Journal of Autism and Developmental Disorders

https://doi.org/10.1007/s10803-019-04159-x

ORIGINAL PAPER

Effects of Diagnostic Severity upon Sex Differences in Behavioural

Profiles of Young Males and Females with Autism Spectrum Disorder
Vicki Bitsika1 · Christopher F. Sharpley1

© Springer Science+Business Media, LLC, part of Springer Nature 2019

Abstract
To determine if diagnostic severity of Autistic Spectrum Disorder (ASD) affected sex differences in the detailed ASD-related
behavioural profiles of young males and female, two samples of males and females with a diagnosis of ASD, aged between
6 and 17 years, were compared across the 65 items of the Social Responsiveness Scale (2nd ed.). Results are reported for a
sample of males and females matched on age and IQ (n = 51 pairs) and a smaller sample matched on age, IQ and ADOS-2
severity (n = 32 pairs). ASD-related behaviours from the SRS-2 that were significantly and meaningfully different across
sexes were identified for both samples. ADOS-2 diagnostic severity was associated with different sets of sex-based differ-
ences in SRS-2 item scores.

Keywords Autism · Sex differences · Diagnostic severity · Behavioural profiles · Social communication

It has been noted for some time that there is a difference
in the prevalence of Autism Spectrum Disorder (ASD)
between males and females (Wing 1981). Although that
difference is often quoted as 4:1 (APA 2013), the reported
prevalence ratio has been found to be between 2:1 and 7:1
males:females, depending on the sample (Halliday et al.
2015), with some recent evidence from a meta-analysis of
54 studies of more than 13 million participants indicating
that the actual ratio was closer to 3:1 (Loomes et al. 2017).
Various explanations have been given for this difference in
prevalence, including genetic factors (Ferri et al. 2018), foe-
tal hormonal influences (Baron-Cohen et al. 2014), neuro-
transmitter effects (Shuffrey et al. 2017) and immunological
expression (Hanamsagar et al. 2017). There is also a sug-
gestion that females do not actually have a lower prevalence
of ASD but are underdiagnosed because they exhibit ‘cam-
ouflage’ behaviour that makes certain ASD symptoms less
noticeable (Hull et al. 2017; Kreiser and White 2014). Some
data to support this suggestion come from an observational
study of social behaviours among ASD and non-ASD chil-
dren of both sexes that found that ASD girls used ‘compen-
satory’ behaviours of staying near peers even though they
* Christopher F. Sharpley
csharpl3@une.edu.au; csharpley@onthenet.com.au
1
Brain‑Behaviour Research Group, University of New
England, Armidale, NSW 2350, Australia
were not actually interacting with them, while ASD boys
tended to play alone (Dean et al. 2017).
This suggestion that females may camouflage certain
aspects of their ASD-related behaviour raises the issue of
sex differences in symptom profiles as a possible contribu-
tor to the prevalence of overall diagnosis, but there is also
some lack of consistency in findings regarding sex dif-
ferences in the profile of symptoms across studies (Ferri
et al. 2018). For example, some papers have reported more
severe ASD core symptom deficits for males (Rynkiewicz
et al. 2016) and some have found the opposite (Frazier et al.
2014). There is also evidence of differentiation in prevalence
within the ASD core symptoms themselves, as shown in van
Wijngaarden-Cremers et al. (2014) meta-analysis of 22 stud-
ies which noted that males tended to show more evidence
of restricted and repetitive behaviours than females but that
there were no significant differences in social behaviour and
communication. Those authors also commented that there
was a potential for differences in IQ to confound these sex-
differences in symptom profiles. That suggestion is sup-
ported by evidence from a recent PRISMA review of the
literature on female camouflaging in ASD (Allely 2018) that
noted that the ability to effectively imitate socially accept-
able behaviour was particularly likely to occur in females
with intelligence within the normal range.
The issue of assessment and participant selection method-
ology in studies of ASD sex differences is therefore relevant

