This is a recent FAQ on self-deprecation in neurodiverse females. As always, If you like it please share and leave your positive comments or other questions below. This video was made by the Neurodiversity Academy, founded by and funded by AspienGirl girl.com
The AspienGirl Project is pleased to announce that the sequel to ‘I am Aspiengirl’ entitled ‘I Am AspienWoman’ recently won a 2016 IPPY eLit Gold Medal Award in the “Women’s Category” in April. I am AspienWoman is the culmination of a blog Tania wrote a couple of years ago entitled ‘Moving Towards a female profile of Asperger Syndrome’, with close to 300,000 views, to date. That blog is regularly updated. You may purchase copies at http://www.aspiengirl.com, Amazon or other fine books stores.
Tania spends her professional time in private practice. She provides diagnostic assessment impressions reports regularly (across the lifespan), and provides interventions and support. For more information regarding diagnosis and assessment, bookstore wholesale discounts, book contracts, interviews, translations, workshops and conferences, please email email@example.com
On the Bright end of the Autism Spectrum and the female Autism Crisis: How and Why Do Bright Autistic Females fly under Professional Radar?
Female Autism is a new and complex area of research with information in this area of Autism growing exponentially. Both empirical studies and qualitative differences are starting to show show that females ‘meet the diagnostic criteria’ in different ways from males. This then leads to females being misdiagnosed, mistreated and/or medicated. In 2015 alone, there have been over 15 gender studies published regarding the differences between males and females. While research is starting to catch up with clinical and anecdotal research, the time it will take for this to trickle down to professionals and those at the ground level may take many years, with females continuing to be under diagnosed and/or misdiagnosed. Many girls and women exist today without a diagnosis. She may have even been assessed by a professional working in the area, but was told she did not meet the “criteria”. If a female can get an accurate diagnosis, she is then often left without intervention and/or support. This is what I call the ‘Female Autism Crisis’.
The ‘Female Autism Crisis’
There is a lack of awareness, understanding and education regarding the female profile or ‘phenotype’, a range of often subtler characteristics, strengths and challenges that do not fit the male profile nor does a female with a diagnosis of Autism feel she fits that profile Common characteristics have been outlined in my initial blogs which were then turned into my book series (bestsellers I Am Aspiengirl and I am AspienWoman).
There is a need for research on:
the differences between neurotypical girls and Autistic girls
camouflaging of autistic symptoms and impairments, adaptation, learning, masking or compensation abilities
diagnostic and classification challenges
the factors that increase or decrease the risk of a female being misdiagnosed or completely missed; the consequences associated with this
information as to how culture, social factors, gender and/or familial upbringing play a part in female Autism
Why do Autistic females fly under the professional radar and why will this continue to occur for some time?
- Autism was and still is presumed by many people, professionals included, to be a “male” condition. Some professionals acknowledge that females have Autism and may be unaware that males and females often present very differently.
2. Adherence to a very strict DSM5 criteria which has a gender bias. Whilst DSM 5 has hinted at sex differences in Autism, it does not acknowledge brighter individuals. It also does not elaborate much on what these actual differences are or whether there is a female profile or phenotype.
Unfortunately, some girls are now being diagnosed with the DSM5 Social Communication Disorder (SCD)
3. A female phenotype is emerging that suggests an inherent gender bias. The Sfari webinar entitled The Female Autism Conundrum is a great place to start to understand this bias
4. Professional ‘bias’
The child’s behaviors are more a function of the families “alternative” lifestyle
The child does not present with significant enough behaviors, appearing to be “normal” externally
The child does not present with the “male” stereotype or “female” stereotype of what Autism should look like
The childs anxiety, eating issues or behaviors are the focus and the diagnosis is missed
Strict adherence to the diagnostic criteria
5.The emerging female phenotype or profile
A steady collation of anecdotal, clinical and autobiographical reports and current research discuss different presentations, phenotypes or a “female profile” and when assessed with “male-biased” or male-centric tools, many females slip through the cracks. Females on the Autism Spectrum can and do hold eye contact and make superficial conversation. If fact, they can hold superficial conversation for an entire session with a professional!
The girl does not have stereotypical repetitive behaviors
1. There is a lack of assessment tools created for females across the lifespan. The ADOS often shows elevated traits, but not enough to meet the criteria for a diagnosis. Females are often missed because they do not meet the cut-off score, although there are often clues in the ADOS results. Females can have the ability to discuss many social-emotional areas by responding cognitively well. However, many parents, school officials, and/or professionals have found that those social-emotional areas are not often displayed or used adequately, and often then, see the individual using other strategies to cope. It appears that the characteristics and traits as captured by “gold standard” assessment tools may be male-biased due to the gender-centric items that contribute to the scoring. A further comprehensive assessment and/or a second opinion then reveals the individual does meet criteria for Autism or Asperger Syndrome.
2. Females often can and do engage in superficial conversation, make good eye contact and conversation, for the first initial session or hour. This can confuse professionals who are used to seeing particular social clues more immediately and who may think that a female is just “too social”.
3. A lack of understanding regarding coping strategies, compensatory strategies, masking behaviors and the more subtle presentations. Female body language can be expressed quite differently as they learn to act, pretend, mask and compensate for their social difficulties.
4. A lack of trained professionals working in the area of female autism
5. Confusion as to the diagnostic overshadowing, for example, whereby a female may be diagnosed may be told she is “shy” rather than “social anxiety”, may be diagnosed with an “eating disorder” rather than Autism.
