Educational Psychology in Practice

theory, research and practice in educational psychology

ISSN: (Print) (Online) Journal homepage: https://www.tandfonline.com/loi/cepp20

Towards a better understanding of girls on the

Autism spectrum: educational support and
parental perspectives

Laura Gray, Ella Bownas, Lucy Hicks, Emma Hutcheson-Galbraith & Sandra
Harrison

To cite this article: Laura Gray, Ella Bownas, Lucy Hicks, Emma Hutcheson-Galbraith & Sandra
Harrison (2021) Towards a better understanding of girls on the Autism spectrum: educational
support and parental perspectives, Educational Psychology in Practice, 37:1, 74-93, DOI:
10.1080/02667363.2020.1863188

To link to this article: https://doi.org/10.1080/02667363.2020.1863188

Published online: 07 Jan 2021.

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EDUCATIONAL PSYCHOLOGY IN PRACTICE
2021, VOL. 37, NO. 1, 74–93
https://doi.org/10.1080/02667363.2020.1863188

Towards a better understanding of girls on the Autism

spectrum: educational support and parental perspectives
Laura Gray a, Ella Bownasa, Lucy Hicksb, Emma Hutcheson-Galbraitha
and Sandra Harrisona
a
Educational Psychology Service, South Tyneside Council, South Shields, UK; bSchool of Education,
Communication and Language Sciences, Newcastle University School of Education, Tyne and Wear,
Newcastle upon Tyne, UK

ABSTRACT KEYWORDS
This UK study aimed to elicit parental voices and school Special Autism spectrum disorder;
Educational Needs Co-ordinator (SENCo) views, to work towards Autism spectrum condition;
a better understanding of sex-specific symptomology in females gender; female; education;
parent; sex
with Autism Spectrum Disorder (ASD), and identify the special
educational needs of these girls. SENCos in a small local authority
(LA) were sent questionnaires investigating their understanding of
ASD and girls. Data were collected from 53 SENCos across the LA.
Parental views were explored through a group interview with three
parents of girls with a diagnosis of ASD. Results indicate that
SENCos have an understanding of male presentations of ASD but
lack confidence in both identifying and supporting girls with ASD.
Qualitative analysis revealed the following key themes: inconsistent
support, paucity of resources, parental emotion and parental initia­
tive. Findings suggest there is a considerable gap between the
needs of girls with ASD and current levels of understanding and
support within educational settings.

Introduction
Autism Spectrum Disorder (ASD) has been defined as a neurodevelopmental disorder that
is associated with difficulties in social communication and the occurrence of restricted
and repetitive behaviours (American Psychiatric Association, 2013; Sedgewick et al., 2019;
World Health Organisation, 2018). It has long been considered that there is a sex dis­
crepancy in the prevalence of ASD, with a ratio of 4:1, in favour of males (Baird et al., 2006;
Rivet & Matson, 2011). However, some literature suggests that the actual ratio of Autism
diagnoses is closer to 2:1 (Dworzynski et al., 2012) and other studies report equal rates of
prevalence between males and females (Matheis et al., 2019). This suggests that girls with
ASD may be going under-recognised.
Research within the field has attempted to disentangle this sex discrepancy and male-
biased aetiology in the core symptomology of ASD. This historical male bias could be
explained by a lack of recognition of a female phenotype of ASD (Kopp & Gillberg, 1992).
Research attests that ASD may present differently within females as compared to the

CONTACT Laura Gray Laura.Gray@southtyneside.gov.uk Educational Psychology Service, Cleadon Park primary
Care Centre, 10 Prince Edward Road, South Shields, Tyne an Wear, NE34 8PS
This article has been corrected with minor changes. These changes do not impact the academic content of the article.
© Association of Educational Psychologists
 EDUCATIONAL PSYCHOLOGY IN PRACTICE 75