13
Vol.:(0123456789)

for consideration. Two of the most pertinent aspects of
that methodology are the instrument used and the source
of information collected. According to van Wijngaarden-
Cremers et al. (2014), the most common instrument used
in sex difference studies in ASD is the ADOS (Lord et al.
2012). Although the ADOS is an excellent instrument for the
purpose of making a diagnosis of ASD, it is firstly designed
to identify the presence of ASD rather than the detailed pro-
file of ASD-related behaviour. Investigation of the detailed
nature of any differences in the profile of ASD-related
behaviour across males and females would benefit from use
of an instrument that can provide a fine-grained account
of the ASD-related observable behaviours of those males
and females rather than overall subscale or total scores, as
are obtained from the ADOS. Similarly, the use of a wide
scale of severity for responses can also provide valuable data
when compiling behaviour-severity profiles.
In terms of source of information about a child’s ASD,
although clinicians decide on the presence of ASD from
their observations during assessment procedures, a major
source of data regarding the everyday functioning of a child
with ASD is the child’s primary caregivers, usually its par-
ents, because they are most familiar with the child’s behav-
iour. One instrument designed to be completed by caregiv-
ers, which collects data on 65 behaviours related to ASD,
and which compiles scores on a four-point Likert scale, is
the Social Responsiveness Scale (2nd ed.) (SRS-2) (Con-
stantino and Gruber 2012), which has been widely used in
studies of people with ASD. Use of such a detailed measure
of ASD symptoms and related behaviours, collected from
the child’s parent, may provide greater depth and validity of
data regarding everyday ASD-related behaviour than clini-
cians’ observations within a limited timeframe.
These findings, suggestions, and comments argue for
the further examination of sex differences in the behaviour
of young people with ASD, but with several methodologi-
cal provisos that may help clarify how any sex differences
in this ASD-related behaviour manifest themselves. First,
although the ADOS is the most commonly-used instru-
ment in studies of sex differences in ASD (van Wijn-
gaarden-Cremers et al. 2014), the sourcing of information
from parents may provide a greater insight into the kinds
of behaviours exhibited by children with ASD when they
are not in structured situations such as clinical assessment
settings. Second, the use of a more detailed instrument
(such as the SRS-2) which asks parents to rate their child
on a four-point Likert scale for severity of ASD-related
behaviours, could provide finer-grained data regarding
sex differences across a wide range of these behaviours
and allow for profile comparisons that are not possible
in studies of the presence/absence of ASD as defined by
the ADOS cutoff. Third, constraining the samples of chil-
dren with ASD to those with an IQ > 70, and who attend
13
Journal of Autism and Developmental Disorders
mainstream schools and are able to self-care, increases
the likelihood of including females who may be adept at
camouflaging, and therefore could provide a basis for com-
paring their ASD-related behavioural profile with males
with the same level of cognitive and self-care skill. Fourth,
sampling from the age ranges during which children usu-
ally attend school (i.e., 6 years to 18 years) and where pre-
vious researchers have observed camouflaging behaviour
(Dean et al. 2017) would allow for the testing of effects
due to age and maturity associated with greater length of
time at school and the likelihood of learning social cam-
ouflaging skills there.
An additional aspect of methodology which has
received scant attention is the effect of ASD severity upon
specific symptom profiles of male and female samples.
That is, most previous studies have focussed upon (a)
applying an instrument such as the ADOS or ADIR, and
(b) testing for the presence of significant differences in
scores from these instruments across males and females
(van Wijngaarden-Cremers et al. 2014). This is an appro-
priate methodology for the early stage of sex difference
investigations, but does not allow for the more detailed
comparison of ASD-related behaviours across males and
females within the same ASD severity range. That is, while
the severity of ASD symptomatology per se via the ADOS
or ADIR has been the research target of most previous
studies, the examination of the profile of detailed ASD-
related behaviours across males and females with matched
age, IQ and ASD severity would provide an opportunity to
compare males and females at a greater level of detail and
with three major potential sources of confound controlled
for by matching of male–female pairs. The inclusion of
ASD severity (as determined by the ADOS-2) rather than
just age and IQ would clarify any sex differences in the
wider set of ASD-related behaviours that may be attribut-
able to the overall severity of the ASD per se (i.e., via the
ADOS-2 Total Score) rather than simply sex or IQ.
Therefore, this study aimed to investigate the detailed
ASD-related parent-reported behavioural profiles of a
sample of school-age males and females who had firstly
been matched on age and IQ (as in most previous research
on sex differences) and then a subsample that had also
been matched on ASD severity. This latter step offers the
opportunity to test for the effects of ADOS-2 diagnos-
tic severity upon differences in ASD-related behavioural
profiles within an age- and IQ-matched sample of young
males and females.
Journal of Autism and Developmental Disorders
Methods
Participants
Total Sample
Fifty-one males and 51 females with ASD and one of their
parents (95 mothers) were recruited from a local parent
support group and ASD service organizations in the Gold
Coast, Queensland, Australia, for a study “about ASD”. As
such, the sample may be described as “community” rather
than “clinical”. The mean age of the 51 males with ASD
was 10.2 years (SD = 2.8 years, range 6 to 17 years) and for
the 51 females with ASD it was 10.1 years, SD = 2.7 years,
range 6 to 17 years). The males and females were formed
into age- and IQ-matched pairs on a one-to-one basis so
that each male was matched with a female whose age was
within 6 months of his, and whose WASI-II Full Scale
IQ score was within five points of his, so that there were
no significant differences in either age (F(1,101) = .020,
p = .887) or IQ (males: M = 97.9, SD = 12.0, range
76–125; females: M = 98.2, SD = 13.1, range 77–128:
F(1,101) = .006, p = .937) between the males’ and females’
samples on these two variables. All the males and females
had received a Total Score of > 7 on the ADOS-2 (Classi-
fication and Severity scores were also calculated to ensure
that each participant met the accepted criteria for a diag-
nosis of ASD as set out in the ADOS-2 Manual), adminis-
tered during intake for this study by a clinically-competent
research assistant who had been trained in the use of the
ADOS-2, as specified by the ADOS-2 Training Protocols
and Manuals developed by the ADOS-2 authors for the
purposes of valid administration of this scale. This sample
had been used in a previous study of sex differences in
Sensory Features in ASD (Bitsika et al. 2018).
All these participants had been originally diagnosed
from a 2-h clinical interview conducted by either a regis-
tered paediatrician or psychiatrist with their parents using
the relevant DSM criteria for ASD, plus family history.
These diagnoses were confirmed by a suitably qualified
and registered clinical psychologist with expertise in
ASD and were again confirmed during the recruitment
process for the current study by the ADOS-2 (Lord et al.
2012) as described above. In addition, all these partici-
pants had their original WISC-IV Full Scale IQ of > 70
confirmed by the WASI-II during recruitment, and all
attended mainstream schools. According to their parents,
who were asked to report any clinical diagnosis previously
given by the psychiatrist or psychologist who was respon-
sible for the care of their child, twenty-nine (56.9%) of the
males and 29 of the females had no concurrent diagnosis
of another psychiatric or developmental disorder, but 17
males had been diagnosed with Attention-Deficit/hyperac-
tivity Disorder (ADHD), two with Obsessive–Compulsive
Disorder (OCD) and 3 with Oppositional Defiant Disorder
(ODD), plus 12 females with ADHD, 2 with Generalised
Anxiety Disorder (GAD), 3 with OCD and 7 with unspeci-
fied “other” disorders, according to the parents of these
children. According to their parents, 14 of the females
had reached menarche, but no comparative data regarding
puberty were able to be obtained from the males’ parents.
Further biological tests for puberty were declined by the
parents of both the males and females. There were no sig-
nificant main effects for ADOS-2, WASI-II Full Scale IQ
or any of the five SRS-5 subscales according to the puber-
tal status of the females F(7,44) = 1.457, p = .208, and so
the females’ data were analysed as a combined sample,
with age included in the analyses (explained below).
ASD‑Severity Matched Sample
The subsample that was matched on the ADOS-2 Total
Scores as well as their age and IQ consisted of 32 males and
females drawn from the original sample (not all participants
had scores that enabled them to be matched with another
participant of the opposite sex). Table 1 shows the age, IQ
and ADOS-2 data for this smaller sample, plus the results of
the MANOVA on these variables, using sex as the independ-
ent variable. Although the statistical power of this reduced
sample was also reduced compared to the original (n = 51)
sample, it was great enough to detect a large effect at p < .05
level with power of almost .80 (Cohen 1988).
Age
As explained above, in the absence of any biological data
for both males and females, a simple dichotomisation based
upon the presumed age of puberty may be inaccurate due
to variable maturation rates. In addition, dichotomisation
of what is actually a continuous variable can have limiting
effects upon the reliability and power of statistical proce-
dures (Chen et al. 2007; Cohen 1983). Therefore, testing
for age effects was done via correlational procedures rather
than ANOVA models.
Table 1  Age, IQ and AOS-2 Scores for males versus females
matched on age, WASI-II IQ, and ADOS-2 Total Score
Variable Males (n = 32) Females (n = 32) F p
Age (years) M = 10.2 (2.8) M = 10.1 (2.7) 0.072 .789
Range 6 to 17 Range 6 to 17
WASI-II Full Scale M = 95.8 (13.7) M = 99.9 (12.8) 1.593 .292
IQ Range 74 to 125 Range 79 to 128
ADOS-2 Total M = 11.8 (2.2) M = 12.4 (2.6) 0.858 .358
Score Range 7 to 17 Range 7 to 17
13

