Natural language markers of social phenotype in girls with autism

Gender and age related brain structural and functional alterations in children with autism spectrum disorder

To explore the effects of age and gender on the brain in children with autism spectrum disorder using magnetic resonance imaging. 185 patients with autism spectrum disorder and 110 typically developing children were enrolled. In terms of gender, boys with autism spectrum disorder had increased gray matter volumes in the insula and superior frontal gyrus and decreased gray matter volumes in the inferior frontal gyrus and thalamus. The brain regions with functional alterations are mainly distributed in the cerebellum, anterior cingulate gyrus, postcentral gyrus, and putamen. Girls with autism spectrum disorder only had increased gray matter volumes in the right cuneus and showed higher amplitude of low-frequency fluctuation in the paracentral lobule, higher regional homogeneity and degree centrality in the calcarine fissure, and greater right frontoparietal network-default mode network connectivity. In terms of age, preschool-aged children with autism spectrum disorder exhibited hypo-connectivity between and within auditory network, somatomotor network, and visual network. School-aged children with autism spectrum disorder showed increased gray matter volumes in the rectus gyrus, superior temporal gyrus, insula, and suboccipital gyrus, as well as increased amplitude of low-frequency fluctuation and regional homogeneity in the calcarine fissure and precentral gyrus and decreased in the cerebellum and anterior cingulate gyrus. The hyper-connectivity between somatomotor network and left frontoparietal network and within visual network was found. It is essential to consider the impact of age and gender on the neurophysiological alterations in autism spectrum disorder children when analyzing changes in brain structure and function.

Exploring Online Communication in Self-Identified Autistic Adolescents

PURPOSE

Social media sites provide autistic youth a familiar space to interact that is devoid of many of the challenges that accompany face-to-face interactions. As such, it is important to determine whether the linguistic profiles observed during online interactions are consistent with face-to-face interactions. This preliminary study took a step in this direction by examining gender differences observed in autistic adolescents in an online forum to determine whether they are consistent with the emerging body of research investigating linguistic gender differences in autistic adolescents.

METHOD

We analyzed the entries of self-identified autistic adolescents in an online forum to determine whether autistic girls (n = 99) and boys (n = 94) differ in their use of linguistic features as a proportion of total words produced. Transcriptions were coded across discourse, lexical, and semantic features and compared to previous research investigating linguistic gender differences in autistic people. Exploratory comparisons were also made to linguistic gender differences in neurotypical people.

RESULTS

Of the linguistic features we examined, three out of four of the gendered usage patterns observed in the online forum language samples were consistent with previous research on face-to-face communication for autistic adolescents. Only one feature out of 12 occurred in the same gender distribution as previous research on neurotypical communication.

CONCLUSIONS

Autistic girls and boys demonstrate largely consistent gender differences in their language use across in-person and online communication contexts. Interestingly, most of the significant gender differences previously reported in neurotypical communicators were not seen in this sample of autistic adolescents, suggesting that perhaps autistic individuals may linguistically express gender characteristics to a different extent or in a different manner than neurotypical individuals.

Developmental Language Differences in Children with Autism Spectrum Disorders and Possible Sex Difference

Developmental difference is a common characteristic of autism spectrum disorder (ASD) with unclear sex differences. The current study included 610 children with ASD, aged between 2 and 7 years, with completed language profiles. We used a nonparametric item response theory model called Mokken scale analysis to examine the order of acquisition of developmental language milestones in children with ASD. Our results demonstrated the developmental language differences in the expressive and receptive language dimensions in children with ASD compared with typical developmental sequences. Furthermore, The acquisition of gestures and pragmatics was more impaired in the female subgroup than in the male subgroup. The identified developmental language sequence could help provide a more comprehensive ASD developmental profile.

