SingaporeMotherhood | Parenting
November 2024
Autism Spectrum Disorder (ASD): A Condition that Remains Underdiagnosed in Girls and Women
If you are female, you could have Autism Spectrum Disorder (ASD), and not know it. Your daughter, female friends, and female relatives could have ASD, and not know it. As it turns out, this could be the case for any girl, or woman. Take Debbie. Identified as twice-exceptional and recognised for her intelligence and empathy, one would expect the 14-year-old to sail through school. Instead, she faced social difficulties and bullying.
Debbie’s struggles to initiate and sustain friendships began in childhood. Labelled “weird” and “awkward” by her peers, she found it easier to interact with adults.
She cut off those who did not meet her rigid expectations of friendship, causing her to be isolated and further misunderstood. When people and things did not adhere to her strict plans and structures, she had meltdowns. This, along with her experiences of bullying, escalated into anxiety attacks.
Her ASD Diagnosis, a Turning Point.
For the first time, Debbie felt understood. She finally knew why she had been reacting in certain ways. The diagnosis helped her family and teachers be more empathetic and supportive towards her, adapting their approaches to meet her needs.
While 14 may seem late in life to learn about having ASD, Debbie is actually one of the lucky ones. In fact, her diagnosis is early for females. This is because despite growing awareness of mental health issues in Singapore and globally, ASD remains significantly underdiagnosed, particularly amongst adults and especially women.
Tan Su-Lynn, the Principal Educational Psychologist at Promises Healthcare, gives us the low-down.
4 reasons why Autism Spectrum Disorder (ASD) is often Underdiagnosed in Women and Girls
1. Traditional studies skewed towards males
Traditionally, autism research and diagnostic criteria were based on studies predominantly involving males. This led to a male-centric understanding of the condition and the creation of a diagnostic framework that often overlooks the more subtle or different presentations of autism commonly seen in females.
2. Different behavioural traits
Girls and women with ASD often exhibit traits that differ from the more stereotypical behaviours associated with the condition. For instance, while boys may show overt signs like repetitive behaviours or difficulties with social interaction, girls are often adept at ‘masking’ or ‘camouflaging’ their symptoms. They may imitate social behaviours or develop coping strategies that help them blend in. Hence others dismiss their challenges as shyness or anxiety rather than as autism.
3. Societal expectations
These play a significant role. From a young age, girls are often socialised to be more nurturing and social, which can further mask autistic traits. When girls do struggle socially or behaviourally, it is often attributed to other factors like emotional or mental health issues. This results in misdiagnoses or overlooking the possibility of ASD.
4. Types of interests
Another critical factor is the difference in the types of interests that girls with autism have. While boys might exhibit more obvious, repetitive interests like fixations on specific objects or activities, girls’ interests align more closely with that which is typical for their age and gender. For example, they might have an intense focus on animals, books, or celebrities.
Not just in Singapore, but Worldwide.
The underdiagnosis of ASD in women and girls is a global issue. In many countries, including Singapore, there’s a growing recognition of this issue, but the challenge remains widespread.
In regions with less developed mental health services or where cultural stigma around mental health and neurodevelopmental disorders exists, the underdiagnosis can be even more pronounced.
What does ASD look like in Girls, compared to Boys?
Girls with ASD are typically more adept at ‘masking’ their symptoms, imitating social behaviours to fit in. While boys may show more overt signs like repetitive behaviours, girls often exhibit subtler signs such as extreme shyness, social anxiety, or intense but socially acceptable interests, like a deep attachment to animals or books.
Girls may also develop better language skills and appear more emotionally expressive. Because of this, their social struggles are misinterpreted as anxiety or other mental health issues rather than autism.
The Significant Impact of Underdiagnosis.
Underdiagnosis of ASD in women carries several significant risks. Without an accurate diagnosis, many women struggle to understand why they feel different, leading to feelings of isolation, confusion, and low self-esteem.
This can result in severe mental health issues, including anxiety, depression, and even suicidal thoughts, as they continuously try to meet social expectations without the necessary support.
Additionally, undiagnosed women may develop unhealthy coping mechanisms. Masking their symptoms to fit in can be mentally exhausting and lead to burnout.
