Changes from the DSM-IV to DSM-V:
- the term 'pervasive developmental disorders' was replaced by 'neurodevelopmental disorders' and subsumed under ASD
- autism was renamed as autism spectrum disorder
- merging of social and communication symptoms of autism into one domain
-including abnormalities in sensory processing under restricted behaviors
-changing the onset age criteria

These changes were supposedly created to ensure that autism was known as multi-dimensional, and would give clinicians a better understanding of cultural and gender-related factors.

Huerta et.al,:
-DSM-V is no better than DSM-IV at diagnosing women with autism
-looked at clinical records to see how sensitive the new criteria was, and compared estimated sensitivities for both men and women
- diagnostic sensitivity for women: .88 - .93
- diagnostic sensitivity for men: .89 - .92
This does not display a significant difference between DSM-IV and DSM-V.

Kim et, al,:
- epidemiological study in South Korean community comparing male to female ratio in DSM-IV versus DSM-V
- DSM-IV: 2.5:1 (male:female)
- DSM-V: 2.7:1 (male:female)


The DSM-V and Gender Bias in Autism and Asperger's Syndrome

Autism screening tools have all been developed on the 'male phenotype', and therefore are not helpful in diagnosing women. 

ASSQ (Autism Spectrum Screening Questionnaire):
- developed by Kopp and Gillberg in 1999 to test for Asperger's and high-functioning autism
- in 2011, they added 18 items onto the questionnaire that they believed would better address the female phenotype
- found that these questions better addressed female phenotype, and were able to differentiate between women with autism and women without autism through this questionnaire

ex.) Girls tended to respond 'yes' to four questions where boys tended to respond 'no' - avoiding chores or demands, daily activities hindered by repetitive behaviors, changing voice or speech, interacting mostly with younger children 

Limitations: in the original study, because the ASSQ was based on the male phenotype, any changes made may still not be fully representative of the female phenotype, needs more research

The Role of Diagnostic Screening Instruments in Gender Bias in Autism and Asperger's Syndrome

Essentially. what these studies are concluding is that:
- there are marked gender differences in women and men when it comes to autism spectrum disorder or asperger's syndrome 
- women may not always exhibit outwardly 'odd' behaviors, like men. This leads to a bias in diagnoses.
- lack of a 'female phenotype' when it comes to autism or asperger's
- most current autism or asperger's research is based in the male experience, therefore, it's harder to diagnose women when their symptoms have not been researched

Therefore, this paper proposes that there should be more research done on the female phenotype in autism.

Conclusions of studies on  Gender Bias in Autism and Asperger's Syndrome

- clinical or social work practice without up-to-date knowledge is harmful for patients
- clinicians. and social workers should keep tabs on developments in autism research, specifically with new diagnostic tools emerging
- autism has a high comorbidity with depression, anxiety, and other mental health concerns due to its isolating effects, but social workers and clinicians need to recognize this and treat accordingly
- diagnostic models are only models, they need critical thinking and examining of the clinician's own gender biases to be correctly used

ex.) Patient 'Sue' who had Asperger's syndrome, but was misdiagnosed as being depressed at age 14. The depression treatments she received were contradictory to the autism stimuli, resulting in a painful three years until she was correctly diagnosed at age 17.

Further Implications of the Gender Bias in Autism and Asperger's Syndrome

People with autism are more likely to rate themselves as being trans or nonconforming, reaching around 25% compared to the general population that shows 5% identifying as trans or nonconforming.

Transgender and gender nonconforming People with Autism

Girls are diagnosed with autism spectrum disorder much less frequently than boys. When they are diagnosed, it is much later. Girls are diagnosed five and a half years later than boys are. 


Girls Diagnosed with Autism Spectrum Disorder at Later Ages Than Boys

A 1981 epidemiological study conducted by Lorna Wing to examine sex ratios in children diagnosed with autism revealed the following:
- difference b/w men and women in language and social impairments, and in the way they reacted to their respective environments
- prompted further sex ratio research

Ehlers and Gillberg (1998):
- study on epidemiology of Asperger's syndrome
- found smaller male:female ratio than expected

Matille et. al, (2007):
- hypothesizied that women with autism display superficial social skills and this is what causes them to be misdiagnosed

Koenig and Tsatsanis (2005):
- found that most autism research stemmed from male experiences alone
- Hartrung and Widiger (1998): concluded that when a disorder's symptoms change based on gender, diagnosis will be skewed towards those who outwardly express symptoms that are out of the social norm



University of California, Davis

Autism Spectrum Disorder is a neurodevelopmental disorder that affects communication and behavior. It displays symptoms such as impaired communication, lack or impairment in social skills and interactions, and repeated patterns of behaviors that interfere with an individual's ability to cognitively function. These symptoms are almost always present in early development, and are considered to be on a 'spectrum' because of the differences in severity of these symptoms.


Although autism can be diagnosed at any age, it is said to be a “developmental disorder” because symptoms generally appear in the first two years of life. Boys tend to be diagnosed more often than girls by approximately 4x. There is also an overrepresentation of transgender or gender nonconforming people with ASD.

Autism Spectrum Disorder

https://www.tandfonline.com/doi/pdf/10.1080/15332985.2015.1031858?needAccess=true

Autism, females, and the DSM-5: Gender bias in
autism diagnosis

Verbal

Gestures

Pictures

Text

Drawing

Communication Styles

Gender Bias in Autism and Asperger's Syndrome

When diagnosed with ASD, one is further classified as level 1, 2, or 3. These classifications correspond with severity of symptoms and dependency, particularly indicating how much support is necessary for that individual’s daily functioning. 

