Autism symptoms and internalizing psychopathology in girls and boys with autism spectrum disorders.

Abstract

Findings regarding phenotypic differences between boys and girls with ASD are mixed. We compared autism and internalizing symptoms in a sample of 8-18 year-old girls (n = 20) and boys (n = 20) with ASD and typically developing (TYP) girls (n = 19) and boys (n = 17). Girls with ASD were more impaired than TYP girls but did not differ from boys with ASD in autism symptoms. In adolescence, girls with ASD had higher internalizing symptoms than boys with ASD and TYP girls, and higher symptoms of depression than TYP girls. Girls ages 8-18 with ASD resemble boys with ASD and not TYP girls, and appear to be at increased risk for affective symptoms in the teen years.

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ORIGINAL PAPER
Autism Symptoms and Internalizing Psychopathology in Girls
and Boys with Autism Spectrum Disorders
Marjorie Solomon•Meghan Miller•
Sandra L. Taylor•Stephen P. Hinshaw•
Cameron S. Carter
Published online: 26 March 2011
? The Author(s) 2011. This article is published with open access at Springerlink.com
Abstract
between boys and girls with ASD are mixed. We compared
autism and internalizing symptoms in a sample of
8-18 year-old girls (n = 20) and boys (n = 20) with ASD
and typically developing (TYP) girls (n = 19) and boys
(n = 17). Girls with ASD were more impaired than TYP
girls but did not differ from boys with ASD in autism
symptoms. In adolescence, girls with ASD had higher
internalizing symptoms than boys with ASD and TYP girls,
and higher symptoms of depression than TYP girls. Girls
ages 8-18 with ASD resemble boys with ASD and not TYP
girls, and appear to be at increased risk for affective
symptoms in the teen years.
Findings regarding phenotypicdifferences
Keywords
psychopathology ? Gender paradox
Sex differences ? Autism ? Girls ? Internalizing
Introduction
Autism spectrum disorders (ASD), including autism, high-
functioning autism (HFA), Asperger’s Syndrome (AS), and
Pervasive Developmental Disorder–Not Otherwise Speci-
fied (PDD-NOS), occur with a prevalence of 1 in 110
(Centers for Disease Control 2009). Male predominance is
estimated at 4–1 (Fombonne 2003). Consequently, there
has been relatively little research on girls with ASD. Extant
findings are complex and difficult to interpret.
There are two schools of thought regarding sex differ-
ences in ASD. Some have theorized that being female con-
fers protection against autism traits because of sex
differences in neuroendocrine function. One such argument
suggests that higher levels of oxytocin, which encourage
nurturance and affiliation, provide protection in girls against
the development of autistic traits (Carter 2007). Alterna-
tively, it has been proposed that high levels of fetal testos-
terone may predispose boys to have ‘‘extreme male brains,’’
characterized by phenotypes involving elevated ‘‘system-
atizing’’ (focus on inanimate systems and details) versus
‘‘empathizing’’ (focus on interpersonal orientation) (Baron-
Cohen et al. 2005). Both lead to the same conclusion that,
despite skill deficits relative to typically developing (TYP)
females, girls with ASD symptoms may not be diagnosed
because of milder symptom presentation (Constantino and
Todd 2003) and referral biases (Posserud et al. 2006), and
given that they are still more socially adept than boys with
and without ASD based on their relative strengths in social
skills and caretaking (Holliday-Willey 1999; Maccoby
1998). It is thus important to directly compare girls with
ASD to TYP girls to more fully understand implications of
being a girl with ASD (Koenig and Tsatsanis 2005).
The second school of thought is that girls with ASD are
more severely impaired than boys with ASD. According to
M. Solomon ? C. S. Carter
Department of Psychiatry & Behavioral Sciences,
University of California, Davis, Davis, CA, USA
M. Solomon ? M. Miller
MIND Institute, University of California, Davis,
Davis, CA, USA
M. Miller ? S. P. Hinshaw
Department of Psychology, University of California, Berkeley,
Berkeley, CA, USA
S. L. Taylor
Clinical and Translational Science Center, Davis
School of Medicine, University of California, Davis, CA, USA
M. Solomon (&)
2825 50th Street, Sacramento, CA 95817, USA
e-mail: marjorie.solomon@ucdmc.ucdavis.edu
123
J Autism Dev Disord (2012) 42:48–59
DOI 10.1007/s10803-011-1215-z

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the ‘gender paradox’ hypothesis (Eme 1992), the least
frequently affected sex is more severely impaired. This
gender paradox has been explained using two types of
models: (1) polygenetic multiple-threshold models, which
suggest that females require a higher genetic/environmen-
tal load to be affected; and (2) constitutional variability
models, which propose that greater genetic variability in
males produces higher rates of less severe manifestations
of disorders, while females are more likely to be affected in
cases where there is a pathological event (e.g., brain
damage) (Eme 1992). Both of these models suggest that
there will be more impairment in affected females.
Indeed, some work suggests that girls with ASD are
more severely impaired than boys with the disorders. In
samples including children with higher cognitive abilities,
a recent study found that, relative to age, ASD symptom,
and cognitively-matched males, female toddlers exhibited
greater deficits in aspects of communication and social
competence (Carter et al. 2007). Consistent with this pat-
tern, investigators have reported that, across a wide age
range, girls with ASD have fewer friendships in a higher-
functioning sample (McLennan et al. 1993), and more
communication deficits and greater adaptive behavior
impairments in a lower functioning sample (Banach et al.
2009) than boys with ASD. Although children with autism
are more commonly male, studies have shown that the sex
ratio approaches equality in lower-functioning samples and
that boys are over-represented in higher-functioning pop-
ulations (Fombonne 2003; Lord et al. 1982; Tsai et al.