6. A lack of understanding how females with Autism present across the lifespan
7. A lack of both quantitative and qualitative data and research regarding females
8. Co-occurring conditions can make assessment a complex and challenging process for diagnosticians working with adults. Whilst many adults have been or are misdiagnosed with a personality disorder, there are adults with both Autism and a personality disorder or those who have been misdiagnosed with Autism and really have a personality disorder
9. A lack of knowledge about the heterogeneity within the female group and the variance in how it presents. There exist different subgroups in females with Autism and range from a more “male” autism profile-type presentation (maybe diagnosed earlier) to those with many “masking” characteristics, where professionals or family members may not believe the person who is telling them about their diagnosis. The female group as a whole consists of much heterogeneity and thus females can present in sub-types (for example, a tomboy, a fashion princess, a bookworm professor type, the athlete). This further causes confusion for diagnosticians who are not familiar with the range of presentations within female Autism (often diagnosed much later, if at all). There is a tendency for an “obsession” to become the person’s identity.
10. For some young females, the need does not appear to be “obvious”, or the “issues” are misinterpreted, UNTIL the teenage years. Presenting concerns may be interpreted as another disorder or generalized. For example, “she’s just got some social issues”, “she”ll grow out of it”, “she is just shy”. Some females present with an eating disorder and Autism is never considered.
11. Some common misconceptions or myths about female Autism can contribute to this issue: “She can make friends, make eye contact and socialize, so she can’t have Autism” “She is too sensitive, so she can’t have Autism” “She holds down a full-time job, so she can’t have Autism” “She has too much empathy so she can’t have Autism”.
12. Females tend to exhibit better expressive behaviors (reciprocal conversation, sharing interests, integrating verbal/nonverbal behavior, imagination, adjusting their behavior by situation) despite similar social understanding difficulties as males), present with different manifestations of friendship difficulties (better initiation but problematic maintenance, overlooked rather than rejected by peers, better self-perceived and parent-reported friendship), and different types of restricted interests and less repetitive use of objects.
13. Some common female differences include: less repetitive behaviors, a greater awareness of the pressure and desire for social interaction, a passive personality, often perceived as “shy”, a “loner”, a tendency to imitate others (copy, mimic, or mask) in social settings, a tendency for social exhaustion (or as I like to call it a “social hangover”), a tendency to “camouflage” their difficulties by masking and/or developing strategies to compensate for the challenges and difficulties they are facing, a tendency to have 1 or few close friendships, a tendency to be “mothered” in a peer group in primary school, BUT often bullied in secondary/high school.
14. There appear to be better linguistic abilities, more imagination (fantasizing and spending time involved in fiction and pretend play and when observed closely the play can be observed to have a lack of reciprocity, to be scripted and/or controlling.
15. Less restricted interests/activities tend to be common involving people and/or animals rather than objects/things (e.g., animals, stationary, soap operas, celebrities, pop music, fashion, horses, pets, and books/literature), which may be seen as less recognized as related to autism. She may be viewed pr perceived as just a “moody bookworm”.
16. A lack of understanding sensory sensitivities and how they impact the ability to function from day to day. An individual may not be able to explain what they are experiencing. In particular, professionals may be more likely to view an individuals’ comments about how they perceive the world as “psychotic”, rather than sensory processing disorder or sensory sensitivities.
17. Diagnostic confusion and not asking the right questions or clarifying what the client has said, can lead to misdiagnosis. Many adult women have multiple labels or diagnoses before they receive the correct diagnosis. As mentioned previously, a lack of understanding as to how sensory sensitivities affect an individual can lead to misdiagnosis. Having a fantasy world and imaginary friends or animals can lead professionals to suspect prodromal schizophrenia in a girl or adolescent. A girl who has developed routines and rituals around food and calories, nutrition and/or exercise may be diagnosed with Anorexia Nervosa and the Asperger Syndrome is missed. Borderline Personality Disorder is a common misdiagnosis with females usually not fitting neatly in the diagnostic criteria. Furthur complications include individuals who meet criteria for both Autism and a personality disorder.
Professionals may not understand that many females have the ability to “feel” other people’s feelings and this can be quite overwhelming for them. They may not trust talking about their hyperempathy, hence they will be misunderstood. Females may not trust other people due to the ‘cognitive dissonance’ between non-verbal body language and what she “feels” off the person. In combination with social and relationship challenges, her behaviors look like Borderline traits or Borderline Personality Disorder.
Until professionals catch up with current research on females, they will continue to be diagnosed and/or misdiagnosed with:
Anxiety Disorder, Social Anxiety
The new DSM5 diagnosis of Social Communication Disorder
Borderline Personality Disorder
Intermittent Explosive Disorder
Schizophrenia or Schizotypal personality disorder
18. Cultural bias can leads to under-identification. For e.g., some immigrant women have been unable to gain an assessment as their differences in communication and behavior are not seen or viewed as unusual, but more of a ‘cultural’ difference
Even if a girl has subtler difficulties than other children with the disorder, those problems may nevertheless have a tremendous impact on her life.
Girls appear to use their intelligence and their abilities to to learn quickly how to combine non-verbal and verbal behaviors in addition to maintaining a reciprocal conversation and be able to initiate, but not maintain friendships. In combination with less to no and different restricted interests and an inability to communicate their needs, girls appear “less” impaired than they really are, especially in the school environment. Females on the Spectrum present with a “look” to them that suggest they are merely more sensitive, emotional and/or anxious than others.
Autism is particularly challenging to detect in girls, especially bright young girls, because generally there are little to no concerns at school. Typically, the Autistic female is doing everything to hide it, from using her cloaking device (hiding in a group) to blending in with the wall (hiding in the classroom) to chameleonism (adopting the social behaviors of another student or adult), allowing them to be much better socially over Autistic males but not neurotypical females. Their ability to hide their Autism is a superpower, but there is a high cost to pay.
Seen in private practice, the subtleties in bright females are abundant, from subtle clues externally (from a slight grimace in their smile to over-exaggerated body language) to social scripts (only observed if you see the girl a few times) to older children or teens who are questioning their gender (because they have always been unable to relate to their peers). Some females want to become boys, some are happy with their androgyny, some are happy to remain female and some change their gender entirely.
