Adolescent Girls and Young Women with Autism Spectrum Disorder are at High Risk for Psychiatric Illness and Hospitalization
Written By: Deborah A. Pearson, Ph.D.
For a number of years, it has been known that individuals with Autism Spectrum Disorder (ASD) are at high risk for developing psychiatric disorders. About 70% of children with ASD have been found to meet diagnostic criteria for at least one psychiatric disorder (Simonoff et al., 2008), and approximately 54% to 79% of adults with ASD have been found to meet criteria for at least one psychiatric diagnosis (Croen et al, 2015; Lever et al., 2016). These rates of psychopathology are thought be higher than the rates psychiatric disorders in the general pediatric population (20%; Shim et al., 2022) and the general adult population (about 21%; SAMHSA, 2021).
Despite the recognition that children and adults with ASD are at high risk for psychopathology, relatively little is known about sex differences in psychiatric concerns in ASD. The limited information available suggests that women with ASD are at higher risk for developing psychiatric disorders than men with ASD (Croen et al., 2015). Interestingly, women are less likely to be diagnosed with ASD on their first visit to a health provider, and they are diagnosed on the average eight to ten years later than men with ASD (Gesi et al., 2021; Takara & Kondo, 2014; Takara et al., 2015). Given the weaker coping skills of individuals with ASD in dealing with emotional and behavioral concerns, this delay in ASD diagnosis may be a serve as a breeding ground for psychiatric illness in individuals with ASD—particularly females with ASD.
A recent population-based cohort study examined sex differences in psychiatric illness and hospitalization in 16-25 year olds with ASD in Sweden (Martini et al., 2022). Tapping into national patient registers, the authors compared rates of psychiatric concerns in males and females with ASD, as well as comparing these concerns in individuals with and without ASD. Martini and her colleagues found that 77% of females with ASD had received at least one psychiatric diagnosis, as compared with 62% of males with ASD. Women with ASD were at particularly higher risk for anxiety, depression, and sleep disorders. Both females and males with ASD were approximately three times more likely to receive a psychiatric diagnosis than individuals of the same sex who did not have ASD.
Women with ASD were also at higher risk for psychiatric hospitalization: by age 25, 22.1% of women with ASD had had a psychiatric hospitalization, as compared with 10.9% of males with ASD. Individuals with ASD were at significantly higher risk for psychiatric hospitalization than same-age individuals without ASD (4%). Martini and her colleagues note that these hospitalization rates have the potential to worsen over time for these older adolescents and young adults with ASD, if their psychiatric concerns are not treated effectively.
Why are women with ASD diagnosed later than men, and why do they have higher rates of psychiatric illness and hospitalization? One possibility is that our current ASD diagnostic framework is geared more closely how ASD presents in males, as compared to females. Yet another possible factor may be the tendency for women with ASD to be better “maskers” of their symptoms—i.e., they may be more willing to compensate for their ASD (and psychiatric) symptoms in order to better meet societal expectations for appropriate behavior. Unfortunately, higher rates of camouflaging of ASD symptoms are associated with worse mental health outcomes (Cook et al., 2021). There may also be access problems, such that females with ASD are not as able as males to access effective psychiatric services.
The clinical implication of this research is that we are missing psychiatric comorbidities in adolescent girls and young women with ASD. Expanding the availability of mental health services for adults with ASD, as well as better tailoring diagnostic techniques to detect these concerns in girls and young women with ASD, are crucial steps in closing the gap in diagnosis and delays in treatment. These issues clearly warrant further investigation—and implementation.
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