- ASD Level 1
- ASD Level 2
- ASD Level 3
- Limitations of the ASD Levels

Three Functional Levels of ASD

The most common co-occurring disorders with Autism Spectrum Disorder include epilepsy/seizures, sleep disorders, gastrointestinal disorders, ADHD, anxiety, depression, and bipolar disorder. Often, these can go undetected due to the overlapping symptoms of ASD and/or inability to communicate these symptoms. This inability to communicate other discomforts can often result in coping mechanisms consisting of inappropriate behaviors, thus a shift in behavior can indicate presence of a comorbid disorder. 

- ASD and Epilepsy

ASD Co-morbidity with Other Disorders

As our understanding of Autism Spectrum Disorder has evolved, our definition and explanations have evolved as well, modifying diagnostic criteria and labels. Most likely, it will continue to adapt and evolve as we learn more about it, as our current understanding is incomplete. 

ASD Definitions Through Time

There is no medical test for ASD. Rather, experts must study an individual's development and behavior and, using their best logic and existing criteria, suggest a diagnosis. Generally, diagnoses are more likely to be accurate by age 2 or older. 

ASD Diagnosis Techniques

People with autism and those with intellectual disability often experience stigma and barriers to forming intimate romantic relationships due to deficits in complex social skills, despite often having the same needs for intimacy and sexuality as typically-developing people.

Forming romantic relationsihps as an individual with ASD

Fragile X syndrome is perhaps the most common genetic form of intellectual disability. It results when the trinucleotide repeats (i.e., CGG repeats) in the long arm of the X chromosome number more than 200 repeats, as opposed to the normal 6-50 repeats. This extension of repeats leaves this region of DNA fragile, or prone to breakage. Specifically, the overexpansion causes methylation and transcriptional repression of the Fragile X Mental Retardation 1 gene (*FMR1*), which encodes an important RNA-binding protein that inhibits RNA translation into proteins known as fragile X retardation protein (FMRP). The condition affects 1 in 3600 males and 1 in 8000 females. The reason for this large discrepancy between incidences in biological sexes is due to the fact that genetic females have two X chromosomes rather than one X like genetic males do. Generally speaking, females have one normally functioning *FMR1* on the non-mutated chromosome in each cell, which allows their symptoms to be milder since the amount of abnormal *FMR1* is more variable than in males.

Fragile X Syndrome

- About 50-60% of transition-age youth and adults with autism spectrum disorder obtain work opportunities following participation in vocational rehabilitation programs, mainly working part-time and for low wages
- Programs primarily focus on modifying behavior as opposed to modifying work environments and practices
- The structures of VR programs, availability of services, eligibility criteria, and funding differ greatly by state, as well as how tailored they are to individuals with ASD
- A shift to a knowledge-based economy makes VR services for individuals on the autism spectrum a necessity

Vocational Rehabilitation for Individuals on the Autism Spectrum

Many autistic individuals have at least one other co-occuring psychological condition. Some common co-morbidities of Autism Spectrum Disorder include: 

- Attention-Deficit Hyperactivity Disorder 
- Obsessive-Compulsive Disorder 
- Depression 
- Anxiety Disorders 

Co-occuring Psychological Conditions in Autism Spectrum Disorder 

Applied behavioral analysis, or ABA therapy, is rooted in understanding learning and behavior. This therapy is intended to help people with ASD learn skills and behaviors to help them live more fulfilling lives. Such as:

- coping mechanisms
- social skills
- communication skills
- self-care
- play, leisure activities
- motor skills

ABA Therapy

The DSM-5 criteria for children with ASD includes deficits in sensory processing, specifically sensory modulation. Any sensory modality may be affected but some evidence suggests that individuals with ASD have a greater frequency of sensory deficits in the domains of taste and smell, as well as tactile sensitivity. 

- neurobiology of sensory symptoms in ASD

Sensory Processing Deficits in Autism Spectrum Disorder

- mental/speech deficits or impairment
- sleep difficulties
- if smiling, laughing, and/or head flapping is a repetitive behavior this could also be a symptom of autism since repetitive behaviors are a part of autism.

Angelman Syndrome and Autism Spectrum Disorder: Common Symptoms

Social Anxiety Disorder and Autism Comparison

Reference for Autism and Social Anxiety Disorder

Avoidant Personality Disorder and Autism Comparison

Neff, M. (n.d.). Avoidant Personality Disorder vs Autism. Neurodivergent insights. https://neurodivergentinsights.com/misdiagnosis-monday/avoidant-personality-disorder-vs-autism




Avoidant Personality Disorder and Autism Comparison Reference 

Autism Spectrum Disorder (ASD) is a category of neurodevelopmental disorders defined by core challenges in social interaction and communication, alongside the presence of restricted and repetitive patterns of behavior.

Autism Spectrum Disorder (ASD) Core Deficits

The capacity for independent living among adults with Autism Spectrum Disorder varies. While individuals with more developed language and intellectual skills may be able to live and work on their own, this is not the reality for the majority. For many, the persistence of ASD symptoms creates significant impairments in various life domains, making it difficult to manage essential daily tasks like personal hygiene, finances, and meal preparation.

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