1981; Volkmar et al. 1993; Wing 1981; Yeargin-Allsopp
et al. 2003), consistent with the gender paradox hypothesis.
However, not all studies have documented sex differ-
ences. Some have found comparable levels of impairment
in girls and boys with autism across high functioning
samples (Holtmann et al. 2007), low functioning samples
(Pilowsky et al. 1998; Tsai and Beisler 1983), and samples
including a range of functioning levels (Lord et al. 2000).
Other studies have shown that boys with ASD exhibit
higher levels of repetitive behaviors in both lower-func-
tioning (Hartley and Sikora 2009) and higher-functioning
samples (McLennan et al. 1993), and higher levels of
stereotypic play in a lower-functioning sample (Lord et al.
1982). Inconsistent matching strategies, diagnostic criteria,
and participant ages make interpretation of these findings
difficult. Furthermore, in clinic-referred samples versus
community/non-referred samples, girls may have to reach a
higher overall level of symptoms in order to present for
treatment (see Gaub and Carlson 1997 for a parallel finding
in ADHD).
In addition to understanding sex differences in ASD
symptoms, an important and clinically significant issue in
the ASD population is whether girls with ASD are at ele-
vated risk for affective disorders. Boys and girls show
similar levels of depression in childhood, but levels in girls
become dramatically greater in adolescence (Nolen-
Hoeksema and Girgus 1994). Additionally, individuals
with ASD demonstrate increased internalizing psychopa-
thology relative to TYP individuals (Kim et al. 2000;
Lainhart and Folstein 1994; Mazefsky et al. 2010; Sukh-
odolsky et al. 2008). Therefore, girls with ASD may be at
especially high risk for internalizing psychopathology
because of the ‘‘double hit’’ conferred by sex and diag-
nostic influences.
In sum, sex differences in the ASD phenotype remain
poorly understood. To our knowledge, no studies have
focused on sex differences in high-functioning preadoles-
cents and adolescents, directly compared TYP girls and
girls with ASD, or examined sex differences in the pre-
sentation of affective disorders in ASD. The goal of the
current study was to address these important gaps in the
literature. The first aim was to investigate whether our
clinically-referred high-functioning sample of boys and
girls differed in ASD symptoms using independent
assessments of language, social, and repetitive behavior
symptoms that were not used to make the ASD diagnosis.
Although there are mixed findings in the literature, evi-
dence for the gender paradox hypothesis has been found in
very low functioning ASD samples, and our sample was
higher functioning. Thus, consistent with theories that
neuroendocrine factors are protective against ASD traits,
we hypothesized that girls with ASD would show fewer
symptoms of social behavior impairments than boys with
ASD, and comparable symptom levels to TYP girls on
parent-reported measures not used to make the ASD
diagnosis. Based on the literature, we also predicted that
boys with ASD would show higher levels of restricted and
repetitive behaviors than all other groups. Last, we aimed
to investigate whether girls with ASD were at greater risk
for internalizing problems than TYP girls and boys with
ASD, as would be predicted by a ‘‘double hit’’ perspective.
Hypotheses were tested using clinician-, parent-, and child-
report measures.
Method
Participants
A total of 76 children (ages 8–11) and adolescents (ages
12–18) participated in this study. Four age-matched groups
were formed: 20 girls with ASD (including HFA, AS, and
PDD-NOS), 20 boys with ASD, 19 TYP girls, and 17 TYP
boys. The ASD groups were matched on IQ. These groups
were further divided such that approximately half of each
were children and half were adolescents (adolescent
ns = 10 for girls with ASD, 10 for boys with ASD, 9 for
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TYP girls, 8 for TYP boys). The decision to include indi-
viduals with HFA, AS, and PDD-NOS was made based on
studies showing that it is difficult to reliably distinguish
between them (Macintosh and Dissanayake 2004; Ozonoff
and Griffith 2000). Participant characteristics are displayed
in Table 1.
Participants were recruited from local physicians, psy-
chologists, speech-language pathologists, occupational
therapists, advocacy groups, regional centers (state centers
for the developmentally disabled), ASD support groups,
and the MIND Institute’s Subject Tracking System, which
includes children with developmental disorders as well as
TYP children. Participants with ASD were required to meet
criteria for Autistic Disorder, AS, or PDD-NOS according
to DSM-IV-TR criteria (American Psychiatric Association
2000). Based on parent report, participants could not have a
diagnosis of depression, anxiety disorders, Attention-Def-
icit/Hyperactivity Disorder (ADHD), Fragile X, Tourette’s,
or seizure disorders. Diagnosed learning disabilities were
not exclusionary. Participants completed all measures
during a single visit. All procedures were approved by the
UC Davis Medical Center Institutional Review Board.
Qualification Measures
Wechsler
Wechsler 1999). The four-subtest (Vocabulary, Block
Design, Similarities, Matrix Reasoning) version of the
WASI was used to provide a short and reliable assessment
of intelligence. It produces Verbal (VIQ), Performance
(PIQ), and Full Scale IQ (FSIQ) Standard Scores with
means of 100 and SDs of 15. The WASI is nationally
standardized and has strong psychometric properties. Test–
retest reliability for IQ scales ranges from .88 to .93. Par-
ticipants were required to have FSIQ scores above 75.
AbbreviatedScaleof Intelligence(WASI;
Scores ranged from 76 to 145 in the ASD groups and
98–139 in the TYP groups.
