The Female Autism Crisis: Assessment and Diagnosis of the Neurodiverse

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Updated February 18th, 2017

This is a sample of the book entitled Behind The Mask and is therefore under copyright law. Behind The Mask give voice to neurodiverse females and discusses the assessment diagnosis and support of females on the Spectrum.

Tania Marshall, M.Sc. is available for diagnostic impressions reports, assessment, diagnosis and intervention, support and problem-solving sessions in-person and/or via Skype. All queries, please email admin@centreforautism.com.au

I chose to write my book series after numerous requests for information on the topic. I also chose to self-publish, so that I can regularly update my work, keep my work current with the speed and amount of the research in the area (a challenge to keep up with for a professionals in the area), keeping my work fresh, current and in real time, rather than a long waiting period and being out-dated.

Over my career, I have I worked with hundreds of neurodiverse, Gifted and Talented, and 2e individuals.They may have labels that consist of Autism, Aspergers, Non-Verbal Learning Disability, Twice-Exceptionality, Semantic-Pragmatic Language Disorder, Oppositional Defiant Disorder, Anxiety Disorder, Bi-Polar Disorder, and many more. Irregardless of the ‘label’, these individuals have many significant strengths, gifts, abilites and/or talents, and this topic is discussed in ‘ AspienPowers’.

In working with neurodiverse individual across the lifespan, I have written and spoken about and or refer the ‘female autism crisis’. There are many factors involved, some of which include:  a lack of professionals trained in the area, gender differences, the female autism bias and the lack of assessment tools.  We are a long way from developing efficient tools for assessing neurodiverse girls and woman. The following slide is from the Recent presentation review of key measures, gender and autism at the 2016 XI Autism-Europe International Congress and shows that the ADOS/ADOS-2, the ADI-R and the SCQ favor males. This is a real problem and a crisis because these are the very tools that many professionals use when they assess females. They are sometimes a cause of females flying under the radar of a professional.

I have been referred many females who have had these tools previously completed on them and have not been given a diagnosis. This can be due to the tools inability to measure the subtle signs, client masking, compensatory mechanisms and strategies and/or the even the rigidness of the professional in using the tool or the over-reliance of using these tools versus asking the right questions and looking for the subtle signs in body language, facial expressions, asking the right social questions, evaluating areas such as context blindness, synaesthesia, Irlen Syndrome, sensory processing issues, and more.

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In assessing girls on the Spectrum, it is important to ask the right questions. I cannot emphasise this enough. There are many questions to ask and what follows are some examples. Keep in mind that high average to profoundly intelligent girls can tell you the socially acceptable answers, but they are unable to actually perform those unwritten social rules or if they can, they are not as fast at it as their peers or it comes off as just slightly awkward.

Many girls and women with Asperger Syndrome or Autism have a tendency to be over-loyal and over-trusting, have a lot of emotional empathy, often just ‘seeing’ that a person needs help or saying they person needs help and taking things literally or not being able to ‘see’ the social context of a situation (for example, bringing home a homeless man because he has no home or food, yet not seeing the inherent dangers in doing this).