Is There a Bias Towards Males in the Diagnosis of Autism? A Systematic Review and Meta-Analysis

Autism is more frequently diagnosed in males, with evidence suggesting that females are more likely to be misdiagnosed or underdiagnosed. Possibly, the male/female ratio imbalance relates to phenotypic and camouflaging differences between genders. Here, we performed a comprehensive approach to phenotypic and camouflaging research in autism addressed in two studies. First (Study 1 - Phenotypic Differences in Autism), we conducted a systematic review and meta-analysis of gender differences in autism phenotype. The electronic datasets Pubmed, Scopus, Web of Science, and PsychInfo were searched. We included 67 articles that compared females and males in autism core symptoms, and in cognitive, socioemotional, and behavioural phenotypes. Autistic males exhibited more severe symptoms and social interaction difficulties on standard clinical measures than females, who, in turn, exhibited more cognitive and behavioural difficulties. Considering the hypothesis of camouflaging possibly underlying these differences, we then conducted a meta-analysis of gender differences in camouflaging (Study 2 - Camouflaging Differences in Autism). The same datasets as the first study were searched. Ten studies were included. Females used more compensation and masking camouflage strategies than males. The results support the argument of a bias in clinical procedures towards males and the importance of considering a 'female autism phenotype'-potentially involving camouflaging-in the diagnostic process.

Intersecting effects of sex/gender and autism on structural language: A scoping review

LAY ABSTRACT

Research about autism is mostly about boys and men, even though many autistic people are girls, women, and transgender/nonbinary. We wanted to learn more about how gender interacts with language skills in autistic people, so we reviewed existing research articles on this topic. We also wanted to know how this previous research talked about gender. Included articles had to measure language skills for autistic people of different genders. They also had to be published between 2000 and 2021. Twenty-four articles met these requirements. We found that autistic girls showed better language skills than autistic boys but worse skills than nonautistic girls. This may be one reason that autistic girls are underdiagnosed compared to autistic boys. If we compare autistic girls to nonautistic girls instead, we can see more language differences and possible areas to target in interventions. This study supports the need to create diagnostic and support measures for autism that take gender into account. Also, only one article mentioned autistic people who are transgender or nonbinary. Researchers who want to learn more about gender and autism need to understand gender diversity and recognize that many autistic people are transgender or nonbinary.

Sex differences in the temporal dynamics of autistic children's natural conversations

BACKGROUND

Autistic girls are underdiagnosed compared to autistic boys, even when they experience similar clinical impact. Research suggests that girls present with distinct symptom profiles across a variety of domains, such as language, which may contribute to their underdiagnosis. In this study, we examine sex differences in the temporal dynamics of natural conversations between naïve adult confederates and school-aged children with or without autism, with the goal of improving our understanding of conversational behavior in autistic girls and ultimately improving identification.

METHODS

Forty-five school-aged children with autism (29 boys and 16 girls) and 47 non-autistic/neurotypical (NT) children (23 boys and 24 girls) engaged in a 5-min "get-to-know-you" conversation with a young adult confederate that was unaware of children's diagnostic status. Groups were matched on IQ estimates. Recordings were time-aligned and orthographically transcribed by trained annotators. Several speech and pause measures were calculated. Groups were compared using analysis of covariance models, controlling for age.

RESULTS

Autistic girls used significantly more words than autistic boys, and produced longer speech segments than all other groups. Autistic boys spoke more slowly than NT children, whereas autistic girls did not differ from NT children in total word counts or speaking rate. Autistic boys interrupted confederates' speech less often and produced longer between-turn pauses (i.e., responded more slowly when it was their turn) compared to other children. Within-turn pause duration did not differ by group.

LIMITATIONS

Our sample included verbally fluent children and adolescents aged 6-15 years, so our study results may not replicate in samples of younger children, adults, and individuals who are not verbally fluent. The results of this relatively small study, while compelling, should be interpreted with caution and replicated in a larger sample.

CONCLUSION

This study investigated the temporal dynamics of everyday conversations and demonstrated that autistic girls and boys have distinct natural language profiles. Specifying differences in verbal communication lays the groundwork for the development of sensitive screening and diagnostic tools to more accurately identify autistic girls, and could inform future personalized interventions that improve short- and long-term social communication outcomes for all autistic children.

