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Sex differences in the evaluation and diagnosis of autism spectrum disorders among children
Open accessAbstract
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, 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
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“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]
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“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
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“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
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“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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“found that boys were more likely than girls to have a diagnosis of ASD even when both sexes had documented ASD symptoms in educational and clinical records.”
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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“It has also been suggested that cognitive impairment increases the likelihood of having a documented ASD diagnosis for boys, but not for girls (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
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“Clinician bias was identified by six studies as a barrier to females obtaining an ASD diagnosis (Beteta 2008; Cridland et al. 2014; Giarelli et al. 2010; Mademtzi et al. 2018; Navot et al. 2017; Watson 2014).”
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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“They concluded that this may result from an ‘interpreting bias’, where the observed experiences differ from the expected behaviours dependent on sex bias.”
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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“They highlighted that clinicians evaluating girls, compared to boys, with a complex developmental profile may be more likely to exclude a classification of ASD if other conditions are present, due to this bias.”
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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“recent research also suggests that females with ASD may be underidentified (see Frazier et al. 2014, Giarelli et al. 2010)”
From Recent Advances in Autism Research as Reflected in DSM-5 Criteria for Autism Spectrum Disorder (2015) · cites this paper as Giarelli et al. 2010
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Citations
Cites
Diagnostic and Statistical Manual of Mental Disorders
Williams, J. B. W., & First, M. B. (2013) · Oxford University Press eBooks · doi:10.1093/acrefore/9780199975839.013.104 · Cited by 109,845
Lord, C., Rutter, M., & Le Couteur, A. (1994) · Journal of Autism and Developmental Disorders · doi:10.1007/bf02172145 · Cited by 9,065 · cited 1×
“Carter and colleagues' study of toddlers reported that sex differences emerged in developmental profiles using the Autism Diagnostic Observation Schedule [17], Autism Diagnostics Interview–Revised [24], Vineland Adaptive Behavior Scales [25], and Mullen Scales of Early Learning [26].”
Method(1943) · The Nervous child · Cited by 8,870
Baird, G., Simonoff, E., Pickles, A., Chandler, S., Loucas, T., Meldrum, D., & Charman, T. (2006) · The Lancet · doi:10.1016/s0140-6736(06)69041-7 · Cited by 2,104
Epidemiological Surveys of Autism and Other Pervasive Developmental Disorders: An Update
Fombonne, E. (2003) · Journal of Autism and Developmental Disorders · doi:10.1023/a:1025054610557 · Cited by 1,505
Prevalence of Autism in a US Metropolitan Area
Yeargin-Allsopp, M., Rice, C., Karapurkar, T., Doernberg, N., Boyle, C., & Murphy, C. (2003) · JAMA · doi:10.1001/jama.289.1.49 · Cited by 1,248 · cited 1×
“Some studies report that the male-to-female ratio of ASD decreases with greater levels of impairment in intellectual functioning [3,28].”
BackgroundSelf-citationThe Screening and Diagnosis of Autistic Spectrum Disorders
Filipek, P. A., Accardo, P., Baranek, G. T., Cook, E. H., Dawson, G., Gordon, B., Gravel, J. S., Johnson, C. P., Kallen, R. J., Levy, S. E., et al. (1999) · Journal of Autism and Developmental Disorders · doi:10.1023/a:1021943802493 · Cited by 1,016
Self-citationAutism From 2 to 9 Years of Age
Lord, C., Risi, S., DiLavore, P. S., Shulman, C., Thurm, A., & Pickles, A. (2006) · Archives of General Psychiatry · doi:10.1001/archpsyc.63.6.694 · Cited by 973 · cited 3×
“Carter and colleagues' study of toddlers reported that sex differences emerged in developmental profiles using the Autism Diagnostic Observation Schedule [17], Autism Diagnostics Interview–Revised [24], Vineland Adaptive Behavior Scales [25], and Mullen Scales of Early Learning [26].”
BackgroundMethodPervasive Developmental Disorders in Preschool Children: Confirmation of High Prevalence
Chakrabarti, S., & Fombonne, E. (2005) · American Journal of Psychiatry · doi:10.1176/appi.ajp.162.6.1133 · Cited by 791 · cited 1×
“However, the age of the first evaluation and age of the first ASD classification are well above the age at which screening can identify many children who are at risk for ASDs during the toddler years [5,20,37,38].”
