Challenges of Females with Autism: A Parental Perspective

Investigation of Menstrual Hygiene and Self-Care Skills of Adolescent Girls with Autism Spectrum Disorder: Mother Views

PURPOSE

Puberty a period of transition from childhood to adulthood, poses problems that are difficult to manage for typically developing adolescents, but even more difficult for adolescents with autism. It is vital that girls with autism spectrum disorder (ASD), like their typically developing peers, are able to manage these physiological processes in a healthy way and learn self-care and hygiene behaviours without being dependent on others. Given the contribution of mothers to the menstrual hygiene and self-care skills of adolescent girls, this study aims to explore the views of mothers.

METHODS

The study is a case study designed in the qualitative research model. The research was carried out with the participation of 10 mothers met the necessary criteria and agreed to take part in the study voluntarily. The data obtained were subjected to descriptive and thematic analysis. Codes, sub-themes and main themes were created.

RESULTS

The research identifies the themes of self-care and menstrual hygiene, preparations made during menstruation, behavioral problems in adolescents, the person who carries out hygiene and self-care, and situations that tire/strain mothers during menstruation.

CONCLUSION

At the end of the research, it was concluded that the adolescent girls with ASD are mostly unable to perform their self-care and hygiene adequately, and that the mothers do nothing to prepare their daughters for adolescence. It was also concluded that the most stressful situation for mothers during adolescence is usually the difficulty their daughters have in using sanitary pads, cleaning armpits and genital hair, and bathing.

Improving autism identification and support for individuals assigned female at birth: clinical suggestions and research priorities

Emerging evidence suggests that the higher prevalence of autism in individuals who are assigned male than assigned female at birth results from both biological factors and identification biases. Autistic individuals who are assigned female at birth (AFAB) and those who are gender diverse experience health disparities and clinical inequity, including late or missed diagnosis and inadequate support. In this Viewpoint, an international panel of clinicians, scientists, and community members with lived experiences of autism reviewed the challenges in identifying autism in individuals who are AFAB and proposed clinical and research directions to promote the health, development, and wellbeing of autistic AFAB individuals. The recognition challenges stem from the interplay between cognitive differences and nuanced or different presentations of autism in some AFAB individuals; expectancy, gender-related, and autism-related biases held by clinicians; and social determinants. We recommend that professional development for clinicians be supported by health-care systems, professional societies, and governing bodies to improve equitable access to assessment and earlier identification of autism in AFAB individuals. Autistic AFAB individuals should receive tailored support in education, identity development, health care, and social and professional sense of belonging.

Sex and gender in neurodevelopmental conditions

Health-related conditions often differ qualitatively or quantitatively between individuals of different birth-assigned sexes and gender identities, and/or with different gendered experiences, requiring tailored care. Studying the moderating and mediating effects of sex-related and gender-related factors on impairment, disability, wellbeing and health is of paramount importance especially for neurodivergent individuals, who are diagnosed with neurodevelopmental conditions with uneven sex/gender distributions. Researchers have become aware of the myriad influences that sex-related and gender-related variables have on the manifestations of neurodevelopmental conditions, and contemporary work has begun to investigate the mechanisms through which these effects are mediated. Here we describe topical concepts of sex and gender science, summarize current knowledge, and discuss research and clinical challenges related to autism, attention-deficit/hyperactivity disorder and other neurodevelopmental conditions. We consider sex and gender in the context of epidemiology, behavioural phenotypes, neurobiology, genetics, endocrinology and neighbouring disciplines. The available evidence supports the view that sex and gender are important contributors to the biological and behavioural variability in neurodevelopmental conditions. Methodological caveats such as frequent conflation of sex and gender constructs, inappropriate measurement of these constructs and under-representation of specific demographic groups (for example, female and gender minority individuals and people with intellectual disabilities) limit the translational potential of research so far. Future research and clinical implementation should integrate sex and gender into next-generation diagnostics, mechanistic investigations and support practices.

