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

The goal of this study was to assess differences in social and emotional insight in youth with autism compared with matched non-autism controls, with a particular focus on potential variation by sex. Transcriptions of selected sections of the ADOS-2 (Module 3) interview portion were rated by trained undergraduate students who were experimentally masked, using the following scales: Five Levels of Emotional Awareness, Social Cognition and Object Relations, Emotional Investment in Relationships, and Understanding of Social Causality. Results revealed that levels of social and emotional insight differ between autistic and non-autistic participants and, between boys and girls. Specifically, autistic children’s insight was rated lower than that of non-autistic peers on 3 of the 4 scales. Additionally, girls exhibited higher levels of insight compared with boys, regardless of diagnosis, for 3 of the 4 scales. Finally, girls with autism exhibited higher levels of insight than boys with autism on 2 of the 4 scales.

The hypothesis that decreased levels of social and emotional insight would be present in individuals with autism was supported by our finding of lower mean ratings on all four of the insight scales for the autism group, with significantly lower mean rating scores for three of the four scales (social cognition and object relation, emotional investment in relationships, understanding of social causality scales). Furthermore, there was no interaction of diagnosis with sex, indicating that participants with autism exhibited lower levels of insight regardless of their sex. These findings are consistent with previous research indicating that individuals with autism exhibit difficulties with different social concepts, including emotional understanding and understanding of different interpersonal relationships [9, 45]. To date, the vast majority of research has focused on difficulties that individuals with autism exhibit in using social skills, with much less research designed to determine whether there are differences in their understanding of social and emotional topics. To our knowledge, this is the first study to analyze insight and understanding of these social and emotional topics in individuals with autism versus non-autistic individuals.

With regards to sex differences, we report mean insight scores which were higher for girls versus boys on all 4 scales, with significant differences observed for the five levels of emotional awareness in children, social cognition and object relations scale, and understanding of social causality scale. These results support our second hypothesis that girls, regardless of diagnosis group, would be rated higher on levels of social and emotional insight when compared with boys of similar age, intellectual abilities, and autism symptom scores. These findings are consistent with previous research which has found that non-autistic girls exhibit greater social understanding and insight compared to boy peers [9]. However, to our knowledge, the current study is the first to analyze sex differences in insight levels across samples of youth both with and without an autism diagnosis. The current findings, therefore, replicate previous findings indicating higher levels of social and emotional insight in non-autistic girls versus boys and further extend these findings by providing direct evidence that this same pattern may be present in girls versus boys with autism. Furthermore, the use of 4 different social and emotional rating scales in the current study along with the absence of a diagnosis by sex interaction suggests that sex differences in social and emotional insight may be very similar in the autism and non-autism populations.

While there was no significant interaction between sex and diagnosis on any of the social or emotional rating scales, we did conduct follow-up statistical tests examining sex differences separately for the autism and non-autism groups, in order to confirm whether or not each of the two groups exhibited the sex differences on their own. The results of these analyses indicated that girls scored significantly higher than boys in both the autism and non-autism groups for the social cognition scale and the understanding of social causality scale, but not for either of the emotional insight scales. These findings suggest that sex differences are most pronounced and/or most consistent in the domain of social insight than in the domain of emotional insight, for both groups. Thus, enhanced social cognitive insight and enhanced insight into social causality for girls versus boys appear to be a consistent population-level sex difference that is preserved in autism, despite the fact that girls with autism exhibit impaired social behavior and social insight relative to non-autistic girls.

The current results indicate that girls with autism demonstrated higher levels of social insight when compared to boys with autism of similar chronological age, intellectual ability, and autism symptom scores. These findings support the hypothesis that girls with autism present with elevated levels of social insight than boys with autism, which was directly supported by girls with autism being rated as significantly more insightful on both the social cognition and object relation scale and the understanding of social causality scale. This pattern of results is consistent with previous research suggesting that girls with autism may have a greater understanding of social topics when compared with boys with autism [9]. However, while girls with autism were rated higher in social insight levels compared with boys with autism, the girls with autism still exhibited lower levels of social insight when compared with non-autistic girls. These findings suggest that, even while girls exhibit an elevated level of insight when compared to boys, an autism diagnosis is still associated with reduced levels of insight on social topics even in girls. Higher levels of social insight while still presenting with reduced social insight compared with non-autistic girls may also help explain why autistic girls tend to have reduced symptoms relative to autistic boys.

