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The Pediatrician Next Door - Simple Advice on Parenting and Family Health
Why Autism in Girls Is Often Missed
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- [00:00]
A
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Hey there, it's Dr. Wendy. You may not think this episode is going to apply to your life, but wait. What I've got for you today is going to change the way you interact with everyone. Your friends, your colleagues, your kids friends. Even if you don't think you know someone with autism, maybe you do and you don't even know it. Maybe they don't know it. Autism is not what you think it is. Have you heard the statistic that four times as many boys are diagnosed with autism than girls? And did that seem odd to you at all? It seems like autism is mostly a boys condition. But just because we diagnose more boys doesn't mean more boys have autism than girls. In fact, by age 20, it's basically even just as many girls are on the spectrum as boys. So maybe we just aren't diagnosing the girls. Yeah, all those girls, especially teenagers with diagnoses like anxiety and depression, some of them are actually on the autism spectrum. That probably also means we are over treating anxiety and depression in girls. And bipolar and personality disorder. All kinds of things. Why do so many more boys get the label of autism than girls? For many years, most autism research was done on boys. The early studies mostly included male subjects. And the examples that doctors, including myself, were taught in training were mostly about boys. So when we learned about autism and what it looks like, we learned one version. Even the screening tools were designed around how boys on the spectrum behave. Their behaviors are easier to spot. So what does a girl with autism look like? How do they act? The answer might change how you think about autism. It might make you see a daughter, a student, or even a grown woman in a new way. It might even make you think about someone you know and say, ah, that explains a lot. Want to know how to spot autism in girls? Hold on. I'm Dr. Wendy Hunter and I'm the pediatrician next door. I'm that doctor friend you call for practical advice about your kid's health. I mix the science of medicine with the reality of parenting. Here's what I see in my office. I see girls who are smart, talkative and socially interested. They make eye contact. They want friends. And some of them tell me they think they might have autism. And at first I thought they were just confused. But I Listened. And I asked an expert to explain this. Dr. Maya Gittleson is with me and she is a clinical psychologist who is. Who was just minding her own business, doing what psychologists do when she noticed a pattern that she could not ignore. Here she explains, I was not trained
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B
to do what I do now. So in terms of my training, my internships, anything at school, I did not learn how to identify females on the spectrum. I did my own type of research. I saw older females and they're explaining these things to me and I'm thinking, wow, that sounds so similar to the themes of autism.
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A
It seems that the internal experience of girls is like what boys with autism experience, but their outward manifestations or symptoms look different. Why do we miss recognizing autism in girls? Why is it so easy to overlook in girls?
- [06:09]
B
I think most likely because we look at the superficial piece a lot of times. I mean, we're only human. I mean, I always say this all the time with the parents. We're only human. And we're pre wired for certain things as being a human. And we're pre wired to like pretty attractive objects and humans. And so usually when the female walking in front of you is meeting that criteria somehow, automatically, unconsciously, you go to a place. But this doesn't look like autism. I see a lot of boys. Because when you work with autism in this field, you are going to see
- [06:51]
A
a lot of boys.
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B
And not to say that they don't have that cue factor, but they don't hide their mask the same way as girls. You can tangibly see something in a boy and then you're like, I feel confident as a provider that this is autism. They just flap their hands, they just line something up. They just spun the wheels of their car that they're bringing with them from home.
- [07:17]
A
Yeah.
- [07:18]
B
So it gives the provider the professional confidence to make that diagnosis. When you're seeing a boy, when you're seeing a female, you don't feel that same confidence. And so you're almost like, I'm seeing something, but I'm not sure. Could it be? No, it's not. My training tells me that it has to look this way. And I don't see that in the female. She's making eye contact.
- [07:45]
A
So this is where the problem starts, that we have a picture in our minds of what autism looks like. And girls with autism often don't fit that picture. Instead, they're often described as anxious, sensitive, or perfectionistic. We miss seeing that it's autism because girls use masking. And that is a very important concept here. Masking means hiding your struggles so other people don't see them. It's when a girl studies the kids around her her and copies what those girls are doing. She forces eye contact because she knows she's supposed to. She laughs when everyone else laughs, even when she doesn't get the joke. She rehearses what she's going to say before she says it. She watches social rules like they're instructions that she has to memorize. And from the outside, she looks fine, maybe she even looks socially skilled. But inside, she's working really hard, and that constant effort is exhausting. And when she finally gets home where it's safe, she falls apart. Not because she's being dramatic, because she's tired. And what does that look like in this context?
