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Cited by 398Autism Spectrum Disorder ResearchChild Nutrition and Feeding IssuesGenetics and Neurodevelopmental Disorders

Sex differences in the evaluation and diagnosis of autism spectrum disorders among children

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Giarelli, Ellen, Wiggins, Lisa D., Rice, Catherine E., Levy, Susan E., Kirby, Russell S., Pinto-Martin, Jennifer, Mandell, David·2010·Disability and Health Journal
DOI 10.1016/j.dhjo.2009.07.001PMC PMC4767258
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Abstract

Background One of the most consistent features of the autism spectrum disorders (ASDs) is the predominance among males, with approximately four males to every female. We sought to examine sex differences among children who met case definition for ASD in a large, population-based cohort with respect to age at first developmental evaluation, age of diagnosis, influence of cognitive impairment on these outcomes, and sex-specific behavioral characteristics.Methods We conducted a secondary analysis of data collected for a population-based study of the prevalence of ASD. The sample comprised 2,568 children born in 1994 who met the case definition of ASD as established by the Autism and Developmental Disabilities Monitoring (ADDM) Network for ASD surveillance. Children who had a history of developmental disability and behavioral features consistent with the DSM-IV-TR criteria for autistic disorder, Asperger's disorder, and Pervasive Developmental Disorder-Not Otherwise Specified in existing evaluation records were classified as ASD cases via two paths: streamlined and nonstreamlined. Streamlined reviews were conducted if there was an ASD diagnosis documented in the records. Data were collected in 13 sites across the United States through the ADDM Network, funded by the Centers for Disease Control and Prevention.Results Males constituted 81% of the sample. There were no differences by sex in average age at first evaluation or average age of diagnosis among those with an existing documented chart diagnosis of an ASD. Girls were less likely than boys to have a documented diagnosis (odds ratio [OR] = 0.76, p = .004). This analysis was adjusted for cognitive impairment status. In the logistic model, with the interaction term for sex and cognitive impairment, girls with IQ of 70 or less were less likely than boys with IQ of 70 or less to have a documented diagnosis (OR = 0.70, 95% confidence interval [CI] = 0.50-0.97, p = .035). Boys with IQ greater than 70 were less likely than boys with IQ of 70 or less to have a documented diagnosis (OR = 0.60, 95% CI = 0.49-0.74, p < .001). This finding (less likely to have a documented diagnosis) was also true for girls with IQ greater than 70 (OR = 0.45, 95% CI = 0.32-0.66, p < .001). Girls were more likely to have notations of seizure-like behavior (p < .001). Boys were more likely to have notations of hyperactivity or a short attention span and aggressive behavior (p < .01).Conclusions Girls, especially those without cognitive impairment, may be formally identified at a later age than boys. This may delay referral for early intervention. Community education efforts should alert clinicians and parents to the potential of ASDs in boys and girls.

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  • When comparing females and males with high ASD traits, males were more likely to have aggression and hyperactivity and/or attention deficits, and females were more likely to exhibit staring and seizure-like activities.

    “When comparing females and males with high ASD traits, it was found that males were more likely to have aggression and hyperactivity and/or attention deficits, and females were more likely to exhibit staring and seizure-like activities (Giarelli et al. 2010).”

    From Barriers to Autism Spectrum Disorder Diagnosis for Young Women and Girls: a Systematic Review (2021) · cites this paper as Giarelli et al. 2010

    The Results (‘Sex differences and behavioral features’; page unavailable) report more documented aggression and hyperactivity or attention deficits in boys, and more staring spells and seizure-like activity in girls. However, this comparison was limited to 1,071 children who met ASD surveillance criteria but had no documented ASD classification; the paper does not establish the same pattern for females and males with high ASD traits generally. (LLM, conf=0.86)

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  • Females with ASD often have a different clinical presentation than males and are commonly diagnosed later in life despite typically being assessed for developmental delays at the same age as boys.

    “For example, females -who often have a different clinical presentation of ASD than males -are commonly diagnosed later in life despite typically being assessed for developmental delays at the same age as boys.”