Sex differences in social and emotional insight in youth with and without autism

Autism was formally recognized by the medical community in the first half of the twentieth century. Almost 100 years later, a small but growing literature has reported sex differences in the behavioral expression of autism. Recent research has also begun to explore the internal experiences of individuals with autism, including social and emotional insight. The current study examines sex differences in language-based markers of social and emotional insight in girls and boys with autism and non-autistic peers during semi-structured clinical interviews. Sixty-four participants aged 5 to 17 years were individually matched on chronological age and full-scale IQ to form four groups: autistic girls, autistic boys, non-autistic girls, and non-autistic boys. Transcribed interviews were scored using four scales that index aspects of social and emotional insight. Results revealed the main effects of diagnosis, such that youth with autism exhibited lower insight than non-autistic youth on scales indexing social cognition and object relations, emotional investment, and social causality. With regards to sex differences, across diagnoses, girls were rated higher than boys on the social cognition and object relations, emotional investment, and social causality scales. Examined within each diagnosis separately, clear sex differences emerged: both autistic and non-autistic girls demonstrated better social cognition and understanding of social causality than boys in their respective diagnostic groups. No within-diagnosis sex differences were found on the emotional insight scales, however. These results suggest that relatively enhanced social cognition and understanding of social causality in girls may be a population-level sex difference that is preserved in autism, despite the core social challenges that characterize this condition. The current findings reveal critical new information about insight into social and emotional thinking and relationships in autistic girls versus boys that have important implications for improving identification and designing effective interventions.

Sex differences in friendships and loneliness in autistic and non-autistic children across development

BACKGROUND

Autistic children have been shown to have less complete definitions of friendships and higher levels of loneliness than their non-autistic peers. However, no known studies have explored sex differences in autistic children's understanding of friendships and reported loneliness across development. Autistic girls demonstrate higher levels of social motivation than autistic boys and appear to "fit in" with their peers, but they often have difficulty recognizing reciprocal friendships during middle childhood. As autistic girls develop a more complex understanding of friendship during adolescence, they may begin to redefine their friendships and experience heightened loneliness. Here, we explored how autistic and non-autistic boys and girls define the meaning of friendship and report feelings of loneliness across development. We also examined their perceptions of friendships and loneliness.

METHODS

This mixed-methods study analyzed the transcribed clinical evaluations of 58 autistic children (29 girls) matched to 42 non-autistic children (21 girls) on age and IQ. Transcripts were coded for four categories that children used to define friendships-personality, companionship, dependability, and intimacy-and for reported loneliness. We then compared these codes across diagnosis, sex, and age. Content analyses were further implemented to gain a more holistic understanding of children's perceptions of friendships and loneliness.

RESULTS

Girls, regardless of diagnosis, were more likely than boys to refer to personality when defining the meaning of friendship, and the likelihood of referring to dependability and intimacy increased with age. Most children reported having at least one friend, though some autistic adolescents reported not having friends or were uncertain whether they had friends. While autistic and non-autistic boys and girls were equally likely to report feeling lonely at times, several autistic girls and boys reported being frequently lonely.

LIMITATIONS

This study was a secondary data analysis. The standardized set of questions on the ADOS limited the amount of information that children provided about their friendships and perceptions of loneliness.

CONCLUSION

As with non-autistic children, autistic children acquire a more complex understanding of friendship throughout development. However, as children begin to prioritize dependability and intimacy in friendships, autistic adolescents may have difficulty developing friendships characterized by these constructs. Furthermore, the quantity and/or quality of autistic children's friendships may not be sufficient to alleviate loneliness.

Intellectual disabilities moderate sex/gender differences in autism spectrum disorder: a systematic review and meta-analysis

BACKGROUND

Girls/women with autism spectrum disorder (ASD) are suggested to exhibit different symptom profiles than boys/men with ASD. Accumulating evidence suggests that intellectual disability (ID) may affect sex/gender differences in ASD. However, a systematic review and meta-analysis on this topic is missing.

METHODS

Two databases (MEDLINE and PsycINFO) were used to search for studies reporting sex/gender differences (girls/women versus boys/men) in social communication and interaction, restrictive and repetitive behaviour and interests (RRBIs), sensory processing, and linguistic and motor abilities in ASD. The final sample consisted of 79 studies. The meta-analysis was performed with Review Manager using a random-effects model. Participants with ASD without and with ID were analysed as separate subgroups, and the effects in these two subgroups were also compared with each other.