more widely recognised and accepted male phenotype of the disorder (Lai et al., 2015;
Mandy et al., 2012). Moseley et al. (2018) describe the detrimental effect that this sex bias
may cause on the diagnostic process for girls and women, stating that the existence of
a sampling bias could mean that only women whose presentation closely mirrors that of
a male presentation are diagnosed, with many females with autism being undiagnosed,
misdiagnosed, or not diagnosed until much later in life than their male peers (Lai & Baron-
Cohen, 2015).
Perceived advantages of an ASD diagnosis include the development of self-identity,
parental empowerment and better access to practical support (Calzada et al., 2012), as
well as further improved developmental outcomes (Filipek et al., 1999). Early identification
of, and intervention for, ASD has also been linked to improved functioning and wellbeing
of children, parents, and the wider family (Estes et al., 2019). Findings highlight concerns
that females who do not receive an ASD diagnosis may not benefit from services and
intervention that may otherwise have been available to them. One factor that could
explain the under-diagnosis of ASD in girls is the lack of recognition of phenotypic
differences between the sexes, within policies and diagnostic criteria. The National
Institute for Health and Care Excellence (NICE, 2013) guidelines encourage the use of
the International Statistical Classification of Diseases and Related Health Problems (ICD-
10) or Diagnostic and Statistical Manual of Mental Disorders (DSM-5) for diagnosing ASD,
both of which include diagnostic criteria which pertain to a more stereotypical male
presentation of ASD.
Core features of the diagnostic criteria for ASD presented in both the DSM-5 and the
ICD-10 relate to difficulties around social communication and social interaction.
Increasing bodies of research suggest that girls interact in a similar way to what may be
expected in comparison to their neuro-typical peers, but that the interaction and type of
friendships formed are qualitatively different (Foggo & Webster, 2017; Kuo et al., 2013;
Sedgewick et al., 2019). This could suggest that social difficulties in females with ASD are
more subtle in their presentation than their male equivalents. Restricted and repetitive
behaviours and interests (RRBI) are also considered to be a key aspect of the core
symptomology of ASD within both diagnostic manuals and act as an essential domain
for a diagnosis of ASD (American Psychiatric Association, 2013). RRBI can be characterised
as behaviours that include repetitive sensory movements, sensory reactions, rituals,
routines and restricted interests. Girls with ASD have been shown to display less RRBI
than boys (Hartley & Sikora, 2009; Van Wijngaarden-Cremers et al., 2014). For example,
girls have been found to display interests that are more similar to that of their typical
developing peers (Gould & Ashton-Smith, 2011; Hiller et al., 2014; Kopp & Gillberg, 1992)
than boys with autism; this can, therefore, mean they are not meeting diagnostic criteria
for RRBI (Hull et al., 2017).
Although sex biases are recognised within academic literature, associated policies and
recommended “gold-standard” assessment tools do not currently reflect this discrepancy
(Lai et al., 2015). It has been suggested that this may be as a result of such measures being
designed and validated with predominately male samples (Koenig & Tsatsanis, 2005;
Mandy & Lai, 2017). Mussey et al. (2017) found that girls who scored similarly to boys
on the Childhood Autism Rating Scale (CARS) received lower standardised scores when
observed using the Autism Diagnostic Observational Schedule, Generic (ADOS-G). As the
ADOS-G is one of the most widely used “gold-standard” diagnostic tools, results suggest
76 L. GRAY ET AL.

that current under-diagnosis of girls with Autism may be a result of a lack of sensitivity to
sex differences within diagnostic criteria.
Alongside suggestions that the diagnostic criteria may lack sensitivity to a female
presentation of ASD, it has been reported that girls are also better able to hide
symptoms of ASD. This type of coping strategy is often referred to in the literature
as camouflaging (Dean et al., 2017; Hull et al., 2017). Camouflaging has been seen to
comprise the distinct coping strategy named masking (Hull et al., 2017). Masking has
been defined as a conscious or unconscious effort to hide ASD characteristics through
the use of strategies that result in a more conforming behavioural presentation (Lai
et al., 2017; Livingston & Happé, 2017), driven by the desire to fit in (Hull et al., 2017).
Girls and women who experience ASD have been found to use masking strategies
more commonly than males (Lai et al., 2017; Sutherland et al., 2017). Recent research
exploring the qualitative experiences of women and girls with ASD identified masking
as a strategy used to disguise any ASD characteristics in order to appear “normal”
(Bargiela et al., 2016; Tierney et al., 2016). The same studies also identified the
negative consequences of masking, with participants describing the process as
“exhausting” and “draining” (Tierney et al., 2016) as well as creating confusion
about one’s sense of true identity (Bargiela et al., 2016)
The use of camouflaging techniques, such as masking strategies, has been linked to the
under-recognition of ASD in females. For example, the masking of ASD characteristics may
develop perceptions that such girls and women function well and do not experience any
difficulties (Hull et al., 2017). This has been said to result in teachers and clinicians being
unaware of such difficulties, as opposed to close family members who see their children
across a range of contexts and situations and therefore have a better awareness of the
problems that their daughters face (Hull et al., 2017).
Alongside this, females with ASD have been found to be more socially motivated than
their male peers (Cook et al., 2018; Kopp & Gillberg, 1992, 2011; Tierney et al., 2016),
challenging a historical view that difficulties with social relationships are the “hallmark of
autism” (Sedgewick et al., 2019, p. 1119). Increased social motivation is said to encourage
the masking of any non-conforming social behaviours (Kreiser & White, 2014). Research
has demonstrated that professionals can be reluctant to diagnose ASD in women who
appear socially able (Bargiela et al., 2016) and that if professionals do rely on a more
stereotypically male presentation of ASD, that is, social isolation, this can contribute to the
under-recognition of ASD in girls (Dean et al., 2017).
Among the professionals that work with children and young people, school staff
can act as an integral part of the identification process and play a key role in the
implementation of support put in place for girls with ASD. Educational settings are
recognised as a key context from which relevant information can be gathered for
diagnostic purposes (NICE, 2017), with teachers being one of the first sources of
information relied upon by a parent (Hiller et al., 2014). Research has found that
teachers report considerably fewer concerns with girls’ behaviour compared to their
male peers (Hiller et al., 2014; Mandy et al., 2012), and that staff believe that
outward behavioural difficulties must be apparent in order for ASD to be present
(Jarman & Rayner, 2015). Similarly, literature has attested to boys with ASD being
 EDUCATIONAL PSYCHOLOGY IN PRACTICE 77

