Sex/Gender Differences in CARS2 and GARS-3 Item Scores: Evidence of Phenotypic Differences Between Males and Females with ASD.
On CARS-2/GARS-3, autistic girls look more typical except for higher fear/nervousness—adjust cut-scores or interpretation to avoid missed diagnosis.
01Research in Context
What this study did
The team looked at CARS-2 and GARS-3 item scores for autistic boys and girls. They wanted to see if the two sexes show different patterns on the same checklist items.
No new kids were tested. The authors simply re-examined existing rating-scale data to spot sex-specific item trends.
What they found
Boys scored higher on almost every restricted and repetitive behavior item. Girls only scored higher on one item: fear and nervousness.
The result is a mixed picture. Girls look more typical on most autism markers, except they stand out as more anxious.
How this fits with other research
Begeer et al. (2013) already showed girls are identified later than boys. The new item data help explain why: girls rack up fewer obvious red-flag points, so they slip under the cut-score.
Green et al. (2020) found no sex difference on broad internalizing scales. The target study disagrees at the item level, but the gap is only one fear item. Broad-band scores can hide narrow spikes, so the papers actually fit together.
Eussen et al. (2016) reported more depression in adolescent autistic girls. The target saw only more fear/nervousness. Age may matter: internalizing blooms in adolescence, while fear items capture younger kids.
Why it matters
If you use CARS-2 or GARS-3, lower the bar for girls on fear/nervousness and raise your index of suspicion when the rest of the profile looks mild. A girl who is 'just anxious' may still be autistic. Add anxiety questions to every intake and re-check totals with sex-specific lenses so you do not miss girls who need services.
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02At a glance
03Original abstract
Growing evidence suggests that autistic females are more likely to be diagnostically overlooked than males, perhaps due to differences in ASD presentations (van Wijngaarden-Cremers in JAMA 44:627-635, 2014). To investigate specific behaviours in which differences lie, we analysed profiles of 777 children using the Childhood Autism Rating Scale (Scholper in JAMA 29:489-493, 2010) or Gilliam Autism Rating Scale (Gilliam, 2014). Males demonstrated greater difficulty in six CARS2-ST items and seven behaviours on the GARS-3, mostly reflecting restricted and repetitive behaviours. Across all instruments, the only area in which females showed greater difficulty was fear or nervousness (CARS2-ST). No meaningful differences emerged from the CARS2-HF analysis. Where males showed greater difficulty, females were more likely to present with developmentally typical behaviour.
Journal of autism and developmental disorders, 2022 · doi:10.1016/0165-1781(81)90043-3