Download ADOS-2 Reliability workshop Girls on the Autism

ADOS-2 Reliability workshop
Girls on the Autism Spectrum
Feb 6th 2014
Regional ASD team: Cork/Kerry
Maria Gleeson & Maeve Feehan
Outline of session
9.30: Overview of girls on the Autism
Spectrum
10.15: Video 1: Toddler module and scoring
11:00: BREAK
11.15: discussion on scoring
11.30: Video 2: module 3
12.15: Scoring and discussion
1.00: Finish
Overview of girls on the
Autism Spectrum
Current Knowledge of girls and ASD
• Recent epidemiological studies on ASD report a male
to female ratio of approximately :
– 4:1 for children with Childhood Autism and 9:1 for children
with Asperger's/PDD-NOS Fombonne E. (2003),(Centers for
Disease Control and Prevention [CDC] 2012).
• Sex differences are reported to be more pronounced
when autism is not associated with learning disability.
• Among coexisting moderate to severe learning
disability, the median male to female ratio is
approximately 2:1, while within the normal range of
intellectual functioning it is approximately 5–6:1.
• Given this marked sex discrepancy, most ASD
research has focused on boys. When girls with
ASD are included in studies, sample sizes are
often too small to allow for comparisons by sex.
• An understanding of sex differences in the
presentation of ASD has important implications
for tailoring assessment measures and
interventions to the potentially unique
presentations and needs of boys and girls.
Why the difference in ratio?
• One interpretation of this is that girls are
simply much less prone to autism and
that, compared with boys, they require
greater disturbances in brain
development, as seen by their intellectual
disability, for any autism features to be
visible.
• Genetic evidence of a possible female protective
effect came in 2011, when two studies in Neuron
showed that girls with autism are more likely to
carry rare, spontaneous copy number variations
(CNVs) — DNA deletions and duplications —
than are boys with autism.
• What’s more, the CNVs that girls carry tend to be
larger, suggesting that they only get autism when
exposed to the most powerful genetic hits. Levy
D. et al. (2011), Gilman S.R. et al. (2011)
there are hormonal and brain
developmental differences
between typically developing children,
adolescents, and adults:
These might also occur among girls and
boys with developmental disabilities.
i.e. ASD might look differently in
boys than girls.
OR
• There may be a distinct, female-typical
presentation of autism that the current
diagnostic criteria and diagnostic tests
miss, because those criteria were mainly
derived from studying the disorder in
males. What’s more, the female autism
phenotype may be especially difficult to
detect in those with average intelligence
and above
OR
• Some have proposed factors, such as high
levels of foetal testosterone, that might
make boys particularly vulnerable.
OR
• Others have suggested that girls may be
protected through a genetic mechanism
related to their second X chromosome.
(Skuse, 2000)
Assessment of girls on the AS
According to unpublished results
presented at IMFAR, girls with Asperger
syndrome are diagnosed on average at 10
years of age, two years older than the
average age of diagnosis for boys.
Nice guidelines (2011) states “autism may be
under-diagnosed in girls”
DSM-V
DSM-5 includes a brief subsection on ‘Genderrelated diagnostic issues’ that says:
“In clinic samples females tend to be
more likely to show accompanying
intellectual disability, which suggests that
girls without accompanying intellectual
disability or language delays may go
unrecognized, perhaps because of subtler
manifestation of social and
communication difficulties.”
Possible issues with current
assessments
Questionnaires/clinical interviews to measure
autism traits are based on ratings from parents,
which are susceptible to cultural biases.
Many instruments used to assess autism and
autism-like symptoms were designed and
validated largely in groups of boys, who may
manifest the symptoms of autism differently
than girls do.
What are the typical differences
between boys and girls?
Play and drawing
• Boys prefer vehicles, building toys, and rough types of physical play,
whereas girls prefer dolls and social play
• differences in the motif, colour choice, figure composition, and use of
motion in children’s pictures Girls draw flowers, butterflies, the sun,
and human motifs significantly more often than do boys, who more
often draw mobile objects such as trains and cars.
• Girls use colour more often and more diffusely; tend to arrange their
figures in a row; and draw each figure equally. Boys tend to use blue
and gray; draw three-dimensionally; and magnify or emphasize a
central figure or theme more often than girls
• Although many studies on play do not control for social experiences
that might contribute to gender specific play behaviour, there is
evidence to suggest that these differences may be at least partially
biological in nature. Play and other gender-specific behaviours are
correlated with prenatal hormone exposure.
Problem Solving
• Men and women show different patterns of intellectual abilities even
though there are no disparities in IQ or general intellectual
functioning on standardized tests of intelligence such as the WISC
and the WAIS (Kimura, 1992).
• Males outperform females on tasks that assess visuospatial and
mathematical problem solving skills.
• On the other hand, women outperform men on tasks that assess
verbal abilities and perceptual speed. Women have superior verbal
episodic memory as measured by free recall and recognition of
abstract words. Women also excel at facial recognition even when
they are not using verbal strategies to facilitate performance, women
are better than men at recalling emotional issues. They used
magnetic resonance imaging to demonstrate that neural responses
to emotional scenes were larger and more active in women than
men.
Emotional well being and Mood
• Women experience higher rates of internalizing psychopathology
such as anxiety, eating disorders, and mood disorders, while men
engage in more externalized behaviour such as aggression.
• Although these differences are likely to be at least partially mediated
by social factors such as gender-specific experiences, there is
evidence to implicate biological factors as well. Many of these
differences emerge after puberty; therefore, much research in this
area has focused on the hormonal environment of the brain during
the reproductive years as a possible explanation for such differences.