more likely to display externalising types of behaviour compared to their female

peers (Gould & Ashton-Smith, 2011; Hiller et al., 2014); this could be a result of girls’
efforts to mask their difficulties in order to fit in (Sutherland et al., 2017). Taken
together, research suggests that school staff may be more likely to notice and
report concerns around autistic traits in boys as a result of their increased externa­
lising behaviours (Dworzynski et al., 2012; Mandy et al., 2012).
Findings from school contexts contrast drastically with parental reports. A recent
systematic literature review exploring the school experiences of autistic girls recognised
differences in staff and parental perspectives as a key theme (Tomlinson et al., 2019).
Research suggests that this disparity in views is a result of parental assessment of need
being of greater severity than that of the school (Moyse & Porter, 2015) or parental views
either not being taken seriously (Cook et al., 2018) or dismissed entirely (Jarman & Rayner,
2015). Tomlinson and colleagues also reported that, across all three studies, assumptions
were made under the premise of ASD being viewed as a male condition (Tomlinson et al.,
2019). Disparities are also reported to exist between parent and teacher reporting of girls
internalising difficulties. Mandy et al. (2012) findings highlighted that parents reported
higher levels of internalising difficulties in girls with ASD; however, these were not
identified by teachers. Qualitative data have also illuminated the voices of parents of
girls with ASD and are helping to shape an understanding of the disparity of views
between school and home. For example, parents have identified the emotional difficulties
that their daughters with ASD experience as a result of masking all day (Jarman & Rayner,
2015; Sutherland et al., 2017). The aforementioned literature highlights potential dispa­
rities that exist between parental and school understanding of ASD and girls. Although
extremely insightful, research eliciting parents’ voices is limited, warranting further
investigation.
This raises questions relating to the under-identification of girls with ASD and how
this may affect the support they can access in key settings. Previous literature
suggests that school staff may lack an understanding of sex differences in the
presentation of ASD and, therefore, females presenting with autistic traits may be
missing out on the benefits that early identification and diagnosis may afford.
Research that aims to improve the understanding of ASD and girls through parental
views is limited. Thus, the current study aims to elicit parental voices and school
SENCo views, with the hope of disentangling any disparities in understanding of sex-
specific symptomology and identifying the specific educational and therapeutic
needs of these girls and women.

Method
Ethical statement
The current project was conducted with regard to The British Psychological Society (2018)
Code of Ethics and Conduct. The code espouses four, key ethical principles, constituting
the main areas of responsibility when conducting psychological research including;
respect, competence, responsibility and integrity.
78 L. GRAY ET AL.

SENCos
Participants and procedure
Questionnaires were disseminated to all 66 educational settings in the local area via post
and email, alongside a letter outlining the aim of the study. These settings comprised
Early Years, Primary and Secondary educational contexts. Participation from SENCos was
completely voluntary. One reminder email and a maximum of two reminder phone calls
were received by participants. Participants returned completed questionnaires via post or
email.

Measure
A questionnaire was developed specifically for the purpose of this study by the research
team and was based on the National Autistic Society’s training on women and girls with
autism. Typical characteristics displayed by girls and women with ASD were adapted from
the module, informing the design of the questionnaire. For more information regarding
the online training that the Research Team accessed please refer to the Autism Training
section of the National Autistic Society’s website (available via https://www.autism.org.uk/
professionals/training-consultancy.aspx). The topics covered in the questionnaire
reflected empirical evidence within the field, clinical insights into the diagnosis of ASD
in boys and girls, and the team’s knowledge of local school systems and staff roles.
A mixture of binary tick boxes, rating scales, and boxes for open-ended written answers
were included in the questionnaire in order to capture a variety of responses (Rattray &
Jones, 2007).

Data analysis
Quantitative data were entered into IBM SPSS Statistics 26 for analysis. Frequency data
were analysed initially which informed decisions for further tests. Chi-square tests were
conducted between items with larger differences in recorded responses.
Qualitative data were also collected from school SENCos. Participants were given
the opportunity to contribute ideas on any other types of characteristics girls with
ASD may present with, what their difficulties may be misinterpreted as, and specific
types of support that they would implement for girls with ASD in their settings.
Data were analysed with the “Scissor and Sort” technique (Stewart & Shamdasani,
2014).

Group interview
Participants
An opportunity sampling method was adopted. Families who attended National
Autistic Society EarlyBird (https://www.autism.org.uk/earlybird) were given a flyer
outlining the study and parents of girls with a diagnosis of ASD were invited to
contact the research team if they were interested in taking part. Four people
expressed an interest, all mothers of girls with a diagnosis of ASD, and each received
a telephone call detailing the full purpose and outline of the study. No fathers
expressed an interest in taking part although some fathers do attend Earlybird
 EDUCATIONAL PSYCHOLOGY IN PRACTICE 79

sessions. Three participants were all able to attend on the same date and time, so
were included in the group interview. No exclusion criteria were set regarding their
or their daughters’ age, comorbidities, or level of functioning. All parents in the study
had daughters who had a diagnosis of ASD. The girls’ ages ranged from 7 to
12 years old.