Instruments
The Autism Diagnostic Observation Schedule Second
Edition (ADOS‑2)
The ADOS-2 (Lord et al. 2012) is recommended in several
Best Practice Guidelines as an appropriate standardized
diagnostic observation tool for ASD (Filipek et al. 1999;
National Research Council 2001). It presents a series of
standardized interactive activities that focus upon social
interactions, communication and repetitive behaviours, pro-
viding data for a diagnosis of ASD.
The Wechsler Abbreviated Scale for Intelligence (WASI‑II)
The WASI-II contains four subtests with average reliability
coefficients of between .92 and .96, and has strong validity
with the WISC-IV when used with high-functioning people
with ASD (Minshew et al. 2005). Results from the WASI-II
provide an accurate estimate of intelligence that is useful
for research screening purposes and produces results on two
composite scales (Verbal Comprehension, Perceptual Rea-
soning), plus a Full Scale IQ based on those two composites.
The Full Scale IQ was used as the measure of cognitive
ability in this study.
Social Responsiveness Scale (2nd Ed) (SRS‑2
The Social Responsiveness Scale (2nd ed.) (SRS-2) (Con-
stantino and Gruber 2012) consists of 65 items that may be
answered by a parent or other caregiver about a child with
ASD. These items describe autistic traits (i.e., interpersonal
behaviour, social communication, and repetitive/stereotypic
behaviour) in respondents aged 4 to 18 years of age. The
SRS-2 uses a four-point Likert scale (not true = 0, some-
times true = 1, often true = 2, almost always true = 3), provid-
ing a total score ranging from 0 to 195 so that continuous
scores of Social Awareness, Social Cognition, Social Com-
munication, Social Motivation, and Restricted and Repeti-
tive Behaviours, as well as a Total score, can be calculated
(Constantino and Gruber 2012).
The SRS-2 has strong agreement with the ADOS (Lord
et al. 2012) and the Developmental, Dimensional and Diag-
nostic Interview 3Di (Duvekot et al. 2014; Skuse et al.
2004). As well as raw scores, sex-specific norms are avail-
able to convert SRS-2 raw scores to Treatment-scores for
individualised treatment planning, although raw scores are
most commonly used in research studies (Constantino and
Gruber 2012) and were used here. Cronbach’s alpha for the
SRS is in excess of .90 for the Total score and from .76 to
.91 (median = .85) for the five subscales (Constantino and
Gruber 2012). The authors of the SRS-2 argued that one of
its major strengths is its ability to provide scores about ASD
13
Journal of Autism and Developmental Disorders
that reflect a range of severities rather than dichotomous
classifications, and also to tap a wide range of ASD-related
behaviours (Constantino and Gruber 2012).
Procedure
Data-collection was conducted in the homes of all partici-
pants in order to avoid stress upon them by attending the
researchers’ laboratory. The parents were given written
instructions on how to complete the SRS-2. The WASI-II
and ADOS-2 assessments were conducted with participants
in their homes within 1 week of the collection of SRS-2 data.
The study was approved by the Bond University Human
Research Ethics Committee approval no. RO 1516 and all
procedures complied with the 1964 Helsinki declaration
and its later amendments. Written informed consent was
obtained from all parents included in the study and their
children gave their assent to the study.
Statistical Analysis
Data were analysed via IBM SPSS 24 to obtain mean and
5% trimmed mean values (as an indicator of the effects of
outliers), SD, and ranges. Normality was assessed by the
Kolmogorov–Smirnov statistic. Pearson correlation analy-
sis tested for any significant association between SRS-2
Total Scores, items and age. MANOVA was used to test
for the presence of significant differences in males’ vs
females’ ages, WASI-II Full Scale IQ scores, and ADOS-2
Total Scores, and for the effects of menarche upon females’
scores on these instruments. MANOVA tested for any sig-
nificant main effects on SRS-2 Total Scores according to
sex. MANOVA main effects were further investigated via
univariate analysis of the 65 SRS-2 items. Wilks’ Lambda
was used as the determining outcome statistic for all mul-
tivariate effects, with appropriate Bonferroni correction for
family-wise error rate.
Results
Overall Data
The SRS-2 Total Scores were within acceptable normality
limits as assessed by the presence of nonsignificant Kol-
mogorov–Smirnov statistics of .056 for the 51 males, and
.065 for the 51 females (both p > .05); similar results were
found for the 32 males (K–S statistic = .087) and 32 females
(K–S = .113), and neither data set required transformation.
The 5% trimmed means were within < 1% of the actual
means for both sexes within both samples, indicating only
negligible effects from outliers. Because multicollinearity is
a potential source of error in MANOVA calculations when
Journal of Autism and Developmental Disorders
many items from the same scale are analysed as individual
dependent variables, Pearson correlations were run for all
65 SRS-2 items but none of the values were greater than
r = .67, which is less than the level of .9 recommended as
the indicator for violation of this assumption (Tabachnik
and Fidell 2013).
Age Effects
There were no significant correlations between age and
WASI-II Full scale IQ, ADOS-2 Total Score or the SRS-2
Total Scores or any of the five SRS-2 Subscale Scores, for
either the larger (n = 51) or reduced (n = 32) male and female
samples.
Sex Differences
SRS‑2 Total Score
Table 2 shows the mean SRS-2 Total Scores for males and
females for each of the samples, with ANOVA results.
Although there was no significant sex difference in these
SRS-2 Total Scores, the focus of this study was upon indi-
vidual ASD-related behaviours, and so the remaining analy-
ses for sex differences were undertaken at the individual
SRS-2 item level. This is congruent with the suggestion
that, although the main effect from MANOVA analyses
may be nonsignificant, exploration of the univariate effects
may be undertaken because “the multivariate F is often not
as powerful as univariate or stepdown F and significance
can be lost” (Tabachnik and Fidell 2013, p. 348). Although
MANOVA was not used at this stage, the analogy holds for
the relevance of this ANOVA on SRS-2 Total Scores.
SRS‑2 Item Data
To reduce the likelihood of an error due to violation of one
of the key assumptions underlying MANOVA (i.e., sam-
ple size:dependent variable ratio), these analyses were
Table 2  Males’ and females’ SRS-2 Total Scores and ANOVA results
Sample M (SD) M (SD) F p Partial
Males Females eta
squared
N = 51a
SRS-2 Total 97.15 (28.91) 99.35 (24.82) 0.667 .409 .007
Score
N = 32b
SRS-2 Total 99.25 (30.41) 95.46 (26.46) 2.861 .096 .000
Score
a
df = 1,101
b
df = 1,63
conducted in groups of 20 to 25 SRS-2 items. The Bon-
ferroni-adjusted level of statistical significance for sex dif-
ferences was 05/65 = .0007, which may have been a poten-
tial source of Type II error. Therefore, a two-step selection
procedure was undertaken to identify SRS-2 items which
showed meaningful differences across the sexes as indicated
by (a) p < .001, plus (b) an effect size (partial eta squared)
of at least .14, that represents a ‘large’ effect (Cohen 1988).
Both of these steps are conservative in that p < .001 repre-
sents a chance of a Type I error that is < 1 in 1000, and an
effect size of .14 is well-recognised as only being present
when the associations being tested are very robust (Tabach-
nik and Fidell 2013). Tables 3, 4 show the SRS-2 items that
met these dual criteria in bold, with the mean (SD) values
for males and females, for both samples (i.e., Table 3: n = 51
males and females; Table 4: n = 32 males and females).
Two sets of information can be drawn from Tables 3,
4, firstly about the differences in frequency of occurrence
across males and females, and secondly, in terms of the
actual content (i.e., behavioural differences) that is repre-
sented by these items. First, in terms of numerical differ-
ences alone, Table 4 table represents those SRS-2 items
on which sex differences existed but which were free from
the effects of a possible confound due to ASD severity as
measured by the ADOS-2. There were 27 SRS-2 items with
meaningful differences (i.e., both p < .001, also a large effect
size). These 27 ASD-related behaviours represent the most
comprehensive account of sex differences across the 6 years
to 18 years age group (with no significant age effects) in a
sample that was controlled for age, IQ and ADOS-2 severity.
Females had meaningfully higher scores on each of these 27
ASD-related behaviours.
Table 5 shows these 27 items classified into the five Treat-
ment Subscales defined by the SRS-2, and indicates that the
most common sex differences were found for Social Com-
munication and Social Motivation, and the least common sex
differences were found for Social Awareness and Restricted
Interests and Repetitive Behaviour. When examined for their
Spearman correlation coefficients with sex, all of these 27
items were statistically significant at the p < .001 level, and
10 of them met the criteria for a ‘large’ effect size of .50 or
greater (Cohen 1988), shown in bold in Table 5. These may
be identified as the SRS-2 items which were most strongly
associated with sex differences in this sample of males and
females matched for their ASD severity.
Second, in terms of the content of these items, com-
parison of Tables 3, 4 allows for the evaluation of possible
ASD severity effects upon sex differences by identifying
the SRS-2 items which were found to be meaningfully sig-
nificant in Table 3 but not in Table 4. There were 20 SRS-2
items which showed meaningful significance in Table 3 (no
ADOS-2 matching for severity) but which did not show
similarly meaningful differences in Table 4 (matched for
13
 Journal of Autism and Developmental Disorders

