The presentation, recognition and diagnosis of autism in women and girls

DSM-5 based algorithms for the Autism Diagnostic Interview-Revised for children ages 4-17 years

BACKGROUND

The Autism Diagnostic Interview, Revised (ADI-R) is a caregiver interview that is widely used as part of the diagnostic assessment for Autism Spectrum Disorder (ASD). Few large-scale studies have reported the sensitivity and specificity of the ADI-R algorithms, which are based on DSM-IV Autistic Disorder criteria. Kim and Lord (Journal of Autism and Developmental Disorders, 2012, 42, 82) developed revised DSM-5-based toddler algorithms, which are only applicable to children under 4 years. The current study developed DSM-5-based algorithms for children ages 4-17 years and examined their performance compared to clinical diagnosis and to the original DSM-IV-based algorithms.

METHODS

Participants included 2,905 cases (2,144 ASD, 761 non-ASD) from clinical-research databanks. Children were clinically referred for ASD-related concerns or recruited for ASD-focused research projects, and their caregivers completed the ADI-R as part of a comprehensive diagnostic assessment. Items relevant to DSM-5 ASD criteria were selected for the new algorithms primarily based on their ability to discriminate ASD from non-ASD cases. Algorithms were created for individuals with and without reported use of phrase speech. Confirmatory factor analysis tested the fit of a DSM-5-based two-factor structure. ROC curve analyses examined the diagnostic accuracy of the revised algorithms compared to clinical diagnosis.

RESULTS

The two-factor structure of the revised ADI-R algorithms showed adequate fit. Sensitivity of the original ADI-R algorithm ranged from 74% to 96%, and specificity ranged from 38% to 83%. The revised DSM-5-based algorithms performed similarly or better, with sensitivity ranging from 77% to 99% and specificity ranging from 71% to 92%.

CONCLUSIONS

In this large sample aggregated from US clinical-research sites, the original ADI-R algorithm showed adequate diagnostic validity, with poorer specificity among individuals without phrase speech. The revised DSM-5-based algorithms introduced here performed comparably to the original algorithms, with improved specificity in individuals without phrase speech. These revised algorithms offer an alternative method for summarizing ASD symptoms in a DSM-5-compatible manner.

Understanding autistic youths' menstrual product preferences and caregivers' product choices

LAY ABSTRACT

There is little research exploring the menstrual product preferences of autistic youth, especially those who recently started their period. Study authors surveyed caregivers' choice of menstrual products for their autistic children. They provided popular menstrual materials to autistic youth to try, then asked them which product(s) they preferred, did not try, and why they did not try it. Caregivers selected sensory impact as the most important feature they consider when choosing a menstrual product for their child, and youth participants preferred to use period underwear. Therefore, autistic youth may benefit from purchasing and using period underwear, and caregivers, clinicians, and companies should consider the impact of menstrual product features, like sensory sensitivities, on young autistic menstruators and how best to support them.

Being a Woman Is 100% Significant to My Experiences of Attention Deficit Hyperactivity Disorder and Autism: Exploring the Gendered Implications of an Adulthood Combined Autism and Attention Deficit Hyperactivity Disorder Diagnosis

This article provides original insight into women's experiences of adulthood diagnoses of attention deficit hyperactivity disorder (ADHD) and autism. Research exploring experiences of adulthood diagnoses of these conditions is emerging. Yet, there is no research about the gendered experiences of an adulthood combined ADHD and autism (AuDHD) diagnosis. This article addresses this gap through interpretative phenomenological analysis of email interviews with six late-diagnosed AuDHD women revealing the complex interplay between late diagnosis, being a woman, and combined diagnoses of ADHD and autism. It underscores how gender norms and stereotypes contribute to the oversight and dismissal of women's neurodivergence. Interpretative phenomenological analysis reveals the inextricability of femininity and neurotypicality, the gendered burden, discomfort, and adverse consequences of masking, along with the adverse outcomes of insufficient masking. Being an undiagnosed AuDHD woman is a confusing and traumatising experience with profound and enduring repercussions. The impact of female hormones exacerbated participants' struggles with (peri)menopause often being a catalyst for seeking diagnosis after decades of trauma. The epistemic injustice of not knowing they were neurodivergent compounded this trauma. Diagnosis enabled participants to overcome epistemic injustice and moved them into a feminist standpoint from which they challenge gendered inequalities relating to neurodiversity. This article aims to increase understanding and representation of late-diagnosed AuDHD women's lived experiences. The findings advocate for trauma-informed pre- and post-diagnosis support which addresses the gendered dimension of women's experiences of being missed and dismissed as neurodivergent. There needs to be better clinical and public understanding of how AuDHD presents in women to prevent epistemic injustice.