Procedure
The interview took place in a private meeting room within a community health
centre. Upon arrival, participants were provided with a participant pack which
included; a welcome sheet, information sheet and consent form. Within this pack,
participants were also given a visual aid of a winding path. The visual aid repre­
sented their daughter’s pathway to diagnosis and was provided to help guide
participants’ thinking. Participants were asked to read the full information sheet
and complete a consent form. At this point, participants were also provided with
information on how the visual aid could be used throughout the hour long con­
versation and were encouraged to take some time to make any notes that may
support their thinking. Following this, the facilitator outlined the purpose of the
group interview and the types of information they hoped to gather. As the topic
had the potential to elicit emotive memories, boundaries for safe and confidential
discussion were set. This was done by setting out group guidelines within the
participant welcome sheet, encouraging participants to consider confidentiality of
the discussion, as well as reinforcing their right to withdraw and leave at any point.
A series of questions had been developed to direct the group interview: using an
approach based on Grounded Theory (Glaser & Strauss, 1967) the facilitator framed
the questions around the participants’ own words to promote open communication
and conversational flow. The guiding questions used in the group interview are
detailed in Table 1. The facilitator interjected at points throughout the group inter­
view, using the agreed follow-up questions to re-focus the discussion. A member of
the research team took field notes of data that could not be obtained through the
audio recording, such as facial expression and body language.

Data analysis
The group interview was audio-recorded and transcribed verbatim, post-hoc.
A framework method of analysis (Ritchie & Spencer, 2002) was selected to identify key
concepts without missing any detail within the data (Gale et al., 2013). Researchers also
adopted a consensus approach (Hill et al., 1997) to avoid over-reliance on one single
perspective and analysis was very much an iterative, data-driven process. Analysis
involved familiarisation with the data, initial double-coding by two researchers to ensure
consistency, a reliability check and review of key themes, final definitions of categories,
and final calculations of frequencies. As per Gale et al. (2013), it was felt necessary to have
an “Other” code for three of the categories to avoid ignoring vital data that did not
directly fit.
80 L. GRAY ET AL.

Table 1. Guiding questions for group interview.

Number Question
Q1 When did you first become concerned that your daughter may be presenting with Autism? What behaviours/
signs did you notice that first concerned you?
Q2 What did the diagnosis mean in terms of the support you then received?
Q3 Do you think that the amount and type of support you received would have differed if it had been for a boy
with Autism?
Q4 Do you feel that school have made an effort to understand the unique needs of your daughter?
Q5 If you could create the perfect school for your daughter, what might that look like?

Results
SENCO questionnaire data
Frequencies
Eighty percent (53/66) of the settings responded; data were available from settings
including early years (10/16, 63%), primary (34/41, 83%) and secondary (9/9, 100%)
educational contexts.
Respondents were asked to rate their knowledge of ASD. Sixty-two percent of respon­
dents rated their knowledge of ASD as “quite high” or “high”, with no respondents rating
their knowledge of autism as “low” (Table 2).
Respondents were less confident in their ratings of their knowledge of ASD and girls
specifically (Table 3). Forty percent of respondents fell into the category of “low” or “quite
low”. Whilst 47% of participants felt moderately confident, only 13% rated their confi­
dence as quite high (with 0% reporting high confidence).
Participants were asked about the difference in presentation between males and
females. Responses indicated that 85% of participants were aware of differential presen­
tations (Table 4).

Table 2. SENCos’ knowledge of Autism – self-ratings.

Question Category Response Rate % (n)
I would rate my knowledge of Autism as: Low 0 (0)
Quite Low 4 (2)
Moderate 34 (18)
Quite High 60 (32)
High 2 (1)

Table 3. SENCos’ knowledge of Autism presenting in girls – self-ratings.

Question Category Response Rate % (n)
I would rate my knowledge of how Autism presents in girls as: Low 2 (1)
Quite Low 38 (20)
Moderate 47 (25)
Quite High 13 (7)
High 0 (0)

Table 4. SENCo reported male and female presentation of Autism.

Question Category Response Rate % (n)
Do you think Autism presents differently in males and females? Yes 85 (45)
No 13 (7)
Did not answer 2 (1)
 EDUCATIONAL PSYCHOLOGY IN PRACTICE 81

Table 5. SENCo reported male and female prevalence.

Question Category Response Rate % (n)
The prevalence of autism is the same in males and females: True 26 (14)
False 66 (35)
Did not answer 8 (4)

Participants were asked about their understanding of the prevalence of ASD in males
and females (Table 5). Sixty-six percent of participants indicated that they thought there
was a difference in prevalence dependent on sex.
When asked about their confidence in recognising ASD in girls, 43% of respondents
reported being less confident, giving responses of “low” and “quite low”. Thirty-six
percent of respondents were moderately confident, with only 21% reporting their con­
fidence as “quite high” and no respondents reporting “high” confidence (Table 6).
Overall, participants were more assured in their confidence in supporting girls with an
ASD diagnosis, with 81% indicating confidence levels between “moderate” and “high”
(Table 7).
Respondents were asked to record their understanding of specific characteristics that
a girl with ASD is more likely to display (Table 8). The highest frequencies indicated that

Table 6. SENCos’ self-reported confidence in recognising Autism in females.

