Barriers to an Autistic Identity: How RRBs may Contribute to the Underdiagnosis of Females.
Autistic girls display more sensory and subtle repetitive behaviors that traditional diagnostic tools often miss, contributing to underdiagnosis.
01Research in Context
What this study did
Spackman et al. (2023) looked at how autistic girls and boys show different repetitive and sensory behaviors.
They studied the kinds of behaviors that current autism checklists count as restricted and repetitive.
The goal was to see if girls display subtler patterns that standard tools overlook.
What they found
Girls with autism showed more tactile sensory behaviors, such as rubbing or tapping fabrics.
Boys more often had the stereotypic movements that checklists usually flag, like hand-flapping.
Because the girls’ behaviors are less obvious, clinicians may miss the diagnosis.
How this fits with other research
Begeer et al. (2013) already showed that girls are identified later than boys; this new work gives a behavioral reason why.
Sutton et al. (2022) found the same sex gap on the CARS2 and GARS-3, with girls scoring lower on most repetitive items.
Sasson et al. (2018) seems to disagree: trans and non-binary autistic adults report less sensory hypersensitivity, not more. The difference is population—cis girls show tactile seeking, while gender-diverse adults show reduced auditory and visual sensitivity.
Delgado-Lobete et al. (2020) add that autistic women also camouflage more, so the subtle RRBs are hidden behind social masking.
Why it matters
If you rely only on stereotypic movements to flag autism, you will under-count girls.
Add sensory-seeking questions and watch for quiet tactile habits during play or work tasks.
A small tweak in your intake form can catch the clients who would otherwise slip through.
Want CEUs on This Topic?
The ABA Clubhouse has 60+ free CEUs — live every Wednesday. Ethics, supervision & clinical topics.
Join Free →Add one sensory-seeking item line to your observation sheet and note any quiet rubbing, tapping, or fabric play during the next session.
02At a glance
03Original abstract
BACKGROUND: Autistic females are frequently underdiagnosed, misdiagnosed, and/or diagnosed later in life. Restricted and Repetitive Behaviors (RRBs) are increasingly critical for diagnosis and yet are commonly rated lower in females. Whether this reflects genuinely lower levels of these traits, or if female-typical RRBs have a different phenotypic presentation that may not register on current quantitative measurement tools is unclear. METHODS: Twenty-one autistic females and 21 autistic males matched on chronological age and FSIQ completed the AQ, ADOS-2, and ADI-R. Items from the ADOS-2 and ADI-R were selected that were relevant to the four areas of restricted and repetitive behavior in the DSM-5 diagnostic criteria of autism. Using a mixed-methods analytical approach, scores and comments on these measures were compared between sexes to better characterize RRBs in autistic females. RESULTS: There were no sex differences on the AQ, which broadly assesses autistic traits. When analyzed by the four DSM-5 RRB criteria, there were no sex differences on the ADI-R when using traditional algorithm scoring that narrows questions down to those that are more sensitive and specific in capturing autism in research samples with a high proportion of males. When incorporating additional items relevant to the DSM-5 to identify sex changes in a broader pool of items, females scored higher on stereotyped movements and speech. Females also engaged in more sensory behaviors during the ADOS-2. Qualitative analyses indicated that females were more likely to engage in stereotyped body rocking and spinning, stereotyped behaviors when anxious, to show major reactions to changes, repetitive language including listing and counting, and sensory behaviors, especially in the tactile domain. CONCLUSION: Exploratory findings highlight sex differences in RRBs that may help enhance diagnostic clarity for females. Higher tactile sensory behaviors in females suggests there may be increased diagnostic sensitivity for females with the updated DSM-5 that now includes sensory components as part of the diagnostic criteria.
Research in autism spectrum disorders, 2023 · doi:10.1101/412619