Transcript Understanding the presentation of females with

Understanding the presentation of
females with autism
Alexandra Sturrock
What is ASD?
Autism Spectrum Disorder: a neuro-developmental
disorder typified by difficulties with:
Social and
emotional
understanding
Flexibility in
thinking and
behaviour
Social
communication
(language)
Diagnosis achieved by identifying cluster of symptoms –
professional opinion is critical in accurate identification
What is the male:female ratio?
Female/Male prevalence ratings:
• 1:4 diagnosed (Frombonne et al, 2009)
• 2:1-7:1 depending on sample
More females (IQ < 70)
less females (IQ > 70)
(Nicholas et al, 2008)
Why?
Why the difference?
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•
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Female protective effect?
Extreme male brain?
X-linked genetic involvement?
Current definition of ASD based on male
presentation of symptoms?
- public/clinicians not recognising ASD in females
Social bias arguement
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Original cases described: male dominant
Kanner: 3:11
•
Asperger: all male cases
Current diagnostic tools based on research in male
(Goldman, 2013)
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Public and clinician opinion based on historic models
Same male bias in other disorders (ADHD, dyslexia etc)
(Gardener et al, 2012)
What evidence is there?
Females are being missed (Dworzynski et al, 2011; Giarelli et
al, 2010; Kopp and Gillberg, 1992)
Females are more likely to be diagnosed
with another disorder (Giarelli et al, 2010); Kopp & Gillberg,
1992; Hiller et al, 2015)
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Language disorder, ADHD, anxiety, GDD
Mental health diagnosis
Later age of diagnosis (Wiggins et al, 2003, Shattuck et al, 2009, GoinKochel et al, 2014)
How could sex influence ASD diagnosis?
Sex could affect ASD outcomes at different levels
(Postova and Young, 2012)
Males and
females have
underlying
difficulties at
biological
level.
females>males
symptoms
muted or
unexpressed
Social
environment
Male> female
express
recognised
ASD
symptoms
Diagnostic
process
Females: more verbal interactions, conversations, play
engagement, eye gaze, reaction to emotion, attribution of
emotion
Females>males
undiagnosed or
receive other
diagnosis
Males>females
Asd diagnosed
Current interest
Self reports
“So I cultivated an image, which I brought out to social
situations”
“I automatically mimic what other people are doing, what they
are saying and how people say things”
“it’s very draining trying to figure out everything all the
time, everything is more like a manual, you’ve got to use one
of those computers where you have to type in every command”
(Bargiela et al 2016)
What do we know so far?
Sparcity of evidence
But growing!
Early limitations of studies
•Few & small scale studies
•Studies have mixed IQ & ages
•No comparison to typical development
•Assessments are often limited to diagnostic tools,
which might have male bias
•No specific language or communication assessments
What do we know so far?
Different Social Skills
(Kopp and Gillberg, 2011; Lai et al, 2011; Horovitz et al, 2011; Holtmann et al, 2007)
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•
More motivated to make friends and be sociable (Sedgewick et al, 2016)
More likely to have a best friend (Dean, 2014)
• May have an older friend who will ‘mother’ her (Tierney, 2016)
• May have a younger or male friend (reduced social
expectations) (Tierney 2016)
•
Less friends overall (Dean 2014) and may become over reliant on
one friend
What do we know so far?
Different Social Skills
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•
More emotionally responsive to
friends than males with asd,
but less than females without
asd (Head et al, 2014)
Conversation more central to
friendship bonding than males
(Sedgewick et al, 2016)
What do we know so far?
Different Social Skills
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Friendships in childhood facilitated by others (Tierney 2016)
Difficulties with maintaining friends:
• Needing to take control of activities (Hiller et al, 2014)
• Difficulties interpreting others behaviour (Tierney, 2016)
• Less able to recognise aggressive social behaviour in
friendship groups (Sedgewick et al, 2016)
Social relationships become more difficult after adolescence:
• Development of sexual identity
• Changes in social groups following move to secondary school
• Different social expectations (Tierney et al, 2016)
•Getting it right is challenging – desire not to stand out
•Likely to mask and imitate
•Feelings of exhaustion.
•Meltdowns at home; covering up in school
What do we know so far?
Different play:
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May do more pretend play (Knickmeyer et al, 2008)
Prefer ‘female’-type play different social environments (Dean et al, 2014)
More likely to choose ‘female’ toys (Harrop et al, 2016; Hiller et al, 2014)
Boys and girls with autism will spend less time in play and symbolic
play (Harrop et al, 2016)
What do we know so far?
Different play:
•
May show less repetitive behaviours (Mandy et al, 2012; Park et al, 2012;
Szatmari et al, 2012)
•
May have less restrictive interests but similar levels of
routines, stereotyped movements and preoccupations (Hiller et al,
2014)
What do we know so far?
Different behaviour: Internalising not
externalising (Mandy et al, 2012; Amr et al, 2011; Cohen et al, 2010;
Giarelli et al, 2010; Hiller et al, 2015)
Why Study differences in Language?
•Core feature in autism (ICD-10: WHO, 1993; Lord and Jones, 2012)
•Differences exist between typically developing females &
males
•Enduring theory explaining difference between females &
male presentation of autism (Wing, 1981)
• Differences in language centres of brain (Menon et al, 2015)
Never been adequately tested
What do we know so far?
Differences in Language & Communication
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More motivated to communicate (Horovitz et al, 2011)
More likely to mimic voices (Kopp & Gillberg, 2011)
Better non-verbal communication (Holtmann et al, 2007) but not
interpret them (Hiller et al, 2014)
Better able to maintain a reciprocal conversation (minimally)
(Hiller et al, 2014)
•
Better narrative memory – linked to better verbal fluency
(Goddard and Howlin, 2014)
What do we know so far?
Differences in Communicative experiences
• More integral to friendships (Sedgewick et al, 2016)
• Different profile across time (McLennan et al, 1993)
• Impact on social outcomes (Lai et al, 2011)
• Perceived difficulties (Holtmann et al, 2007; Lai et al, 2011)
10
20
8
15
5
6
actual difficulties
males
10Degree of
males
4difficulty
percieved difficulties
females
females
5
0
2
age 4-5
age 10+
0
language
males
delay in childhood females
outcome in adulthood
Summary
Less repetitive
behaviours
Coping strategies
including masking
and mimicking
More pretend
play
Female
with
autism
Different types of
preoccupations
Better ability to
make but not
maintain friends
Better verbal skills
in early years
More socially
motivated
Better non-verbal
skills
Social interactions
in childhood
supported by others
More likely to
internalise
difficulties
Still struggle in
comparison to typically
developing girls!
Increased social
difficulties in
adolescence and
adult-hood
Study
Who has supported this study?
Questions?