Observing, describing and understanding the unique presentation of autism in girls is the beginning to improve identification rates and create unique resources just for females. Understanding the heterogeneity of this group of females is also very important. In my 2nd book I Am AspienWoman, I discuss the differences and subtypes. Developing diagnostic tools is imperative as are intervention resources specifically for female
Tania can be reached for fee-for-service impressions assessments (in person or Skype), consultations, problem solving consultations and/or support, interviews and/or presentations/workshops, and/or book translations at firstname.lastname@example.org
Tania divides her time between full-time private practice, research and writing her books series.
To subscribe to the AspienGirl newsletter or to become and affiliate and earn 10% on all books referred, go to http://www.aspiengirl.com
To purchase I Am AspienGirl or I Am AspienWoman or pre-order AspienPowers or I Am AspienBoy, go to http://www.aspiengirl.com
For more information about female Autism or female Asperger Syndrome, go to http://www.taniamarshall.com
Future Books and Webinar Series
I Am AspienWoman, Foreword by Dr. Shana Nichols, and fabulous Mentor section headed by Dr. Temple Grandin is finally here on Amazon USA! It debuted at #39 (Disabilities) and #41 (Autism and Asperger Syndrome)
To find I Am AspienWoman on Amazon:
The book is also available at http://www.aspiengirl.com
For more information on female Autism go to http://www.aspiengirl.com
About the Author
Tania Marshall is a best selling author, a 2015 ASPECT Autism Australia National Recognition Award Nominee (Advancement Category) and a 2015 eLIT Gold Medal Award winner. She is the author of I am AspienGirl(2014), I Am AspienWoman (2015) and AspienPowers. She currently works in busy full-time private practice, providing diagnostic assessments, intervention, support and problem solving consultations to males and females ages 2-76 years of age, in-person or via Skype. All inquiries to email@example.com
Tania is an Australian Psychological Society (APS) Identified Autism Practitioner, a Helping Children with Autism Early Intervention Service Provider (HWCA), a Better Start for Children with a Disability Provider, an approved Medicare provider of psychological services and a trained Secret Agent Society (SAS) Practitioner.
20 Reasons for obtaining an Adult Autism diagnosis
One of the most frequent questions I am asked is about the relevance of obtaining a formal diagnosis or formalizing a self-diagnosis. My 2nd book, I Am AspienWoman alludes to this very topic through powerful images, experiences, thoughts and feelings of many adult autistic women. There are many valid reasons for obtaining a diagnosis and the majority of women who receive one explain the benefits in the book. I have included a couple of pages from the book and you can now pre-order I Am AspienWoman, available in eBook, paperback and hardcover, at http://www.aspiengirl.com You will receive $10 off if you order an I Am AspienGirl© and I am AspienWoman Combo. I hope you enjoy the book as much as I did writing it!
Tania is available for in-person or Skype consultations, assessments or problem-solving sessions. To book appointments or discuss and/or book availability for presentations, conferences, publishing, translation and media interviews or inquiries, please email Tania@aspiengirl.com
ABOUT THE AUTHOR
Tania Marshall is a best selling author, a 2015 ASPECT Autism Australia National Recognition Award Nominee (Advancement Category) and a 2015 eLIT Gold Medal Award winner for her first self-published book entitled “I Am AspienGirl© : The Unique Characteristics, Traits and Strengths of Young Females on the Autism Spectrum”, foreword by Dr. Judith Gould. The sequel to this book entitled “I Am AspienWoman: The Unique Characteristics, Traits and Strengths of Adult Females on the Autism Spectrum”, Foreword by Dr. Shana Nichols is available September, 2015. Tania is currently writing the third book in her book series entitled “AspienPowers: The Unique Constellation of Strengths, Talents and Gifts of Females with Autism Spectrum Conditions”. The Spanish version of I am Aspiengirl© , entitled Soy AspienGirl is now available. Tania’s work has been translated and/or cited in numerous publications including Sarah Hendrickxs’ recent release entitled “Women and Girls with an Autism Spectrum Disorder” (2015), foreword by Dr. Judith Gould.
Tania currently works in busy full-time private practice, providing diagnostic assessments, intervention and support to males and females ages 2-76 years of age. Tania is an Australian Psychological Society (APS) Identified Autism Practitioner, a Helping Children with Autism Early Intervention Service Provider (HWCA), a Better Start for Children with a Disability Provider, an approved Medicare provider of psychological services and a trained Secret Agent Society (SAS) Practitioner.
© 2015-2017 All rights reserved Tania Marshall
Assessing the behaviors, traits and abilities of young females on the Autism Spectrum: For professionals and parents
Girls with high functioning Autism (Asperger Syndrome) often have subtler characteristics that lead them to be missed by professionals. Many (not all) are able to use compensatory strategies to mask their difficulties and these are learned from before they start grade school. Autism tends to be a condition of extremes; an either/or condition in which two girls who present quite differently can both be on the Spectrum. For example, one is shy, quiet and mute and the other is loud, has a lack of boundaries and talks too much. The both have social communication and interaction difficulties.
Girls on the Spectrum may present as shy, quiet and at times mute, taking a long time to warm up to situations or they may present as overly talkative, verbal and lacking boundaries.
The quiet girl can be described as passive, a follower, watching and observing her peers much of the time to learn what to say or how to act. She is very shy in social situations. The verbal girl is often dominating, described as “bossy and controlling”, often described as having to have the best at everything and have her own way. She dominates and controls social situations.
Both girls may not receive many birthday invites, prefer one or two close friends, prefer to play with younger or older children rather than their peers, prefer to talk to boys or have boys as friends.
The quiet type may be attracted to extraverted personalities who tell her what to do or are controlling towards her due to her passivity and shyness. The verbal type may be domineering and controlling in her interactions with others.
Why do girls who have an assessment not receive a diagnosis?
Females can and do make eye contact and can have superficial reciprocal conversations in initial interviews with professionals.