Randomized Study of Survey Recruitment Strategies for Parents of Autistic Children

INTRODUCTION

This study aimed to compare phone, email, or text message recruitment strategies for engaging parents of autistic children in an online survey.

METHOD

In this randomized study, a sample of 1,624 parents of autistic children spectrum disorder (autism) from an integrated health system in Southern California were sent an initial mailed letter and email simultaneously for baseline survey outreach. Then, participants were randomly assigned to one of three follow-up recruitment groups: phone, email, or text message. We compared the efficacy of recruitment strategies in multivariate models.

RESULTS

All three follow-up methods were equally effective for eliciting a survey response. Parents of girls were less likely to respond to survey outreach attempts than parents of boys.

DISCUSSION

Multiple modalities of survey recruitment, including digital and mobile approaches, effectively recruit parents of children in research.

Bullying experiences and mothers’ responses to bullying of children with autism spectrum disorder

Despite the fact that children with disabilities generally have been shown to be at a greater risk of bullying, which include physical attacks and threats, being picked on and teased and verbal abuse, there is still a need to understand bullying of children with autism spectrum disorder (ASD) and the strategies used by parents to support them in tackling this issue. This study aims to investigate the type and level of occurrence of bullying and parental support for children aged five with ASD who suffer from bullying. This study used both quantitative and qualitative analysis; a questionnaire, distributed to mothers of children with ASD, adopted from the Bullying for ASD Survey developed by Chen and Schwartz (Focus Autism Other Dev Disabil 27(4):200–212, 2012) measured types and frequency of bullying and parental support. An open-ended question was added to the survey to enable parents to write about the ways in which their child was bullied and the ways in which they supported their child. The results showed that while children suffered from all types of bullying, especially being picked on, being excluded and called names. Parental support showed a higher prevalence of involving peers and teachers for the prevention of bullying as well as avoiding strategies which included avoiding bullies and none of the mothers encouraged their children to stand up to bullies.

Parenting Challenges and Reasons for Not Availing Rehabilitation Services Among Families of Adolescents with Autism Spectrum Disorder: A Qualitative Study

Background:

Autism spectrum disorder (ASD) is a lifelong condition requiring continued rehabilitation services. However, children with ASD who seek rehabilitation services tend to drop out once they enter puberty, because of varying reasons, some of which are unknown. This study intended to explore the reasons for not availing of rehabilitation services in families of adolescents with ASD and the parental challenges in taking care of adolescents with ASD.

Method:

The study followed a descriptive qualitative research design by conducting in-depth interviews with 12 primary caregivers of adolescents with ASD (10 to 19 years; mean age 16.3 years) who were not availing of any direct rehabilitation services. All interviews were conducted by telephone, and data obtained were subjected to thematic analysis.

Results:

The results showed two major themes, viz. reasons for discontinuing the rehabilitation services and parental challenges among primary caregivers of adolescents with ASD, and their corresponding subthemes. The reasons for discontinuation of rehabilitation included financial difficulties, difficulties in handling the child, and a lack of improvement in the child. A few of the parental challenges were disruptive behaviors and associated medical conditions of the child and difficulty in managing changes during adolescence.

Conclusion:

The study revealed several reasons as well as potential barriers to avail rehabilitation services in Indian families of adolescents with ASD. The data further unveil related parenting challenges specific to the Indian context. Further, implications for service providers and policymakers are discussed.

Living arrangements and community participation among autistic adults: Exploring the possible influences of living alone or with others

BACKGROUND

With the increasing prevalence of autistic individuals, it is greatly needed to examine the factors impacting their community participation experiences. Where autistic adults live and how that may be related to their participation and quality of life is one environmental factor that has received little attention.

AIMS

This study explored the association between living arrangements in the community and community participation for autistic adults.

METHOD

This study used data from a statewide survey of autistic adults (N = 744) to investigate the relationship between living arrangements (live alone with or without support, live with roommate/spouse, or live with family) and the amount, breadth, and sufficiency of community participation.