Autism and sexual and gender minority identity in college students: Examination of self-reported rates, functional outcomes, and treatment engagement

LAY ABSTRACT

Autistic individuals and those who identify with a sexual and/or gender minority are both at risk for various mental health concerns and related impairments. However, the connection between autism and sexual and/or gender minorities and mental health and functional outcomes is not clear. Here, we provide evidence of these connections by analyzing data from a large nationally representative dataset from the American College Health Association-National College Health Assessment III. We found that autistic college students who identify with both sexual and gender minorities reported the highest rates of stress, academic, and mental health concerns including suicidality when compared with autistic college students with or without a sexual and/or gender minority. In addition, college students with at least two identities, such as autism and a sexual minority identity or both a sexual and gender minority identity, reported the next highest rates of concern. These findings affirm the need for mental healthcare providers to consider the intersections of a sexual and gender minority identities in non-autistic and, especially, in autistic college students to develop and provide better support and resources.

Emotion regulation and emotion dysregulation in children and adolescents with Autism Spectrum Disorder: A meta-analysis of evaluation and intervention studies

Children and adolescents with Autism Spectrum Disorder (ASD) often experience challenges in emotion regulation (ER) and emotion dysregulation (ED) which can interfere with their adaptive functioning. This study aimed to systematically review and meta-analyze the evidence on ER/ED in children and/or adolescents with ASD, examining its relationship with the following variables: internalizing and externalizing symptoms, cognitive function and social skills, and the effectiveness of non-pharmacological interventions addressing ER difficulties. Both electronic and manual searches were conducted to identify potential studies. Fifty-five studies were included in the meta-analysis. A statistically significant between-group difference was found, suggesting greater ER/ED challenges in the ASD group. Also, the ASD group showed more maladaptive ER strategies and fewer adaptive ER strategies compared to the non-ASD participants. Additionally, more severe ASD and poorer social skills were associated with greater ED and poorer ER skills, respectivelly. Furthermore, there was a significant correlation between internalizing symptomatology and both adaptive and maladaptive ER strategies. Studies of non-pharmacological interventions showed significant improvement in both ER and ED. These results imply that assessing ER/ED in children and adolescents with ASD should be part of the evaluation process, and it should also be a focal point for intervention in this population.

The Diagnosis and Management of Autism Spectrum Disorder (ASD) in Adult Females in the Presence or Absence of an Intellectual Disability

We review the reasons for the greater male predominance in the diagnosis of autism spectrum disorder in the non-intellectual disabled population and compare it to autism diagnosed in intellectually disabled individuals. Accurate and timely diagnosis is important, as it reduces health inequalities. Females often present later for the diagnosis. The differences are in core features, such as in social reciprocal interaction through 'camouflaging' and restricted repetitive behaviours, that are less noticeable in females and are potentially explained by the biological differences (female protective effect theory) and/or differences in presentation between the two sexes (female autism phenotype theory). Females more often present with internalising co-occurring conditions than males. We review these theories, highlighting the key differences and the impact of a diagnosis on females. We review methods to potentially improve diagnosis in females along with current and future management strategies.

Autistic women's diagnostic experiences: Interactions with identity and impacts on well-being

OBJECTIVE

There has been suggestion that current diagnostic instruments are not sufficient for detecting and diagnosing autism in women, and research suggests that a lack of diagnosis could negatively impact autistic women's well-being and identity. This study aimed to explore the well-being and identity of autistic women at three points of their diagnostic journey: self-identifying or awaiting assessment, currently undergoing assessment or recently diagnosed, and more than a year post-diagnosis.

METHODS

Mixed-methods were used to explore this with 96 women who identified as autistic and within one of these three groups. Participants completed an online questionnaire, and a sub-sample of 24 of these women participated in a semi-structured interview.

RESULTS

Well-being was found to differ significantly across groups in three domains: satisfaction with health, psychological health, and environmental health. Validation was found to be a central issue for all autistic women, which impacted their diagnosis, identity, and well-being. The subthemes of don't forget I'm autistic; what now?; having to be the professional; and no one saw me were also identified.

CONCLUSION

These results suggest that autistic women's well-being and identity differ in relation to their position on the diagnostic journey in a non-linear manner. We suggest that training on the presentation of autism in women for primary and secondary healthcare professionals, along with improved diagnostic and support pathways for autistic adult women could go some way to support well-being.