Autism Diagnostic Observation
(ADOS-G; Lord et al. 2000). To confirm diagnosis, par-
ticipants with ASD were administered module 3 or 4 of the
ADOS-G by a clinical psychologist. The ADOS-G is a
semi-structured protocol that offers standardized observa-
tion of social-communication behavior. Each module has
approximately 10 standardized interactional ‘‘presses.’’
Participants are rated based on their responses and scored
for communication, reciprocal social behavior, and repet-
itive behaviors and stereotyped interest patterns. An algo-
rithm score that combines the communication and
reciprocal social interaction domains is the basis for diag-
nostic classification. Algorithm scores ranged from 7 to 18
in girls with ASD and 7–22 in boys with ASD.
Social Communication Questionnaire (SCQ; Rutter
et al. 2003). Participants’ parents completed the SCQ, a
40-item questionnaire to evaluate communication and
social skills. It contains parallel questions to those on the
Autism Diagnostic Interview-Revised (Lord et al. 1994),
the gold standard parent-report diagnostic measure, in a
briefer format. Berument et al. (1999) reported that a cutoff
of 15 gave sensitivity of .96 and specificity of .80 for
autism versus other diagnoses. Children with ASD were
required to score C15 while TYP groups were required to
score\11. Scores ranged from 15 to 37 in the ASD
groups and 0–8 in the TYP groups.
Schedule-Generic
Autism Symptom Measures
The measures used to assess autism symptoms included the
Social Responsiveness Scale (SRS; Constantino 2002),
Children’s Communication Checklist-2nd Edition (CCC-2;
Bishop 2003), and the Repetitive Behavior Scale-Revised
Table 1 Participant characteristics
Variable A. Girls with ASD
(n = 20)
B. Boys with ASD
(n = 20)
C. TYP girls
(n = 19)
D. TYP boys (n = 17) Group differencesa
M
SD
M
SD
M
SD
M
SD
p
Age (years) 12.003.4212.45 3.72 12.53 3.3211.47
121.65 11.01 \.001 C, D[A, B
122.12 12.12 .001
2.37 ns
–
FSIQ 104.20 15.29103.9516.87 113.2610.23
VIQ 108.7515.12 103.0516.00113.6812.64C[B; D[A, B
C, D[A
–
PIQ99.00 17.10 107.1016.93 109.89 11.48116.65 11.98 .006
ADOS total10.752.73 10.503.95––––
ns
ADOS communication2.95.943.752.07––––
ns
–
ADOS social7.802.35 7.30 2.49––––
2.12 \.001 A, B[C, D
ns
–
SCQ total21.95 6.1923.056.641.581.92 2.00
ASD autism spectrum disorder, TYP typically developing, FSIQ full scale IQ, VIQ verbal IQ, PIQ performance IQ, ADOS autism diagnostic
observation schedule, SCQ Social Communication Questionnaire
aA = Girls with ASD, B = boys with ASD, C = TYP girls, D = TYP boys
50 J Autism Dev Disord (2012) 42:48–59
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(RBS-R; Bodfish et al. 1999). Subscale and total scores
were used as dependent variables in analyses; however, we
emphasize the relative importance of total versus subscale
scores given that subscale scores consist of fewer items and
thus are less reliable than total scores.
SRS (Constantino 2002) The SRS is a 65-item scale used
to assess autism symptom severity. Subscales include:
Social awareness (ability to pick up on social cues), social
cognition (interpretation of social cues), social communi-
cation (expressive social communication), social motiva-
tion (how motivated the child is to engage in social
behavior), and autistic mannerisms (stereotyped behav-
iors). The SRS has acceptable levels of internal consistency
(.93–.97) and test–retest reliability (.77–.85). We obtained
parent-reported SRS scores. A T-score of 60 constitutes a
clinical cutoff.
CCC-2 (Bishop 2003) The CCC-2 is a 70-item parent-
reported measure of communication. We examined the
General Communication Composite (GCC), Social Inter-
action Deviance Index (SIDI), and subscale scores. The
GCC measures structural language skills and is used to
identify children who have communication problems. The
SIDI assesses pragmatic abilities (e.g., nonverbal commu-
nication, scripted language, use of humor and irony) and is
used to identify children who may have ASD (scores B
-11). Subscale reliability estimates range from .66 to .80
in TYP children.
RBS-R (Bodfish et al. 1999) The RBS-R is a 43-item
parent-reported measure assessing restricted and repetitive
behavior. Subscales include the following: Stereotyped
behavior, self-injurious behavior, compulsive behavior,
ritualistic behavior, sameness behavior, and restricted
behavior, and an overall score. The RBS-R has acceptable
levels of inter-rater reliability (.88), test–retest reliability
(.71), and internal consistency (.78 to .91).
Internalizing Psychopathology Measures
The following measures were used to assess internalizing
psychopathology, and constitute relevant dependent vari-
ables: Behavior Assessment System for Children-2nd
Edition (BASC2 subscales: Reynolds and Kamphaus 2004)
and Children’s Depression Inventory (CDI; Kovacs 1992).
BASC2 (Reynolds and Kamphaus 2004) The BASC2 is
used to evaluate adaptive and problem behaviors of children
ages 2–25, and has exhibited acceptable levels of test–retest
reliability (.76 to .84) and internal consistency (.80 to .87).
We utilized raw parent-reported scores from the depression,
anxiety, and internalizing problems (a composite of anxiety,
depression, and somatization items) scales. T-scores above
60 fall within the clinical range.
CDI (Kovacs 1992) The CDI was used to assess
depression levels in children 7–17. It is a self-report
inventory with 27 items, each scored on a 3-point metric.