    From Tackling healthcare access barriers for individuals with autism from diagnosis to adulthood (2022) · cites this paper as [55]

    The Results (Age at first developmental evaluation and likelihood of a documented classification; page not provided) report nearly identical ages at first evaluation for girls and boys, and the behavioral-features Results describe some sex differences. But among children with a documented ASD classification, girls were not diagnosed later: their average age at classification was 59 months, versus 61 months for boys, a nonsignificant difference. Girls were less likely to have a documented ASD classification, which is different from being diagnosed later. (LLM, conf=0.88)

    Experimental — accuracy not yet measured

  • Four papers described gender comparisons in behavioural problems and presented conflicting findings.

    “Four papers described comparisons between genders and presented conflicting findings (Duvekot et al. 2017; Dworzynski et al. 2012; Giarelli et al. 2010; Petrou et al. 2018).”

    From Barriers to Autism Spectrum Disorder Diagnosis for Young Women and Girls: a Systematic Review (2021) · cites this paper as Giarelli et al. 2010

  • Autistic females are being missed, diagnosed later than males, or misdiagnosed.

    “There are increasing concerns that autistic females are being missed, diagnosed later than males or misdiagnosed (Giarelli et al. 2010; Holtmann et al. 2007; Loomes et al. 2017; Shattuck et al. 2009).”

    From Barriers to Autism Spectrum Disorder Diagnosis for Young Women and Girls: a Systematic Review (2021) · cites this paper as Giarelli et al. 2010

  • Girls with an IQ of 70 or less were less likely than boys with an IQ of 70 or less to have a documented ASD diagnosis.

    “Girls with an IQ of 70 or less were less likely than boys with an IQ of 70 or less to have a documented ASD diagnosis.”

    From Barriers to Autism Spectrum Disorder Diagnosis for Young Women and Girls: a Systematic Review (2021) · cites this paper as Giarelli et al. 2010

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1 of the 38 references couldn’t be matched to a known paper.

Research works printed but not linked: 1

  1. [25]Sparrow SB Balla DA Cichetti DV Vineland Adaptive Behavior Scales: Interview Edition, Survey Form Manual 1984 American Guidance Service Circle Pines, MN

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Authors
Giarelli, E., Wiggins, L. D., Rice, C. E., Levy, S. E., Kirby, R. S., Pinto-Martin, J., & Mandell, D.
Affiliations
  • University of Pennsylvania (US)
  • Centers for Disease Control and Prevention (US)
  • Children's Hospital of Philadelphia (US)
  • University of South Florida (US)
Corresponding author
Giarelli, Ellen
ORCID
Venue
Disability and Health Journal
Publisher
Elsevier BV
Published
2010-04
Volume
3
Issue
2
Pages
107-116
ISSN
  • 1876-7583 (ISSN-L)
  • 1936-6574
DOI
10.1016/j.dhjo.2009.07.001
PMC
PMC4767258
OpenAlex
W2064689669
Cited by
398
References
38
Citations by year
2026: 15 · 2025: 28 · 2024: 33 · 2023: 39 · 2022: 33 · 2021: 35 · 2020: 32 · 2019: 26 · 2018: 22 · 2017: 20 · 2016: 27 · 2015: 28 · 2014: 18 · 2013: 19 · 2012: 16
FWCI
3.71
Type
journal article
Language
en
Open access
Licence
www.elsevier.com/tdm/userlicense/1.0/ (tdm)
Locations
  • Disability and health journal (publishedVersion)
  • PubMed (publishedVersion)
  • Europe PMC (PubMed Central) (acceptedVersion)
  • PubMed Central (acceptedVersion)
Funders
National Institute of Mental Health (R01MH077000, K01MH067628)
Topics
  • Life Sciences › Neuroscience › Cognitive Neuroscience › Autism Spectrum Disorder Research
  • Health Sciences › Medicine › Psychiatry and Mental health › Child Nutrition and Feeding Issues
  • Life Sciences › Biochemistry, Genetics and Molecular Biology › Genetics › Genetics and Neurodevelopmental Disorders
Keywords
autism spectrum disorder, sex differences, age at diagnosis, cognitive impairment, autistic girls, autism prevalence, Asperger syndrome, pervasive developmental disorders, seizure-like behavior
MeSH terms
Child, Child Development Disorders, Pervasive, Child Welfare, Child, Preschool, Cognition, Cognition Disorders, Female, Humans, Male, Population Surveillance, Risk Factors, Sex Factors, United States, Prevalence, Odds Ratio

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