Current diagnostic practices focus on the core ASC characteristics that have been historically established from the behavioural presentation in males, and so do not necessarily reflect the areas in which females with ASC may display different behaviours to males. These ‘qualitative’ differences between male and female presentation, including camouflaging behaviours, need to be included in measures used to assess ASC, as sex differences at a nosological level are likely to have an impact on diagnosis (Lai et al. For instance, males with ASC are more likely to experience externalising difficulties such as hyperactivity and conduct problems, whereas females with ASC are more likely to experience internalising problems such as anxiety and depression (May et al. 2014), comparisons of associated characteristics have shown differences between the female and male presentations (Kreiser and White 2014 Rivet and Matson 2011). While few significant quantitative sex differences in the core symptoms have been found (Hull et al. In addition to camouflaging, there are other gender differences in autistic characteristics which may contribute to late diagnosis or misdiagnosis of females. Clinical experience suggests that females with ASC may be more likely than males with ASC to have been previously misdiagnosed with other mental health conditions, such as personality disorders or eating disorders (Lai and Baron-Cohen 2015 Mandy and Tchanturia 2015). 2009) and behavioural-emotional challenges (Duvekot et al. 2011), and those who receive a diagnosis on average are more likely than males receiving the same diagnosis to be older and have more additional needs, including increased intellectual disability (Shattuck et al. Females are less likely to receive a diagnosis of ASC than males with similar levels of autistic traits (Dworzynski et al. This discrepancy suggests that there are biases that work against females with ASC receiving accurate, timely diagnoses from clinical services. Amongst clinical samples, male to female gender ratios for ASC diagnosis are generally around 4:1 (Fombonne 2009), but when active case ascertainment is used within the general population, the ratio lowers to around 3:1 (Sun et al. 2016), unlike ordinary reputation management in typically developing individuals.Ĭamouflaging has also been proposed as an explanation for the missed or late diagnosis of females with ASC, as part of the female phenotype or behavioural presentation (Gould and Ashton-Smith 2011 Kirkovski et al. For instance, camouflaging by ASC individuals has been reported as extremely effortful and challenging to one’s identity (Bargiela et al. However, self-reported evidence suggests possible categorical differences between autistic and non-autistic camouflaging. Camouflaging is likely to exist on a spectrum (similar to autistic traits) in those who have an ASC diagnosis and those who are subclinical. However, the research in this area has focused on the manipulation of typical social behaviours, rather than how individuals with ASC may want and be able to adapt their ASC-related characteristics. 2011), research suggests that individuals with ASC have a reduced ability to do so (Cage et al. While many neurotypical people, of all genders, manage the way others perceive them in social situations (Izuma et al. In this paper we will refer to these behaviours as ‘camouflaging’. These strategies may include hiding behaviours associated with their ASC, using explicit techniques to appear socially competent, and finding ways to prevent others from seeing their social difficulties. One behaviour associated with ASC that has recently attracted interest is the development of camouflaging or coping strategies for use in social situations (Attwood 2007 Gould and Ashton-Smith 2011 Kopp and Gillberg 2011 Lai et al. ASC is generally viewed as dimensional, with traits found amongst the general population and a specified cut-off point, when present with concurrent functional impairments, used to identify the clinical diagnosis (Baron-Cohen et al. Autism Spectrum Conditions (ASC) 1 are atypical developmental conditions characterised by impairments in social interaction and communication, alongside unusually restricted/repetitive behaviours and interests, need for sameness, and atypical sensory processing (APA 2013).
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