RESULTS

After controlling for sociodemographic and clinical factors known to be associated with community participation, autistic adults living with family members participated less frequently in community activities over 30 days than those living with a roommate/spouse. However, they experienced similar levels of sufficiency with their participation. Autistic adults living alone with support reported the lowest levels of sufficiency with their participation, although the amount and breadth of their participation were no different from other adults.

CONCLUSION

These findings have several implications for providing support to enable autistic adults to participate in the areas that are important to them and to the extent they desire. Future research is needed to gain a better understanding of how interests and expectations for participation may be influenced by living situations.

Habilitative Teletherapy for Children with Autism Spectrum Disorder: A Survey of Parents

OBJECTIVE

The purpose of this study was to investigate whether service losses during the coronavirus disease 2019 (COVID-19) pandemic were associated with worsened parent mental health or child behavioral health among families of children with autism spectrum disorder and to identify factors associated with favorable parent appraisals of habilitative teletherapy (applied behavior analysis; speech, occupational, physical therapy) for their child.

METHOD

This web-based survey study was conducted from May to July 2021 with parents whose children were receiving habilitative therapy for autism from an integrated health system. A total of 322 parents responded to the survey (20% response rate). The outcome variables were pandemic-related parent mental health, pandemic-related child behavioral health, and appraisal of habilitative teletherapy. Predictors were COVID-19-related services changes in health care or child care, COVID-19 history (COVID-19 stress, testing positive for COVID-19), and child autism factors (autistic behaviors, caregiving strain).

RESULTS

Loss of regular child care was associated with higher odds of worsened parent mental health (odds ratio [OR] = 2.7, 95% confidence interval [CI] = 1.5-4.8); higher levels of caregiving strain were associated with worsened child behavioral health (OR = 2.3, 95% CI = 1.4-3.8). Higher levels of COVID-19 stress were associated with more favorable appraisals of telehealth (β = 0.4, p < 0.01), whereas higher caregiving strain scores were associated with less favorable appraisals of telehealth (β = -0.2, p < 0.01).

CONCLUSION

During COVID-19, caregiving factors were associated with worsened parent mental health and worsened child behavioral health, and telehealth is not preferred by all families. Policy interventions to support caregivers, such as affordable, high-quality child care and paid family leave, are a high priority.

Barriers to Autism Spectrum Disorder Diagnosis for Young Women and Girls: a Systematic Review

There is increased recognition that women and girls with autism spectrum disorders (ASD) are underserved by the clinical criteria and processes required to receive a diagnosis. This mixed-methods systematic review aimed to identify key barriers to obtaining an ASD diagnosis in girls and young women under 21 years. Six themes were identified that focused on perceived gendered symptoms, namely behavioural problems, social and communication abilities, language, relationships, additional diagnoses/difficulties and restricted and repetitive behaviours and interests. Five themes were identified as (parental) perceived barriers to diagnosis, namely compensatory behaviours, parental concerns, others’ perceptions, lack of information/resources and clinician bias. This review highlights the importance of enhancing widespread understanding and recognition of ASD presentation in females across development. PROSPERO Centre for Reviews and Dissemination (ID 2018 CRD42018087235)

Preparing for Puberty in Girls With Special Needs: A Cohort Study of Caregiver Concerns and Patient Outcomes

STUDY OBJECTIVE

To characterize the patient population with cognitive or physical impairments that presents for anticipatory guidance of puberty, evaluate caregiver concerns with respect to puberty, and describe chosen management strategies and outcomes following menarche.

DESIGN

Retrospective cohort study SETTING: Academic tertiary care women and children's hospital PARTICIPANTS: Eligible female patients with special needs up to age 26 years presenting for anticipatory guidance from 2009 to 2018 MAIN OUTCOME MEASURES: Primary outcomes included characterization of patients presenting for anticipatory guidance and their reasons for menstrual management. Secondary outcomes were satisfaction with menstrual management and bleeding patterns.