Question Category Response Rate % (n)
How confident are you of being able to recognise autism in females? Low 9 (5)
Quite Low 34 (18)
Moderate 36 (19)
Quite High 21 (11)
High 0 (0)

Table 7. SENCos’ self-reported confidence in supporting Autism.

Question Category Response Rate % (n)
How confident are you at supporting females after diagnoses? Low 4 (2)
Quite Low 15 (8)
Moderate 47 (25)
Quite High 25 (13)
High 9 (5)

Table 8. SENCos’ perception of female characteristics of Autism.

Response
Question Category Rate % (n)
Which of the following characteristics do you think a girl with Does not have lots of friends 62 (33)
Autism may be likely to display? Have an imaginary friend 68 (36)
Have the same interests as their 42 (22)
female peers
Find changes in routine difficult 96 (51)
Have an intense relationship with 83 (44)
one particular friend
Copy the behaviours of people 79 (42)
around them
Display challenging behaviour 56 (29)
Have unusual interests/obsessions 89 (47)
82 L. GRAY ET AL.

respondents thought girls would be likely to “find changes in routine difficult” and to
“have unusual interests/obsessions”.
Seventy-seven percent of participants reported that they came into contact with
between 1 and 5 females with a diagnosis with ASD each year (Table 9). Only 8% of
respondents reported being brought into contact with higher numbers of diagnosed
females.
Seventy-seven percent of respondents also recorded that they came into contact with
1–5 females who they suspect to have undiagnosed ASD each year (Table 10).
Respondents were asked what “next steps” would be most appropriate to help
identify and support girls with ASD (Table 11). Participants were not restricted in their
choices and could indicate as many next steps as they thought were appropriate for
their setting. Seventy percent of respondents felt that specific training on identifying
ASD in girls would be beneficial. Eighty-three percent of participants agreed that
training on strategies and intervention specific to girls would be of benefit within
their setting, whereas 62% of respondents did not indicate that workshops for staff on
the subject of women and girls would be a beneficial next step. Finally, 57% did not
indicate that they thought post-diagnostic support for parents would be beneficial in

Table 9. Reported numbers of females with Autism that SENCos work with each year.
Response Rate
Question Category % (n)
How many young females with a diagnosis of autism does your role bring you into None 15 (8)
contact with each year? Between 77 (41)
1–5
Between 6 (3)
6–10
More than 2 (1)
10

Table 10. Reported numbers of undiagnosed females the SENCos work with each year.
Response Rate
Question Category % (n)
How many young females who you suspect may have undiagnosed autism does your role None 2 (1)
bring you into contact with each year? Between 77 (41)
1–5
Between 17 (9)
6–10
More than 4 (2)
10

Table 11. SENCos’ reports of helpful next steps to support schools.

Response
Question Category Rate % (n)
What do you feel would be most helpful in supporting your setting to best Identification 70 (37)
help identify and understand the needs of young women and girls with Strategies and 83 (44)
autism? Intervention
Staff workshops 38 (20)
Post diagnostic 43 (23)
workshops for
parents
Other 4 (2)
 EDUCATIONAL PSYCHOLOGY IN PRACTICE 83

supporting their setting to understand the needs of young women and girls with
autism.
Lastly, respondents were asked where their knowledge base of autism derived from.
Eleven percent of respondents reported that this came from “teacher training”, whilst 79%
stated “experience at work” (Table 12).

Questionnaire qualitative data

Qualitative data were also collected from school SENCos. Participants were given the
opportunity to contribute ideas on other types of characteristics that they thought girls
with ASD may present with, what their difficulties may be misinterpreted as and specific
types of support that they would implement for girls with ASD in their settings. Data were
organised into categories and codes as summarised in Table 13.

Group interview for parents

Data were organised into categories and codes; the final thematic framework is displayed
in Table 14, below. Eight categories were identified, comprising 31 separate codes. Key

Table 12. SENCos’ report of the basis of their knowledge about Autism.
Question Category Response Rate % (n)
My knowledge about Autism has mainly come from: Local Authority Training 43 (23)
External Organisation 49 (26)
Teacher Training 11 (6)
Experience at Work 79 (42)
Personal Experience 9 (5)
Other 6 (3)

Table 13. Qualitative data from SENCos’ questionnaires.

Response
Question Category Rate (%)
What type of support would you put in place for a girl with Generic ASD support 85
a diagnosis of autism? Individualised to child 37
Support from other agencies 17
Girl specific support 5
Detail any other characteristics you are aware of, that a girl with Generic ASD traits 69
autism may display: Masking 31
Mental health difficulties 19
Individualised to child 12
Issues with gender and/or 8
sexuality
Females with autism are often misdiagnosed. What do you think their Social, emotional & mental 41
difficulties may be interpreted as? health difficulties
Behavioural difficulties 36
Overlooked due to other 29
strengths and/or masking
Personality traits, e.g., shy, 21
quirky
Other developmental disorders, 19
e.g., ADHD
Communication difficulties 17
84 L. GRAY ET AL.

Table 14. Summary of group interview data analysis.