- [08:51]
B
Masking definitely wears on the person. So you're masking all day. It takes a lot of internal resources, so you're depleted. So that's another way that we see meltdowns, right? So the female goes to school all day. She's masking. She's trying to hide everything, mimic or model what she sees, you know, with her peers. And then she comes home and she's going to have a meltdown because she's just depleted. In the world of autism, we've kind of developed this phrase of meltdowns, which to me makes more sense than tantrums when you're talking in the realm of asd. And I like the term to actually give that to an individual, to a client, to talk about it in a meltdown format. That, oh, I had a meltdown today, or, oh, this caused a. This triggered a meltdown. So I give them that language. I think it's very. If you think of what a meltdown is versus a tantrum, it's more relevant.
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A
This is another subtle sign to look for is a girl having meltdowns, especially at an age when it's no longer an appropriate coping mechanism. In what way is this related to a possible autism diagnosis?
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B
Individuals with ASD have a hard time filtering sensory input. So when they're filtering sensory input, either they're craving it because they're not feeling grounded, and they need to feel grounded, and they need the sensory piece to regulate them, or they're on sensory overload, and then that's where that emotional dysregulation occurs. They just can't take it anymore. They can't naturally filter out. So you and I can filter out a small sound, or we could filter all the smell and still move forward. And at some point, they can't filter that out anymore and then they have more of that emotional dysregulation.
- [10:40]
A
So what does autism look like? It can look different in different people, but one aspect is that they filter the world differently and that can be tiring and make it hard to regulate emotions. Another misconception is that people on the autism spectrum have deficiencies. They can't empathize.
- [10:58]
B
A lot of times we talk about all these areas that they can't do this and their inability. They actually have all these abilities. When they're feeling co regulated with the person they're with, when they're feeling balanced with all the sensory in the moment when they're feeling supported, all of those things have to line up and they can do a lot of these things, even having empathy.
- [11:22]
A
So I just wonder if there are so many people on the spectrum, is there some kind of advantage to having it?
- [11:29]
B
They usually have a higher intellect. We might not be able to know exactly for some of the non verbal children and individuals at first what their higher level of intellect is. There is a small percentage that have intellectual disability, but a lot of times even with the intellectual disability, their intellect in some area is heightened, that they have some gift. Again, even if I'm giving them a coexisting diagnosis of ID intellectual disability, they still have something. If it's music, if it's art, there is an intellect advantage. Okay, I like that they can see something that we cannot see with our human eyes and they can put numbers together or they could put shapes together or they can put music, a tone. They're a lot musically inclined. Again, we might not see it exact, but it's hidden. It's always there, some type of intellect advantage. But they're like, it can't be autism. My child can read and he's three. And I'm thinking, well actually that's more of a red flag to me that you just told me that for supporting autism, a three year old. Again, neurotypical brain is not pre wired to read.
- [12:52]
A
At 3.
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A neurodiverse brain has some capabilities to be able to reach that ability. And it's something that's pre wired in their intellect. And it actually should be on some of the rating scales.
- [13:09]
A
When we evaluate young children for autism, we do use rating scales which are generally questionnaires like the M Chat, you may have heard of that one. They ask about things like eye contact, pretend play, language, repetitive behaviors, sensory sensitivities, and how a child interacts with other people.
- [13:28]
B
A lot of parents will enter and say, yes, my child makes eye contact and I'm looking at the child and I'm like, well, have you ever noticed that sometimes they're looking past you like they're looking in your direction? And yes, I guess you could say it's eye contact. But the quality is not necessarily visual connection and engagement. It actually has that quality piece that's a little less engaged than maybe another person that is neurotypical or that we're not looking at autism in the same age.
- [14:02]
A
How does that apply to interests? So the classic autistic thing is these focused interests. So what kind of things do you see in what appears to be a typical teenager that might actually be autism in terms of their interests?
