Asperger’s Syndrome in Females – A biased perception.

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Tony Attwood (2006) observed that parents and teachers often send boys for evaluation at the point when their aggressive behaviour becomes a significant problem at home or school. The practice of making referrals based on acting out behaviour, means that overall, more boys will be evaluated, and the perception that aggressive behaviour is significant in AS may mean that parents and teachers overlook children who do not display disruptive behaviour (Attwood, 2006; Wagner, 2006). Girls, for example, may not have tantrums or meltdowns at school, but may instead, refuse to respond to requests or participate in activities (Wilkinson, 2008).

An often present feature in Asperger syndrome is an intense interest in one or more areas (Beteta, 2009), and long, encyclopaedic monologues, often on obscure subjects, are usually recognized as indicating a possible AS diagnosis in boys (Attwood, 2006). Findings suggest, though, that girls tend to have more age-appropriate interests, that generally reflect those of their peers, e.g., horses, or creative pursuits (Attwood, 2006; Beteta, 2009).

Attwood (2006) emphasizes, however, that the dominant role these interests play in the life of a girl with AS is qualitatively different from the role that the same interests play in the lives of her female peers. Attwood (2006) stresses further that a girl’s intense interests can extend well beyond an appropriate age,  and that this can help to determine abnormal intensity and focus.

Overall, these observations suggest that increased insight into how these interests function differently for girls with AS, may help to clarify diagnosis.

The use of social echolalia, i.e., mimicking others through imitation and modelling, exists almost exclusively in girls with Asperger syndrome  (Beteta, 2009; Wilkinson, 2008). In an effort to reduce their social and communication impairments, girls may copy the mannerisms, voice, persona, and behaviour of others, often quite successfully (Attwood, 2006).

However, Beteta (2009) points out that although girls may seem to benefit from the use of social echolalia, often they do not truly understand the contextual meanings of what they are mimicking.

Ryden and Bejolet (2008) found that adult females also seemed more successful at mimicking social behaviour than adult males, and for this reason, they rarely fit the original description of Asperger syndrome.

This suggests that the use of social echolalia may hinder the recognition and diagnosis of AS, and consequently, access to relevant support (Attwood, 2006), and that girls and women may experience increased stress in dealing with the consequences of mimicking behaviours that they may not quite understand.

Overall, a greater awareness of gender differences in phenotypic expression is vital so that girls will receive an accurate diagnosis, and access to services that could lessen the impact of AS, particularly beyond childhood.

Furthermore, as researchers discover the extent to which statistical gender differences translate into clinical significance, it is likely that support services will need modification to accommodate this new knowledge (Giarelli et al., 2010).

Differences in attitudes and behaviour towards females with Asperger Syndrome may also contribute to a delayed or missed diagnosis (Giarelli et al., 2010; Hartley & Sikora, 2009).

Attwood (2006) noticed that parents were more hesitant to seek a formal diagnosis if their daughters appeared to be functioning adequately, and that clinicians tended to hesitate in making a diagnosis unless the signs were quite conspicuous. This reinforces the observation made by Hully and Lamar (2006) that AS traits need to be exaggerated in females for a formal diagnosis.

In contrast to boys with AS, who are more often teased, ignored, or bullied by their male peers, girls more often experience support and even protection from some of their female peers, which could result in failure to recognize significant social impairments (Attwood, 2006). Beteta (2009) stresses that these friendships rely on the willingness of a girl’s peers, and accordingly, Rastam (2008) found that many girls with AS tended to have only one friendship that was usually tenuous in nature, and few peer relations overall.

In addition, the perception that many girls with Asperger syndrome seem to manage in social situations, can cause others to question the accuracy of diagnosis.

One result may be that when a girl exhibits behaviour common to AS, it is misunderstood as deliberate or wilful (Beteta, 2009), and she may not receive the necessary supports. Cooper and Hanstock (2009) found, for instance, that school staff continued to feel that Jane’s behaviour was “put on”, even after she received a diagnosis of Asperger syndrome.

Moreover, parents and teachers often connect social and functioning difficulties with intrinsic personality traits rather than to a developmental disorder like AS (Cooper & Hanstock, 2009). Specifically, they may misinterpret deficits in social skills, such as poor eye contact, as signs of shyness, embarrassment, or naivety (Wagner, 2006).

Girl’s social impairments, for example, are often misconstrued as stemming from their reserved natures, hence girls initially received an incorrect diagnosis of early onset anxiety disorder (Wilkinson, 2008).