Category Code Quote Freq
Recognition of Parental “I just thought oh she might need speech” 12
Differences Health “paediatrician said it was Global Developmental Delay” 5
School “In nursery . . . they were treating it as behavioural” 4
Birth & Pregnancy “I had a difficult pregnancy” 5
“My birth with M was horrendous”
Maternal Emotion Upset “I was absolutely devastated” 6
Guilt “It is an overwhelming guilt” 4
Anxiety “I literally nearly had a breakdown” 4
Loneliness “I think a lot of people feel totally let down and alone” 4
Other “I was relieved in some way” 2
“I was mortified she was doing it in front of the paediatrician”
Key Difficulties Masking “My daughter masks a lot of stuff” 9
Sensory “She does sensory seeking . . . she’s rubbed from about one and 8
a half”
Invisible Need “If you just looked in a room you wouldn’t think that L was any 6
different to any other child”
Feeding “M won’t eat nothing” 3
Friendships “She doesn’t really know what a friendship is” 3
Attainment “She couldn’t do her . . . phonics . . . she kept failing it and the other 3
tests”
Other “She would just follow him” 1
Comorbidities and co- Physical “She’ll fall down . . . the stairs because she’s floppy, she’s low tone” 5
occurring conditions Difficulties
Mental Health “Her anxiety was getting too much . . . it’s just her anxiety . . . taking 3
over”
Other “She’s dyspraxic and she’s got sensory processing disorder” 2
Appreciation of Parental “I’ve got more out of it myself by going to groups and talking to 11
parental voice and Initiative parents than I’ve got through . . . specialists”
skill Not being heard “I’d felt like they weren’t listening to me” 8
Parental “I . . . did the whole visual in preparation for it, I was prepared for it” 5
strategies
Parent as Expert “I can sometimes tell what type of day I’m going to have just by the 2
way she looks”
Availability of resources Lack of resources “They say they haven’t got the time . . . the staff . . . the money” 12
and support Support for “I think they should have counsellors there for parents” 6
parents
Other “They need to do a different approach to diagnosing girls” 5
ASD-specific “All teachers to be fully trained up . . . for children with Autism” 4
Inconsistent Lack of “the school have got things in place that they’re supposed to 15
support educational follow and . . . she’s never done it for I don’t know how long”
support
Lack of health “All the specialist health visitor gave me was a whole load of 9
photocopied material on Autism and I felt really insulted”
Positive “the teachers understand, the whole of school understands” 9
educational
Poor “I think there’s a massive, massive deficit of understanding” 6
understanding
Positive health “It’s been health [services] . . . that have provided the support for 4
us”

quotes were provided for each code to provide context and give weight to participants’
views (Richards & Hemphill, 2018).
The most frequently discussed category was “Inconsistent Support” which was men­
tioned 39 times across the group interview. Following this, “Key Difficulties” was discussed
33 times and “Availability of resources and support” was referred to 27 times.
Within the 8 categories, there were key codes that recurred throughout. Most notable
were “Lack of educational support”, discussed 15 times, “Parental recognition of differences”
 EDUCATIONAL PSYCHOLOGY IN PRACTICE 85

(12 times), “Lack of resources” (12 times), and “Parental initiative” (11 times). The category
of maternal emotion (mentioned 20 times) was not driven by questions asked in the
group interview but, rather, was a salient theme that emerged naturally through discus­
sion of other topics.

Discussion
The researchers elicited the views of parents and SENCos in order to investigate the sex-
specific symptomology and support needs of girls with a diagnosis of ASD. Taken as
a whole, these findings support a wider body of research which describes the phenotypic
differences in the presentation of ASD in girls and women, often misunderstood or
misinterpreted due to a male-biased understanding of the condition (Lai et al., 2015;
Mandy et al., 2012). This research suggests that this misconception may exist within
educational settings and that SENCos, who can play an important role in identifying
and supporting such girls, may hold a more male-based understanding of ASD.
Questionnaire data indicated that the majority of SENCos reported moderate to high
levels of confidence in supporting girls with ASD. However, qualitative responses revealed
that 85% of SENCos would provide types of support consistent with a male profile of ASD,
for example, “I do not have any gender specific ideas”, “The same support I would put in
place for a boy”. This suggests that, although SENCos feel confident in their ability to
support girls with autism in their settings, the actual support they are providing may not
be specific enough to their needs. This was echoed within the group interview, with
parents discussing the lack of girl-specific support in their daughters’ educational settings,
“[teachers] need to do a different approach to . . . girls”. Parents felt that this was
particularly important in terms of their daughters’ anxiety levels; “there should be some
kind of mental health support”.
Parental views are reinforced by research indicating that girls with ASD may experience
more internalising difficulties, such as anxiety and depression (Hartley & Sikora, 2009;
Holtmann et al., 2007), and that amongst young people with a diagnosis of autism girls
are more likely to have high levels of anxiety than boys (May et al., 2014). The findings
highlight potential disparities between parental views of what would best support their
daughters in educational settings and what is currently being offered within schools for
girls with ASD, adding to a limited body of research in this area. Parental knowledge has
been referred to as a key aspect of understanding additional needs and health conditions
(Giallo et al., 2013); therefore, schools may want to consider the importance of acknowl­
edging parental views and working collaboratively towards well-informed, tailored inter­
vention for girls with ASD.
The results indicate that SENCos report feeling moderately confident in both recognis­
ing girls with possible ASD and supporting girls post-diagnosis (Tables 6 and 7). However,
within these scales, there were also large clusters of responses suggesting that SENCos
rated their confidence as “low” or “quite low” (43%) for recognising girls with possible
ASD. A large cluster of responses (34%) also indicated that SENCos rated their confidence
as “quite high” or “high” for supporting girls post-diagnosis. The pattern of these clusters
of responses seem to suggest less confidence in recognising possible ASD in girls than in
feeling able to support those already diagnosed. Despite a relative lack of confidence,
a high frequency of SENCos (79%) did identify that girls with ASD may copy behaviours
86 L. GRAY ET AL.