- [14:13]
B
Well, for girls, that's easy. Makeup. So a lot of the girls are obsessed about makeup. So I talk about this a lot. That's pretty typical, right? 12, 13, 14. I mean, some of my 10 year olds, 8 year olds are obsessed with makeup and that's their fixated interest. A parent would never come to me and say, I'm concerned, my child's obsessed with makeup, she's a girl, versus I can't get my child to leave cars at home and all he wants to do is go to the airport to watch the planes. That is more of something that parent would come and talk to you about.
- [14:51]
A
So obviously the way most kids are evaluated for autism have limits, which every clinician is aware of and would make an entire episode on its own. But in terms of diagnosing older girls, the bottom line is that they are sometimes misdiagnosed, and that's a huge issue. So those girls that came into you when they were older, what diagnoses did they have when they came to see you that turned out to be autism.
- [15:14]
B
Right. So mood disorders, generalized anxiety, bipolar disorder, a lot of bipolar disorder. Because a lot of the females that come to me for differentials have been hospitalized and so they've made gestures of self harm and when they go to the hospitalization, they get discharged, most likely with a mood disorder related to the incident. Right. They're not going deeper to look at autism in a hospital setting. They're looking at what was the presenting concern. So it's no fault to them that they leave with a mood disorder, bipolar disorder diagnosis, because they're looking at the symptoms that they're treating in that hospital stay. The difficulty is then that diagnosis, if it's the first diagnosis that child has received, it carries with them. So then they go somewhere else and then they use the diagnosis, oh, you have bipolar. Okay, bipolar. And then they can it just perpetuates and that's a really upsetting thing for me because what's the underlining issue that's going on? It's never touched. And then the medications you put on for bipolar or mood disorder are not actually possibly what the child really needs if they're underlining issue because you can't medicate autism.
- [16:28]
A
Unfortunately, we do medicate autism accidentally. And yeah, that's lame and unhelpful. And not just because we cause new problems without support. Older girls who aren't diagnosed often have severe anxiety or depression and low self esteem. And when they finally get a diagnosis, they discover that their social differences aren't personal failures, but part of a different neurotype. And that is life changing. That's what we talk about after this break. I have to tell you, I love when I walk into one of my exam rooms and I see a patient making something. I'm not kidding. Some parents bring craft projects or science builds to their doctor's appointment. And here's the thing. These aren't parents that have unlimited time. They're just resourceful. And I know their secret. Most of them subscribe to Kiwico. Kiwico delivers those hands on project crates and they have them for every age filled with activities that spark curiosity. I recently got one of their baby crates and it had the coolest developmental play mat. As kids get older, there are crates that are focused on science, engineering, geography, you name it. You never know what your child is going to fall in love with until they're exposed to it. And Kiwico makes it so convenient. A crate just shows up at your door every month and you can pause it or cancel anytime. Tinker Create and innovate with Kiwico. Get up to 50% off your first monthly crate at kiwico.com with code drwendy. That's up to 50% off your first crate at k-I w I c o.com Code D R W E N D Y PandaCrate is an exception. See site for details. As someone who talks about health every day, I can tell you that lasting change beats extreme change every time. And when it comes to weight loss, having medical guidance matters with weight loss. By hers, you're connected to a licensed provider who learns your history and determines whether treatment is right for you. If it is, your plan can include oral medications or GLP1 injectables, plus ongoing support, medication adjustments and practical tools for tracking sleep, hydration and movement. I like that hers is personalized science backed care designed to help you make steady progress. You can maintain. Not something you're going to abandon in three months. If feeling stronger, healthier and more like yourself is part of your plan this year, this could be worth exploring. Feel like your best self again? Visit fourhers.com drwendy to get a personalized, affordable plan that gets you that's F O R H E-R-S.coM-R-W-E N- dash y forhers.com Dr. Wendy Weight loss by hers is not available everywhere. Compounded drug products are not approved or evaluated for safety, effectiveness or quality by the fda. Prescription required. See website for full details, important safety information and restrictions. Actual price depends on product and plan purchased. I just got back from a ski trip and I forgot to pack my Cure hydration packs. But my daughter remembered some Irae is a real good kid there. So guess who was drinking hers? Me. Here's the thing. In cold weather and at elevation you get dehydrated faster than you realize. You're breathing harder, the air is dry and you don't always feel thirsty. That's where CURE hydration packs really help. They're plant based electrolytes, no added sugar, only 25 calories and they hydrate better than water alone. I love that. They actually taste good too. Refreshing flavors like berry pomegranate, never overly sweet or artificial