RESULTS

A total of 61 patients presented for anticipatory guidance of puberty, on average 13.5 months prior to menarche. Compared to the overall adolescent population with special needs who presented for gynecologic care, patients who had autism spectrum disorder (ASD), were nonverbal, or had attention-deficit/hyperactivity disorder (ADD/ADHD) were more likely to present for a pre-menarchal visit to discuss anticipated pubertal development (P < .001, P = .009, and P = .04, respectively). More than half of families described potential behavioral changes as their main concern. The majority of post-menarchal patients (80%) desired hormonal management of menses, including 30% of patients who had placement of a levonorgestrel intrauterine device. In all, 96% of patients were satisfied with their final menstrual bleeding pattern; 50% achieved amenorrhea or light spotting.

CONCLUSIONS

This study describes the important role of pre-menarchal reproductive counseling for girls with disabilities. Anticipation of puberty causes great anxiety in families and patients, especially those with ASD, ADD/ADHD, and non-verbal status. Providers should consider initiating these conversations early in pubertal development.

A parent-sibling dyadic interview to explore how an individual with Autism Spectrum Disorder can impact family dynamics

BACKGROUND

Autism Spectrum Disorder (ASD) is a life-long condition which affects the individual and their family system. Little research understands the impact of an ASD upon families, how this may change over time and how COVID-19 has impacted these dynamics.

AIMS

To explore the impact of an ASD on the lived experiences of parents and neurotypical adult siblings, including during the UK COVID-19 lockdown.

METHODS

Eight parent-sibling dyads (16 individuals) completed semi-structured interviews discussing their family before, during and after receiving the ASD diagnosis, and in relation to the first UK lockdown. Interview transcripts were analysed using Interpretative Phenomenological Analysis.

RESULTS

Three super-ordinate themes were identified: Dominated by ASD; Family Cohesion; and the Need for Support.

CONCLUSIONS

The data suggested a closeness within the families and an adoration towards the individual with ASD (IWA). Dyads were, to an extent, consumed by the diagnosis both presently and in the future, implicating the need for a stretch in services to support parents and neurotypical siblings. In terms of the first UK lockdown, the IWA added an extra layer of difficulty to the dyads work-life balance yet there was an essence of family cohesion. Future research should consider longitudinal methods and explore the impact of ASD co-morbidities upon family dynamics.

The Expectancies and Motivations for Heavy Episodic Drinking of Alcohol in Autistic Adults

Background

For autistic adults, the perceived benefits of drinking alcohol to facilitate social interaction may be particularly appealing. Alcohol may be considered "self-medication" for clinical features of autism or may be used to help cope with elevated levels of co-occurring anxiety.

Methods

We developed an online survey and 507 autistic adults responded to questions concerning their expectancies and motivations for heavy episodic drinking. The survey also included questions about ways of seeking support, if needed, and barriers to seeking support.

Results

Over half of those who had drunk alcohol reported heavy episodic drinking in the past year (6 or more units of alcohol at one time). Heavy episodic drinkers endorsed traditional expectancies (e.g., "Alcohol generally has powerful positive effects on people") and autism-specific expectancies (e.g., "Alcohol makes verbal communication easier") to a greater degree than nonheavy episodic drinkers. Autism-specific expectancies, not traditional expectancies, related to frequency of drinking. The strongest motivations for heavy episodic drinking were for social reasons and to enhance positive feelings, rather than for conformity or coping. If support was required for problematic drinking, the internet was the most commonly chosen resource, although 45% of the participants indicated that they would not seek support. Perceived barriers to support included concern that it would take place in an unfamiliar chaotic environment and concern about being misunderstood and judged by a therapist.

Conclusions

This study is the first to identify the expectancies and motivations for heavy episodic drinking in autistic adults as well as identifying barriers to seeking support. There may be some autism-specific expectancies related to the nature of autism that impact upon heavy episodic drinking, as well as impacting upon seeking support. The autistic and broader autism communities can benefit from an awareness of these findings, and service providers can adapt support appropriately.