Females are reluctant to admit they are having difficulty and will say they have friends, that they know what to do socially, when they are actually socially confused
Females start learning, often from before grade school to camouflage their difficulties and pretend every thing is fine
Females will say everything is ok and there are no problems even in the face of contrary evidence or difficulties
Professionals are viewing the female as just a “shy” and/or “sensitive” child or a “hormone driven” teenager, when in fact they have Autism. Around the age of 12-13 are when the proverbial wheels may begin to fall off and the inability to cope comes to the forefront
Professionals may diagnose only the presenting issue (for e.g., anxiety disorder)
They may receive high scores on the ADOS but not enough for a diagnosis
The majority of assessment tools are based on males
Professionals are not trained in understanding the gender differences, the gender bias, the questions to ask, compensatory strategies and camouflaging techniques
Some clues look for in an assessment
The Social World
1. exaggerated facial mannerism or a flatter affect. Many girls I have worked with have a slight grimace to their smile. This is a clue that they may be having difficulties with their own non-verbal body language. Many childhood photos reveal either no smiling or a slight exaggerated smile or facial expressions
2. look for facial expressions not matching the mood or the situation being discussed. For example, it is common to observe smiling or laughing whilst talking about a situation that would usually be associated with a different emotion (and therefore a different facial expression and tone of voice).
3. many girls say they know what to do in a social situation but when asked, are not able to tell you what they would do or give an answer that leads to to believe otherwise. An investigation into levels and types of friendships and social skills often reveals difficulties
4. exaggerated non-verbal body language is often a clue. Some girls present in the clinic with body language that appears “odd”, unnatural or like they are acting with you in a conversation.
5. Many females are well-behaved (often too well-behaved) in school but the opposite at home (due to social exhaustion and holding it all in)
6. Many females are observed using behaviors or words from their peers, other people or television. They may copy, look like or act like others, taking on the characteristics, mannerisms, voice, sayings, of others.
7. Many females present in different ways depending on the situation and this can be confusing to family members.
8. Many females will tell you they know what to do in social situations, but the evidence is contrary and/or you will get the impression that they are confused or are not being truthful.
9. Some females may not apologize when they have made a social error and some females over-apologize due to being confused about social rules. Some females refuse to apologize even when it is plainly obvious it would be in their best interests to do so.
10. Many females are able to socialize quite well for small periods of time but them experience social exhaustion or a ‘social hangover’, needing solitude to recharge her batteries.
The Play World
1. Some girls have a preference to play with stereotypical boys toys, having no interest in dolls whilst others have an obsessive-like quality towards dolls and stereotypical girls toys (for e.g., collecting all barbie dolls).
2. Girls can often be observed spending the majority of their time putting together the scene of play, rather that actually playing. For example, spending the majority of time ensuring all the furniture, accessories and dolls are in the right place). They often have elaborate scenes of play set up and organized.
3. Whilst playing on their own, girls are often observed to be role-playing adults. For example, a girl may set up all her teddy bears bears, dolls, etc., and role play the teacher, doctor, nurse or other role. She may take attendance, give time-outs, write out lesson plans and/or teach class lessons.
4. Girls on the Spectrum are often far more imaginative than their peers. They are often observed pretending to be animals and/or imitating them. They may also have some difficulty distinguishing between reality and fantasy
5. A tendency to have imaginary friends and/or animals who are very real to the child, to the point that they may have table settings for them at the table, seats for them in the car, and so on.
6. Girls often spend more time playing with the family pets and/or on nature than their peers, having a natural affinity/gift in the areas of nature and animals. It is the intensity of the interest as compared to neurotypical peers that is key here.
7. May have obsessions with other people which can be observed as too clingy, not allowing the friend to have other friends, not giving them enough ‘space’, or obsessing over them
8. Females tend to have more avoidance traits and strategies when demands are placed on them
9. Some females may flitter from group to group in school not really having any real friends but giving the appearance of having friends, so that no one would pick up on this
Abilities, Gifts and Talents
Abilities, Gifts and Talents are plural due to the many females I have met who display multiple talents. These abilities often include:
hyperlexia/reading ability, perfect or near-perfect pitch, languages, art, performing arts (dance, acting/drama, singing, musical theatre, modelling, involvement in a band, comedy), the care of animals, mathematics, writing fiction and/or fan-fiction and/or poetry and/or songwriting, intelligence,
Mature interests may include interests advanced for her age (philosophy, psychology, opera, a language)
Immature interests may include an interest well past her developmental age (for example, my little pony, doll or teddy bear collections).
Some females present as more of a “tomboy” appearance (preferring an androgynous clothing style) and disliking make-up and sterotypical girls clothing
Some females present as a “ultra-feminine” or “princess” like appearance (love make-up, fashion, trends and shoes). they may spends time involved in shopping for clothes and/or designing clothes, perfecting the art of makeup and.or modelling
Regardless of presentation, a difference in terms of clothing as compared to her peers is usually observed. My screener which was the basis of I Am AspienGirlL The Unique Characteristics, Traits and Gifts of Females on the Autism Spectrum is here:
A female autism assessment tool I often use in conjuction with other tools includes this screening questionnaire developed by Kopp and Gilberg and it is excellent.
THE AUTISM SPECTRUM SCREENING QUESTIONNAIRE (ASSQ)-REVISED EXTENDED VERSION (ASSQ-REV), by Kopp and Gilberg
Kopp and Gilberg found that certain single ASSQ-GIRL items are often much more typical of girls than of boys with ASC. These items include “avoids demands”, “very determined” and “interacts mostly with younger children”. The ASSQ-REV is a new assessment tool that includes a set of “girl” items.
