The art of camouflage: Understanding the social behaviors of girls with ASD
April 10, 2015
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Authors: Michelle Dean California State University, Channel Islands, Robin Harwood Health Resources and Services Administration, Autism Intervention Research Network for Behavioral Health (airbnetwork.org)
Author Note: The Autism Intervention Research Network for Behavioral Health team includes Connie Kasari, Jim McCracken, and Fred Frankel,at Center for Autism Research and Treatment, UCLA; Rebecca Landa at Kennedy Krieger Institute, Johns Hopkins University School of Medicine, Baltimore, MD; Catherine Lord at Center for Autism and the Developing Brain, Weill Cornell Medical College; Felice Orlich and Brian King at Seattle Children's Hospital, University of Washington; Robin Harwood at the U. S. Maternal and Child Health Bureau.
This project is supported by the Health Resources and Services Administration (HRSA) of the U.S. Department of Health and Human Services (HHS) under grant number UA3MC11055, Autism Intervention Research Network on Behavioral Health. The information or content and conclusions are those of the author and should not be construed as the official position or policy of, nor should any endorsements be inferred by HRSA, HHS, or the U.S. Government.
Empirical findings suggest that our difficulties identifying and diagnosing girls with ASD without cognitive impairment (Girelli et al, 2010; Shadduck et al., 2009) may be due to a male bias in our perception of ASD. Girls are described as being better able than boys to "camouflage" their symptoms of ASD, and to use compensatory behaviors that mitigate their social challenges (Dworzynski et al., 2012). Camouflage and compensatory behaviors refer to mimicking or echoing other children's play routines. But girls with ASD lack an understanding of underlying social goals and motivations, and their reenactment of play appears odd and superficial (Knickmeyer et al., 2008). The word camouflage highlights the importance of the environment. Looking more closely at the way that boys and girls with ASD interact with, or blend into, their natural social environment at school may give us a better understanding of why it is difficult to identify ASD in girls. When we consider the potentially unique abilities of girls, we should also recognize that elementary school children generally segregate by gender when they play (Dean et al., 2014; Maccoby, 1999), and girls socialize differently than boys (Pellegrini, Kentaro, Blatchford & Bains, 2004; Maccoby, 1999). So for girls with ASD to camouflage, they will blend into a different social landscape than boys with ASD.
To deepen our understanding of girls with ASD, we examined the social behaviors of children with and without ASD at school. This study is a secondary analysis of observation data (Playground Observation of Peer Engagement (POPE)) that were collected on the playground during recess through the MCHB-funded Autism Intervention Research Network on Behavioral Health (AIR-B). The following research questions were examined: (a) Are girls with ASD better at 'camouflaging' their symptoms of ASD and using compensatory behaviors to mitigate their social difficulties? (b) Are the symptoms of ASD more obvious and easier to detect in boys? (c) To what extent do environmental factors like gender-related social behaviors and peer preferences play a role in helping girls with ASD to mask their symptoms?
The POPE yielded quantitative data (the proportion of time that children were engaged in a game, jointly engaged in social activities, or were solitary), and qualitative data (field notes describing social activities, peer groups, and participant affect). We used mixed methods to analyze data from 185 children with and without ASD (ASD: girls=24; boys=24; TD: girls=69; boys=68). Children with ASD had a diagnosis confirmed by the ADOS (Lord et al., 2002), were without cognitive impairment (IQ≤ 70), and were educated in the general education classroom. Typically developing children were classmates of the children with ASD; their data gave us insight into the natural social environment at school, including gender segregation during play.
Our results indicated that boys and girls with ASD experienced social difficulties that were qualitatively different. Children with ASD spent more time alone during recess than the typically developing children, but boys with ASD spent significantly more time alone than girls with ASD. Girls with ASD generally hovered close to female groups, and this proximity provided some access to social opportunities. As a result, girls with ASD socialized significantly more than boys with ASD. Solitary periods of girls were interspersed with short social interactions- girls alternated between joint engagement and solitary without fully belonging to a group or sustaining their conversations. This made them appear more socially integrated than they actually were. In situations when girls with ASD were involved in a group activity, their participation was less than their typically developing peers. For example, one girl spent a majority of recess in a group swinging a jump rope, but she never got a turn to jump. Without close observation, this girl would look mutually engaged in a group activity, but in fact, she was being left out within the group.
The social environment at school makes it easier to overlook the social challenges of girls with ASD, but easier to detect the social challenges of boys with ASD. Typically developing girls generally engaged in unstructured social activities, flitting from one group to the other. The fluidity of female social groups created an ideal backdrop to conceal the girls with ASD who were often hovering close by. Scanning the playground environment (as one would expect a playground attendant to do) would be insufficient to identify the social struggles of girls with ASD. From a distance, girls with ASD looked like typically developing girls. In contrast, a large proportion of typically developing boys played structured games with rules, or spent time planning to play games. In structured games with rules, a large group of boys play one game throughout the duration of recess (Pellegrini, Kentaro, Blatchford & Bains, 2004). This stable group structure makes it easy to spot the boy with ASD who is often alone and not playing. So contrary to the social challenges of girls with ASD, scanning the playground environment on a regular basis would be sufficient to identify the social struggles of boys with ASD.
Our findings corroborate the camouflage hypothesis; compared to boys with ASD, it more difficult to detect the social challenges of girls with ASD in a natural social environment. By blending in, girls masked but did not solve their social challenges. One way to decrease a possible male bias in our perception of ASD is to recognize that social withdrawal and exclusion may be more nuanced and less obvious in female groups (Dean, Adams, and Kasari, 2013). In order to improve our ability to identify girls with ASD, one important first step is to change the way we scan the playground, to look more closely and to pay more attention to the quality of children's social interactions. In addition, typically developing children have great insight into the social dynamics at school, and if asked, they can often identify which children have a hard time making friends, are left out, or don't 'fit in.' Increasing our understanding of the social environment at school can help to discriminate between children with unusual behaviors who are accepted by their peers, and the children with unusual behaviors who are left out and distressed, and would benefit from intervention.