Items describe different aspects of child mood, interper-
sonal problems, feelings of effectiveness, physical symp-
toms, and self-esteem. It has acceptable levels of internal
consistency (.86), test–retest reliability (.54 to .56), and
discriminant validity, with sensitivity of 80% and speci-
ficity of 84% in distinguishing children with depression
from those without. A raw score of 19 constitutes a clinical
cutoff. Seven participants (two girls with ASD, three boys
with ASD, two TYP girls) were older than the age-norms
cutoff. However, we utilized raw scores, and results did not
differ when excluding these participants.
Data Analytic Plan
The two ASD groups were well matched on IQ and age.
However, as shown in Table 1, there were significant dif-
ferences between ASD and TYP groups on some IQ
measures (ps\.05). Girls and boys with ASD did not
differ on the ADOS-G algorithm score and its subscales,
although in terms of comparing autism symptom levels, the
focus is on the examination of measures of autism symp-
toms that were not used as the basis for diagnosis (i.e.,
SRS, CCC-2, RBS-R).
Because variable scores for a particular measure are
likely correlated, a multivariate analysis of variance
(MANOVA) would have been a preferable analytical
approach. However, because the distributions of variable
scores strongly deviated from a multivariate normal dis-
tribution, significance determinations based on a MANO-
VA would not have been reliable. Therefore, we used
univariate methods to identify variables that differed sig-
nificantly among the four groups and adjusted p-values to
account for multiple hypothesis testing within a measure.
IQ scores differed significantly among some groups
(Table 1). To account for the potential confounding effect
of IQ, we regressed variable scores on IQ and used the
residuals for analysis. We examined differences among the
four groups in autism symptom and internalizing psycho-
pathology variables using Kruskal–Wallis tests. We then
used Mann–Whitney U tests to examine four planned
contrasts: (1) girls and boys with ASD, (2) girls with ASD
and TYP girls, (3) boys with ASD and TYP boys, and (4)
TYP girls and boys. Next, we applied this procedure to
internalizing psychopathology variables in adolescents
only. Within each measure, a Bonferroni correction was
used to control the Type I error rate at .05 across the
analyses of several scores within the measure. A second
Bonferroni adjustment was applied to the planned con-
trasts; thus maintaining the Type I error rate for a measure
at .05 across all tests and contrasts. Significance thresholds
are noted for each variable and follow-up comparisons.
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Sex-norms were available for some measures (SRS,
BASC-2, CDI). We reasoned that normed scores could
mask potential sex differences, given that norms may be
quite different for males and females. Raw scores provide,
by definition, a clearer view of sex effects on a given scale.
Thus, if a measure included sex-specific norms, analyses
examined both normed and raw scores. Results remained
essentially the same with normed versus raw scores; results
from raw scores are presented.
Results
Autism Symptoms
We first examined raw SRS scores. Means, SDs, and effect
sizes (Cohen’s d) are listed in Table 2. With six SRS
variables, the Bonferroni-adjusted alpha was .0083 for
determining significance. There was a main effect of group
on SRS total scores, v2= 33.36; social awareness,
v2= 36.25; social cognition, F(3, 76) = 31.81; social
communication,v2= 35.11;socialmotivation,v2= 25.96;
andautisticmannerisms,v2= 34.77,df = 3,N = 76forall.
Follow-up comparisons using an adjusted alpha level of
.0021 (.0083/4) revealed that there were no differences
betweenboysandgirlswithASDonanySRSvariables.TYP
girls had lower scores than girls with ASD on all SRS sub-
scales (ps = .001). There were no differences between TYP
boys and boys with ASD that withstood the Bonferroni
correction. Finally, TYP girls did not differ from TYP boys.
Next,we examined age-normed
(Table 2). With 12 CCC-2 variables, a Bonferroni-adjusted
alpha level of .0042 was employed. There was a main
effect of grouponboth
v2= 39.26; and SIDI, v2= 25.28, df = 3, N = 76,
p\.001 for both. There was also a main effect of group on
all subscales: Speech, v2= 21.15; syntax, v2= 21.37;
semantics, v2= 32.23; coherence, v2= 38.03; initiation,
v2= 47.90; scripted language,
v2= 41.68; nonverbal communication, v2= 48.17; social
relations, v2= 49.26; and interests, v2= 49.88, df = 3,
N = 76 for all. Follow-up comparisons using an adjusted
alpha level of .0011 (.0042/4) revealed that boys and girls
with ASD did not differ on any variable. TYP girls had
higher (less impaired) scores than girls with ASD on all
variables (ps = .001). TYP boys also had higher scores
than boys with ASD on all variables (ps = .001). TYP girls
and TYP boys did not differ.
Finally, we examined seven RBS-R scores (Table 3)
using a Bonferroni-adjusted alpha level of .0071. Because
of a data collection problem, scores were missing for five
girls with ASD and five TYP girls. There was a main effect
of group on all RBS-R scores: Stereotyped behavior,
CCC-2 scores
compositescales:GCC,
v2= 46.21; context,
v2= 38.48; self-injurious behavior, v2= 25.80; compul-
sive behavior, v2= 32.25; ritualistic behavior, v2= 39.65;
sameness behavior,
v2= 45.93;
v2= 43.34; and overall scores, v2= 43.40, df = 3,
N = 66 for all. Follow-up comparisons using an adjusted
alpha level of .0018 (.0071/4) revealed that boys and girls
with ASD did not differ on any subscale, although the
results are suggestive of higher scores in boys with ASD on
the restricted interests subscale, U = 77.50, z = -2.43,
p = .015 without such stringent corrections for multiple
comparisons. Girls with ASD had higher scores than TYP
girls on all subscales (ps\.001) with the exception of the
compulsive behavior subscale. Boys with ASD had higher
scores than TYP boys (ps = .001), but TYP girls and TYP
boys did not differ.
