Sex Differences in Parental First Concerns for Children Screened at-Risk for ASD

Background:  Autism spectrum disorders (ASD) are more prevalent in males than females, with a ratio of approximately 4:1. Furthermore, research suggests that there may be sex differences in early ASD symptomology, with boys exhibiting more readily observable non-verbal impairments and restrictive and repetitive behaviors than girls (Hiller et al., 2015). Due to this more obvious presentation of behaviors in males, ASD may be perceived by parents as being a “boys’ diagnosis,” which may affect parent report of ASD concerns.

Objectives:  This study examines whether there are differences in the timing and type of parent report of first concerns between boys and girls who are at-risk for ASD based on the Modified Checklist for Autism in Toddlers (-Revised), with Follow-Up (M-CHAT(-R)/F).

Methods:  The sample included 532 (N_male=373) toddlers considered at-risk for ASD based on the M-CHAT(-R)/F administered during 18- and 24-month well-child visits at pediatricians’ offices in metro-Atlanta and Connecticut. Upon comprehensive diagnostic evaluation, 274 (N_male=205) were diagnosed with ASD, 226 (N_male=150) were diagnosed with a developmental delay, and 32 (N_male=18) did not meet criteria for any DSM-IV/5 disorder. Prior to evaluation, parents completed a history questionnaire that included open-ended questions regarding concerns about their child. Parent concerns were coded using a scheme adapted from Ozonoff et al. (2009) into ASD-related concerns (Speech/Communication, Repetitive/Restrictive Behaviors (RRBs), Social, and specific mention of “autism/ASD”) and Non-ASD concerns (Motor, Behavior/Temperament, Medical/Regulatory, Feeding/Eating, Disruptive Behavior, and Unspecified). Age and type of first concerns were compared between all boys and girls who were at-risk (i.e., ASD and non-ASD). These were also compared within the ASD group only.

Results:  For the entire at-risk sample, there was no difference in age of first concern between boys (M=13.76, SD=6.75) and girls (M=13.83, SD=5.57; t(163)=-.057, p=.96); however, parents reported more overall ASD-related concerns in boys (M=1.23, SD=.80) than girls (M=1.05, SD=.72; t(327)=-2.46, p=.014). Parents also expressed concern about RRBs more often for boys (13.7%) than for girls (7.5%; X²(1, N=532)=4.01, p=.029). Furthermore, parents specifically named “autism/ASD” as a concern more often for boys (5.6%) compared to girls (1.3%; X²(1, N=532)=5.15, p=.014). In the subsample of children diagnosed with ASD, parents also specifically named “autism/ASD” as a concern more often for boys (7.3%) than girls (0%; X²(1, N=274)=5.34, p=.011); no other sex differences emerged.

Conclusions: Parents of male toddlers at risk for ASD expressed more ASD-related concerns than parents of female toddlers. Parents of boys reported concern about RRBs and specifically named “autism/ASD” more often than parents of girls. It was notable that no parents of girls who were diagnosed with ASD had named autism/ASD as a specific concern. Thus, parents may not recognize or report concerns about ASD in girls, even though symptoms are clinically significant and warrant diagnosis. In an effort to reduce missed or later diagnosis of ASD in girls, future research should focus on assisting parents in recognizing ASD symptoms in girls to improve the utility of parent-reported ASD concerns in the early diagnosis of ASD, and revising the diagnostic process to account for potential sex differences.