The consequences of a (Attwood, 2007). Girls on the higher end of

missed or late diagnosis include social isola- the spectrum also have fewer special interests,

tion, peer rejection, lowered grades, and a better superficial social skills, better language

greater risk for mental health and behavioral and communication skills, and less hyperac-

distress such as anxiety and depression during tivity and aggression than boys (Gillberg &

adolescence and adulthood.

Coleman, 2000). Likewise, girls are more

likely than boys to be guided and protected by

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same gender peers and to have special interests that appear to be more gender appropriate (Attwood, 2006). These characteristics lessen the probability of a girl being identified as having the core symptom of autism spectrum disorder: an impairment in social skills. In fact, it may be a qualitative difference in social connectedness and reciprocity that differentiates the genders (Attwood, 2007; Kopp & Gillberg, 1992). As a result, parents, teachers, and clinicians may not observe the obvious characteristics associated with the male prototype of higher functioning autism spectrum conditions such as Asperger syndrome (Kopp & Gillberg, 1992; Nyden, Hjelmquist, &

Gillberg, 2000). Although each case is unique, the fol-

lowing vignette provides an example of how gender specific differences contribute to the diagnostic gender gap in Asperger syndrome. The case of Heather is based on the author's own clinical experience with students with autism spectrum disorders. Identifying information has been removed or altered to ensure confidentiality. Bulleted comments have been inserted throughout the case presentation to illustrate links between constructs, diagnostic criteria, and differences in phenotypic expression between boys and girls.

Table 1: Weblinks for Additional Information

Autism Research Centre ()

Autism Society of America ()

National Autistic Society ()

Online Asperger Syndrome Information and Support (OASIS) ()

Organization for Autism Research (OAR) ()

The Council for Exceptional Children (CEC) (cec.)

Treatment and Education of Autistic and Related Communication Handicapped Children (TEACCH) ()

Yale Child Study Center ()

Case Example: Heather Heather is currently a fourth grade student who was diagnosed with Asperger syndrome and found eligible for special edu-

cation and related services. Developmental history indicates that Heather spoke her first words by 12-18 months and used sentences and communicative phrases by approximately

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24 months. She sat unsupported at six usually stayed on the periphery of the group.

months, crawled at nine months, and walked She was also described as a shy, undemand-

by 14 months. Although no obvious social ing, and even-tempered student who was un-

problems were reported, Heather's parents assuming and soft spoken. While Heather ap-

recalled their daughter's temperament as be- peared to enjoy a special friendship with an-

ing inhibited and "slow to warm up." She other girl at school, she preferred solitary ac-

was also a "fussy" eater and had difficulty tivities such as creating small, imaginary

transitioning to different food textures. De- worlds with blocks and figures and playing

spite some parental apprehension regarding games involving puppies or kittens for ex-

early development, they were advised by their tended periods of time. Her teacher voiced

pediatrician that Heather's social and com- some concern over Heather's reluctance to

municative functioning did not seem typical engage in reciprocal conversation and diffi-

of a specific developmental disorder or delay culty maintaining focus in the classroom. At

and did not warrant an evaluation.

home, Heather was viewed as a "sweet" and

amicable child who was compliant and well-

? Although social and communication

liked by friends and relatives. Yet, Heather's

symptoms are the most reliable indica- parents were also troubled about their daugh-

tors of autism spectrum disorders in

ter's periods of aloofness, inattentiveness, and

young children, they are very difficult lack of initiative and social responsiveness.

to identify. For example,

we have no precise

?Social communication and

definitions of mile-

The most salient

pragmatic deficits may not be

stones for social skills feature appeared to be readily discernible because of

development compared to motor and language skills (Stone, 2006). There are also some pediatricians who prefer to take a

a significant qualitative impairment

in reciprocal social behavior and responsiveness.

a non-externalizing behavioral profile, passivity, and lack of initiative. Girls who have difficulty making sustained eye contact and appear socially withdrawn may also

"wait-and-watch" ap-

be perceived as "shy," "na-

proach, hoping children will catch up.

ive," or "sweet" rather than hav-

Unfortunately, this can delay early

ing the social impairment associ-

identification and intervention.

ated with an autism spectrum dis-

order (Wagner, 2006).

Heather was enrolled in a preschool

program three days per week where she was

Heather was evaluated by the school

observed to marginally participate in most and found to have age-appropriate skills. The

activities and was considered a happy and school psychologist concluded that Heather

placid child. Following an unremarkable pre- was a shy, immature, and fearful student

school experience, Heather attended a com- whose ability to perform academically was

bined kindergarten-first grade class in an most likely affected by an early-onset anxiety

early childhood center. In class, she was ob- disorder, word retrieval problems, and/or a

served to be a quiet and reserved student who

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