Potential explanations

One potential explanation for the current finding of sex differences in girls versus boys relates to both the quality and quantity of social experiences between boys and girls. When examining peer interactions between girls and boys, girls have been found to heavily rely on social and communicative interaction when forming and maintaining relationships [31]. In previous studies, girls were found to typically put themselves in more situations that focused on socializing with other peers and activities that were centered around talking and being around others without structure (e.g., [30]). This differential experience, in turn, exposes girls with and without autism to more opportunities to learn about and practice different social situations. These sex-specific stereotypes present in today’s society may play a critical role in the sex differences in social and emotional insight in the current study and others.

Along with the potential for direct impacts on social and emotional insight, sex-specific social demands and sex-specific social experience may also impact social and emotional functioning, motivation, and engagement in other ways. When mothers talked to their children, there is typically a difference in the topics discussed between genders [46]. Talking to their sons, the conversations are usually more about learning and instruction, while talking to their daughters the conversations focus more on social interaction and emotions. The topics of conversations have then been observed to be what the child focuses on during free time, either instruction-based play or social play [31].

In addition, girls who face rejection and bullying are often met with more mental harassment [44]. In contrast to this, boys who are rejected are often met with more physical bullying and harassment, yet girls are more impacted by the mental bullying and harassment they experience [47]. Mental bullying refers to name-calling, group exclusion, and talking behind someone’s back, which girls experience more frequently [47]. Therefore, girls and boys, including autistic girls and boys, experience different risks if and when they exhibit reduced social and/or emotional insight. Besides the potential to lead to anxiety, depression, and social isolation, this type of bullying may also lead individuals to learn particular social behaviors and characteristics in an effort to better fit into societal norms and to avoid bullying.

As previously discussed, autism throughout its history has been primarily studied and diagnosed using male-dominated samples [48]. At the same time, most early-onset developmental disorders (i.e., those identifiable within the first 6 years of life) are more commonly diagnosed in boys and the populations are, therefore, heavily male-dominated [5]. Therefore, one possible explanation for the current study findings and their relationship to the identification and diagnosis of girls with autism is that girls simply are not affected by autism at the same rate as boys, and that when girls are affected by autism one of their characteristics is that they exhibit more intact insight into social relationships, reflecting a more mild form of internal social cognitive difficulty. However, several other potential explanations might suggest that current clinical and diagnostic tools and practices might need to be reconsidered and modified.

Another potential relationship between the current study’s findings and current efforts to identify and diagnosis girls with autism relates to the potential for sex differences in camouflaging. As described earlier, camouflaging is the act of modifying behaviors to fit situational contexts [41]. The finding of greater social insights in girls versus boys with autism in the current study opens up the possibility that girls with autism may, on average, be more capable than boys with autism when it comes to camouflaging their behavioral social interaction difficulties and hiding them from others. If this were the case, then girls with autism may be harder to identify and diagnose than boys with autism; yet, as highlighted previously by Parish-Morris, these girls may be experiencing internal symptoms such as negative emotionality as a result of their social experience and lack of support as an un-diagnosed or mis-diagnosed individual [49].