ASSQ-GIRL, 18 new screening items believed to tap into the autism phenotype of girls
ASSQ-GIRL item No Somewhat Yes
- Copies you (can be in a very discrete way)
- Episodes of eating problems
- No time perception*
- Too much sympathy
- Extremely interested in pop/ rock bands, soap operas or natural disasters
- Avoids demands*
- 34 Very determined*
- 35 Difficulties with choice; always avoids choosing
- 36 Difficulties with self-care*
- 37 Carefree or overmeticulous as regards physical appearance/dress
- Comes too close to others
- Interacts mostly with younger children*
- Engages in dangerous activities
- Exaggeratedly fanciful
- Talks without content*
- Writes long stories (can be in stark contrast to level of talk)
- Acts or lives different parts (TV stars, videos, animals)
Note. *indicates items which were considered most specific in girls with ASD (see study V)
To contact Tania for assessments, Skype or clinic consultations, problem solving sessions, workshops and presentations, book interviews, book translations, or publishing, please contact Tania at firstname.lastname@example.org
For more information about Autism Spectrum Conditions in females go to:
Copyright Tania A. Marshall 2015
Asperger Syndrome (AS) is thought to be the highest functioning form of Autism Spectrum Condition. Females on the Autism Spectrum are underdiagnosed and often come into a clinic with other mental health issues, many labels or diagnoses, some of which include: anxiety disorders, ADHD, sleep disorders, panic disorders, obsessive-compulsive disorder, depression, bi-polar disorder, borderline personality disorder, eating disorders or schizophrenia.
Females on the Spectrum are generally much more social, really good at “faking” it, understanding non-verbal body language, working very hard to “fit in” and “pretending to be normal”.
Women tend to be much more social than men, observe and watch others more in order to learn what to do, learn how to hold their bodies, what to say and when to say it. All of these skills do not come naturally and an enormous amount of energy is put into these skills. Females are generally able to hold it all together during the day and then let it all out at night. At night, the “falling apart” may look like, jumping, screaming, flapping, outbursts or withdrawing into their caves.
Women generally tend to have better empathy and theory of mind skills. However, these theory of mind skills become affected by sensory issues, stressful situations, social situations, processing of verbal information, high levels of anxiety, conflict and/or arguments.
Of those that come into clinics, anorexia nervosa appears to be the most common eating disorder that females (21.7%) on the Spectrum tend to experience (Nichols).
What is the link between eating disorders and Autism Spectrum Conditions (ASC)?
There is a overlap, possibly a genetic link between ASC and AN.
The lifetime prevalence of an eating disorder is 0.9%. ASD is highly over represented in AN (12-32%). Some commonalities between ASC and AN include:
1. Executive function deficits
2. Mood and anxiety disorders
4. Rigidity in behavior and thinking
5. Theory of Mind Deficits
Autism Spectrum Characteristics that increase the risk of developing an eating disorder include:
1. Clumsiness and knowing where one’s body is in space
2. Body awareness issue, distorted image of body in space
3. Limited social insight; difficulty with understanding how others see their body
4. Stomach issues, a feeling of no appetite, bloatedness
5. A lack of sense of being hungry or thirsty
6. Medication side effects (SSRI’s, antipsychotic and associated side effects of weight gain)
7. Sensory processing sensitivities
8. Stress management
10. Picky eating
Where does a percentage of almost 1/3 of the population with AN having ASC come from?
51 women over 18 years were evaluated using formal interviews, developmental histories and 32% of those met criteria for ASC, but only 11% of them knew that they had ASC. Their families had no idea that they had ASC. The highest prevalence of personality disorders (OCD) were also present.
In terms of intervention and treatment, a modified treatment schedule is important due to learning difficulties, mental health issues including ASC, a balanced/different course load.
What is desperately needed is a routine global screening program for all females who come into a clinic with an eating disorder. It is critical to know if a client has an ASC or has symptoms of an ASC because the symptoms of ASC do not go away post-treatment. The eating disorder may be alleviated, however the symptoms of the ASC have not. This will help the client, their families and their treatment professionals.
Goals for treatment of an ASC and AN include:
1. Treating the sensory processing condition
2. Improving the rigidity and inflexible thinking processes
3. Improving the range of foods eaten
4. Rigid repetitive behaviors need to be replaced with more functional behaviors
5. Increasing and widening the range of foods eaten
6. Decreasing anxiety levels and improving depression levels
7. Work with the preference for sameness and routine
8. Improving sensory processing issues and desensitizing to aversive foods
S Baron-Cohen, A Jaffa, S Davies, B Auyeung, C Allison, S Wheelwright (2013)
Do girls with anorexia nervosa have elevated autistic traits?
Gillberg C, Cederlund M, Lamberg K, Zeijlon L: Brief report: “the autism epidemic”.
The registered prevalence of autism in a Swedish urban area. J Autism Dev Disord 2006,
Eating Problems and Overlap with ADHD and Autism Spectrum Disorders in a Nationwide Twin Study of 9- and 12-Year-Old Children
CAVEAT: My research is focused on females, due to the lack of research and information on the female profile
Tania Marshall 2013. All rights reserved.
Tania Marshall©. 2013. All rights reserved. Duplication in
whole or part is explicitly forbidden. Thank you.
I write based on my own clinical and anecdotal evidence,
research studies and the work of world experts.
The statistics for boys to girls with Asperger Syndrome sit at 1:4, so
for every 1 girl there are 4 boys who meet criteria for Asperger
Syndrome. However, for those of us professionals who work solely in
this field we know that the statistics reflect a prevalence rate of
Asperger Syndrome in girls that is in reality, 1:2, meaning for every one female, there are two boys. Dr. Judith Gould, director of the National Autistic Society’s Lorna Wing Centre for autism and co-founder of the Centre for Social and Communication Disorders discussess the difference in prevalence rates between boys and girls. The statistic most commonly reported is that ASDs are four times more common in males than in females. Many clinicians, however, believe that the ratio is as high as 16 boys to every girl. But Gould believes that significantly more girls have the condition than is recognised; she estimates the ratio to be 2.5 boys to every girl.