RESULTS

Girls/women with ASD without ID displayed fewer RRBIs, more sensory symptoms and less problems in linguistic abilities than their boys/men counterparts. In contrast, girls/women with ASD with ID displayed more social difficulties and RRBIs, poorer linguistic abilities and more motor problems than boys/men with ASD with ID. Comparisons of groups of participants with ASD without ID versus participants with ASD with ID confirmed differences in sex/gender effects on social difficulties, sensory processing, linguistic abilities and motor abilities.

CONCLUSIONS

Our results clearly suggest that the female phenotype of ASD is moderated by ID. Among individuals with ASD with ID, girls/women seem to be more severely affected than boys/men, whereas among individuals with ASD without ID, girls/women with ASD may have less symptoms than boys/men. Such phenotypic differences could be a potential cause of underrecognition of girls/women with ASD, and it is also possible that observed phenotypic differences may reflect underdiagnosing of girls/women with ASD.

"Um" and "Uh" Usage Patterns in Children with Autism: Associations with Measures of Structural and Pragmatic Language Ability

Pragmatic language difficulties, including unusual filler usage, are common among children with Autism Spectrum Disorder (ASD). This study investigated "um" and "uh" usage in children with ASD and typically developing (TD) controls. We analyzed transcribed Autism Diagnostic Observation Schedule (ADOS) sessions for 182 children (117 ASD, 65 TD), aged 4 to 15. Although the groups did not differ in "uh" usage, the ASD group used fewer "ums" than the TD group. This held true after controlling for age, sex, and IQ. Within ASD, social affect and pragmatic language scores did not predict filler usage; however, structural language scores predicted "um" usage. Lower "um" rates among children with ASD may reflect problems with planning or production rather than pragmatic language.

Towards equitable diagnoses for autism and attention-deficit/hyperactivity disorder across sexes and genders

PURPOSE OF REVIEW

Sex/gender-related factors contribute to contextual issues influencing the recognition of autism and attention-deficit/hyperactivity disorder (ADHD), and modulate how neurodevelopmental characteristics are manifested. This review summarizes the empirical literature to provide directions for improving clinical diagnostic practices.

RECENT FINDINGS

Timing of autism and/or ADHD diagnosis, particularly in girls/women, is related to the individual's developmental characteristics and co-occurring diagnoses, and expectancy, alongside gender stereotype biases, of referral sources and clinicians. This is further compounded by sex and gender modulations of behavioural presentations. The emerging 'female autism phenotype' concept may serve as a helpful illustration of nuanced autism phenotypes, but should not be viewed as essential features of autism in a particular sex or gender. These nuanced phenotypes that can present across sexes and genders include heightened attention to socially salient stimuli, friendship and social groups, richness in language expression, and more reciprocal behaviours. The nuanced female-predominant ADHD phenotypes are characterized by subtle expressions in hyperactivity-impulsivity (e.g., hyper-verbal behaviours). Optimizing neurodevelopmental diagnoses across sexes and genders also requires an understanding of sex-related and gender-related variations in developmental trajectories, including compensation/masking efforts, and the influences of co-occurring conditions on clinical presentations.

SUMMARY

Equitable diagnoses across sexes and genders for autism and ADHD require understanding of the nuanced presentations and the Gestalt clinical-developmental profiles, and addressing contextual biases that influence diagnostic practices.

Conversational adaptation in children and teens with autism: Differences in talkativeness across contexts

