Where Are All of Us?

Are there really more males than females with autism/Asperger’s and AD/HD?

Reading the diagnostic literature, one finds references to the “fact” that there are more autistic boys than girls. There certainly seem to be more hyperactive, inattentive boys diagnosed (and consequently treated with medication) than there are girls.

Curiously, when one reads through bulletin board sites for autistics/Asperger’s, there seems to be a pretty evenly balanced gender ratio (as far as one can discern from screen names or profiles). Looking at the “autiebiographies” available, the male to female author ratio is fairly even. However, such reviews are not necessarily going to be a representative sampling of a population. Publishing houses require authors to be able to present novel perspectives (pardon the pun), to have good written verbal skills, and may try to present a balance of authors. A bulletin board is naturally self-selecting for individuals who have computer access, a comfortable grasp on the language used, a willingness to identify one’s self as belonging there, plus just as importantly, an interest in socializing through Web media. The first two factors are universal requirements for access, but the last one is distinctive for a different reason.

Females are generally perceived by society as being more socially -oriented than are males, or more interested in people than in things, hence the “Men are from Mars, Women are from Venus” analogy or Dr. Simon Baron-Cohen’s recent writings on male/female differences. They are also perceived as having higher verbal skills than do males, or at least girls develop higher levels of verbal skills at younger ages than do boys. There is the possibility that even if women are outnumbered in these populations, they are more likely to crave socialization and be more adept at, or feel more comfortable with, socializing through the written medium of a Web board. But does the sex ratio evinced reflect this self-selection, or is it a good sampling and therefore indicative of the overall population?

Currently more males than females are diagnosed with autism and AD/HD, at a general rate of around 4:1. The causes of autism are proving to be complex; autism is not a single, simple thing, but varies in collative properties by individual. Thus far it is indicated to be polygenic and also affected by factors in embryonic development as well, as twins do not even develop similarly. It would not surprise anyone to find that males are more likely to be autistic; the susceptibility derived from only having one X chromosome is seen in a variety of genetic factors.

These off-repeated ratios are likely not true prevalence rates, but rather reflects diagnostic rates. Both autism and AD/HD are diagnosed by sets of behaviours that differ from the norm, and thus attract attention of those people who would make initial remarks (parents, teachers) leading to those individuals being brought to the attention of those who would make final assessments (pædiatricians, psychiatrists, psychologists).

Females often do not “present” in the same manner that males do. This is rather a reflection of the fact that the diagnostic criteria were based more upon behaviour of males from the sample populations than upon a gender-balanced population samples. Currently the psych field is abuzz with discussion that girls are being missed for ADD diagnoses because they present more in the Inattentive qualities. The quiet, daydreaming girl staring out the window is not a problem for her school teacher, so there is less concern about her erratic scholastic achievements. (After all, maybe it’s just a “blonde thing” /sarcasm.)

Part of autism is inherent in the “wiring” of the human brain, and part of autism is a social construct. That Kanner and Asperger both met with unusual children who gave them the impetus to dually conceive of the concept of autism at the same time in history, may have more to do with the fact that a public awareness of psychology, the development of social and scholastic statistical norms that created specific definition of abnormal, plus the evolving field of child psychology, more than any sudden incidence of autistics.

Likewise the concept of “minimal brain dysfunction” that has evolved to its current status of AD/HD reflects changing understanding, including distinctions between hyperactive, inattentive and combined forms. As mentioned, a hyperactive boy is simply more noticeable in a classroom setting than is a daydreaming girl, although they may have very similar difficulties with their school work, personal and social lives, and ultimately their adult worlds of work.

Amazingly, kids with AD/HD grow up to be adults with AD/HD, although the problems of the adult can be less “noticeable” because adults can develop coping mechanisms (including the acquisition of helpful spouses who eventually become very frustrated if no one realises what’s really going on). Likewise, the addition of Asperger’s to the DSM and ICD criteria reflects a greater understanding of the breadth of autistic expression, and the number of adults that would now qualify for an AS diagnosis is far greater than those who actually have such a diagnosis, simply because it was not available as a diagnosis during the school years when such things are often diagnosed. The lack of available diagnoses is not the same thing as the lack of diagnosable individuals existing.

Just as autistics sometimes face the gross error of being misdiagnosed with schizophrenia, mental retardation or other disorders, females face the similar problem of being misdiagnosed with personality disorders. The complementary dilemma to Misdiagnoses are the Missed Diagnoses, those girls and women who continue to struggle through life never understanding why they feel so different and why they find many things difficult. For these people the secondary problems with relationships, schooling and work result in lifelong stress and all too frequently in depression.

To better understand how autism or AD/HD affects the abilities of females, we need to better understand how to recognize them and to be able to see those cues when they are expressed in girls and women.