BackgroundMullen Scales of Early Learning: Ags Edition
Dumont, R., & Willis, J. O. (2008) · Encyclopedia of Special Education · doi:10.1002/9780470373699.speced1402 · Cited by 667
Developmental Surveillance and Screening of Infants and Young Children
(2001) · PEDIATRICS · doi:10.1542/peds.108.1.192 · Cited by 548
The development of psychopathology in females and males: Current progress and future challenges
Crick, N. R., & Zahn‐Waxler, C. (2003) · Development and Psychopathology · doi:10.1017/s095457940300035x · Cited by 514 · cited 3×
“Carter and colleagues' study of toddlers reported that sex differences emerged in developmental profiles using the Autism Diagnostic Observation Schedule [17], Autism Diagnostics Interview–Revised [24], Vineland Adaptive Behavior Scales [25], and Mullen Scales of Early Learning [26].”
ResultCan Autism Be Diagnosed Accurately in Children Under 3 Years?
Stone, W. L., Lee, E. B., Ashford, L., Brissie, J. S., Hepburn, S., Coonrod, E. E., & Weiss, B. (1999) · Journal of Child Psychology and Psychiatry · doi:10.1111/1469-7610.00435 · Cited by 428 · cited 1×
“Furthermore, diagnosis of an ASD by a qualified professional remains relatively stable from 2 years to middle childhood [17,18].”
BackgroundWIGGINS, L. D., BAIO, J., & RICE, C. (2006) · Journal of Developmental & Behavioral Pediatrics · doi:10.1097/00004703-200604002-00005 · Cited by 411 · cited 1×
“One study by Wiggins and colleagues found that despite a heightened awareness of the higher rate of ASDs among boys, there was a tendency for girls to be evaluated and diagnosed with an ASD at earlier ages than boys, and there was a longer delay between first evaluation and diagnosis for girls than for boys [23].”
BackgroundSelf-citationA Five- to Fifteen-Year Follow-up Study of Infantile Psychosis
Lockyer, L., & Rutter, M. L. (1969) · The British Journal of Psychiatry · doi:10.1192/bjp.115.525.865 · Cited by 407
Brief Report: Screening Tool for Autism in Two-Year-Olds (STAT): Development and Preliminary Data
Stone, W. L., Coonrod, E. E., & Ousley, O. (2000) · Journal of Autism and Developmental Disorders · doi:10.1023/a:1005647629002 · Cited by 389
The prevalence of autism spectrum disorders
Charman, T. (2002) · European Child & Adolescent Psychiatry · doi:10.1007/s00787-002-0297-8 · Cited by 380
Sex ratios in early childhood autism and related conditions
Wing, L. (1981) · Psychiatry Research · doi:10.1016/0165-1781(81)90043-3 · Cited by 370 · cited 2×
“Wing L. Sex ratios in early childhood autism and related conditions.”
BackgroundA Five to Fifteen Year Follow-up Study of Infantile Psychosis: I. Description of Sample
Rutter, M., & Lockyer, L. (1967) · British Journal of Psychiatry · doi:10.1192/bjp.113.504.1169 · Cited by 356
Sex differences in pervasive developmental disorders
Volkmar, F. R., Szatmari, P., & Sparrow, S. S. (1993) · Journal of Autism and Developmental Disorders · doi:10.1007/bf01046103 · Cited by 329 · cited 1×
“Two older studies reported that females with autism manifested lower IQs than males and ID occurred in higher percentages of girls with autism than in boys [8,29].”
BackgroundHoltmann, M., Bölte, S., & Poustka, F. (2007) · Developmental Medicine & Child Neurology · doi:10.1111/j.1469-8749.2007.00361.x · Cited by 308
Lord, C., Schopler, E., & Revicki, D. (1982) · Journal of Autism and Developmental Disorders · doi:10.1007/bf01538320 · Cited by 303 · cited 1×
“Two older studies reported that females with autism manifested lower IQs than males and ID occurred in higher percentages of girls with autism than in boys [8,29].”
BackgroundEarly identification of autism by the CHecklist for Autism in Toddlers (CHAT)
Baron‐Cohen, S., Wheelwright, S. J., Cox, A., Baird, G., Charman, T., Swettenham, J., Drew, A., & Doehring, P. (2000) · Journal of the Royal Society of Medicine · doi:10.1177/014107680009301007 · Cited by 289 · cited 2×
“However, the age of the first evaluation and age of the first ASD classification are well above the age at which screening can identify many children who are at risk for ASDs during the toddler years [5,20,37,38].”