Successful social communication is complex; it relies on effectively deploying and continuously revising one's behavior to fit the needs of a given conversation, partner, and context. For example, a skilled conversationalist may instinctively become less talkative with a quiet partner and more talkative with a chattier one. Prior research suggests that behavioral flexibility across social contexts can be a particular challenge for individuals with autism spectrum condition (ASC), and that difficulty adapting to the changing needs of a conversation contributes to communicative breakdowns and poor social outcomes. In this study, we examine whether reduced conversational adaptation, as measured by talkativeness, differentiates 48 verbally fluent children and teens with ASC from 50 neurotypical (NT) peers matched on age, intelligence quotient, and sex ratio. Participants completed the Contextual Assessment of Social Skills with two novel conversation partners. The first acted interested in the conversation and talked more (Interested condition), while the second acted bored and talked less (Bored condition). Results revealed that NT participants emulated their conversation partner's behavior by being more talkative in the Interested condition as compared to the Bored condition (z = 9.92, p < 0.001). In contrast, the ASC group did not differentially adapt their behavior to the Bored versus Interested context, instead remaining consistently talkative in both (p = 0.88). The results of this study have implications for understanding social communication and behavioral adaptation in ASC, and may be valuable for clinicians interested in improving conversational competence in verbally fluent individuals with autism. LAY SUMMARY: Social communication-including everyday conversations-can be challenging for individuals on the autism spectrum. In successful conversations, people tend to adjust aspects of their language to be more similar to their partners'. In this study, we found that children and teens with autism did not change their own talkativeness in response to a social partner who was more or less talkative, whereas neurotypical peers did. These findings have clinical implications for improving conversational competence in verbally fluent individuals with autism.

Predictive language processing in young autistic children

Recent theories propose that domain-general deficits in prediction (i.e., the ability to anticipate upcoming information) underlie the behavioral characteristics associated with autism spectrum disorder (ASD). If these theories are correct, autistic children might be expected to demonstrate difficulties on linguistic tasks that rely on predictive processing. Previous research has largely focused on older autistic children and adolescents with average language and cognition. The present study used an eye-gaze task to evaluate predictive language processing among 3- to 4-year-old autistic children (n = 34) and 1.5- to 3-year-old, language-matched neurotypical (NT) children (n = 34). Children viewed images (e.g., a cake and a ball) and heard sentences with informative verbs (e.g., Eat the cake) or neutral verbs (e.g., Find the cake). Analyses of children's looking behaviors indicated that young autistic children, like their language-matched NT peers, engaged in predictive language processing. Regression results revealed a significant effect of diagnostic group, when statistically controlling for age differences. The NT group displayed larger difference scores between the informative and neutral verb conditions (in looks to target nouns) compared to the ASD group. Receptive language measures were predictive of looking behavior across time for both groups, such that children with stronger language skills were more efficient in making use of informative verbs to process upcoming information. Taken together, these results suggest that young autistic children can engage in predictive processing though further research is warranted to explore the developmental trajectory relative to NT development.

Friend matters: sex differences in social language during autism diagnostic interviews

BACKGROUND

Autistic individuals frequently experience social communication challenges. Girls are diagnosed with autism less often than boys even when their symptoms are equally severe, which may be due to insufficient understanding of the way autism manifests in girls. Differences in the behavioral presentation of autism, including how people talk about social topics, could contribute to these persistent problems with identification. Despite a growing body of research suggesting that autistic girls and boys present distinct symptom profiles in a variety of domains, including social attention, friendships, social motivation, and language, differences in the way that autistic boys and girls communicate verbally are not yet well understood. Closely analyzing boys' and girls' socially-focused language during semi-structured clinical assessments could shed light on potential sex differences in the behavioral presentation of autistic individuals that may prove useful for identifying and effectively supporting autistic girls. Here, we compare social word use in verbally fluent autistic girls and boys during the interview sections of the ADOS-2 Module 3 and measure associations with clinical phenotype.

METHODS

School-aged girls and boys with autism (N = 101, 25 females; aged 6-15) were matched on age, IQ, and parent/clinician ratings of autism symptom severity. Our primary analysis compared the number of social words produced by autistic boys and girls (normalized to account for differences in total word production). Social words are words that make reference to other people, including friends and family.

RESULTS

There was a significant main effect of sex on social word production, such that autistic girls used more social words than autistic boys. To identify the specific types of words driving this effect, additional subcategories of friend and family words were analyzed. There was a significant effect of sex on friend words, with girls using significantly more friend words than boys. However, there was no significant main effect of sex on family words, suggesting that sex differences in social word production may be driven by girls talking more about friends compared to boys, not family. To assess relationships between word use and clinical phenotype, we modeled ADOS-2 Social Affect (SA) scores as a function of social word production. In the overall sample, social word use correlated significantly with ADOS-2 SA scores, indicating that participants who used more social words were rated as less socially impaired by clinicians. However, when examined in each sex separately, this result only held for boys.