Girls with Asperger Syndrome present very differently to boys with the same condition and “fly under the radar of a diagnosis”, often being MISdiagnosed,
MISunderstood, MISmedicated and sometimes, institutionalized. In my
clinic, boys tend to be diagnosed before formal schooling or in
their primary school years. Whilst I have diagnosed girls with
Aspergers as young as two year of age, the majority are closer to
the teen years. They appear to be able to cope with the basic more
“play-based” socialization. However, in secondary school the social
world changes dramatically from play-based to a more socially and
emotionally based conversation, social hierarchies are more
apparent, and the typical “bitchiness” and “mean girl” behaviors of
teenage girls is distinct. This difference often flies over the
heads of the female with Aspergers, who are often left behind
repeatedly analyzing their social faux pas, social confusion and
replaying the day’s social events in their minds over and over
again, often late at night, in their attempts to make sense of
them. Their female peer group’s interests have changed from
childhood friendships to teenage talk, emotional conversations,
cliques, groups, backstabbing, and “bitchiness”. They find they
cannot understand or “read” the unwritten rules, the non-verbal
facial expressions/glances/eyerolls and the non-verbal body
language that is critical to being an important member of a group.
As much as they observe, copy, and mimic their peers, they finds
that they just cannot keep up or fit in appropriately. Their peers
sense that there is something “ödd” about the Aspien, despite the
enormous amount of energy that they generally expend in their
attempts to fit in. In secondary school, girls with Aspergers
utilize a variety of coping mechanisms in their attempts to “fit
in”, “pretend to be normal”, “be accepted”, hide and camouflage
their confusion, imitate, copy, fake it until they make it, but
still appear to come off just a little “ödd” or “strange”, despite
their best efforts. Most of the girls I have seen have had previous
diagnoses of anxiety disorder, depression, ADHD, an eating
disorder, oppositional defiance disorder, bi-polar disorder and
even Borderline Personality Disorder (although they are still young
teenagers) and at times, reactive attachment disorder or selective
mutism. An enormous amount of energy is spent on observing,
learning and trying to understand and then copying their peers
social behaviors. I have met females who have utilized some or all
of the following strategies: Reading body language books and
practicing in front of the mirror in a repetitive way until the
skill is perfected the mirror
Learning from television shows or books about others inner thoughts, feelings and
Replaying specific daily social situations in their own play at home in an effort to learn and
Using imaginary friends to specific daily social situations in their own play at home in an effort to learn and understand
Over-apologizing, appeasing or pleasing others, giving gifts for social faux pas or social
I have seen many teenage girls who have been brought into to see me and are have been described as having “gone off the rails”, in terms of their appearance, their attitude,
their mood, skipping or dropping out of school, running away from
home, involvement in drugs, sex, crime and/or the Police. They later met formal criteria for Asperger Syndrome.
Using “chameleon” strategies, where the Aspien girl can adapt and fit into a variety of roles. In one example, I met a female who successfully fit into a very rough
motorcycle gang, a conservative church sect, and a traveling
circus! She had acted so well for so many years that she came in
with clinical depression, having no idea who she was. I have seen
teenage girls with Aspergers reject all social norms/values and
turn to drugs and sex and even crime.
Girls with Asperger’s need very specific and appropriate social skills
interventions designed for them, in terms of learning about levels
of friendships, boundaries, social hierarchy, the unwritten social
rules, non-verbal body language, cliques and groups and the role of
people in those particular groups. They also need interventions
designed to help them with identity, self-esteem, managing intense
emotions, rigid black and white thinking and negative thinking.
Most typically, Aspien girls have the greatest difficulty in the
adolescent years, when they tend to “go off the rails”. Most, but
not all, Aspiens tend to be non-conformists and conforming to
social rules they don’t understand begins to take it’s toll. I had
one parent show me a picture of her daughter just a few months
before she saw me. He appearance was one of a typical teenager.
Then I had the chance to meet her daughter, who had in just a few
months gone “goth”, gotten several piercings and tattoos, was using
drugs and hanging around “bikers”. This young teen was rebelling
against all those groups that had not accepted her. Her desire was
to be accepted and approved of by anyone. This group and the men
she was having sex with accepted her, approved of her and took care
of her. She felt both accepted and popular. It is imperative that
any girl who comes into a clinic with either/or an eating disorder,
social difficulties, intense emotions, difficulties expressing
themselves, anxiety or depression, must be screened for Asperger
Syndrome, in a female. Then, once a comprehensive and detailed
developmental history is taken by an experienced clinician, the
diagnosis of Asperger’s becomes apparent, and then the appropriate
intervention can take place. Currently, information on female
Aspergers and Autism is occurring at a
rapid pace and there will be a
knowledge explosion within the next 10 years.
A recent study Dr Meng-Chuan Lai of the University of Cambridge
found that Autism affects male and female brains
Generally speaking, my doctoral research is in the area of females.
Having said that I am not saying that males do not experience these
issues. I am merely writing about my
Tania Marshall©. 2013-14.
Professional Q and A Series I. All rights reserved. Duplication in
whole or part is explicitly forbidden. Thank
Updated December 11th, 2016
There has been intense interest in the area of high sensitivity, different perceptual experiences, and the 6th sense, including Synaesthesia and will be written about in more detail in the future.
Professional FAQ Series: High Sensitivity, Female Aspergers, Referred Emotion and the Superpower 6th Sense gift
My writings are based on my professional work with individuals of all ages, most diagnosed with Autism or Asperger Syndrome (and some with co-existing conditions). I work full-time with individuals of all ages with Asperger Syndrome or Autism. I have supported hundreds of females with diagnoses of Asperger Syndrome. I also blog, write articles and am now writing a book series.
FAQ: My daughter was diagnosed with Asperger Syndrome three years ago. Since very early on in her life, she has regularly told me things she couldn’t possibly know. She seems to just “know” things all the time. It’s spooky and I worry about her.
FAQ: I am a self-diagnosed Aspie and have known for a long time that I cannot cope being around people. I just get so emotional and at times, even break down crying. I broke down walking past an obese man the other day. I don’t know what it wrong with me.