In conclusion, there are a number of possible explanations for the 10:1 gender ratio in Asperger syndrome. Some think that the large number of diagnosed males accurately reflects natural sex differences in brain specialization, or points to sex-specific genetic susceptibility to AS (e.g., Baron-Cohen &Wheelwright, 2004; Jones et al., 2008).

Others believe that the current gender ratio misrepresents the incidence of AS in females (Thompson et al., 2003).

A biased perception of how AS presents may contribute to underdiagnosis (Attwood, 2006; Beteta, 2009), as many emphasize the overuse of a male prototype (e.g., Hully & Lamar, 2006; Thompson et al., 2003). Clinicians may attribute symptoms to psychiatric disorders more commonly seen in the general female population (Cooper & Hanstock, 2009; Rastam, 2008; Ryden & Bejolet, 2008), gender differences in phenotypic expression could mean that core impairments go unnoticed or are misinterpreted (Attwood, 2006; Beteta, 2009; Wilkinson, 2008), and the attitudes and behaviour of others towards females with AS may also contribute to underdiagnosis (Cooper & Hanstock, 2009; Wagner, 2006).

It is clear that one explanation for the uneven gender ratio is not sufficient on its own. The reasons are multifaceted and complex, and it is likely that other possibilities will emerge with additional research.

However, a greater understanding of gender differences in Asperger syndrome will likely play a large role in balancing the 10:1 ratio, as more females will receive an accurate diagnosis.

Written by A. MacMillan

The Importance of Identifying Asperger’s Syndrome / High Functioning Autism in Adults

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“Growing up with undiagnosed Asperger’s Syndrome can be traumatic for many individuals.”

Many adults with undiagnosed Asperger’s Syndrome are usually keenly aware that they do not ‘fit in’, yet are unable to either express or understand exactly what it is that makes them feel differently to others.

For this reason many undiagnosed adults develop negative perceptions of themselves as “weird”, “crazy,” or “broken.”

Despite these negative self-images, many undiagnosed adults are able to hide their difficulties by developing coping mechanisms, such as mirroring or mimicking those around them in social settings.

They are therefore seen as being able to engage in the everyday routines of life such as working, having relationships, getting married and having children.

Yet though they have the ability to apply such coping mechanisms, many individuals with undiagnosed AS, are never able to shake off the underlying awareness of themselves as inherently ‘different’ to those around them.

Ironically, the very skill sets that adults with undiagnosed moderate to mild Asperger’s apply, in order to try and ‘fit in,’ have meant that they have flown “under the diagnostic radar”.

Other individuals with undiagnosed AS, who have not learnt such skill sets, may show greater signs of having social communication difficulties.

This can make them more susceptible to situations such as chronic unemployment and social isolation due to the fact that they may be mistakenly perceived as people who are deliberately anti-social, argumentative, objectionable or aloof loners who crave only their own company.

In reality, these people may be individuals who are displaying the lack of social skills required to communicate and act appropriately, that make up the characteristics or traits commonly described in Asperger’s Syndrome.

It is now well established that individual with AS may display varying degrees of some or all of the following characteristics:

A lack of social skills which manifest in inappropriate social approaches, responses or social awkwardness.

Difficulty recognizing the facial expressions or emotions of others.

Difficulties in considering or understanding others’ viewpoints.

Limited interest in friendships


Difficulties with being able to communicate their ideas, thoughts and emotions.

Difficulties in comprehending and following social reasoning and adhering to the status quo.

Difficulty with transitions and changes.

Hold a strong need for routines.

Narrow range of interests or idiosyncratic special interests.

Be overly sensitive to sounds, tastes, smells and sights.

Have motor coordination difficulties.

Experience difficulty managing their own negative feelings, especially anxiety, anger and depression

Adults with undiagnosed AS are susceptible to experiencing high degrees of stress, frustration, confusion and anxiety due to their awareness that they do not ]fit in’.

These additional difficulties have often been misinterpreted, misdiagnosed, misunderstood and mistreated, especially when their underlying AS is undiagnosed or not adequately understood.

Some of the most common additional difficulties include:

Angry outbursts (physical or verbal aggression, verbally threatening behavior)

Agitation and restlessness

Increase in obsessive or repetitive activities, thoughts, or speech

Low mood or depression

Apathy and inactivity

Unfortunately many professionals who are unfamiliar with AS often only focus on the surface symptoms and behaviors that an individual with undiagnosed AS may display.