tasting. As a physician, what matters to me is that cure is science backed. It uses the same electrolyte ratio proven to hydrate as effectively as an IV drip. And for families, Cure also makes kids mixes formulated with pediatricians with no artificial ingredients and no added sugars. Kids lose electrolytes all day long, sports play, even skiing and replacing them matters. Staying hydrated isn't just about water. You also need electrolytes. That's why I recommend cure. It's clean, tastes great and my patients love it. You can grab Cure on Amazon or find a store near you@curehydration.com Dr. Wendy that's-r w e n D Y Real ingredients, real hydration ready for the whole family. It is common and easy to miss autism in girls and diagnose something like anxiety, depression or bipolar. When we give it a different label, a girl may end up on medication. That doesn't help or makes things worse. But the deeper problem is about identity. If you're told for years that you're anxious or dramatic or too sensitive, you start to believe something is wrong with you. You try harder. You blame yourself. When social things feel confusing. You wonder why your friendships seem harder for you than for everyone else. And that feeling that Sense of being out of sync doesn't feel good. When we recognize autism, it doesn't necessarily label a child in a limiting way. It explains why things feel hard. It shifts the story from what's wrong with me to, oh, that's how my brain works. I asked Dr. Gittleson why girls seek help at an older age. If they're getting along okay in school and at work and with other people, why do they even bother to seek a diagnosis? What do they come to her for exactly? And how much of an impact is this on daily function as a college student, early career, those kinds of things? What are they struggling with?
- [21:49]
B
Finding where they fit in. I mean, I've had a couple that have come to me to make sure they have a diagnosis because they want to go to that support or they want to be in that grouping that they found on campus, but they don't want to be an imposter. So they're still trying to feel if they fit into this group, that group. Are they asd? Are they not? That's who I see. They're like, we need confirmation because we don't want to be an imposter. And again, that's a little bit of a black and white thought process with that. I also see those that have transgender questions. You know, that's a whole nother topic we could talk about.
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A
Yeah, no, I definitely see that too.
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B
There's a lot of overlap.
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Just because they don't know who they are.
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B
Yeah, because they're told they're female. They don't connect with females. So, again, the black in my thinking is, how could I be that if I don't feel that?
- [22:49]
A
The place where I see this issue of having a label is in middle and high school girls who need some support at school to get through their day. I've had patients ask for IEPs or individualized education programs at school and not get what they need from the school. And Dr. Gittleson has experienced this as well.
- [23:07]
B
I go to a lot of IEP meetings to advocate for my girls. And the thing is, they sit there, the whole team in front of me, saying, we don't see this at school. I'm like, but you're not going to. But let me tell you, because she's asking. You're causing emotional distress with this child. This child is in emotional distress. They're hiding their emotional distress from you. But I can guarantee and tell you their emotional stress is coming from your school placement, your environment. You're causing emotional distress. That's upsetting to me. I Can't fix their emotional distress without you. Especially with girls. Because the mom who this particular recent case was, the mom's like, they're telling me I'm a liar. They're telling me that, like, oh, per mom's report, you know, when we talk
- [23:52]
A
about IEPs for girls with autism, one of the biggest challenges is this. The school often doesn't see the problem. From the school's point of view, there's nothing to fix. But what do you do if you see something different at home? You're the one who sees the crash after school or how long it takes her to recover from a small social mistake. You see how rigid your daughter gets when plans change and how much coaching it takes to get her through birthday parties and sleepovers. So what should parents pay attention to? You want to pay attention to the effort. Is she studying other kids to figure out how to act? Is she exhausted after social time even if she says it went fine? Does she take things very literally? Does she have intense interests that feel more like deep dives than just hobbies? Does she seem more mature in some ways, but younger in others? Also, notice how she talks about herself. Does she say things like, I'm just bad at people. What advice does Dr. Gilson have about this?
- [24:56]
B
I would pay attention to the masking piece. So being an observer of how those social interactions are going to. So, yes, again, they're happening, but what is the quality? Is their child on the outskirts? Are they really connecting, engaging in those moments of socialization? Do they get stressed when they come home from a social outing or social interaction? Does take a lot out of them to have those experiences. I would focus on that. I also want to say, with females, a lot of times, we'll make a diagnosis of eating disorder. I forgot to mention that.
