Autism in Adolescent Girls – A hidden pattern as observed by a psychologist.
Very early on in my private practice journey, I noticed a pattern emerging of a specific type of referral we would receive from GPs. It would be a request for psychological support for a twelve- or thirteen-year-old girl citing issues with social anxiety and school avoidance, which had escalated following the return to school post COVID lockdown. They would read something like this…
“Referred for you input, regarding difficulties with friends, anxiety and school avoidance, emerging following COVID lockdown.”
On assessment with the parent(s), a couple of other things would often be noted:
Parents describe her personality as “quirky,” stands out from her peers.
Loved lockdown, “thrived.”
Long history of school avoidance, preference to not go, starting from primary school.
Previous input from other providers, lots of previous psychologists, generally working on anxiety issues.
And inevitably after a few months of work together with the young person and their family, I’d start to suspect an undiagnosed Autism Spectrum Disorder (ASD). For those who don’t know, ASD is a neuro-developmental disorder, characterised by difficulties with social-emotional communication and often marked by restricted interests and behaviours. The most widely known depiction of ASD is Sheldon in Big Bang Theory. But I’d say Beth from The Queens Gambit is a great depiction too.
When I’d raise my suspicion with the families, they’d generally say, “yes we suspected that when she was little, but everyone dismissed us – told us that she’s just anxious.”
In our training at university, we are taught that ASD is grossly under-identified in females; the diagnostic ratio is something like 4:1 males/females. And I was starting to see the pattern play out in front of me. And even more interestingly, despite being cautioned against overlooking ASD in females, we still seemed to be delayed in our identification.
I started to think about this a lot - why are we missing this? Why are we dismissing the instinct of parents?
I think the answer is masking. Early socialisation for little girls, has such a focus on relationships and communication, that it gives them just enough skills to just get by. One example of this is that traditional female-based play focuses on social exchanges – Playing dolls, shops etc., These social scripts are practiced and then reinforced, giving girls enough ways to just “follow along.” But this starts falls apart with the transition to high school, because the social and communication demands start to move off script and the “mask” unravels. This means that the presentation of ASD in girls is so subtle and nuanced, that unless you know specifically what you’re looking for, you might not see it.
So, I thought I’d put together a list the subtle observations I’ve made of young girls in this population. This list is intended for both care-providers and parents. Please remember this is not a diagnostic list and should be read with flexibility. These are personal observations from my work, which should be understood as different to validated scientific facts.
The presenting anxiety is very generalised, somatically focused and is about discomfort avoidance. Generally, there is very limited cognitive elements to the fears, more a “sense” that something will go wrong, which will lead to discomfort (as opposed to fear).
Significant rigidity in thinking to the point where they really struggle with basic cognitive challenging. For example, will argue with you about “but and what ifs...” of anxious thinking beyond what you would normally see in pure anxiety.
Gravitating towards younger friends i.e., peers still in primary school. I suspect this is due to play and socialising remaining activity based, rather than the more complex conceptual socialising of adolescent girls.
Strong interest in visual arts, including specifically cartoons & anime. I discussed this with a colleague of mine several years ago; she wondered whether the exaggerated nature of anime (in terms of characterisation, physical attributes, very dramatic expressed emotion) all helped to increase understanding of social-emotional communication between characters and thus is easier to follow.
Disregard for social trends, not as interested in mainstream adolescent culture, does not care to be alienated from social media i.e., if phone is taken away for misbehaviour.
Difficulties with subjects/activities/things at school that don’t have a specific or tangible real-world purpose i.e., Why do I have to learn about this book that has make-believe characters in it? Why do I have to a personal reflection that isn’t marked?
Significant difficultly with navigating peer conflict i.e., anxiety when friends are fighting/disagreeing. I think this is due to difficulty with the “grey area” and struggles to understand that in conflict there isn’t necessarily a right person vs. a wrong person.
Preference for home and wanting to maintain a strong alliance with parents. Although lovely in some respect, this is contrary to normal adolescent development whereby there is an increased desire to spend as much time with friends as possible.
Until next time,
Courtney
