Female Autism; strengths, vulnerability and misdiagnosis.

Developing as an autistic girl, woman, and mother includes moments of vulnerability, despair, confusion and self-doubt.

Girls and women who are austistic are different, not in terms of the core characteristics but in terms of their reaction to being different. We use specific coping and adjustment strategies to camouflage or mask our confusion in social situations or achieve superficial social success by imitation or escaping into a world of fantasy or nature.?

There may be single but intense friendships with another female, who may provide guidance for in social situations, perhaps in a benevolent way and in return, the autistic female is not interested in the 'bitchy' behaviour of her peers and is a loyal and helpful friend. Unfortunately, sometimes the autistic female is vulnerable to friendship predators who take advantage of her naivety, social immaturity and longing to have a friend. Inevitably there will be times when she has to engage with other children and she may prefer to play with boys, whose play is more constructive than emotional and adventurous rather than conversational. Many autistic girls and women have described to clinicians and in autobiographies how they sometimes think they have a male rather than a female brain, having a greater understanding and appreciation of the interests, thinking and humour of boys. The girl who is autistic can be described as a 'Tom Boy' eager to join in the activities and conversations of boys rather than girls.

Autistic females are more likely to apologise and appease when making a social error. Peers and adults may then forgive and forget, but without realising that a pattern is emerging. However, the autistic female is increasingly recognising her social confusion and frequent faux pas. She may react by trying not to be noticed in a group, for others to be aware of her social confusion, preferring to be on the periphery of social situations. However, autistic females can be avid observers of human behaviour and try to decipher what they are supposed to do or say. Another strategy to having problems with social reasoning is by being well behaved and compliant at school so as not to be noticed or recognised as a different. An autistic female may suffer social confusion in silence and isolation in the classroom or playground but she may be a different character at home, the 'mask' is removed, and she uses passive aggressive behaviour to control her family and social experiences.

Another constructive adaptation to the characteristics of autism used by girls and women is to use imitation or imagination. The girls may identify someone who is socially successful and popular, either from her peers or a character in a television soap opera and adopt that person's persona in mimicking speech patterns, phrases, body language and even clothing and interests using a social script. She becomes someone else, someone who would be accepted and not recognised as different. She learns how to act in specific situations, a strategy that some find so successful that people thought her social abilities were intuitive and could not believe this was an artificial performance. Autistic girls and women can be like a chameleon, changing persona according to the situation, but no one knowing the genuine persona. She fears that the real person must remain secret because that person is defective.

Some girls may not seek integration but escape into imagination. If you are not successful with your peers, you can try to find an alternative world where you are valued and appreciated. The girl may identify with a fictional character such as Harry Potter or Hermione Granger, who faces adversity but has special powers and friends. If she feels lonely, then imaginary friends can provide companionship, support and comfort. There can be an interest in ancient civilisations to find an old world in which you would feel at home, or another country such as Japan where you would be accepted and of like mind or even another planet with an interest in science fiction or a special and intense interest in the traditional fantasy worlds of witches, mermaids, fairies and mythology. Many typical children occasionally enjoy escaping into imagination, but for the autistic child , and especially the autistic girl, the reasons are qualitatively different and the fantasy world can become a means of avoiding reality and experiencing a relatively safe and successful social life.

While these coping and camouflaging mechanisms can mask the characteristics of autism, such that the female with autism slips through the diagnostic net, there is a psychological cost that may only become apparent in adolescence. Observing and analysing social behaviour and trying not to make a social error are emotionally exhausting. Adopting an alternative persona can lead to problems of self-identity and low self-esteem regarding who you really are. Both of these coping and camouflaging strategies can contribute to a clinical depression in a young adult. Girls and women who are autistic can spend many years searching for an explanation of why they are different, questioning whether they are defective or demented and why they feel so depressed.

Autistic people are prone to excessive anxiety, especially performance anxiety in social situations. This can contribute to selective mutism, being too anxious to speak in a group situation. A well known method of alleviating anxiety for typical children and adults is to develop routines and rituals and to focus on a special interest that can act as a 'thought blocker' to act as a shield for intrusive anxious thoughts. An autistic female may develop routines and rituals around food and a special interest in calories and nutrition that under the increasing stress associated with adolescence, develops into the signs of Anorexia Nervosa.

From my own extensive clinical and personal experience and reading autobiographies, autistic females can be extremely sensitive to the emotional atmosphere at a social gathering. There is an almost 'sixth sense' for feelings within others of antagonism, fear and despair in group situations. When an autistic female who has emotional sensitivity to the negative moods of others has also been bullied and teased by peers and rejected or 'betrayed' by friends, there can be a suggestion of the characteristics of Borderline Personality Disorder. Being a 'Tom Boy' in childhood, not being interested in fashion and femininity, make up and perfumes, as well as appreciating the logic of the male brain can lead to concerns regarding sexuality and gender identity. Social immaturity and naivety can also lead to vulnerability to sexual predators and a risk of sexual assault.

Having a very sensitive sensory system, for example hearing sounds inaudible to others and an emotional 'sixth sense' can lead to an interest in the supernatural which could also be misinterpreted as a sign of not being in touch with reality. Thus an autistic adolescent or young adult may only come to the attention of clinicians for the diagnostic assessment of a secondary mood or personality disorder or psychosis. A detailed developmental history by a clinician experienced in the clinical presentation of adolescent girls with autism may confirm the characteristics. At last an accurate diagnosis and explanation, but she has missed the opportunity for understanding, guidance and support in her earlier childhood.

We need to know about those moments experienced by actual autistics and listen to their wisdom to reduce the likelihood of other girls and women having the same experiences. Our experiences and abilities change with maturity and we now have insight and perspective and constructive coping strategies that will be appreciated by autistic girls and women but also by all those who support and love them.