Table 3  Mean (SD) scores for N = 51 males and females Males Females F Partial
selected SRS-2 items showing eta
meaningful sex differences in SRS-2 item (abbreviated; reverse scoring removed) M (SD) M (SD)
squared
bold for total sample (51 males,
females) 1. More fidgety in social situations 2.92 (0.82) 3.64 (0.55) 27.206* .214
2. Facial expressions don’t match what he/she is saying 2.04 (0.87) 3.01 (0.73) 37.764* .274
3. Is not self-confident when interacting 2.66 (1.01) 3.02 (0.78) 3.859 .037
4. When under stress, shows inflexible behaviour 2.82 (0.86) 3.51 (0.62) 21.388* .176
5. Doesn’t recognise when others are taking advantage 2.86 (0.98) 3.71 (0.51) 29.900* .230
6. Would rather be alone than with others 2.27 (0.91) 3.17 (0.68) 31.639* .240
7. Is unaware of what others are thinking or feeling 3.00 (0.82) 2.88 (0.62) 0.638 .006
8. Behaves in ways that seem strange or bizarre 2.15 (0.86) 3.25 (0.65) 52.617* .345
9. Clings to adults, seems too dependent on them 2.09 (1.060 3.13 (0.80) 31.101* .237
10. Takes things too literally 2.92 (0.74) 3.61 (0.56) 27.393* .215
11. Has poor self-confidence 2.65 (0.99) 2.94 (0.86) 2.551 .025
12. Is unable to communicate his/her feelings to others 2.68 (0.88) 2.96 (0.66) 3.155 .031
13. Is awkward in turn-taking interactions 2.62 (0.94) 3.39 (0.75) 21.692* .178
14. Is not well coordinated 2.25 (1.02) 3.07 (0.82) 20.257* .168
15. Able to understand meaning of others’ voice and face 2.80 (0.80) 3.09 (0.67) 4.044 .039
16. Avoids eye contact or has unusual eye contact 2.41 (0.92) 3.19 (0.75) 22.284* .182
17. Does not recognise when something is unfair 2.12 (0.95) 3.39 (0.66) 61.410* .380
18. Has difficulty making friends 2.76 (1.01) 3.41 (0.73) 13.771* .121
19. Gets frustrated trying to get ideas across 2.94 (0.88) 3.67 (0.52) 25.733* .205
20. Shows unusual sensory interests 2.08 (1.07) 3.20 (0.83) 34.726* .258
21. Unable to imitate others’ actions 2.39 (0.85) 3.43 (0.67) 46.942* .319
22. Plays appropriately with children his/her age 2.51 (0.76) 3.22 (.76) 22.146* .181
23. Does not join group activities unless told to 2.49 (0.99) 3.06 (0.66) 11.521 .103
24. Has difficulty with changes in routine 3.08 (0.840 3.55 (0.64) 10.028 .091
25. Doesn’t mind being out of step with others 2.69 (0.88) 3.22 (0.83) 9.710 .089
26. Offers comfort to others when they are sad 2.67 (0.95) 3.27 (0.75) 12.820 .114
27. Avoids starting social interactions 2.20 (0.98) 3.04 (0.75) 23.864* .193
28. Thinks or talks about the same thing over and over 2.94 (0.99) 3.53 (0.64) 12.690 .113
29. Is regarded by other children as odd or weird 2.72 (0.90) 3.59 (0.57) 33.588* .251
30. Becomes upset in a situation with lots going on 2.94 (0.90) 3.69 (0.51) 26.312* .208
31. Can’t get his/her mind off something 3.20 (0.89) 3.80 (0.45) 18.814* .158
32. Does not have good personal hygiene 2.45 (0.97) 3.25 (0.77) 21.596* .178
33. Is socially awkward 2.59 (0.90) 3.47 (0.61) 33.616* .252
34. Avoids people who want to be emotionally close to him 2.02 (0.81) 2.90 (0.76) 32.286* .244
35. Has trouble keeping up with the flow of conversation 2.63 (0.82) 3.31 (0.62) 22.702* .185
36. Has difficulty relating to adults 1.82 (0.74) 2.73 (0.63) 43.611* .304
37. Has difficulty relating to peers 2.71 (0.81) 3.49 (0.64) 29.412* .227
38. Responds inappropriately to mood changes in others 2.92 (0.82) 2.94 (0.70) 0.017 .000
39. Has an unusually narrow range of interests 2.86 (1.00) 3.22 (0.76) 4.038 .039
40. Is unimaginative, poor at pretending 2.67 (0.99) 3.31 (0.79) 13.293* .117
41. Wanders aimlessly from one activity to another 1.90 (0.83) 3.00 (0.75) 49.184* .330
42. Seems overly sensitive to sounds, textures, or smells 2.78 (1.08) 3.55 (0.64) 18.815* .158
43. Does not separate easily from caregiver 2.37 (1.02) 3.23 (0.76) 23.404* .190
44. Doesn’t understand how events relate to one another 2.49 (1.03) 3.37 (0.69) 25.895* .206
45. Does not focus attention to where others are looking 2.61 (0.90) 3.20 (0.66) 14.187* .124
46. Has overly serious facial expressions 2.29 (1.03) 3.10 (0.81) 19.366* .162
47. Is too silly or laughs inappropriately 2.33 (0.97) 3.35 (0.72) 36.325* .266
48. Has no sense of humour, does not understand jokes 2.31 (0.910 3.27 (0.70) 36.138* .265
49. Does extremely well at a few tasks 2.76 (0.97) 3.39 (0.70) 14.074* .123