• Pubertal stage (rather than chronological age) seems to be a
stronger predictor for mood disorders. Thus, depression, anxiety
disorders may result from a biological vulnerability that heightens
sensitivity to environmental stressors.
Social skills (in general!)
• Girls:
– more emotional sensitivity in helping a newcomer to
join a group
– show more sharing of toys
– more communication,
– use fewer direct commands
– less aggression
– from teens onward, strive for greater emotional depth
and intimacy than males.
(Geary, 1998, Kimura, 1999)
• Boys:
– More concerned re social rank and
competition
– Emphasis on doing things rather than on
communication for it’s own sake (Caplan et al,
1997)
Gender differences in Autism
Spectrum Disorder: what the
research says
• Girls are more likely to have intellectual disability,
particularly in the severe and profound range,
than boys (CDC 2007); Lord et al. 1982; Lord and
Schopler 1985; Tsai and Beisler 1983; Tsi et al.
1981; Volkmar et al. 1993; Wing 1981).
• In a sample of 22 girls and 68 boys with ASD aged
18–33 months using the Mullen Scales of Early
Learning (MSEL; Mullen 1995),Carter et al.
(2007) found that boys had better developed
language and fine motor skills than girls. In
contrast, girls had better developed visual
reception abilities than boys.
• However, some studies suggest that young
boys and girls with ASD evidence a similar
pattern of developmental strengths and
weaknesses. Both boys and girls perform
better on visual reception and fine motor
tasks than gross motor and language tasks
(Carter et al. 2007; Joseph et al. 2002;
Lincoln et al. 1995).
• Holtmann et. al (2007).
Found no differences in the sample of highfunctioning participants with ASD,
independent of confounding effects of IQ
and age
Found no difference concerning the core
triad of ASD
• On the other hand, in several domains of
coexisting psychopathy, females exhibited
significantly more symptoms than males:
– Social
– Attention
– Thought problems
(On CBCl)
Scales reflect
difficulties in:
•Peer relations
•Social immaturity
•Social dependency
•Inattentive,
Impulsive,
Hyperactive,
Compulsive, Bizarre
behaviour
Play
• games that did not require pretence, girls
with an ASD did not show a preference for
female-typical items
• girls with an ASD had higher scores on
game involving pretence than males with
an ASD. Girls with an ASD showed a
significant preference for female pretence
items as opposed to male pretence items.
(Knickmeyer et al. 2007)
• researchers noted that girls with ASD had
more appropriate interests than boys
(Kopp and Gillberg 1992; Wolff and
McGuire 1995).
• Girls tended to "avoid demands" at a
significantly higher level than boys. Girls
may be more likely to avoid demands
passively, by ignoring them, rather than
acting out like boys.
• parents of a girl are more likely to report
that their daughter "interacts mostly with
younger children" than are parents of boys
Specific “red flags” for a possible
ASD in girls/young women
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Social immaturity
Preservative interests- the intensity of them
Different eye contact
Poor handwriting
Poor gross motor co-ordination
Isolation or teasing by peers
Lowering grades
Viewed as “odd” by teachers
Disorganised
Passive and lack of interest in classroom activities
Lack of empathy
Repetitive questioning
Useful reading
*in the RASD drop box
• Middletown Centre for Autism: Autism Spectrum Disorder and Girls.
Research Bulletin no .4 (2010).
• http://femaleasd.wordpress.com
• *Hartley & Sikora. (2009). Sex differences in Autism Spectrum
Disorders: An examination of Developmental Functioning, Autistic
Symptoms and Coexisting Behaviour problems in Toddlers. Journal of
Autism & Developmental Disorders. Vol. 39(12) pp1715-1722.
• *Werling & Geschwind. (2013). Understanding sex bias in autism
spectrum disorder. Proceedings of the National Academy of
Sciences. Vol. 110, no 13.
• *Holtmann, Bolte & Poustka. (2007). Autism Spectrum disorders: sex
differences in Autistic behaviour domains and coexisting
psychopathology. Developmental medicine & Child Neurology, Vol.
49: pp 31-36.
• *Stacy et al. (2013). Sex differences in co-occurring conditions of
children with autism spectrum disorders. Autism.
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*Thompson
et. al. (2003). Sex matters in Autism and other
developmental disabilities. Journal of Learning Disabilities. Vol. 7(4).
*Lai et al. (2011). A Behavioural Comparison of Male and Female
Adults with High Functioning Autism Spectrum Conditions. PLoS, Vol.
6(6).
*Lai et al. (2013). Biological sex affects the neurology of Autism.
Brain: a journal of Neurology. Vol. 136.
*Ingudomnukul et. al. (2006). Elevated rates of testosterone-related
spectrum conditions disorders in women with autism. Hormones and
Behaviour.
Fombanne. (2003). Epidemiological Surveys of Autism and Other
Pervasive Developmental Disorders: An Update. Journal of Autism
and Developmental Disorders, Vol. 33 (4).
Carter et al. (2007). Sex differences in toddlers with Autism Spectrum
Disorders. Journal of Autism and Developmental Disorders, Vol 37.
*Begeer et al. (2012). Sex differences in the timing of Identification
among children and adults with Autism Spectrum Disorders. Journal
of Autism and Developmental Disorders.
*Knickmeyer et al. (2007). Sex-typical Play:
Masculinization/Defeminization in Girls with an Autism Spectrum
Condition. Journal of Autism and Developmental Disorders.