restricted interests,
Internalizing Psychopathology
Rawscoresfromtheinternalizingproblems,depression,and
anxiety scales of BASC-2 were examined first across the
entiresample(Table 4).Therewasamaineffectofgroupon
all BASC2 subscales, using a Bonferroni-adjusted alpha
level of .0167 for the three BASC2 variables: Anxiety,
v2= 18.07; depression, v2= 38.80 and internalizing
scores, v2= 32.52, df = 3, N = 75 for all. Follow-up
comparisonsusinganadjustedalphalevelof.0042(.0167/4)
revealedthat boys and girlswith ASD did not differ on these
variables. Girls with ASD had higher scores than TYP girls
on all variables (ps\.001). Boys with ASD had higher
depression scores than TYP boys (p\.001) but did not
differ on anxiety or internalizing scores. TYP boys and
TYP girls did not differ from each other on any BASC2
variables.
We next examined raw scores from child-reported CDI
across the entire sample using an alpha level of .05. There
wasamain effectofgroup
N = 76) = 20.35. Follow-up comparisons using an alpha
level of .0125 (.05/4) revealed that girls and boys with
ASD did not differ, whereas girls with ASD had higher
scores than TYP girls (p\.001). Boys with ASD and TYP
boys did not differ, nor did TYP girls and TYP boys. It is
noteworthy that five of the seven scores that fell in the ‘‘at
risk’’ or ‘‘significant’’ range for depression on the CDI
belonged to girls with ASD, totaling 26% of this group.
The other two scores belonged to TYP boys, equating to
12% of this group. A chi square test indicated that the
percentage of participants who fell in the ‘‘at risk’’ or
‘‘significant’’ range for depression significantly differed by
group, v2(3, N = 76) = 10.05, p\.02.
We also examined raw scores from internalizing psy-
chopathology variables in adolescents alone (ages 12–18,
Table 5). There was a main effect of group on the three
onthe CDI,
v2(3,
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Table 2
Means, SDs, and significance for ASD symptom variables
Variable
A. Girls with ASD
(n = 20)
B. Boys with ASD
(n = 20)
C. TYP girls
(n = 19)
D. TYP boys
(n = 17)
p
Group differencesa
Cohen’s da
M
(range)
SD
M
(range)
SD
M
(range)
SD
M
(range)
SD
A–B
A–C
B–D
C–D
SRS Total
103.85
(47–152)
27.64
104.60
(23–149)
32.04
18.11
(0–79)
18.79
62.12
(3–148)
60.81
\.001
A[C
.03
3.63
.87
.96
Social awareness
13.60
(7–19)
3.50
13.45
(5–19)
3.15
3.37
(0–9)
2.56
8.82
(0–19)
6.80
\.001
A[C
.05
3.34
.87
1.06
Social cognition
17.55
(10–26)
4.74
19.95
(5–29)
6.58
3.47
(0–14)
3.67
11.29
(0–29)
11.87
\.001
A[C
.42
3.32
.90
.89
Social communication
35.65
(15–58)
10.12
34.90
(7–49)
11.36
4.58
(0–22)
5.90
20.29
(0–50)
20.58
\.001
A[C
.07
3.75
.88
1.04
Social motivation
17.10
(3–30)
6.74
16.55
(1–30)
7.44
4.32
(0–21)
5.43
11.41
(0–30)
10.76
\.001
A[C
.07
2.09
.56
.83
Autistic mannerisms
20.15
(8–31)
6.32
19.60
(5–30)
6.85
2.68
(0–13)
3.70
10.29
(0–28)
11.85
\.001
A[C
.08
3.37
.89
1.09
CCC-2
Speech
7.20
(1–12)
3.47
7.90
(1–12)
3.28
10.63
(4–12)
2.65
11.12
(4–14)
2.57
\.001
A\C; B\D
.21
1.11
1.09
.19
Syntax
8.10
(1–12)
2.99
8.30
(1–12)
3.01
10.84
(4–12)
2.50
11.35
(5–14)
2.23
\.001
A\C; B\D
.07
.99
1.15
.22
Semantics
7.10
(1–12)
2.69
6.80
(2–12)
3.17
11.21
(7–14)
2.14
12.18
(5–18)
3.64
\.001
A\C; B\D
.10
1.69
1.58
.32
Coherence
5.50
(1–13)
2.76
5.40
(1–12)
2.96
10.53
(1–13)
3.24
11.94
(6–18)
3.47
\.001
A\C; B\D
.03
1.67
2.03
.42
GCC
76.00
(46–115)
14.93
80.95
(50–160)
24.55
113.05
(83–146)
16.20
111.00
(74–143)
16.37
\.001
A\C; B\D
.24
2.38
1.44
.13
Initiation
4.80
(1–9)
2.26
5.25
(1–15)
2.90
12.32
(7–15)
2.91
12.06
(5–19)
3.49
\.001
A\C; B\D
.17
2.89
2.12
.08
Scripted language
4.87
(1–12)
3.03
4.35
(1–12)
3.25
11.53
(5–13)
2.29
11.59
(7–15)
2.40
\.001
A\C; B\D
.17
2.48
2.53
.03
Context
5.35
(1–16)
3.34
5.15
(1–10)
2.48
10.53
(6–14)
2.39
11.59
(6–16)
2.83
\.001
A\C; B\D
.07
1.78
2.42
.40
Nonverbal
2.70
(1–7)
1.75
4.20
(1–13)
3.22
10.74
(4–13)
2.98
11.00
(6–14)
2.37
\.001
A\C; B\D
.58
3.29
2.41
.10
Social relations
3.00
(1–8)
2.13
4.90
(1–12)
3.01
11.00
(4–13)
2.77
11.12
(7–14)
2.18
\.001
A\C; B\D
.73
3.24
2.37
.05
J Autism Dev Disord (2012) 42:48–5953
123

Page 7

parent-reported BASC2 subscales: anxiety, v2= 12.28;
depression, v2= 20.86; and internalizing, v2= 17.98,
df = 3, N = 37 for all, using a Bonferroni-adjusted alpha
levelof.0167.Therewasalsoamaineffectofgrouponself-
reported CDI scores using an alpha level of .05, v2(3,
N = 37) = 12.73. Follow-up comparisons with BASC2
scores using an alpha level of .0042 (.0167/4) revealed
marginally significantly higher anxiety scores in adolescent
females with ASD than males with ASD, U = 15.50, z =
-2.62, p = .009. These two groups did not differ in
depression scores, but females with ASD had significantly
higherinternalizingscoresthanmaleswithASD(p\.001).
