Underdiagnosis of autistic girls: Are our diagnostic tools missing them? - תת אבחון של של אוטיזם בבנות, האם כלי האבחון שלנו מפספסים אותן?
- motim51
- Mar 27
- 3 min read
Diagnosing autistic girls is a complex issue. Since most commonly used diagnostic tools have been validated primarily on boys, and given that autism in girls may present differently than in boys, diagnosing girls is often more challenging.
A new Israeli study, conducted at the Hebrew University and in Ramat Gan and published in an international medical journal, examined the characteristics that autistic boys and girls display at the time of their initial referral for diagnosis.
The findings of this study should be of interest to any parent raising questions about autism, and especially to parents of girls.
What did the researchers find?
The study included 135 children (69 boys and 66 girls), all referred for assessment due to suspected autism.
All the children were similar in age and cognitive ability.
Parents completed questionnaires about social and behavioral functioning.
The children underwent a semi-structured diagnostic assessment (ADOS) and an in-depth parent interview (ADI), and their empathy and daily functioning (such as communication, independence, and social behavior) were also evaluated.
The surprising finding was this:
According to the parent-report questionnaires, girls showed more autistic symptoms than boys across all measures.
However, according to the classic diagnostic tools, ADOS and ADI, there were almost no differences between boys and girls.
In other words, girls are referred for diagnosis when their difficulties are already very noticeable at home, but the tools used to measure and diagnose autism do not always reflect that they have higher levels of symptoms than boys.
And what about empathy and daily functioning?
Here, the picture becomes even more complex:
Autistic girls received higher scores in empathy, especially in cognitive empathy, the ability to understand what others feel and think.
Among girls, higher empathy was associated with better daily functioning. In other words, more empathetic girls tended to function better in everyday life.
Among boys, this relationship was almost absent, empathy did not predict their level of functioning.
In addition, it was found that among girls, the link between symptom severity and daily functioning was much stronger than among boys.
In other words, the same severity score in a boy and a girl does not necessarily reflect the same level of difficulty in real-life functioning.
So why are so many girls missed?
The researchers explain that girls are often more socially adaptive: they learn to imitate, understand social codes, and show empathy, sometimes at the cost of a significant internal emotional load.
The environment (including teachers, kindergarten staff, and even professionals) tends to interpret girls’ difficulties as shyness, anxiety, or sensitivity, rather than immediately considering autism.
In addition, most diagnostic tools were originally developed based on samples of boys, and are therefore better suited to identifying the more typical presentation of autism in boys, and less sensitive to the ways autism may present in girls.
We have written in other posts about diagnosing autism in girls and about the characteristics of high-functioning autistic girls.
What does this mean for parents?
If you are parents of a girl with social, emotional, communication, or behavioral difficulties, don’t assume that if she appears empathetic, social, or high-functioning, she is not autistic. According to the research, autistic girls can appear highly empathetic, and still struggle with significant underlying difficulties.
If your intuition tells you that something doesn’t quite add up, it’s worth insisting on a thorough, gender-sensitive assessment.
It’s also important to share with clinicians the full picture of everyday life at home: how she is after school, how much energy it takes for her to hold herself together, whether there are meltdowns, extreme fatigue, or anxiety. These are things that a brief clinic-based assessment does not always capture.
What does the research suggest for the system?
The main takeaway from the findings is the need to develop diagnostic frameworks that are tailored to girls, rather than trying to fit girls into criteria that were originally built based on boys.
It is also important to emphasize that even when boys and girls receive the same scores on diagnostic tools, we must ask how this translates into daily life, because in girls, the same numerical severity may sometimes be associated with more significant functional impairment.
The article:
Shulman, C., Nir, Z., & Bitton, D. (2026). Gender Differences in Autism Presentation at Initial Clinical Referral: Diagnostic Measures, Empathy, and Adaptive Functioning. Medical Research Archives, 14(1). DOI: https://doi.org/10.18103/mra.v14i1.7164
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