that they observe around them, otherwise referred to as masking (Hull et al., 2017). This
characteristic was also identified by parents within the group interview. Masking types of
behaviours were discussed nine times throughout the parental group interview with
statements such as “she just used to follow” and “my daughter masks a lot of stuff”.
Current findings, from both SENCo and parental perspectives, support a wider body of
past research which report on the tendency of girls with ASD to engage in this type of
masking behaviour (Lai et al., 2017; Schuck et al., 2019). In contrast, 56% of SENCO
respondents reported that a female with ASD may display “challenging behaviour” and
36% suggested that a girl with autism may be misinterpreted as having behavioural
difficulties. This not only conflicts with responses that recognise masking as a key trait of
ASD in girls but also opposes parental views and existing literature. All three parents
discussed the fact that their daughter does not display challenging behaviour at school;
“she’s a . . . model student at school, she wouldn’t dare get in trouble with the teachers”.
Empirical research has found that boys with ASD displayed significantly higher levels of
behavioural problems and difficult interactions within a school context than girls with
ASD (Hsiao et al., 2013), a finding which does not generalise to home contexts (Kozlowski
et al., 2012).
Alongside this, 96% of SENCos in the current study reported that girls with ASD would
find changes in routine difficult to manage. Although it is understood that routine may be
important to girls presenting with ASD (Egerton & Carpenter, 2016), it is also understood
from the literature that girls are more likely to conform to classroom norms (Hiller et al.,
2014) and mask any difficulties associated with autism (Lai et al., 2017; Livingston &
Happé, 2017). As such, it is possible that girls may approach routines more flexibly than
boys in an effort to hide autistic traits. As previously mentioned, girls with ASD have been
shown to display less RRBI than boys (Hartley & Sikora, 2009; Van Wijngaarden-Cremers
et al., 2014), which may include strict adherence to routine. If SENCos are looking for
difficulties in managing changes to routine in order to recognise girls with ASD, as in the
current study, this could explain why, to some degree, girls are going un-recognised in
classroom settings.
Similarly, 89% of SENCos reported that having unusual interests would be a key
behavioural marker of ASD in females. Empirical evidence has found that where boys
with ASD frequently have overly intense, restricted interests that may be viewed as
unusual (for example, bus timetables), females with ASD often have intense interests in
the same topics as their peers, such as pop stars (Dean et al., 2017; Gould & Ashton-Smith,
2011; Hiller et al., 2014). Despite their awareness of girls with ASD masking some of their
difficulties, SENCos may be relying on characteristics that have been considered a more
male-based presentation of ASD, including rigidity in routine, unusual interests or displays
of challenging behaviour, to identify autism in females. This could partly explain why
many girls are going undiagnosed. Although findings on SENCos’ understanding of RRBI
and the female presentation of ASD are insightful, wider research on the topic has been
described as limited and inconsistent and therefore should be viewed with caution (Allely,
2019).
Copying, masking, or camouflaging behaviour is fundamentally difficult to recog­
nise. Therefore, although SENCos may be aware that this is one type of behaviour
evident in the female presentation of ASD, actually identifying when this behaviour
is occurring within a classroom setting perhaps represents more of a difficulty.
 EDUCATIONAL PSYCHOLOGY IN PRACTICE 87