BackgroundBerry, C. A., Shaywitz, S. E., & Shaywitz, B. A. (1985) · PEDIATRICS · doi:10.1542/peds.76.5.801 · Cited by 262
Sex Differences in Toddlers with Autism Spectrum Disorders
Carter, A. S., Black, D. O., Tewani, S., Connolly, C. E., Kadlec, M. B., & Tager-Flusberg, H. (2007) · Journal of Autism and Developmental Disorders · doi:10.1007/s10803-006-0331-7 · Cited by 262
Sex differences in higher functioning people with autism
McLennan, J. D., Lord, C., & Schopler, E. (1993) · Journal of Autism and Developmental Disorders · doi:10.1007/bf01046216 · Cited by 245
The Very Early Identification of Autism: Outcome to Age 41/2–5
Eaves, L. C., & Ho, H. H. (2004) · Journal of Autism and Developmental Disorders · doi:10.1023/b:jadd.0000037414.33270.a8 · Cited by 203
Yeargin‐Allsopp, M., Oakley, G. P., Murphy, C. C., Sikes, R. K., & Staff, T. M. A. D. D. S. (1992) · PEDIATRICS · doi:10.1542/peds.89.4.624 · Cited by 158
A public health collaboration for the surveillance of autism spectrum disorders
Rice, C. E., Baio, J., Braun, K. V. N., Doernberg, N. S., Meaney, F. J., Kirby, R. S., & ADDM Network (2007) · Paediatric and Perinatal Epidemiology · doi:10.1111/j.1365-3016.2007.00801.x · Cited by 158 · cited 3×
“For a complete description of this process see Rice and colleagues [33] and Van Naarden Braun and colleagues [35].”
BackgroundMethodSelf-citationPilowsky, T., Yirmiya, N., Shulman, C., & Dover, R. (1998) · Journal of Autism and Developmental Disorders · doi:10.1023/a:1026092632466 · Cited by 153
The Development of Sex Differences in Infantile Autism
Tsai, L. Y., & Beisler, J. M. (1983) · British Journal of Psychiatry · doi:10.1192/bjp.142.4.373 · Cited by 147
Braun, K. V. N., Pettygrove, S. D., Daniels, J. L., Miller, L. A., Nicholas, J. S., Baio, J., Schieve, L. A., Kirby, R. S., Washington, A., Brocksen, S., et al. (2007) · PubMed · Cited by 121
Self-citationAre Abilities Abnormally Interdependent in Children With Autism?
Dyck, M. J., Piek, J. P., Hay, D., Smith, L., & Hallmayer, J. (2006) · Journal of Clinical Child & Adolescent Psychology · doi:10.1207/s15374424jccp3501_3 · Cited by 88 · cited 1×
“This difference was also found among individuals with typical cognitive functioning [30,31].”
BackgroundDo I see only what I expect? Evidence for an expectancy-guided retrieval model.
Hirt, E. R. (1990) · Journal of Personality and Social Psychology · doi:10.1037/0022-3514.58.6.937 · Cited by 50
(2018) · Canadian Museum of History eBooks · doi:10.2307/j.ctv16xv7.12 · Cited by 41
Epidemiology and Early Identification of Autism: Research Challenges and Opportunities
Charman, T. (2003) · Novartis Foundation symposium · doi:10.1002/0470869380.ch2 · Cited by 15
Flagged first, then by citations
1 of the 38 references couldn’t be matched to a known paper.
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Sorted by citations
What Is the Male-to-Female Ratio in Autism Spectrum Disorder? A Systematic Review and Meta-Analysis
Loomes, R., Hull, L., & Mandy, W. P. L. (2017) · Journal of the American Academy of Child & Adolescent Psychiatry · doi:10.1016/j.jaac.2017.03.013 · Cited by 2,804
Lai, M.-C., Lombardo, M. V., & Baron-Cohen, S. (2014) · The Lancet · doi:10.1016/s0140-6736(13)61539-1 · Cited by 2,371
Lord, C., Brugha, T. S., Charman, T., Cusack, J., Dumas, G., Frazier, T., Jones, E. J. H., Jones, R. M., Pickles, A., State, M. W., et al. (2020) · Nature Reviews Disease Primers · doi:10.1038/s41572-019-0138-4 · Cited by 1,859
Sex differences in autism spectrum disorders
Werling, D. M., & Geschwind, D. H. (2013) · Current Opinion in Neurology · doi:10.1097/wco.0b013e32835ee548 · Cited by 1,245
Sex/Gender Differences and Autism: Setting the Scene for Future Research
Lai, M.-C., Lombardo, M. V., Auyeung, B., Chakrabarti, B., & Baron-Cohen, S. (2015) · Journal of the American Academy of Child & Adolescent Psychiatry · doi:10.1016/j.jaac.2014.10.003 · Cited by 1,120
Metadata
- 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
- 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
- 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
- green
- www.ncbi.nlm.nih.gov
- 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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