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A
Oh, tell me all about that.
- [25:33]
B
Yeah, we'll get kids not with makeup, but with food obsessions. I had a case in the past that she had for years been treated by eating disorder specialist and had all types of treatment in and out of, you know, inpatient. She came to see me on her own of like, I want to see this person. And we made her diagnosis and it made so much sense. She just was wanting to eat the same thing every day for periods of time. So she wanted to eat this apple bowl, or she wanted to eat sushi, or she would go on these things where she would eat the same thing every single day. And that was called because she's a female, because she was concerned how she looks. That was called eating disorder, but it was Actually, the rigidity and her obsessiveness in terms of what that fell on. It fell on food. It wasn't trains, it wasn't makeup. It was the food.
- [26:24]
A
So this girl, does she know why she wants to eat the same food all the time?
- [26:28]
B
Because she knows how it's gonna taste.
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A
Okay.
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B
It's predictable.
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A
Yeah.
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B
So why in a. You know a lot. And I'll ask when I see this trend happening with others. Now that I've learned from her, I can ask that question and they're like, well, why would I not eat it? I know how it's gonna taste. Why wouldn't I watch the same movie? I know what's gonna happen. I like the predictability. I don't wanna watch something. I don't know what's gonna happen. I don't wanna taste something of. I don't know what it's going to taste like.
- [26:52]
A
I can see how that would be confused with anxiety, though, or an expression of anxiety that you're more comfortable because it's too scary to eat something different. That's different from. I know what it's going to taste like.
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B
Right.
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A
That's different from. I'm scared of trying something else.
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B
No. Yeah. Their concrete brain is. Why would I try something that I don't. I'm not familiar with. And I know I'm going to like this, so I'm going to eat it.
- [27:13]
A
This helped me to see the perspective of someone on the autism spectrum. The outward behaviors may look like something we recognize, like an oppositional or difficult child or an anxious child, but the root of why it's happening, what's going on in their minds, that's different. And that means that the treatment is going to be different too. The coaching or counseling piece has to help the child, support them in the environments that are stressful or overstimulating. And there are a variety of treatments that I'll get to when Dr. Gittleson is back on the show in a few weeks. And she's using things like neurofeedback and photobiomodulation. And you can learn more about this on her website, Gittleson Psychology Services. The links in the show notes diagnosis and treatment of autism are clearly not straightforward, especially for girls. Why is that?
- [28:04]
B
There's so many different types of autism. That's again, why I don't feel that there's going to be a one way to assess or one method or one genetic test or blood test or, you know, it's so intricate.
- [28:21]
A
There's one last aspect of this that I see. And Dr. Gittleson does, too. Sometimes a child gets diagnosed and then the mother recognizes it in herself as well. I can't tell you how many times I've heard as I was filling out the forms for my daughter, I thought, wait, this is me. I mean, women in their 30s, 40s, 50s, realizing that their anxiety, their social exhaustion, the feeling of being slightly out of sync, their whole lives might have a name. There's a memoir called Autism and Heals that captures this experience beautifully. It's the story of a woman who looked back on her life and finally understood her brain in a new way. So if you're listening and wondering about your child or maybe about yourself, you're not alone. That feeling that something isn't quite right, it's worth paying attention to. Thank you to Dr. Maya Gittleson for sharing her experience and for doing this work. For more from the pediatrician next door, find me on the web@ pediatriciannextdoorpodcast.com if you've got a question about the weird things kids do, send an email to hellopediatriciannextdoorpodcast.com for a chance to hear your voice on the show. Come hi, I'm Dr. Wendy Hunter, and I'm the pediatrician next door. This show is produced by Red Rock Music. Make sure to subscribe and leave a review wherever it is you're listening. I'll be back next time with more.
- [29:53]
C
Close your eyes, exhale, feel your body
- [29:56]
B
relax and let go of whatever you're carrying today.
- [30:01]
C
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- [30:09]
B
And breathe.
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C
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- [30:18]
A
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- [30:21]
D
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A
Cute.
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D
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- [30:51]
C
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