Femaleswith ASD also had higherscoresthan TYP females
onanxiety,depression,andinternalizing(ps\.001).Males
with ASD and TYP males did not differ on anxiety or
internalizing scores, but males with ASD had marginally
significantly higher depression scores than TYP males
(p = .011). TYP females and males did not differ on any
scale.ForCDIscores,therewasamaineffectofgroupusing
analphalevelof.05,v2(3,N = 37) = 12.73.Usinganalpha
level of .0125 (.05/4) for follow-up comparisons, there was
no difference between adolescent males and females with
ASD. Females with ASD had higher scores than TYP
females(p = .01).MaleswithASDdidnotdifferfromTYP
males nor did TYP males differ from TYP females.
Discussion
Our primary aims were (1) to determine whether girls with
ASD show fewer social and language ASD-related symp-
toms than boys with ASD, and whether boys with ASD
exhibit higher levels of restricted and repetitive behaviors
than all other groups; (2) to assess whether girls with ASD
are more impaired than TYP girls in terms of social and
language abilities; and (3) to examine whether girls with
ASD show elevated levels of internalizing symptoms
compared to all other groups. We found that ASD symp-
tom profiles were very similar in boys and girls with ASD,
and that girls with ASD differed markedly from TYP girls
on symptom measures that were not used as a basis for
diagnosis, indicating that girls with ASD did not resemble
TYP girls in terms of language and social abilities. Dif-
ferences also emerged with respect to internalizing psy-
chopathology as adolescent girls with ASD evidenced
significant internalizing symptoms compared to boys with
ASD and TYP girls.
There were marginally significant differences in the area
of restricted interests, which was consistent with some
previous research that has found that these interests (an
aspect of repetitive behaviors) are more pronounced in
boys with ASD than girls with ASD (e.g., Hartley and
Table 2
continued
Variable
A. Girls with ASD
(n = 20)
B. Boys with ASD
(n = 20)
C. TYP girls
(n = 19)
D. TYP boys
(n = 17)
p
Group differencesa
Cohen’s da
M
(range)
SD
M
(range)
SD
M
(range)
SD
M
(range)
SD
A–B
A–C
B–D
C–D
Interests
4.55
(1–7)
2.01
4.90
(1–15)
3.42
13.11
(6–16)
3.11
11.94
(8–16)
2.36
\.001
A\C; B\D
.12
3.27
2.40
.42
SIDC
-10.85
(-25 to 12)
10.33
-9.40
(-27 to 16)
11.18
2.84
(-16 to 9)
6.18
-.06
(-8 to 9)
5.18
\.001
A\C; B\D
.13
1.61
1.07
.51
ASD autism spectrum disorder, TYP typically developing, SRS Social Responsiveness Scale, CCC-2 children’s communication checklist, 2nd edition, GCC general communication composite,
SIDC social interaction deviance composite, RBS-R Repetitive Behavior Scale-Revised
aA = Girls with ASD, B = boys with ASD, C = TYP girls, D = TYP boys
54 J Autism Dev Disord (2012) 42:48–59
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Page 8

Sikora 2009; McLennan et al. 1993). Differences in
repetitive behaviors may be linked to variations in neuro-
peptides such as oxytocin and vasopressin (Carter 2007;
Hollander et al. 2003; Insel et al. 1999), and small studies
have shown that infusions of oxytocin reduce these
behaviors in adult males with ASD (Hollander et al. 2003).