Girls have Perfected the Art of ‘Camouflaging’.
While camouflaging is not exclusive to girls and women with autism, we see it more commonly and more intensely in females than in males. This behaviour involves consciously or subconsciously masking autistic traits to fit in better with social norms.
Girls and women with autism often become adept at imitating social behaviours. They copy the actions and speech patterns of their peers, and use learned social scripts to navigate interactions.
They often engage in camouflaging for several reasons. One of the main motivations is the desire to fit in and avoid social exclusion or bullying.
From a young age, girls are encouraged to be more socially aware and nurturing, so they may feel a strong pressure to conform to these expectations. This can lead them to suppress their natural behaviours and mimic what they perceive as ‘normal’ to avoid standing out.
Another reason is self-protection. Women and girls may camouflage to avoid negative reactions or criticism from others who might not understand their differences.
They may also do it to meet the demands of social environments like school or work, where there is a strong emphasis on social interaction and conformity.
Cultural expectations and Societal norms in Singapore Influence ASD Diagnosis Rates
In Singapore the emphasis is on high academic achievement and social conformity. From a young age, children strive to excel academically and fit into established social norms.
For girls, this often means adhering to expectations of being more socially adept, nurturing, and emotionally expressive. These societal pressures can lead to masking behaviours, where girls with ASD learn to imitate social cues and adapt their behaviours to align with cultural expectations.
This makes it challenging for parents, educators, and even healthcare professionals to recognise the signs of autism in girls.
Additionally, there is still some stigma around mental health and neurodevelopmental disorders in Singapore. This can affect the willingness of families to seek evaluation and support. This stigma can be particularly pronounced when it comes to girls, as parents might be more hesitant to seek a diagnosis that could carry a social label, affecting their child’s future opportunities.
Families might be more inclined to attribute a child’s social or behavioural difficulties to personality or situational factors, rather than considering the possibility of ASD.
Educational settings in Singapore also play a role. Schools often focus on academic performance, and girls with ASD who excel academically may have their social or communication challenges overlooked.
Furthermore, teachers may not be able to easily identify ASD in girls because these girls often do not display the more overt behavioural issues typically associated with boys on the spectrum.
Other ASD Case Studies in Singapore
Case Study 1: Jane
Jane, a 21-year-old teaching assistant at a private learning centre struggled with social interactions and fitting in throughout her schooling years. Social situations left her feeling drained, and she coped better with advanced preparation and routines.
Jane developed a system for almost everything in her life and felt compelled to stick to it, which made her seem rigid and compulsive. However, her passion for drama provided her with an outlet to hone her social skills, creativity, and imagination. Despite this, Jane continued to find it challenging to navigate dynamic social situations where she could not plan or rehearse responses in advance.
She was particularly concerned about her sensory overload and frequent burnout, which began to affect her work. Although she was previously diagnosed with anxiety, Jane suspected she might have undiagnosed ASD.
Upon receiving her diagnosis, Jane felt a profound sense of relief as everything started to make sense. She described the experience as finally understanding why she had always felt different and overwhelmed. The diagnosis brought her and her family clarity and a pathway to seek more tailored support and accommodations.
Case Study 2: Michelle
Michelle, 17, was often perceived as ‘bossy’ by her peers due to her tendency to take charge in social settings. Her literal interpretation of language, like struggling with expressions such as “pull up your socks”, and her quirky demeanour made it difficult for her to sustain friendships. She was unaware of why people avoided her, despite her efforts to research and self-train to improve her social skills.
Michelle’s sensitivities to touch, smell, and certain clothing materials led to emotional meltdowns, which further alienated her from her peers. Her intense obsession with certain games and fantasy books was another area where she struggled to balance her interests with social norms.
The diagnosis of ASD brought a sense of understanding and validation for Michelle and her family. It provided clarity about why she had anxiety attacks and meltdowns, despite excelling academically. Her parents and teachers, who once attributed her behaviour to her character or a phase, now understood her needs better.
With school accommodations and support, Michelle’s parents were finally able to comprehend and support their daughter’s unique challenges and strengths.
Featured image: lifeforstock on Freepik
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