LIMITATIONS

This study cannot speak to the ways in which social word use may differ for younger children, adults, or individuals who are not verbally fluent; in addition, there were more autistic boys than girls in our sample, making it difficult to detect small effects.

CONCLUSIONS

Autistic girls used significantly more social words than boys during a diagnostic assessment-despite being matched on age, IQ, and both parent- and clinician-rated autism symptom severity. Sex differences in linguistic markers of social phenotype in autism are especially important in light of the late or missed diagnoses that disproportionately affect autistic girls. Specifically, heightened talk about social topics could complicate autism referral and diagnosis when non-clinician observers expect a male-typical pattern of reduced social focus, which autistic girls may not always exhibit.

Flexibility in autism during unpredictable shifts of socio-emotional stimuli: Investigation of group and sex differences

LAY ABSTRACT

Flexibility difficulties in autism might be particularly common in complex situations, when shifts (i.e. the switch of attentional resources or strategy according to the situation) are unpredictable, implicit (i.e. not guided by explicit rules) and the stimuli are complex. We analyzed the data of 101 autistic and 145 non-autistic adults, without intellectual deficiency, on two flexibility tasks performed online. The first task involved unpredictable and non-explicit shifts of complex socio-emotional stimuli, whereas the second task involved predictable and explicit shifts of character stimuli. Considering the discrepancies between laboratory results and the real-life flexibility-related challenges faced by autistic individuals, we need to determine which factor could be of particular importance in flexibility difficulties. We point out that the switch cost (i.e. the difference between shift and non-shift condition) was larger for autistic than for non-autistic participants on the complex flexibility task with unpredictable and non-explicit shifts of socio-emotional stimuli, whereas this was not the case when shifts were predictable, explicit and involved less complex stimuli. We also highlight sex differences, suggesting that autistic females have better social skills than autistic males and that they also have a specific cognitive profile, which could contribute to social camouflaging. The findings of this work help us understand which factors could influence flexibility difficulties in autism and are important for designing future studies. They also add to the literature on sex differences in autism which underpin better social skills, executive function, and camouflaging in autistic females.

Conversation During a Virtual Reality Task Reveals New Structural Language Profiles of Children with ASD, ADHD, and Comorbid Symptoms of Both

Many studies have utilized standardized measures and storybook narratives to characterize language profiles of children with Autism Spectrum Disorder (ASD) and Attention Deficit/Hyperactivity Disorder (ADHD). They report that structural language of these children is on par with mental-age-matched typically developing (TD) peers. Few studies have looked at structural language profiles in conversational contexts. This study examines conversational speech produced in a virtual reality (VR) paradigm to investigate the strengths and weaknesses of structural language abilities of these children. The VR paradigm introduced varying social and cognitive demands across phases. Our results indicate that children from these diagnostic groups produced less complex structural language than TD children. Moreover, language complexity decreased in all groups across phases, suggesting a cross-etiology sensitivity to conversational contexts.

Diagnostic Tools for Autism Spectrum Disorders by Gender: Analysis of Current Status and Future Lines

Studies on the prevalence of autism spectrum disorders have shown gender disproportion. In recent years, there has been an increasing interest in this investigation area. There are two main research lines; the first is focused mostly on gender-related biological reasons that could account for low ASD prevalence in women (i.e., related to some protective factors related to hormones or the immune system, among others), and the second research line studies possible diagnostic biases. In the present study, a review of the latter line of research is made based on two main objectives: (a) analysis of possible biases in diagnostic tools and (b) other nonbiological ASD prevalence explained by gender differences. As a result of our theoretical review, we found that the articles reviewed showed contradictory results and possible diagnostic biases, not only in their design but also in their assessment standards. We concluded that specific or complementary diagnostic tools and procedures differentiated by gender should be developed in order to reduce these biases.