Factors influencing the probability of a diagnosis of autism spectrum disorder in girls versus boys.
Girls need louder emotional red flags—and fewer repetitive ones—before they get an ASD label, so widen your lens.
01Research in Context
What this study did
The team looked at the preschoolers sent to an autism clinic. They asked: which behaviors push doctors to say "yes, ASD" for girls versus boys?
They pulled data from charts, rating scales, and ADOS scores. Then they ran odds ratios to see how each behavior changed the chance of a diagnosis.
What they found
Girls with lots of repetitive behaviors were less likely to get an ASD label than boys showing the same level. Odds dropped a large share.
But girls with big emotional or behavior problems were a large share more likely to be diagnosed. Social, sensory, and cognitive scores showed no sex gap.
How this fits with other research
Bitsika et al. (2019) extends this picture. They show that the sex gap flips once ADOS severity is high. Mild girls look "less autistic," severe girls look "more autistic." Same kids, different lens.
Gaines et al. (2025) also extends the story into sensory issues. They found girls actually score worse on hearing and balance items, yet these signs rarely trigger diagnosis. Together the papers hint girls must fail in louder, emotional ways before we notice.
Mantzoros et al. (2022) seems to clash at first. Their meta-analysis says repetitive vocal stereotypy is a prime treatment target, implying it is core to ASD. Jorieke says repetitive behavior can lower diagnosis odds in girls. The gap is viewpoint: Mantzoros asks "how do we treat it?" Jorieke asks "how do we see it?" Both can be true.
Why it matters
If you wait for classic repetitive play or flapping in girls, you may miss them. Add sensory and emotional checklists to your intake. When a girl shows meltdowns but little stimming, pause before ruling ASD out. Use the ADOS severity score and parent stress reports together. This small shift can catch girls who once slipped through the cracks.
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02At a glance
03Original abstract
In order to shed more light on why referred girls are less likely to be diagnosed with autism spectrum disorder than boys, this study examined whether behavioral characteristics influence the probability of an autism spectrum disorder diagnosis differently in girls versus boys derived from a multicenter sample of consecutively referred children aged 2.5-10 years. Based on information from the short version of the Developmental, Dimensional and Diagnostic Interview and the Autism Diagnostic Observation Schedule, 130 children (106 boys and 24 girls) received a diagnosis of autism spectrum disorder according to Diagnostic and Statistical Manual of Mental Disorders (4th ed., text rev.) criteria and 101 children (61 boys and 40 girls) did not. Higher overall levels of parent-reported repetitive and restricted behavior symptoms were less predictive of an autism spectrum disorder diagnosis in girls than in boys (odds ratio interaction = 0.41, 95% confidence interval = 0.18-0.92, p = 0.03). In contrast, higher overall levels of parent-reported emotional and behavioral problems increased the probability of an autism spectrum disorder diagnosis more in girls than in boys (odds ratio interaction = 2.44, 95% confidence interval = 1.13-5.29, p = 0.02). No differences were found between girls and boys in the prediction of an autism spectrum disorder diagnosis by overall autistic impairment, sensory symptoms, and cognitive functioning. These findings provide insight into possible explanations for the assumed underidentification of autism spectrum disorder in girls in the clinic.
Autism : the international journal of research and practice, 2017 · doi:10.1177/1362361316672178