FAQ: I am a diagnosed Aspie who has been told I “care too much” about the world. I can’t even watch the news anymore, without going into a meltdown over the latest war, injustice, or crime. How is it that others just don’t seem to care or that it doesn’t affect them like it does me?
I have interviewed hundreds of girls, teens and women with Asperger Syndrome who have talked to me about high sensitivity, referred emotion, a “sixth” sense, knowing things without knowing how they know them, “feeling” presences, knowing when people are lying (through their feelings), and much more. It appears that females with Asperger Syndrome have a unique way, or “channel”, of accessing information about others or about events, or another way of “reading” people. Many females I have seen have expressed difficulties reading people in the usual way, that is through reading others non-verbal communication (facial expressions, hand and body movements). However, all have discussed their unique abilities to accurately sense what they cannot easily explain.
When should you consider that you may have Superpower 6th Sense?
In interviews I have listened to females, who are extraordinarily sensitive to the pain and feelings of others, so much so, that they are unable to watch the news, read the paper, listen to the radio or watch horror or violent movies. They have discussed being able to feel other people’s feelings and being able to tell or feel when people are lying to them, even though they were given no indication through body language evidence, but had later on found out through physical evidence. They have described their sensitivity as akin to a “fragile flower with a gentle breeze blowing them right over”. They describe being in continual emotional pain in the presence of other people. Many females have discussed “feeling” the emotional atmosphere of the room, “feeling” someone’s anger (although the person said they were not angry, did not look angry, but were actually angry on the inside) or “feeling” someone’s sadness as they passed by the person on the street. They have also discussed experiencing referred emotion or others thoughts (picking up stuff from other people or being “invaded” by other people’s thought’s). Many of the females I have worked with have told me they have been told by others that they “care too much”, are “”too sensitive””, are “highly sensitive”, and/or “need to stop caring” or “harden up”.
Some females have discussed knowing about future events happening before they happened, experiencing “precognitive dreams”, experiencing extrasensory perceptions and describing their experiences as seeing pictures in their head of what they are supposed to know (a “knowing” of a future event, the location of an item or a person, where a person is).
Many females have discussed realizing that they need to limit the time that they spend around people or avoid social situations because they are overwhelmed by others moods, feelings, emotions and/or the emotional atmosphere or because they simply just “know” too much about the people they are around, even though these people are strangers to them. Some of them have discussed how they have immensely benefited from a medication to “take the edge” off their emotional sensitivities, learned how to harnass and utilize their extra-sensory abilities (including learning to differentiate between the emotions of themselves and those of others, how to shield and protect themselves, among other techniques), and what to do when they pick-up on or feel the pain of people or animals in their environment. There exists females with Asperger Syndrome who are professional psychics and/or mediums.
The Superpower of referred emotion, ESP, the “6th Sense” is a gift. In my experience, females with Aspergers tend to have this gift to a greater degree than others. This is not to say that males with Aspergers or people without Aspergers do not also have this gift. However, my research is on females with Asperger and so I write with this focus in mind.
Females with Aspergers are often much more aware of the emotional atmosphere that others miss. Many clients have discussed with me about their experiences in group, family, or conference settings, where they can “see” right through a person (their intuition tells them to be careful) whilst everyone else appears to really like them. Neurotypicals pay much more attention to other people’s words, non-verbal body language, actions, facial expressions, whereas Aspiens use a different sensing channel that tells them important information about a person. Learning to trust the “gut”, “ïnstinct”, “ïntuition”, “6th sense”, is crucial to overcoming naivety that tends to comes with being an Aspien, so that the individual is not taken advantage of.
1. Knowledge and awareness. Believe your traits are real. Learn all you can about highly sensitive people, “empaths” and/or “ïntuitives”. Accept that you have this gift.
2. Learn about emotions. What are your emotions? What are degrees of delight and distress? What are other people’s emotions? How do you know what emotions are yours and what emotions belong to others?
3. Journal regularly. This will enable you to get to know yourself and provide a greater knowledge of what is yours and what is NOT your “stuff”
4. Learn to self-regulate your emotions
5. Learn shielding techniques, so that you do not ‘soak up’ others pain and emotions like a sponge.
6. Learn to separate your pain and emotions from those of other people, animals, nature.
7. Learn to trust and listen to your feelings, your vibes, your intuition. They are your guide in life.
8. Learn to embrace this gift, utilize it and trust it.
9. Take solitude (meditation, alone time)
10. Get enough rest and/or sleep.
11. Take minimum one day off per week
12. Cut down on the stimulation (TV, radio, newspapers, advertisements)
13. Learn to say Say NO
14. Be preventative. Take breaks often. Eat before you are hungry and drink before you are thirsty.
15. Learn about your gifts, strengths, assets and utilize them.
16. Reframe your life based on your high sensitivity, your Aspergers, your whatever. This will take time for you to do.
17. Work on healing your childhood, your upbringing, your sensitivities.
18. Meet and be friends with other highly sensitive people.
19. Embrace your spirituality, whatever that is.
20. Use your sense of justice in a healthy and empowering way.
1. Aron, Elaine. The Highly Sensitive Person, http://www.hsperson.com/
2. Bogdashina, Olga, Autism and the Edges of the Known World
Sensitivities, Language and Constructed Reality. (2010). Jessica Kingsley Publishers
Tania Marshall©. 2013. Professional Q and A Series I. All rights reserved. Duplication in whole or part is explicitly forbidden. Thank you.
Professional Q and A Series I: Female Asperger Syndrome and “Burning Bridges Aspie-Style”
I have had a number of questions and comments related to what is referred to as “Burning Bridges”. Below are common comments/concerns that I have heard from my clients over the years.
“My question is How could I sometimes be such a bitch? After all, as an Aspie, I needed support and sympathy. Yet, I sometimes treated people so badly, either with unveiled criticism, I ignored them, broke hearts and at the same time wasn’t able to take what I gave to others. How is this possible?”