13
Journal of Autism and Developmental Disorders

Table 3  (continued) N = 51 males and females Males Females F Partial

SRS-2 item (abbreviated; reverse scoring removed) M (SD) M (SD) eta
squared

50. Has repetitive, odd behaviours such as hand flapping 1.88 (1.05) 2.84 (0.81) 26.737* .211
51. Has difficulty answering questions directly 2.33 (0.86) 3.35 (.69) 43.473* .303
52. Does not know when he/she is talking too loudly 3.27 (0.94) 2.67 (0.71) 13.558* .119
53. Talks to people with an unusual tone of voice 1.92 (1.02) 2.92 (0.84) 29.185* .226
54. Seems to react to people as if they are objects 1.65 (0.82) 2.57 (0.70) 37.239* .271
55. Does not know when too close to others 3.13 (0.96) 2.86 (0.83) 2.400 .023
56. Walks between two people talking 2.76 (1.03) 3.41 (0.75) 13.095* .116
57. Gets teased a lot 2.49 (0.950 3.29 (0.81) 21.311* .176
58. Concentrates too much on parts of things 2.41 (0.92) 3.39 (0.78) 33.802* .253
59. Is overly suspicious 1.98 (0.91) 2.75 (0.82) 19.971* .166
60. Is emotionally distant 2.00 (0.80) 2.90 (0.85) 30.280* .232
61. Is inflexible, difficult to change his mind 2.84 (0.83) 3.61 (0.60) 26.188* .220
62. Gives unusual or illogical reasons for doing things 2.33 (0.93) 3.25 (0.69) 32.314* .244
63. Touches others in an unusual way 1.63 (0.87) 2.71 (0.83) 40.900* .290
64. Is too tense in social situations 2.31 (0.88) 3.35 (0.72) 42.612* .299
65. Stares or gazes off into space 1.75 (0.72) 3.11 (0.71) 94.231* .485

*p < .001

ADOS-2 severity). There was one SRS-2 item which showed
a meaningful difference in Table 4 but not in Table 3 (SRS-2
item 26: Does not offer comfort to others when they are sad)
which is underlined in Table 6. These 21 items are shown
in Table 6, and indicate that the most common sex differ-
ences fell into the SRS-2 Treatment Scale for Social Com-
prehension, followed by Social Cognition and Restricted and
Repetitive Behaviours. These 21 SRS-2 items represent the
change in sex differences that were due to ASD severity
as assessed via the ADOS-2. All sex differences in either
set of participants were in the direction of females showing
greater severity than males on the SRS-2 scores given by
their parents.
Discussion
Few previous studies have provided a direct comparison of
the sex differences in detailed ASD-related behaviour when
males and females were matched for ASD severity as well as
for age and IQ. The current results identified those specific
ASD-related behaviours that were found to be significantly
and meaningfully more severe in females than in males,
as rated by their parents. Those SRS-2 items represented
difficulties in expressive social communication aspects of
reciprocal social behaviour plus the individual’s willingness
to engage in social communication. (Constantino and Gru-
ber 2012, p. 77). However, when examined for their rela-
tive power in defining sex differences, the strongest (largest
effect size) differences were found across ability to inter-
pret social cues once they had been noticed, plus reciprocal
social behaviour. There were also some differences in being
aware of social cues, being motivated to engage in social
interaction, and behaving in ways that appear to be bizarre.
These widespread differences (i.e., across all five SRS-2
Treatment Subscales) argue for a general sex difference
across the range of ASD traits. The finding that females
consistently had higher (i.e., worse) scores than males, and
that there was no significant effect due to age, suggests that
females’ camouflaging of their ASD behaviour may com-
mence before school age, so that, in order to be identified
as ASD, females might usually exhibit the wider range of
ASD-related behaviours more severely than males, despite
being matched on a standardised screening instrument (i.e.,
the ADOS-2). The latter instrument is applied by clini-
cians, whereas the SRS-2 is completed by parents, and it
may be that the lack of agreement between the matching via
ADOS-2 Scores versus the SRS-2 Scores could be a func-
tion of the source of information, as well as the greater detail
provided by the SRS-2. Instrumentation was not a focus of
this study, but these data suggest that it might repay future
research. It should also be mentioned that parents may have
expectations of greater levels of social interactive behaviour
from their female offspring than from their male offspring,
and this may have resulted in parents rating their daughters
more severely than parents rated their sons on the SRS-2.
The finding of 21 SRS-2 items that exhibited sex dif-
ferences when age and IQ were matched across males and
females but not when ADOS-2 Scores were also matched,
plus one SRS-2 item that showed sex differences when
samples were matched on age, IQ and the ADOS-2 but not
when they were matched solely on age and IQ (shown in

