1. Puzzling girls Rachel Brooks

2. What are the questions? Are we missing girls with ASD? How do we diagnose them? Does it matter if they are missed?

3. Prevelance ASD 0.6 -1% Male : Female 3-4 : 1 (school aged children population cohorts) 5-14 : 1 in clinical settings (6:1 (ish) for our tertiary clinic) Suggests girls with low normal to above normal IQ are not being diagnosed

4. ASD and the Extreme Male Brain Simon Baron-Cohen Postulates that the ASD brain is an extreme of the male brain Females with ASD have a more male brain than those without ASD Foetal testosterone? X and Y linked theories?

5. Why else ? Girls are more motivated to learn to conform socially and have better imitation skills to pretend to be normal Diagnostic instruments are unable to detect more subtle ways ASD presents in females

6. Are neuro typical girls and boys intrinsically different? Baron-Cohen would say so, boys are systemisers, girls are empathisers Wing – general population females better language skills, poorer visuo-spacial and maths skills Girls better at decoding facial expressions and non verbal cues, empathising and theory of mind

7. Girls build relationships by sharing thoughts and emotions Boys build relationships on object/activity related themes Girls world is definitely different to boy world!

8. Diagnostic instruments All designed to pick up ASD and calibrated for the original male phenotype of ASD Girls with ASD may not be picked up by current screening and diagnostic tools Little research in this area

9. ASSQ-REV Lack of a best friend B>G Interacts mostly with younger children G>B

10. ASSQ-REV Avoids demands G>B Why? Parents less demanding of boys? Girls with ASD may meet criteria for PDA Higher co-morbid anxiety in girls Girls avoid passively (ignore, etc,) and this is effective

11. ASSQ-REV Has a different voice /speech G>B Not robotic Unusual, high pitched, hoarse childish

12. ASSQ-REV Carefree or over meticulous with physical appearance and dress Difficulties completing daily activities because of compulsive repetitions

13. Girls special interests Animals, foreign cultures, fairy tale figures, famous people, comic strip personalities Painting, pottery, collecting, reading, beauty products, clothes Horse riding, Ice dancing

14. Play and imagination Is it imagination or re-enactment? There may be a script The girl needs to be in control

15. Kopp and Gillberg 2010 A girl who Avoids demands Is very determined Who interacts (mostly) with younger children Who is carefree or over meticulous with physical appearance and dress Who acts or lives different parts (animals, TV stars) Who had a different voice or speech Who often has intense girl-oriented interests

16. Risks of non identification Bullying Vulnerability Depression, Negative self perception Self harm Anorexia (18-23% of girls with anorexia also present with signs of Asperger syndrome – Gillberg and Billstedt, 2000 )