Lay summary

Why was this study done?: Little is known about how alcohol is used within the autistic community. One population-based study found that autistic adults were four times more likely to experience problematic drinking compared with nonautistic adults.What was the purpose of this study?: This study identified the expectations and motivations for heavy episodic-or "binge"-drinking alcohol among autistic adults. Binge drinking is a risk factor for problematic drinking. The study also identified how autistic adults accessed support should it be needed, and what the potential barriers were to accessing support.What did the researchers do?: We conducted an online survey with 507 autistic adults with formal or informal diagnoses of autism. The survey asked about the frequency of drinking alcohol and binge drinking. Participants then answered a questionnaire about why they drank alcohol. The questions asked about general reasons for drinking (such as: "Alcohol generally has powerful positive effects on people [e.g., makes you feel good or happy; future seems brighter]") as well as autism-related reasons (such as: "Alcohol makes verbal communication easier [e.g., starting conversations, responding to what other people say, or maintaining a normal back-and-forth conversation]"). Finally, participants answered questions about seeking help and potential barriers to help-seeking.What were the results of the study?: Binge drinkers reported a greater number of traditional and autism-relevant expectations for drinking alcohol than nonbinge drinkers. The strongest motivations for drinking alcohol were for social reasons and to enhance positive feelings, rather than coping or to conform. The internet was the most common source of support for problematic drinking (49% of participants); however, 45% of participants indicated that they would not seek any support. Perceived barriers to support were an unfamiliar chaotic environment and being misunderstood and judged by a therapist. Around one fifth of participants self-diagnosed themselves with autism, rather than having a formal diagnosis from a clinician. These two groups were very similar to each other.What do these findings add to what was already known?: This is the first study to identify the expectations and motivations for binge drinking alcohol in the autistic community.What are potential weaknesses in the study?: This was an online survey, and the diagnostic status of participants cannot be verified. Participants chose to take part in the study, and this may represent a bias as some people may not want to take part in online surveys or may not have access to the internet, or may not be part of networks that send out invitations to take part in research. In addition, the sample was largely female and well educated, which is not reflective of the autistic population as a whole.How will these findings help autistic adults now or in the future?: Better understanding the expectations and motivations for binge drinking alcohol can help inform support that is targeted at the autistic community. Alcohol support services can be better informed about how to adapt their provision for the autistic community specifically.

Sex Differences in Age of Diagnosis and First Concern among Children with Autism Spectrum Disorder

OBJECTIVE

Early identification of autism spectrum disorder (ASD) is an essential healthcare priority. Girls may be at risk for late diagnosis, although research is equivocal regarding how sex and other factors relate to ASD identification. The goals of the current investigation were to (1) identify how child sex, cognitive abilities, and demographic factors relate to age of first concern (AOC) and age of diagnosis (AOD), (2) evaluate trends in AOC/AOD over time, and (3) consider whether main effects of sex on AOC/AOD are moderated by cognitive abilities or time.

METHOD

Children (N = 365; 20% female; 85.6% identified as White) with ASD participated through the Province of Ontario Neurodevelopmental Disorders (POND) Network. Study records included AOD, date/timing of diagnosis (between 1996 and 2017), age of first parent concern, demographics, and standardized cognitive testing results (24.7% of children had IQ scores below standard scores of 70).

RESULTS

Average AOC occurred before 2 years of age whereas average AOD occurred after 5 years of age. Girls did not differ on AOC but had a later AOD than boys. Higher verbal IQ was associated with later AOD more strongly in girls than boys. Regarding time-related changes, average AOC and AOD increased across the study period, more strongly for girls.

CONCLUSIONS

Results support that sex is a key factor underlying delays in ASD identification and highlight the urgent need to improve diagnostic practices among girls. Limitations and implications for improving the diagnostic process are discussed.