13
 Journal of Autism and Developmental Disorders

Table 4  Mean (SD) scores for N = 32 males and females Males Females F Partial
selected SRS-2 items showing eta
meaningful sex differences in SRS-2 item (abbreviated; reverse scoring removed) M (SD) M (SD)
squared
bold for subsample (32 males,
32 females) 1. More fidgety in social situations 2.66 (0.97) 3.69 (0.59) 26.313* .298
2. Facial expressions don’t match what he/she is saying 2.03 (0.82) 2.91 (0.73) 20.153* .245
3. Is not self-confident when interacting 2.56 (0.95) 2.94 (0.76) 3.049 .047
4. When under stress, shows inflexible behaviour 2.75 (0.98) 3.59 (0.61) 16.928* .214
5. Doesn’t recognise when others are taking advantage 3.28 (0.85) 3.69 (0.540 5.223 .078
6. Would rather be alone than with others 2.16 (0.92) 3.13 (0.71) 22.315* .265
7. Is unaware of what others are thinking or feeling 3.03 (0.970 3.00 (0.72) 0.022 .000
8. Behaves in ways that seem strange or bizarre 2.34 (0.79) 3.22 (0.71) 21.895* .261
9. Clings to adults, seems too dependent on them 2.25 (1.16) 3.19 (0.860 13.439 .178
10. Takes things too literally 2.84 (0.88) 3.56 (0.62) 14.198* .186
11. Has poor self-confidence 2.75 (0.92) 2.97 (0.86) 0.969 .015
12. Is unable to communicate his/her feelings to others 2.59 (0.87) 3.09 (0.64) 6.806 .099
13. Is awkward in turn-taking interactions 2.59 (0.91) 3.31 (0.78) 11.492 .156
14. Is not well coordinated 2.44 (0.91) 2.97 (0.86) 5.732 .085
15. Unable to understand meaning of others’ voice and face 2.97 (0.78) 3.19 (0.64) 1.491 .023
16. Avoids eye contact or has unusual eye contact 2.50 (1.05) 3.16 (0.81) 7.880 .113
17. Does not recognise when something is unfair 2.25 (0.95) 3.31 (0.69) 26.120* .296
18. Has difficulty making friends 2.72 (1.02) 3.38 (0.71) 8.906 .126
19. Gets frustrated trying to get ideas across 2.84 (0.88) 3.69 (0.54) 21.340* .256
20. Shows unusual sensory interests 2.03 (1.06) 3.06 (0.84) 18.559* .230
21. Unable to imitate others’ actions 2.47 (0.76) 3.41 (0.71) 25.881* .295
22. Plays inappropriately with children his/her age 2.63 (0.87) 3.19 (0.74) 7.774 .111
23. Does not join group activities unless told to 2.66 (0.90) 3.06 (0.76) 3.799 .058
24. Has difficulty with changes in routine 3.03 (0.97) 3.63 (0.61) 8.642 .122
25. Doesn’t mind being out of step with others 2.53 (0.95) 3.16 (0.85) 7.721 .111
26. Does not offer comfort to others when they are sad 2.69 (0.86) 3.47 (0.72) 15.587* .201
27. Avoids starting social interactions 2.22 (0.94) 3.13 (0.75) 18.117* .226
28. Thinks or talks about the same thing over and over 3.16 (0.88) 3.41 (0.71) 1.552 .024
29. Is regarded by other children as odd or weird 3.13 (0.87) 3.56 (0.62) 5.367 .080
30. Becomes upset in a situation with lots going on 2.97 (1.09) 3.72 (0.52) 12.281 .165
31. Can’t get his/her mind off something 3.28 (0.85) 3.81 (0.470 9.541 .133
32. Does not have good personal hygiene 2.13 (0.87) 3.34 (0.75) 36.186* .369
33. Is socially awkward 2.84 (0.81) 3.38 (0.66) 8.303 .118
34. Avoids people who want to be emotionally close 2.00 (0.92) 2.81 (0.74) 15.274* .198
35. Has trouble keeping up with the flow of conversation 2.59 (0.98) 3.19 (0.69) 7.842 .112
36. Has difficulty relating to adults 1.91 (0.89) 2.66 (0.65) 14.708* .192
37. Has difficulty relating to peers 2.63 (0.87) 3.50 (0.57) 22.672* .268
38. Responds inappropriately to mood changes in others 2.63 (0.91) 2.84 (0.68) 1.195 .019
39. Has an unusually narrow range of interests 2.94 (1.01) 3.06 (0.80) 0.300 .005
40. Is unimaginative, poor at pretending 2.47 (1.02) 3.38 (0.75) 16.469* .210
41. Wanders aimlessly from one activity to another 1.97 (0.86) 2.72 (0.73) 14.149* .186
42. Seems overly sensitive to sounds, textures, or smells 2.72 (1.11) 3.56 (0.67) 13.492 .179
43. Does not separate easily from caregiver 2.31 (0.93) 3.13 (0.79) 14.121* .186
44. Doesn’t understand how events relate to one another 2.63 (0.98) 3.25 (0.80) 7.828 .112
45. Does not focus attention to where others are looking 2.72 (0.81) 3.31 (0.64) 10.488 .145
46. Has overly serious facial expressions 2.19 (0.99) 2.97 (0.82) 11.679 .159
47. Is too silly or laughs inappropriately 2.22 (1.10) 3.31 (0.74) 21.837* .260
48. Has no sense of humour, does not understand jokes 2.16 (0.85) 3.41 (0.67) 43.130* .410
49. Does extremely well at a few tasks 3.03 (0.78) 3.34 (0.79) 2.537 .039

13
Journal of Autism and Developmental Disorders

Table 4  (continued) N = 32 males and females Males Females F Partial

SRS-2 item (abbreviated; reverse scoring removed) M (SD) M (SD) eta
squared

50. Has repetitive, odd behaviours such as hand flapping 2.03 (1.09) 2.72 (0.81) 8.163 .116
51. Has difficulty answering questions directly 2.56 (0.84) 3.22 (0.79) 10.333 .143
52. Does not know when he/she is talking too loudly 3.19 (0.99) 2.78 (0.75) 3.387 .052
53. Talks to people with an unusual tone of voice 2.28 (1.05) 2.75 (0.80) 4.002 .061
54. Seems to react to people as if they are objects 1.84 (1.05) 2.44 (0.67) 7.272 .105
55. Does not know when too close to others 3.25 (0.98) 2.97 (0.86) 1.481 .023
56. Walks between two people talking 2.69 (1.15) 3.34 (0.79) 7.109 .103
57. Gets teased a lot 2.53 (0.98) 3.25 (0.760 10.683 .147
58. Concentrates too much on parts of things 2.44 (0.91) 3.28 (0.81) 15.239* .197
59. Is overly suspicious 1.78 (0.79) 2.72 (0.81) 21.831* .260
60. Is emotionally distant 1.94 (0.80) 2.88 (0.87) 20.101* .245
61. Is inflexible, difficult to change his mind 2.72 (1.050 3.66 (0.60) 19.083* .235
62. Gives unusual or illogical reasons for doing things 2.34 (1.00) 3.13 (0.71) 12.960 .173
63. Touches others in an unusual way 1.81 (1.03) 2.56 (0.80) 10.578 .146
64. Is too tense in social situations 2.28 (0.92) 3.38 (0.66) 29.691* .324
65. Stares or gazes off into space 2.00 (0.84) 2.94 (0.80) 20.821* .251

*p < .001

Table 5  Twenty-seven SRS-2 items (and their SRS-2 Treatment Subscale) that showed meaningful sex differences for males and females
matched for age, IQ and ASD severity
SRS-2 Treatment Social Awareness Social Cognition Social Communica- Social Motivation Restricted and Repeti-
Subscale N=2 N=6 tion N=8 tive Behaviours
N=8 N=3

Items showing mean- Expressions on face Taking things literally Gets frustrated More fidgety Shows inflexible behav-
ingful sex differ- don’t match state- Recognises unfair- Unable to imitate Would rather be iour under stress
ences ments ness others alone Behaves strangely or
Poor personal Unimaginative Doesn’t offer comfort Clings to adults bizarrely
hygiene No sense of humour Difficulty relating to Avoids starting social Shows unusual sensory
Concentrates on parts adults interactions interests
Overly suspicious Difficulty relating to Avoids emotional
peers closeness
Wanders aimlessly Does not separate
Is too silly from caregiver
Emotionally distant Is too tense in social
Inflexible settings
Gazes into space

