Diagnosis of females with autism
Diane Adreon, M.S.
There has been considerable discussion among parents and professionals about the way females with autism spectrum disorders (ASD) demonstrate their major characteristics. Some females have obvious social difficulties, whereas others appear to have excellent skills because they imitate the behaviors of others – often without understanding them. I suspect that there are many girls with ASD who do not receive an ASD diagnosis, possibly because, compared to boys, (a) their clinical presentation is “different,” (b) their “special interests” are different, and/or (c) they appear to have fairly good social interaction skill, particularly when interacting with adults in a one-to-one situation.
What’s needed are good diagnostic instruments that address the profile of girls on the spectrum. To date, only one instrument has been normed on girls: The Social Responsiveness Scale (SRS; Constantino, 2005). The SRS is a useful tool to assist in the diagnosis of individuals with subtle symptom presentation, including girls and women. This 65-item scale measures the severity of core autism spectrum symptoms in natural social settings. Specifically, it examines social impairments by assessing social awareness, social information processing, reciprocal social communication, social anxiety/avoidance, and autistic preoccupations and traits.
One of the major advantages of the SRS over other instruments examining symptoms of autism is that it measures symptom severity/social impairment on a quantitative scale, which rates behaviors from 1 to 4 on the basis of frequency.
Another advantage of the SRS is that it relies on the observations of parents and teachers in naturalistic settings, compared to one of the “gold standard” diagnostic instruments for autism, the Autism Diagnostic Observation Schedule (ADOS; Lord, Rutter, DiLavore, & Risi, 2000), which relies on symptoms exhibited in a one-on-one testing situation. As mentioned, children with ASD with subtle symptom presentation may perform well in a one-on-one situation but may exhibit deficits on reciprocal social interaction in more complex social environments. As a result, their performance on an instrument like the ADOS may be misleading.
The SRS may be completed by either a parent or a teacher in approximately 15-20 minutes, and it is appropriate for children 4-18 years of age. Standardization is based on the responses of parents and teachers on a sample of 1,600 children from this age group in the general population. Norms are available by parent or teacher and by the child’s gender. Questions on the SRS are identical for both parent and teacher forms; however, scoring profiles are different for each group.
Testing yields a total score reflecting severity of social deficits, as well as five domains that may be used in determining treatment priorities. High scores are indicative of significant impairment in reciprocal social behavior.
The SRS has been shown to reliably differentiate between children with ASD and children with other psychiatric disorders, such as attention deficit-hyperactivity disorder, mood disorders, psychotic disorders, and conduct disorders (Constantino et al., 2003; Constantino, Przybeck, Friesen, & Todd, 2000).
To this writer’s knowledge, the SRS is the only rating scale for ASD that has different norms for males and females. As noted, this may be of particular importance because it is suspect that females with ASD may exhibit subtle symptoms that are often not detected by most of the instruments currently utilized for the assessment of ASD (Ernsperger & Wendel, 2007).
Clinicians should consider using the SRS to as an additional tool to obtain information of the reciprocal social behavior of individuals in the natural setting. It may be especially useful in assessing females who may have an ASD. Even in instances where the symptom presentation appears mild, deficits on reciprocal social behavior can have a major impact on one’s life. Recognition of problem areas is an essential prerequisite to accessing intervention that can target areas of need.
Constantino, J. N. (2005). Social Responsiveness Scale. Los Angeles: Western Psychological Services.
Constantino, J. N., Davis, S. A., Todd, R. D., Schindler, M. K., Gross, M. M., Brophy, S. L., Metzger, L. M., Shoushtari, C. S., Splinter, R., & Reich, W. (2003). Validation of a brief quantitative measure of autistic traits: Comparison of the Social Responsiveness Scale with the Autism Diagnostic Interview-Revised. Journal of Autism and Developmental Disorders, 33, 427-433.
Constantino, J. N., & Gruber, C. P. (2005). Social Responsiveness Scale manual. Los Angeles: Western Psychological Services.
Constantino, J. N., Przybeck, T., Friesen, D., & Todd, R. D. (2000). Reciprocal and social behavior in children with and without pervasive developmental disorders. Journal of Developmental and Behavioral Pediatrics, 21,2-11.
Constantino, J. N., & Todd, R.D. (2003). Autistic traits in the general population: A twin study. Archives of General Psychiatry, 60, 524-530. Retrieved January 15, 2008, from www.archgenpsychiatry.com.
Ernsperger, L., & Wendel, D. (2007). Girls under the umbrella of autism spectrum disorders: Practical solutions for addressing everyday challenges. Shawnee Mission, KS: Autism Asperger Publishing Company.
Lord, C., Rutter, M., DiLavore, P. C., & Risi, S. (2000). Autism Diagnostic Observation Schedule. Los Angeles: Western Psychological Services.
Diane Adreon, M.S., is Associate Director University of Miami/Nova Southeastern University Center for Autism & Related Disabilities co-author of Asperger Syndrome and Adolescence: Practical Solutions for School Success