This leaves individuals with undiagnosed AS at risk of being incorrectly diagnosed with conditions such as:

Personality Disorders

Psychosis

Bipolar Disorder

Obsessive Compulsive Disorder

Mood disorder

It is therefore essential, that in order to prevent individuals with undiagnosed Asperger’s Syndrome from being incorrectly diagnosed with conditions, treatment plans and medications that will not help them, that a thorough Autism assessment must be applied to adults who fall within this criteria.

A proper diagnosis of AS can better help adults put their difficulties into perspective and enable them to understand the underlying reasons for their lifelong struggles.

Correct diagnosis and effective treatment can help improve self-esteem, work performance and skills, educational attainment and social competencies.

More importantly a correct diagnosis can trigger both a journey of self-discovery and a healing process for the individuals concerned. 

 

Tony Attwood – The Pattern of Abilities and Development for Girls with Asperger’s Syndrome

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The overwhelming majority of referrals for a diagnostic assessment for Asperger’s Syndrome are boys. The ratio of males to females is around 10:1, yet the epidemiological research for Autistic Spectrum Disorders suggests that the ratio should be 4:1. Why are girls less likely to be identified as having the characteristics indicative of Asperger’s Syndrome? The following are some tentative suggestions that have yet to be validated by academic research, but they provide some plausible explanations based on preliminary clinical experience.

It appears that many girls with Asperger’s Syndrome have the same profile of abilities as boys but a subtler or less severe expression of the characteristics. Parents may be reluctant to seek a diagnostic assessment if the child appears to be coping reasonably well and clinicians may be hesitant to commit themselves to a diagnosis unless the signs are conspicuously different to the normal range of behaviour and abilities.

We have a stereotype of typical female and male behaviour. Girls are more able to verbalise their emotions and less likely to use physically aggressive acts in response to negative emotions such as confusion, frustration and anger. We do not know whether this is a cultural or constitutional characteristic but we recognise that children who are aggressive are more likely to be referred for a diagnostic assessment to determine whether the behaviour is due to a specific developmental disorder and for advice on behaviour management. Hence boys with Asperger’s Syndrome are more often referred to a psychologists or psychiatrist because their aggression has become a concern for their parents or schoolteacher. A consequence of this referral bias is that not only are more boys referred, clinicians and academics can have a false impression of the incidence of aggression in this population.

One must always consider the personality of the person with Asperger’s Syndrome and how they cope with the difficulties they experience in social reasoning, empathy and cognition. Some individuals are overtly active participants in social situations. Their unusual profile of abilities in social situations is quite obvious. However, some are reluctant to socialize with others and their personality can be described as passive. They can become quite adept at camouflaging their difficulties and clinical experience suggests that the passive personality is more common in girls.

Each person with Asperger’s Syndrome develops their own techniques and strategies to learn how to acquire specific skills and develop coping mechanisms. One technique is to have practical guidance and moral support from one’s peers. We know that children with Asperger’s Syndrome elicit from others, either strong maternal or ‘predatory’ behaviour. If the person’s natural peer group is girls, they are more likely to be supported and included by a greater majority of their peers. Thus girls with Asperger’s Syndrome are often ‘mothered’ by other girls. They may prompt the child when they are unsure what to do or say in social situations and comfort them when they are distressed. In contrast, boys are notorious for their intolerance of children who are different and are more prone to be ‘predatory’. This can have an unfortunate effect on the behaviour of a boy with Asperger’s Syndrome and many complain of being teased, ignored and bullied by other boys. It is interesting to note that some boys with Asperger’s Syndrome actually prefer to play with girls who are often kinder and more tolerant than their male peers.

The author has conducted both individual and group social skills training with boys and girls with Asperger’s Syndrome. Experience has indicated that, in general, the girls are more motivated to learn and quicker to understand key concepts in comparison to boys with Asperger’s Syndrome of equivalent intellectual ability. Thus, they may have a better long-term prognosis in terms of becoming more fluent in their social skills. This may explain why women with Asperger’s Syndrome are often less conspicuous than men with the syndrome and less likely to be referred for a diagnostic assessment. The author has also noted that, in general, mothers with Asperger’s Syndrome appear to have more ‘maternal’ and empathic abilities with their own children than men with Asperger’s Syndrome, who can have great difficulty understanding and relating to their children.

Some individuals with Asperger’s Syndrome can be quite ingenious in using imitation and modelling to camouflage their difficulties in social situations. One strategy that has been used by many girls and some boys is to observe people who are socially skilled and to copy their mannerisms, voice and persona. This is a form of social echolalia or mirroring where the person acquires a superficial social competence by acting the part of another person. This is illustrated in Liane Holliday-Willeys intriguing new autobiography, titled, “Pretending to be Normal’.