Items with a large effect size are in bold

Table 6), provides some evidence for the hypothesis that
ASD severity influences sex difference data, and comple-
ments previous studies that used only age and IQ as match-
ing variables. Although the general direction of sex differ-
ence was consistent across the two samples (i.e., females
had more severe selected SRS-2 item scores), the specific
ASD-related behaviours identified within each sample
were different. The comment by van Wijngaarden-Cremers
et al. (2014) from their meta-analysis of 22 sex difference
studies, that IQ might confound sex difference findings,
could now be augmented by suggesting that ASD severity
might also provide a similar confound when testing for sex
differences in ASD-related behaviours.
The finding that the females in the current sample had
significantly higher ASD-related behaviour scores on the
SRS-2 than the males is in contradiction of some of the
previous studies in this field which found more severe
ASD traits for males (e.g., Rynkiewicz et al. 2016) (which
did not match males and females on ADOS-2 Scores) but
does confirm previous studies reporting that females have
more severe ASD traits than males (e.g., Frazier et al.
2014) (in which males and females did not have significant

13
 Journal of Autism and Developmental Disorders

Table 6  Twenty-one SRS-2 items (and their SRS-2 Treatment Subscale) showing change in meaningful sex differences according to ASD-sever-
ity
SRS-2 Treatment Social Awareness Social Cognition N = 6 Social Communica- Social Motivation Restricted and
Subscale N=1 tion N = 9 N=0 Repetitive Behav-
iours N = 5

Items showing mean- Reacts to people as Doesn’t recognise Awkward in turn Not well coordinated
ingful sex differ- objects when others are try- taking Regarded as odd or
ences ing to take advantage Difficulty making weird
Becomes upset in a friends Can’t get his or her
complex situation Socially awkward mind off something
Overly sensitive to Has trouble keeping Repetitive, odd
sounds, textures, up with conversation behaviours
smells Overly serious facial Touches others in an
Doesn’t understand expressions unusual way
how events relate Difficulty answering
Gives unusual or questions directly
illogical reasons for Talks to people with
doing things an unusual tone of
Plays appropriately voice
with others Gets teased a lot
Doesn’t offer comfort

differences on ADOS-2 diagnostic criteria scores). The
current results also do not agree with the overall findings
from van Wijngaarden-Cremers et al. (2014) meta-analysis
of 22 studies in which males tended to show more evi-
dence of restricted and repetitive behaviours than females
but there were no significant differences in social behav-
iour and communication. Instead, the sex differences found
here when ASD severity was matched were across social
behaviour and communication and also RRB. However,
as noted above, van Wijngaarden-Cremers et al. (2014)
pointed to the potential for differences in IQ to confound
these sex-differences in symptom profiles, and it may be
that the process of controlling for IQ and ASD severity
was the underlying factor in these different results between
the current study and some previous reports. The current
findings do agree with those reported by Allely (2018)
from her review about camouflaging, in that the females
in this study did not show significant differences in the
formal ASD diagnosis process via the ADOS-2 but did
exhibit greater severity in ASD traits when SRS-2 data
from their parents were analysed. That is, the females in
this sample may have only been identified as ASD when
they had a higher level of ASD-related behaviour than the
males because they had effectively camouflaged it from
observations by the clinicians who assessed them during
intake but not from their parents who observed them on
a daily basis. Finally, it has been suggested that matching
males and females on ASD severity may also mask sex dif-
ferences in ASD symptomatology (Postorino et al. 2015),
but that was not found here. Instead, matching males and
females on the standard assessment instrument allowed
for identification of those ASD-related behaviours that are
differently expressed by males and females. As such, these
sex differences may be considered to be more robust that
if ADOS-2 matching had not been undertaken.
These findings hold implications for clinical settings,
where the identification and assessment of females with
ASD may be relatively difficult compared to males, princi-
pally because of the females’ ability to disguise their ASD
behaviour by learning socially-appropriate behaviour despite
not understanding or actually engaging in reciprocal social
interaction at a level more than males. It may be that, as has
been suggested by others, the 4:1 male:female prevalence
ratio is a function of females’ ability to behave in ways that
appear neurotypical. If this is the case, then greater atten-
tion must be paid to those females who may exhibit some
behaviours that cause concern to those who live beside them.
Limitations
There are several limitations to the generalisability of the
current findings, including age, geographic and cultural
source of the participants, the collection of SRS-2 data at
a single point in time, and the use of the SRS-2 rather than
another scale of ASD-related behaviour. While none of these
are sources of invalidity, they limit the applicability of these
findings to data from other populations, times, and instru-
ments. Although there were no significant associations found
for menarche or the presence of other psychiatric conditions,
the possibility of a confound between these factors and sex
differences in other populations must always be considered.
Strengths of this study include its statistical power, the use
of a conservative yardstick for meaningful effects in the
form of the two-step (p < .001, plus a large ES) procedure
which effectively reduced the likelihood of a Type I error,