  1. What is bullying? What is teasing? What is bitchiness? How do you know the differences? When should you help someone? When shouldn’t you help someone?
  2. Sample questions in the area of friendship friendship should consist of: What is a good friend? What are some healthy ways of making and keeping friends? How long does it take to make and keep a best friend? Who are your friends? How do you know they are your friends? Do your friends try to get you to do things you dont feel is the right thing or that you feel uncomfortable with? (For example, do they try to get you to do your their homework, reports school work? Do they get you to buy things for them? Do they try to get you into trouble (for example, do they say they’ll be your friend if you do something for them?) What do you do at lunchtime? What do you do with your friends? What kinds of activities do you do with your friends? Do you prefer one best friend or a few friends? How long have you known your friend/friends for? Do they come stay over at you house and vice versa (if applicable). What do you talk about with your friend(s)? Professional Tip: Try to find out if the conversations are more one-sided or are they reciprocal, that is the conversation takes turns; it is a two way street rather than just a one person conversation involving 2 or more people.
  3. Sample Questions of play or hanging out may involve: How often do you play it hang our with your best friend/friends? Who initiates the play? Do you ask your friends to come over? Do they ask you to come over? Professional Tip: Often girls will text or cling too much to a girl, often driving them away.
  4. Does the girl or teen understand the social hierarchy? Do they understand how groups in school work? Do they understand the role the group members play? Why do you think the girls at school engage in these behaviors?
  5. Why is it important to keep a promise? Should every promise be kept?
  6. Why is it important to apologize when you’ve hurt someone? Professional Tip: Some girls adamantly refuse to apologize and some girls over-apologize.
  7. How do you know if someone is trying to get you into trouble? How do you know who you can and cannot trust as a friend?
  8. How do you know a particular person is safe to have as a friend? What kinds of clues might alert you that this person is dangerous? How would you know you are being taken advantage of?
  9. What are boundaries? How do you enforce a boundary?
  10. Do you prefer one-on-one friendships or hanging out in a group?
  11. Do you feel anxious around other girls? Girls often internalize their anxiety and can hide it very well. For those girls that are unable to “hold it in”, they may receive a diagnosis earlier than other girls. Remember that is it common for girls to be unable to explain why they are having difficulty in a social situation. They do often discuss not feeling well or may speak of feeling sick, feeling nervous or scared. They may often be in the sick bay.
  12. How long can you socialize for? Do you feel like you need a break? Does socializing make you tired?
  13. Teenagers with Aspergers often have eating disorders, an escalation of anxiety and depression and/or self-harm. Asking these questions is important. Investigating self-harm is also important. Girls are very good at hiding their cutting. Demand Avoidance is commonly seen in girls and women with Aspergers. Avoiding demands is caused by anxiety and/or not knowing how to do the task at hand and /or being embarrassed or socially anxious about a task. This is context-dependent and can look like making up excuses as to why she cannot do something that you know she can do to refusal to do something asked of her to refusing to comply with requests by an adult to avoiding the social playground.
  14. Many girl and women have a flat affect on their face, so that family members or professionals cannot tell how they are feeling.
  15. Some girls and women have Alexythymia and/or Faceblindness. Most experience extreme emotions and some girls may receive a diagnosis earlier than others to their meltdowns and/or violence.
  16. Many, if not all girls and women mis-interpret social situations (for e.g., “none of the teachers or kids at school like me”). Upon further investigation/assessment, it is found out that the individual misinterpreted facial expressions and social context, in an assessment.
  17. An assessment should involve reading of the eyes to see how well an individual can read non-verbal facial expressions from the eyes.
  18. An assessment may include listening to a variety of different tones of voice to see if the individual can distinguish the underlying feeling behind the tone.
  19. An assessment should also investigate other senses (both sensory issues and emotional empathy or “empath” characteristics). These questions need to be asked in a certain way as many females are literal, so a careful exploration is essential. An investigation of synaesthesia may be warranted.
  20. An assessment should also explore social naivety, the differences between lying and ‘white lies’, ‘pink lies’, social diplomacy, social tact and theory of mind.
  21. For teens and women, how do you know when someone is flirting with you or wants to go on a date with you? Do you know how to diplomatically reject the advance of another person? Professional Tip: Assertiveness training is essential for many females.
  22. In relation to gender and sexuality, a smaller group of girls (and boys) feel confused by their gender, and this can range from mild to severe. A thorough exploration of this issue often finds the individual relating better to the opposite gender, with girls getting along better with boys, being androgynous and/or Tomboy-like, and boys seeing other females as very socially successful and appearing to have lots of friends. Sometimes, an individual in their search for why they are different or why the social aspect of their life are so much more work for them, then come to the conclusion, for a variety of reasons (the feeling that others do not like or accept them, they do not like themselves, always having that feeling of being “different” to their peers), that they may have been born in the wrong body (they may be able to have more friends or be liked more, feel more accepted, feel “better” inside their body, be happier within themselves and within their family, be socially better or more popular), if they change their gender or their sexuality. Rarely, does changing one’s gender or sexuality fix the underlying social communication and identity issues, including being bullied, ignored or excluded and/or self-esteem challenges. Depending on how rigid or black and white the person is in their thinking, this can be a challenging issue to work on with the person.
  23. An exploration of identity in teenagers and women is important. This is because, over time, an assimilation of other people’s characteristics traits, voices, accents, behaviors has occurred, in addition to what others and society expect of them and from them. This high price (masking) often leads to a complete loss of identity.
  24. Many professionals are not aware that females can and do make eye contact, do make superficial conversation for short periods of time, and can have friends.
  25. Many professionals are unaware of the variety of sub-type presentations of girls across the Spectrum, with the ‘princess’ or ‘supermodel’ type, and/or those with higher intelligence, being the ones to be least diagnosed or diagnosed at a much later age. They are often Twice-exceptional (2e) individuals and blend in very well.
  26. Strengths and abilities are often overlooked due to the “presenting problem(s)”. Once these are addressed, then can an individual’s true gifts (for example, perfect pitch, artistic creativity, acting, dancing, programming, languages, just to name a few) can be nurtured and evolve into careers.
  27. Individuals on the Spectrum can and do lie, just like anyone else does. They dont do it as well as their peers and the reasons for lying may be different
  28. In terms of friendships, females are able to make friends, however they can often have a challenging time keeping them.
  29. A females sense of justice and high moral compass can be a clue and some females have been known to take their enlarged justice glands too far in their causes.
  30. Females with social problems often use their intelligence (sometimes quite successfully) to compensate for their lack of social skills, often falling into leadership roles, caring roles, teaching roles, acting roles, lawyers, professors, amongst other, where social reciprocity is least expected and social scripts (and slides!) can be adhered too.

Briefly, what we need to be asking are the right questions, looking and searching for and asking about questions that have to do with social confusion, camouflaging (how are the hiding it?), compensatory mechanisms (strategies they use to attempt to fit in, hide their confusion), eating disorders, gender, sexuality (if appropriate) and identity issues.

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This is a sample chapter of ‘Behind The Mask’, and is therefore under copyright law. In Part I of this book, it  explores the narratives and themes of the neurodiverse female clients that Tania has worked with over the course of her 20-year career. Part II includes chapters on assessment, diagnosis, how to explain the diagnosis, what next and support and intervention. For more information on female neurodiversity, go to:

http://www.aspiengirl.com

http://www.taniamarshall.com

Copyright 2014-2017 © All rights reserved. Duplication in whole or part is explicitly forbidden. Thank you.

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