However, it remains possible that a gender bias exists on
the RBS-R restricted interests subscale in particular, which
refers to objects such as trains, dinosaurs, and toy cars—
traditionally male interests. Clinical lore suggests that
restricted interests of girls with ASD may be different and
it remains possible that parents of girls with ASD might
report higher levels of restricted interests if examples on
this parent-report measure included a wider range of
Table 3 Means, SDs, and significance for RBS-R variables
VariableA. Girls with ASD
(n = 15)
B. Boys with ASD
(n = 20)
C. TYP girls
(n = 14)
D. TYP boys
(n = 17)
Group
differencesa
Cohen’s da
M
(range)
SD
M
(range)
SD
M
(range)
SD
M
(range)
SD
p
A–B A–C B–D C–D
RBS-R overall 2.47
(6–72)
1.775.00
(0–91)
3.16 .00
(0–18)
.00 .41
(0–11)
1.23 \.001 A[C; B[D .51 1.97 1.91 .47
Stereotyped4.27
(0–13)
3.635.20
(0–15)
3.83.00
(0)
.00 .71
(0–6)
1.83 \.001 A[C; B[D .25 1.66 1.50 .55
Self–injurious2.53
(0–6)
2.073.75
(0–12)
4.14.00
(0)
.00 .41
(0–4)
1.06 \.001 A[C; B[D .37 1.73 1.11 .55
Compulsive4.40
(0–18)
5.036.80
(0–18)
4.99.93
(0–5)
1.73 .29
(0–3)
.77 \.001 B[D .48 .92 1.82 .48
Ritualistic4.93
(0–14)
4.03 7.00
(0–17)
5.42 .36
(0–5)
1.34 .29
(0–2)
.69 \.001 A[C; B[D .43 1.52 1.74 .07
Sameness9.13
(2–23)
6.15 11.20
(0–31)
8.31 .71
(0–8)
2.13 .24
(0–2)
.56 \.001 A[C; B[D .28 1.83 1.86 .30
Restricted interests 2.47
(0–6)
1.775.00
(0–11)
3.16.00
(0)
.00 .41
(0–5)
1.23 \.001 A[C; B[D .991.97 1.91 .47
ASD autism spectrum disorder, TYP typically developing, RBS-R Repetitive Behavior Scale-Revised
aA = Girls with ASD, B = boys with ASD, C = TYP girls, D = TYP boys
Table 4 Means, SDs, and significance for internalizing psychopathology variables
VariableA. Girls with ASD
(n = 20)
B. Boys with ASD
(n = 20)
C. TYP girls
(n = 19)
D. TYP boys
(n = 17)
Group
differencesa
Cohen’s da
M
(range)
SD
M
(range)
SD
M
(range)
SD
M
(range)
SD
p
A–B A–C B–D C–D
BASC2b
Anxiety17.45
(6–26)
6.15 15.74
(3–39)
9.49 9.58
(0–24)
5.81 9.47
(0–25)
6.08 \.001 A[C; B[D .211.32 .79 .02
Depression 17.15
(6–26)
6.9313.00
(2–31)
8.99 3.79
(0–10)
2.78 4.29
(1–16)
4.21 \.001 A[C; B[D .522.53 1.24 .14
Internalizing 189.85
(126–226)
28.91174.32
(120–269)
40.00 136.95
(101–179)
20.15 142.53
(109–184)
17.84 \.001 A[C; B[D .45 2.12 1.03 .29
CDI11.95
(0–33)
7.839.80
(1–17)
5.27 3.47
(0–17)
4.01 5.65
(0–17)
5.41 \.001 A[C.32 1.36 .78 .46
ASD autism spectrum disorder; TYP typically developing, BASC2 behavior assessment system for children, 2nd edition, CDI children’s
depression inventory
aA = Girls with ASD, B = boys with ASD, C = TYP girls, D = TYP boys
bFor all BASC2 variables, n = 19 for boys with ASD
J Autism Dev Disord (2012) 42:48–59 55
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Page 9

choices. This is consistent with the assertion that sex-spe-
cific diagnostic criteria for neuropsychiatric disorders
would be more precise and useful (see Hartung and
Widiger 1998).
As predicted, girls with ASD appeared to be at greater
risk for internalizing psychopathology than boys with ASD
and TYP girls. None of the boys with ASD or TYP girls
fell within the clinical range on the self-report CDI, com-
pared with 26% of the girls with ASD. In adolescence, girls
with ASD had significantly higher parent-reported inter-
nalizing scores than boys with ASD and TYP girls. This
contention is consistent with work indicating there are
more internalizing problems in girls with ADHD than in
boys with the disorder (Gershon 2002; Rucklidge and
Tannock 2001) and comparison girls (Rucklidge and
Tannock 2001), and is also consistent with the suggestion
that being female and having a neurodevelopmental dis-
order may confer particularly high risk with regard to
internalizing psychopathology.
Prior research indicates that TYP girls tend to express
concern about others’ feelings and interact in smaller, more
intimate social groups (Maccoby 1998). Additionally, it
has been shown that affiliative orientation intensifies in
girls in adolescence (Larson and Richards 1989), and
conversations becomemore
(Raffaelli and Duckett 1989). These differences in basic
social processes, along with dramatic social changes in
adolescence, could reveal relative social skill deficits in
girls with ASD and lead to greater isolation during this
developmental period. It is also possible that emotion
socialization plays a role given that girls are more likely to
interpersonally-focused
be encouraged to express their emotions—particularly fear
and sadness—than boys (for a review, see Brody 2000),
leading parents of girls with ASD to have more knowledge
of their daughters’ internal states than their sons’. Still,
girls with ASD might be expected to do this less than TYP
girls, yet they still exhibited more internalizing symptoms
than TYP girls. Such hypotheses should be investigated
further, due to their potential clinical significance.
Indeed, the clinical relevance of understanding elevated
levels of internalizing symptoms in girls with ASD is high.
Determining ways to best treat such symptoms in girls
with ASD will be critical. Studies using cognitive-behav-
ioral strategies to address anxiety in higher-functioning
children with ASD have shown promise (Reaven et al.
2009; Wood et al. 2008). Little research has focused on
using cognitive-behavioral methods to address depression
in this population although such pursuits may be fruitful.
Additionally, group-based social skills interventions that
include components targeting emotion recognition, emo-
tion regulation, and additional problem solving/coping
strategies along with skills for developing more successful
social relationships have been shown to have an effect on
depression scores in boys with ASD and their parents
(Solomon et al. 2004). Developing and implementing
interventions—cognitive, behavioral, and psychotropic—
to address internalizing symptoms in this high risk popu-
lation of girls with ASD could prove to have dramatic
effects on adult outcomes that have been associated with
adolescent depression, including risk for affective disor-
ders, psychiatric hospitalization, and suicidal ideation
(Colman et al. 2007).