13
Journal of Autism and Developmental Disorders
a well-established measure of ASD-related behaviours, and
matching for age, IQ, and ASD severity. As in all research,
replication of these findings in other, and larger, samples is
needed for firm conclusions to be drawn. Similarly, although
the ADOS-2 is widely used for diagnosis, and therefore is
the relevant instrument here for the process of identifying
the presence of ASD, the Autism Diagnostic Interview
(revised) might provide alternative valuable adjunct data.
Conclusion
Despite these limitations, the data from this study provide a
new insight into the way that young males and females with
ASD exhibit behaviours that are related to ASD. The males
and females in this study did show some significant and
meaningful differences in ASD-related behaviour when they
were, and were not, matched for ASD diagnostic severity.
These findings suggest that males and females between the
ages of 6 and 17 years exhibit different ASD-behaviour pro-
files, and that the nature of those differences varies accord-
ing to whether they have the same ADOS-2 Scores. The
identified sex differences were spread across four of the five
SRS-2 Treatment Subscales and support the ‘camouflage’
hypothesis that females learn to disguise their ASD-related
behaviour, at least from clinical observations if not from
their parents who see them on a daily basis and are more
familiar with those behaviours than observers who see the
child on a single occasion.
These results do not provide the final picture of sex differ-
ences in ASD, but, with the recent focus upon female cam-
ouflage of ASD-related behaviour, suggest that there are sig-
nificant and meaningful sex differences in the ASD-related
behaviours exhibited by males and females aged 6 years
to 17 years, that females who have similar ADOS-2 Total
Scores (i.e., the accepted cutoff for a diagnosis of ASD)
may also exhibit more severe ASD-related behaviours, and
that the usual prevalence ratios for males and females may
change as further information is compiled.
Acknowledgments The authors wish to acknowledge the valued time
and efforts by the participants in this study.
Author Contribution Both VB and CFS designed and performed the
study. Data were analysed by CFS and the draft manuscript was written
by both VB and CFS.
Funding This research did not receive any specific grant from funding
agencies in the public, commercial, or not-for-profit sectors.
Compliance with Ethical Standards
Conflict of interest The authors have no competing interests to declare.
Ethical Approval All procedures performed in studies involving human
participants were in accordance with the ethical standards 1964 Hel-
sinki declaration and its later amendments or comparable ethical stand-
ards.
Informed Consent Informed consent was obtained from all individual
participants included in the study.
References
Allely, C. (2018). Understanding and recognising the female phenotype
of autism spectrum disorder and the “camouflage” hypothesis:
A systematic PRISMA review. Advances in Autism.. https​://doi.
org/10.1108/AIA-09-2018-0036.
APA. (2013). Diagnostic and statistical manual of mental disorders
(5th ed.). Washington, DC: American Psychiatric Association.
Baron-Cohen, S., Auyeung, B., Norgaard-Pedersen, B., Hougaard, D.,
Abdullah, M., Melgaard, L., et al. (2014). Elevated fetal steroi-
dogenic activity in autism. Molecular Psychiatry, 20, 369–376.
Bitsika, V., Sharpley, C., & Mills, R. (2018). Sex differences in sensory
features between boys and girls with autism spectrum disorder.
Research in Autism Spectrum Disorders, 51, 49–55.
Chen, H., Cohen, P., & Chen, S. (2007). Biased odds ratios from
dichotomization of age. Statistics in Medicine, 26, 3487–3497.
Cohen, J. (1983). The cost of dichotomization. Applied Psychological
Measurement, 7, 249–253.
Cohen, J. (1988). Statistical power for the behavioural sciences. Hills-
dale, NJ: Erlbaun.
Constantino, J., & Gruber, C. (2012). Social Responsiveness Scale
second edition (SRS-2). Los Angeles, CA: Western Psychologi-
cal Services.
Dean, M., Harwood, R., & Kasari, C. (2017). The art of camouflage:
Gender differences in the social behaviors of girls and boys with
autism spectrum disorder. Autism, 21(6), 678–689. https​://doi.
org/10.1177/13623​61316​67184​5.
Duvekot, J., van der Ende, J., Verhulst, F., & Greaves-Lord, K. (2014).
The screening accuracy of the parent and teacher-reported Social
Responsiveness Scale (SRS): Comparison with the 3Di and
ADOS. Journal of Autism and Developmental Disorders, 45,
1658–1672. https​://doi.org/10.1007/s1080​3-014-2323-3.
Ferri, S., Abel, T., & Brodkin, E. (2018). Sex differences in autism
spectrum disorder: A review. Current Psychiatry Reports, 20, 9.
Filipek, P., Accardo, P., Baranek, G., Cook, E., Dawson, G., Gordon,
B., et al. (1999). The screening and diagnosis of autistic spectrum
disorders. Journal of Autism and Developmental Disabilities, 29,
439–484.
Frazier, T. W., Georgiades, S., Bishop, S. L., & Hardan, A. Y. (2014).
Behavioral and cognitive characteristics of females and males
with autism in the Simons simplex collection. Journal of the
American Academy of Child and Adolescent Psychiatry, 53(3),
329–340. https​://doi.org/10.1016/j.jaac.2013.12.004.
Halliday, A., Bishop, S., Constantino, J., Daniels, A., Koenig, K.,
Palmer, K., et al. (2015). Sex and gender differenecs in autism
spectrum disorder: Summarizing the evidence gaps and identify-
ing emerging areas of priority. Molecular Autism, 6, 36.
Hanamsagar, R., Alter, M., Block, C., Sullivan, H., Bolton, J., & Bilbo,
S. (2017). Generation of a microglial developmental index in mice
and in humans reveals a sex difference in maturation and immune
reactivity. Glia, 65(9), 1504–1520. https​: //doi.org/10.1002/
glia.23176​.
Hull, L., Petrides, K., Allison, C., Smith, P., Baron-Cohen, S., Lai,
M., et al. (2017). “Putting on my best normal”: Social camou-
flaging in adults with autism spectrum conditions. Journal of
13

Autism and Developmental Disorders, 47, 2519–2534. https​://
doi.org/10.1007/s1080​3-017-3166-5.
Kreiser, N., & White, S. (2014). ASD in females: Are we overstating
the gender difference in diagnosis? Clinical Child and Family
Psychology Review, 17(1), 67–84. https​://doi.org/10.1007/s1056​
7-013-0148-9.
Loomes, R., Hull, L., & Mandy, W. (2017). What is the male-to-female
ratio in autism spectrum disorder? A systematic review and meta-
analysis. Journal of the American Academy of Child and Ado-
lescent Psychiatry, 56(6), 466–474. https​://doi.org/10.1016/j.
jaac.2017.03.013.
Lord, C., Rutter, M., DiLavore, P., Risi, S., Gotham, K., & Bishop, S.
(2012). Autism diagnostic observation schedule (2nd ed.). Los
Angeles, CA: Western Psychological Services.
Minshew, N., Turner, C., & Goldstein, G. (2005). The application of
short forms of the Wechsler intelligence scales in adults and chil-
dren with high functioning autism. Journal of Autism and Devel-
opmental Disorders, 35, 45–52.
National Research Council. (2001). Educating children with autism.
Washington, DC: National Academy Press.
Postorino, V., Fatta, L., De Peppo, L., Giovagnoli, G., Armando, M.,
Vicari, S., et al. (2015). Longitudinal comparison between male
and female preschool children with autism spectrum disorder.
Journal of Autism and Developmental Disorders, 45(7), 2046–
2055. https​://doi.org/10.1007/s1080​3-015-2366-0.
Rynkiewicz, A., Schuller, B., Marchi, E., Piana, S., Camurri, A., Las-
salle, A., et al. (2016). An investigation of the ‘female camouflage
13
Journal of Autism and Developmental Disorders
effect’ in autism using a computerized ADOS-2 and a test of sex/
gender differences. Molecular Autism, 7, 10.
Shuffrey, L., Guter, S., Delaney, S., Jacob, S., Anderson, G., Sutcliffe,
J., et al. (2017). Is there sexual dimorphism of hyperserotonemia
in autism spectrum disorder? Autism Research, 10(8), 1417–1423.
https​://doi.org/10.1002/aur.1791.
Skuse, D., Warrington, R., Bishop, D., Chowdhury, U., Lau, J., &
Mandy, W. (2004). The developmental, dimensional and diagnos-
tic interview (3di): A novel computerized assessment for autism
spectrum disorders. Journal of the American Academy of Child
and Adolescent Psychiatry, 43, 548–558.
Tabachnik, B., & Fidell, L. (2013). Using multivariate statistics (6th
ed.). Boston: Pearson Education.
van Wijngaarden-Cremers, P., van Eeten, E., Broen, W., van Deurzen,
P., Oosterling, I., & Van der Gaag, R. (2014). Gender and age dif-
ferences in the core triad of impairments in autism spectrum dis-
orders: A systematic review and meta-analysis. Journal of Autism
and Developmental Disabilities, 44, 627–635.
Wing, L. (1981). Sex ratios in early childhood autism and related con-
ditions. Psychiatry Research, 5(2), 129–137.
Publisher’s Note Springer Nature remains neutral with regard to
jurisdictional claims in published maps and institutional affiliations.