Abbreviations: ASD=autism spectrum disorder; IQ=intelligence quotient; AOC=parental report of age of first concern; AOD=age of diagnosis.

Gender Differences in Social Inclusion of Youth with Autism and Intellectual Disability

The aim of this study was to delve into the role of gender differences in social inclusion of children and youth with autism spectrum disorder (ASD) and intellectual disability (ID). A sample of 420 participants with ASD and ID aged between 4 and 21 years was evaluated using the ASD-KidsLife Scale. Females obtained lower scores in most of the items of social inclusion. These differences remained when the covariables of level of ID, support needs, and age were controlled. None of the items presented differential item functioning as a function of gender. Gender differences, as were found in social inclusion, are discussed and recommendations are given in order to provide equal opportunities to girls and boys with ASD.

A Qualitative Exploration of the Female Experience of Autism Spectrum Disorder (ASD)

Autism spectrum disorder is thought to be a predominantly male diagnosis, however recent research suggests a smaller gender disparity in prevalence than previously assumed. Accounts of the female experience of autism are important to help reduce likely male-bias in current understanding and recognition of autism. Eighteen autistic females and four mothers of autistic females took part in discussions with a topic guide around diagnosis, impact and coping. A thematic analysis was conducted. Five themes were identified: fitting in the with the norm, potential obstacles for autistic women and girls, negative aspects of autism, the perspective of others, and positive aspects of having autism. We hope that greater understanding of the experiences of autistic females may lead to improved awareness, diagnosis and support for women and girls.

Exploring the female autism phenotype of repetitive behaviours and restricted interests (RBRIs): a systematic PRISMA review

Purpose

The purpose of this paper is to address the need for increased understanding, awareness and recognition of the autism female phenotype in terms of repetitive behaviours and restricted interests (RBRIs).

Design/methodology/approach

A systematic PRISMA review was conducted. The main aim of the present systematic review is to identify studies which have investigated RBRIs in females with autism spectrum disorder (ASD) or the differences in RBRIs between males and females with ASD.

Findings

In sum, 19 relevant articles were identified: 5 studies found no significant evidence to support the notion of sex differences in RRBIs in ASD; 1 study did not report any differences in RRBIs between males and females with ASD; 12 studies found evidence that males with ASD had significantly more RRBIs compared to females with ASD; and, lastly, 1 study found that girls with ASD have features of RRBIs which are exhibited more compared to boys with ASD.

Research limitations/implications

There is a real lack of in-depth knowledge and understanding of the female phenotype of ASD, and such lack of knowledge has a detrimental impact on the identification of autistic females and a lack of identification can have negative consequence. This is important to address in future research as it is well established that the earlier the diagnosis, the better the outcomes, due to the timely access to appropriate interventions.

Practical implications

The RBRIs exhibited in autistic females are not sufficiently captured by most currently diagnostic instruments. Clinicians are less likely to identify the RBRIs in females as they tend not to be the typical repetitive behaviours commonly associated with ASD. It has been recommended that clinicians consider “females as a whole” in terms of their clinical presentation and look for any indication of RBRIs, even repetitive interests which appear clinically innocuous.

Originality/value

There is relatively little research investigating RBRIs in autistic women and girls. There is a real need to highlight the importance of understanding and recognising how RBRIs can differ between males and females with ASD.

The Scientific Study of Parents and Caregivers of Children with ASD: A Flourishing Field but Still Work to be Done

There is a long history of research on parents and caregivers of individuals within autism. Parents and other primary caregivers typically play the most important part in the lives of persons with ASD although the need for support as the child becomes of age varies widely. This special issue includes 30 articles on central areas related to parenting and caregiving for people with ASD. Some of the key themes include intervention and training, mental health issues related to parent and family stress, measurement and assessment, and parent-child transactional processes. Other articles in this issue consider different but equally important topics such as sibling as potential future caregivers and parent support of preschool peer relationships.