“My daughter has a long history of ending relationships badly, walking out of jobs, packing up her room-mates belongings with no notice, and for no good reason. I’ve had calls from her former boyfriend, her former boss and now her room-mate. I am at my wit’s end and I feel she has got no future”.
“I have been in counselling for some time now and my psychologist has told me I lack empathy and need to work on my friendship skills, because I just can’t maintain a friendship.”
“I am writing to you because I have a long history of broken relationships, loss of jobs and relationships, and depressive meltdowns/breakdowns. I have thought about this alot and do find communicating with people stressful. I avoid conflict like the plague, am socially anxious and misunderstand people often. Why can’t I maintain relationships?”
“Whenever I get stressed or overwhelmed, things don’t work out, or I have trouble in relationships, I just cut ties with them like that. I pack up and move on, leaving jobs, friends, business partners, marriages, often not even giving them a valid reason for doing so. I just can’t deal with conflict”
“I have left a few situations rather quickly. Through counselling I realized some of my burning bridges were healthy and some were not”
Burning bridges is a set of behaviors in response to an event or events, often (but not always) disproportionate to the situation or event.
What causes individuals to burn bridges?
Briefly, I have found the following factors, in part or combination, to precede the burning of bridges, and of course, depend on the situation and context
The inability to manage stress, anxiety and/or anger
Misinterpreting or misunderstanding other people intentions
Difficulties communicating and/or working through the inevitable ebbs and flows of relationships
A meltdown, (depressive, toddler temper-like, violent, angry or suicidal)
Impulsive reactions, which are often then later regretted by the individual, but not always (i.e. packing their suitcases and leaving a relationship, throwing their room-mates belongings out, obsessing, stalking and harassing others)
Feel their lives will improve by changing friends, partners, jobs, countries
An inability to see other people’s perspectives, or understand other’s thought and feelings about a given situation
A tendency to argue and/or behave in ways, so much so, that I have seen individuals engage in behaviors that only hurt themselves, just to make a point, be the “winner”, or have the last word
A combination of blaming, passive-aggressive behaviors, avoidance of conflict, arguing rather than talking, criticizing and/or making excuses for their behaviors (“well, if you didn’t………, then I wouldn’t have had to throw out all your stuff!”).
The difficulty in understanding the unwritten social rules, of social and emotional reciprocity in relationships and how to maintain friendships or relationships.
Seeking revenge, stalking or obsessing over perceived injustices
A tendency to ‘catastrophize’ (thinking things are worse than they actually are) leads to panic, which then, in turn, leads to burning a bridge
Lacking the ability to understand the feelings and perspectives of others
A tendency to think negatively or in black or white terms
How Does Burning Bridges Happen?
In my professional work, I have found that children on the Autism Spectrum tend to fall into groups or sub-types. There are those who have a quieter, shier personality and generally dislike conflict or stress intense, keep their own opinions to themselves or take on the opinions of others, are unable to defend themselves when needed and are passive. There is also another group I have come across, those who tend to be overly-expressive in their opinions, despite the consequences. Some individuals in this group have been described by their family members as “över the top” or “drama queens”, “engage in publicly defaming others, playing dirty and extremely difficult to maintain a relationship with”. These two particular groups are quiet different in their presentation, yet share similar difficulties in communication, social and emotional intelligence, maintaining relationships, both context and mind-blindness and difficulties seeing another person’s perspective.
Both groups tend have difficulties keeping jobs, healthy friendships and partners. One group due to the inability to stand up for themselves, discuss their concerns with others and handle conflict when typical difficulties arise; and the other group, often having difficulty self-monitoring their behaviors and actions in the workplace, community, or in relationships, in essence, difficulty reigning their behaviors and emotions in. Their behaviors and lack of emotional control often scare, or intimidate their family members, co-workers partners, friends, or children.
Over time and development, individuals who have not been diagnosed and/or received appropriate intervention develop a number of coping mechanisms, usually in order to cope with the symptoms of Asperger Syndrome. Some adults have developed co-existing conditions, for example, personality disorders.
Is is ever appropriate to burn bridges?
That’s a great question. Sometimes, it is appropriate to leave a situation, and quickly, however, depending on the situation, in as professional a way as possible. Sometimes, it just isn’t appropriate or safe to do so. I have heard of many examples over the years where I believed it was in the best interests and healthy for the person to leave a situation, as quickly as possible. One example that comes to mind is a client who’s co-worker aggressively bullied her in front of her own client and that client’s young child. The client then intervened on her behalf to stop the bully and protect his caseworker. Serious forms of aggressiveness and bullying can and do occur in the workplace or community and are unacceptable, especially in front of children. I do not classify these situations as “burning bridges”.
What type of support or intervention is available to individuals who burn bridges?
Briefly, some of the following interventions and supports are useful in helping individuals improve the areas associated with the often seen impulsive and irrational behaviors associated with burning bridges
Social Skills training
Theory of Mind Training/Mind Reading Training/Cognitive Empathy Training
Emotion Management (Anxiety, Anger and Stress)
Perspective Taking Training
Speech/Language and/or communication training/semantic pragmatics
Social and Emotional Intelligence
Cognitive Affective Training (CAT Kit)
Learning to manage impulsivity
Assertiveness Training and learning to manage conflict in health ways
On going training in social awareness (learning how to read facial expressions and social interaction skills)
Training related to healthy boundaries and understanding and respecting the social hierarchy
It is important to remember that each individual needs to have the intervention specifically designed for them. For e.g., the quiet shy type highly benefits by learning boundaries, to assert herself by speaking up and standing up for herself in healthy ways whilst the dramatic talkative type benefits from learning to let others talk, slow down, speak and act in calmer ways, so that others are not threatened.
Tania Marshall©. 2013. Professional Q and A Series I. All rights reserved. Duplication in whole or part is explicitly forbidden. Thank you.