“I could take part in the world as an observer. I was an avid observer. I was enthralled with the nuances of people’s actions. In fact, I often found it desirable to become the other person. Not that I consciously set out to do that, rather it came as something I simply did. As if I had no choice in the matter. My mother tells me I was very good at capturing the essence and persona of people. At times I literally copied someone’s looks and their actions. I was uncanny in my ability to copy accents, vocal inflections, facial expressions, hand movements, gaits and tiny gestures. It was as if I became the person I was emulating. (p.22)”

Girls are more likely to be enrolled in speech and drama lessons and this provides an ideal and socially acceptable opportunity for coaching in body language. Many people with Asperger’s Syndrome have a prodigious memory and this can include reciting the dialogue for all characters in a play and memorizing the dialogue or ‘script’ of real life conversations. Knowing the script also means the child does not have to worry about what to say. Acting can subsequently become a successful career option although there can be some confusion when adults with Asperger’s Syndrome act another persona in real life as this can be misconstrued as Multiple Personality Disorder rather than a constructive means of coping with Asperger’s Syndrome.

When a child would like more friends but clearly has little success in this area, one option is to create imaginary friends. This often occurs with young girls who visualise friends in their solitary play or use dolls as a substitute for real people. Girls with Asperger’s Syndrome can create imaginary friends and elaborate doll play which superficially resembles the play of other girls but there can be several qualitative differences. They often lack reciprocity in their natural social play and can be too controlling when playing with their peers. This is illustrated in Liane Holliday-Willey’s autobiography.

“The fun came from setting up and arranging things. Maybe this desire to organise things rather than play with things, is the reason I never had a great interest in my peers. They always wanted to use the things I had so carefully arranged. They would want to rearrange and redo. They did not let me control the environment.”

When involved in solitary play with dolls, the girl with Asperger’s Syndrome has total control and can script and direct the play without interference and having to accept outcomes suggested by others. The script and actions can be an almost perfect reproduction of a real event or scene from a book or film. While the special interest in collecting and playing with dolls can be assumed to be an age appropriate activity and not indicative of psychopathology, the dominance and intensity of the interest is unusual. Playing with and talking to imaginary friends and dolls can also continue into the teenage years when the person would have been expected to mature beyond such play. This quality can be misinterpreted as evidence of hallucinations and delusions and a diagnostic assessment for schizophrenia rather than Asperger’s Syndrome.

The most popular special interests of boys with Asperger’s Syndrome are types of transport, specialist areas of science and electronics, particularly computers. It has now become a more common reaction of clinicians to consider whether a boy with an encyclopaedic knowledge in these areas has Asperger’s Syndrome. Girls with Asperger’s Syndrome can be interested in the same topics but clinical experience suggests their special interest can be animals and classic literature. These interests are not typically associated with boys with Asperger’s Syndrome. The interest in animals can be focussed on horses or native animals and this characteristic dismissed as simply typical of young girls. However, the intensity and qualitative aspects of the interest are unusual. Teenage girls with Asperger’s Syndrome can also develop a fascination with classic literature such as the plays of Shakespeare and poetry. Both have an intrinsic rhythm that they find entrancing and some develop their writing skills and fascination with words to become a successful author, poet or academic in English literature. Some adults with Asperger’s Syndrome are now examining the works of famous authors for indications of the unusual perception and reasoning associated with Asperger’s Syndrome. One example is the short story, “Cold” in ‘Elementals: Stories of Fire and Ice’ by A.S. Byatt.

Finally, the author has noted that some ladies with Asperger’s Syndrome can be unusual in their tone of voice. Their tone resembles a much younger person, having an almost child like quality. Many are concerned about the physiological changes during puberty and prefer to maintain the characteristics of childhood. As with boys with Asperger’s Syndrome, they may see no value in being fashionable, preferring practical clothing and not using cosmetics or deodorants. This latter characteristic can be quite conspicuous.

These tentative explanations for the apparent under representation of girls with Asperger’s Syndrome have yet to be examined by objective research studies. It is clear that we need more epidemiological studies to establish the true incidence in girls and for research on the clinical signs, cognitive abilities and adaptive behaviour to include an examination of any quantitative and qualitative differences between male and female subjects. In the meantime, girls with Asperger’s Syndrome are likely to continue to be overlooked and not to receive the degree of understanding and resources they need.

Originally sourced from cloudnine.wordpress.com

Reference:
Holliday-Willey, L. (1999) Pretending to be Normal: Living with Asperger’s Syndrome. London. Jessica Kingsley Publications.