Limitations

As with any study, the current study has some limitations that need to be addressed when continuing this type of work in the future. The first limitation is related to the age of our sample. The current study focused on children and adolescents; thus, we are not able to generalize whether the observed insight differences persist into adulthood or, instead, if age and/or experience increases or decreases the gaps in social and emotional insight. Another limitation of the current study is that the sample consisted of autistic youth without co-occurring language impairments or intellectual disabilities. Due to the sample, we cannot generalize the findings of sex differences in social and emotional insight to autistic individuals who have co-occurring language impairments or intellectual disabilities. The study results should be interpreted and generalized with consideration for the study sample, which is primarily white youth with average to high average cognitive abilities and mild to moderate autism symptoms as measured by the ADOS-2 and SCQ. Future research on this topic will need to use broader samples in order to produce a more clear understanding of how insight varies for all autistic individuals across the spectrum. The current study measured insight by transcribing and scoring participants’ verbal responses to questions related to social and emotional insights on a standardized clinical/diagnostic assessment. Measuring insight this way allows us to measure a participant’s outward expression of social and emotional insight through verbal language is an objective way to index internal states through self-report. However, this approach does not necessarily capture the complete level of insight present in the individual. Future research should attempt to expand upon the current study by developing measures that probe deeper into the potential for additional internal aspects of insight.

Future directions

The results of the current study provide direct evidence for differences in levels of social and emotional insight between autistic girls and boys. These findings help to further the field’s understanding of unique differences potentially present in autistic girls versus boys. Currently, little is known about autistic girls and women due to females accounting for only a small percentage of the autistic population. The current findings, while promising, are one of only a relatively small number of studies on this topic and population. More research is needed to draw firmer conclusions and to develop more comprehensive theories related to girls and women with autism.

There are three future directions which we believe should be taken. The first is related to examining the potential for modifications of diagnostic tools and processes or creation of new tools and processes to better serve not currently diagnosed autistic girls. A majority of the current diagnostic tools in use today for autism diagnosis were standardized using primarily male populations with only 22% of female participants [50]. Recent research studies, including this study, are starting to demonstrate subtle but important differences in the characteristics and symptoms of autism in girls and women when compared to boys and men. With new information and ideas about autistic girls produced by the current study, it is clear that diagnostic tools and processes need to be examined in greater detail in order to assess if they need to be modified to address the likely differences in social and emotional insight between autistic boys and girls. For example, just as clinical/diagnostic training explicitly addresses the need for clinicians to consider the chronological and developmental age of each participant when evaluating and scoring patient responses to questions probing social and emotional insight, the results of the current research indicate that these trainings should also explicitly address the need for clinicians to consider the sex of the patient. Future research using larger samples of participants should also directly examine the impacts of sex and gender on ADOS-2 clinical/diagnostic insight-related and other scores given to girls versus boys, and women and men, as well as how these relate to Clinical Best Estimate diagnosis decision-making.

Second, there is a need to conduct studies that will help to determine how best to modify different interventions to better serve autistic girls and women. The results of this study present a difference in the insight into social and emotional topics in autistic girls and boys. In addition to these observed differences, the explanation of social motivation theory suggests that there are not only differences in understanding of social topics, but additionally in how this understanding leads to behaviors and attempts to form bonds based on these understandings [11, 51]. Future research should examine the real-world impacts of deficits and differences in social and emotional insight in girls versus boys, including how these deficits and differences impact their interactions, comfort, self-advocacy, and success in interactions with both same-sex and opposite-sex individuals and groups. For example, how autistic girls are impacted by having lower social and emotional insight than their non-autistic female peers, and how they are impacted by having similar social and emotional insight as their non-autistic male peers. The results of these studies could lead to intervention programming that is more tailored to, and more impacting for, autistic girls.

Finally, there is a need to conduct follow-up research in order to more fully characterize and understand the nature, depth, and breadth of social and emotional insight differences across autistic and non-autistic girls and boys, and women and men. For example, although the transcripts utilized in the current study, which were derived from a relatively short discussion relevant to social and emotional insights between a clinician and a patient, have provided the opportunity to examine and compare social and emotional insight in autistic and non-autistic girls and boys, the transcripts are insufficient for a qualitative or thematic analysis. Future research which involves developing and deploying more involved interview-based assessments of social and emotional insight in autistic and non-autistic girls and boys will be very valuable for ensuring that we come to a more complete understanding of the nature, extent, depth, and variability of sex differences in social and emotional insight.

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