Table 5 Means, SDs, and significance for adolescent age and internalizing psychopathology variables
VariableA. Girls with ASD
(n = 10)
B. Boys with ASD
(n = 10)
C. TYP girls
(n = 9)
D. TYP boys
(n = 8)
Group
differencesa
Cohen’s da
M
(range)
SD
M
(range)
SD
M
(range)
SD
M
(range)
SD
p
A–B A–C B–D C–D
Age 14.90
(12–18)
2.13 15.70
(12–18)
2.06 15.56
(12–18)
2.07 13.38
(12–17)
1.85
ns
.38.31.07 1.11
BASC2
Anxiety18.00
(8–26)
5.85 10.40
(3–20)
6.068.78
(1–14)
4.24 8.75
(1–16)
4.83.006A[C 1.28 1.08.30 .01
Depression16.80
(7–25)
7.45 9.50
(2–21)
6.79 3.22
(0–7)
2.28 3.25
(1–12)
3.73 \.001 A[C 1.022.47 1.14 .01
Internalizing 200.80
(151–226)
25.64155.90
(120–209)
28.60 137.33
(113–170)
19.47 141.75
(109–184)
21.82 \.001 A[B, C 1.652.79 .56.21
CDI11.50
(0–33)
9.188.90
(2–15)
4.86 2.33
(0–6)
2.24 4.25
(1–10)
3.11.005 A[C .351.37 1.14 .71
ASD autism spectrum disorder; TYP typically developing, BASC2 behavior assessment system for children, 2nd edition, CDI children’s
depression inventory
aA = Girls with ASD, B = boys with ASD, C = TYP girls, D = TYP boys
56 J Autism Dev Disord (2012) 42:48–59
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While the purpose of this investigation was not to
address whether girls with ASD are under-diagnosed, we
note the importance of this issue to the field. Furthermore,
consistent with ADHD findings, boys and girls were simi-
larly impaired as evidenced by comparable diagnostic and
non-diagnostic ASD symptom scores. Research about sex
differences in ADHD may be instructive. Although the
belief that girls with ADHD are less symptomatic than boys
was prevalent, large longitudinal studies of girls with
ADHD have found this population to be significantly
impaired (e.g., Hinshaw 2002; Hinshaw et al. 2006). As in
our study, a meta-analysis by Gaub and Carlson (1997)
found similar ADHD symptom profiles between boys with
ADHD and clinic-referred girls with ADHD. However, they
also found that non-referred girls displayed lower rates of
ADHD behaviors. Similarly, it may be that only girls with
substantial impairments in core ASD symptoms are refer-
red, so that clinic samples mask sex differences in symp-
toms existing in the community. Population-based studies
are needed to address these important questions. Given that
our sample was clinic-referred, it is likely to have consisted
of a more severely impaired group of girls and boys than
would be found in the community, resulting in groups that
were very similar in terms of ASD symptoms.
Limitations of the study include its small size and lack
of perfect IQ matching. Additionally, we did not include an
observer-report standardized assessment of comorbid psy-
chopathology in either ASD or TYP participants, and the
measures we did use were validated for TYP youth. Thus,
it is not clear that the measures used in this study are
accurately assessing internalizing symptoms in individuals
with ASD. Unfortunately, no other assessment measures
exist to specifically measure internalizing symptoms in
ASD populations, and there may be high overlap between
ASD-like traits and internalizing traits (Hallet et al. 2010).
However, we still found that higher levels of internalizing
symptoms were specific to adolescent girls with ASD and
not boys with ASD, suggesting that these assessments of
internalizing symptoms were not merely reflecting mani-
festations of ASD symptoms. Finally, although results of
analyses were corrected for multiple comparisons, many
variables were examined given our sample size, increasing
the potential for Type II error. Thus, this study serves as an
initial platform for future empirical investigations of the
female ASD phenotype using multivariate strategies.
In conclusion, the study of girls with ASD represents an
important area for future research. This group appears to be
at enhanced risk for developing affective symptoms in
adolescence, suggesting the potential need for screening
and intervention. Also, the question of whether girls with
ASD in the community are less impaired and/or under-
detected relative to boys remains unanswered. Finally,
while we addressed questions related to our specific
hypotheses, we did not address the underlying neurobio-
logical questions from which they were derived. Future
studies should examine neuropeptide levels in TYP boys
and girls and boys and girls with ASD, as well as the
genetics of sex differences in the prevalence and expres-
sion of the male and female phenotypes of the disorders,
and relate this information to observed behavioral differ-
ences. Both lines of research hold the potential to advance
the study of the pathophysiology of ASD and to provide
information relevant to treatment development.
Acknowledgments
from the National Institute of Mental Health (1-K-08 MH074967-01)
and a Building Interdisciplinary Research Careers in Women’s Health
Award (K12 HD051958) funded by the National Institute of Child
Health and Human Development (NICHD), Office of Research on
Women’s Health (ORWH), Office of Dietary Supplements (ODS),
and the National Institute of Aging (NIA) to Marjorie Solomon.
Statistical support was made possible by Grant Number UL1
RR024246 from the National Center for Research Resources (NCRR),
a component of NIH and NIH Roadmap for Medical Research. Its
contents are solely the responsibility of the authors and do not nec-
essarily represent the official view of NCRR or NIH. Information on
Re-engineering the Clinical Research Enterprise can be obtained from
http://nihroadmap.nih.gov/clinicalresearch/overview-translational.asp.
This work was supported by a K-08 Award
Conflicts of interest
related to this manuscript.
The authors report no conflicts of interest
Open Access
Creative Commons Attribution Noncommercial License which per-
mits any noncommercial use, distribution, and reproduction in any
medium, provided the original author(s) and source are credited.
This article is distributed under the terms of the
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