Although measures have been developed to support the identification of camou­

flaging behaviours (Hull et al., 2019), additional research into the reliability of such
tools within clinical settings is warranted (Allely, 2019). Similarly, researchers have
called upon further investigation into the sensitivity and appropriateness of diag­
nostic tools, with current “gold standard” measures lacking sensitivity to a more
female presentation of ASD (Lai et al., 2015). This may be creating a trickledown
effect, influencing a wider societal understanding of autism based on a more male
understanding of the condition. Through more frequent use of diagnostic tools that
are more sensitive to a female presentation of ASD, such as the Diagnostic
Interview for Social and Communication Disorders (DISCO) (Wing, 2006), improved
identification of girls displaying autistic traits may be possible.
The majority of school SENCos (66%) believe that there is a difference in the prevalence
of ASD between males and females; SENCos’ views support the longstanding presump­
tion of prevalence estimates (Rivet & Matson, 2011); however, recent evidence suggests
the prevalence of autism to be relatively equal between males and females (Matheis et al.,
2019). Prevalence estimates are also more balanced amongst males and females when not
relying on “gold standard” diagnostic tools described as male-biased (Mussey et al., 2017).
In contrast, parents in the group interview felt that many females presenting with autistic
traits have “gone undiagnosed” due to a “massive lack of understanding” and, therefore,
historical prevalence estimates were likely to be inaccurate. Current findings of SENCos’
perception of prevalence may help to explain why so many young girls with autistic traits
are not receiving ASD diagnoses, contributing to the widespread under-recognition of
ASD in females.
In terms of SENCos’ knowledge base, only 11% reported that their understanding
of autism had come from their teacher training. Seventy percent of SENCos felt that
training in identifying and supporting girls with a diagnosis of ASD would benefit
them.
Recent literature details the lack of school training on special educational needs,
and, in particular, ASD; given this shortage of training, Critchley has argued that
“expecting teachers to know what to do to support autistic girls . . . is unrealistic”
(Critchley, 2019, p. 168). Research that has explored the outcomes of ASD-specific
teacher training has found significant improvements in staff’s inclusive practice and
their outlook in supporting these young people (McCulloch & Noonan, 2013; Nolan &
Hannah, 2019). The parental group interview also reflected the need for educational
practitioners to receive further training in this area; participants agreed that “all
teachers [need] to be fully trained up . . . for children with autism, especially girls”.
Previous research, involving parents of girls with ASD, reflects current findings,
highlighting a lack of knowledge within mainstream schools and a lack of under­
standing of female-specific ASD symptomology within school staff (Cridland et al.,
2014). The findings from the current study demonstrate that there is significant
demand for school staff training on the subject of autism and, more specifically,
the female presentation of autism. Future educational policy, practice, and research
should account for this and consider gathering parental input.
A strong theme to emerge throughout the focus group was the highly emotive nature
of parental experiences and their need for post-diagnosis support. All parents discussed
intense feelings of guilt and isolation, supporting previous literature (Cridland et al., 2014).
88 L. GRAY ET AL.

Conversely, many SENCos did not identify additional parental support in the form of post-
diagnostic workshops as an important “next step” in supporting girls with ASD. Although
findings illuminate an important issue, research on how educational settings can support
parents of girls with ASD is limited. Future studies could explore the impact of parental
support and collaborative school-home working on the symptomology and mental health
of young females with autism.

Limitations
Findings from the current study should be viewed in light of their limitations. Firstly, the
sample size was representative of a relatively small LA, reflected in the number of
participants who attended the group interview. Similarly, the sample for the question­
naire data was self-selecting. This presents challenges in drawing firm conclusions and
generalising findings; for results to be more conclusive, the study should be replicated
with a larger, less-biased, sample.
As the study was originally devised to help inform practice within the LA, the ques­
tionnaire used for this purpose was not piloted and is not a standardised measure. Studies
that would like to replicate current findings may wish to pilot the questionnaire before
use. The question, regarding what SENCos felt would be most helpful for their setting in
supporting and identifying the needs of young women and girls with ASD, allowed
respondents to choose as many options as they thought relevant. In order to understand
this area in more detail, it may have been better to ask SENCos to rank the options, thus
providing an idea of which areas might be more useful for EPs to develop training and
support around. A pilot study may have clarified thinking in this area for the researchers.
In addition, a pilot study might have led to a four-part Likert scale being used rather than
a five-part scale; this would lead to responses being more confidently categorised as one
side of the scale or the other.
It is also important to acknowledge that many of the questions asked respondents to
rate their level of skill and knowledge in particular areas. This is naturally a subjective
opinion and does not give insight into individual differences in how respondents might
categorise or evidence levels of skill or knowledge.
The nature of the sample, which comprised of parents of girls with a diagnosis of ASD,
may also act as a limitation to the study. In line with the referral bias that exists, it is
possible that as these girls had met the diagnostic criteria for ASD, their behaviours and
experiences may be more closely linked to a typically “male” presentation of the condition
than girls who have not, yet, received diagnoses. Therefore, the findings cannot be said to
represent the views of those with ASD who may be discriminated by a male-biased
referral process and diagnostic criteria.
As informed by Lai et al. (2015), “sex” (the biological and physiological characteristics
which define men and women) and perceptions of “gender” expression (socially con­
structed) differences in the presentation of ASD could be viewed as challenging to
disentangle. As it was not the purpose of the research to understand or identify any
potential overlap between sex and gender, researchers adopted the terminology of “sex
differences” when referring to the phenotype differences that exist between the male and
female presentation of ASD. Future work may wish to consider further defining the
 EDUCATIONAL PSYCHOLOGY IN PRACTICE 89

terminology adopted, identifying any overlap between sex and gender in the presenta­
tion of ASD.

Conclusion and implications

Overall, current findings highlight potential discrepancies between the understand­
ing of the female-specific symptomology of ASD within educational contexts and the
real life, lived experiences of these girls. Although the majority of SENCos in this
study felt moderately confident in recognising and supporting girls with ASD, current
findings suggest that school staff’s knowledge of autism is predominantly based on
a typically male presentation. This male-biased understanding of ASD could be
explained by the wider under-representation of females with autistic traits in both
clinical practice and research (Lai et al., 2015). Moreover, “gold standard” diagnostic
tools lack sensitivity to the female presentation of ASD (Lai et al., 2015; Mussey et al.,
2017), which may be having a trickledown effect and further influencing SENCos’
understanding of autism.
Gaps in SENCos’ knowledge could also be explained by a shortage of ASD-specific
training for school staff. The study’s findings highlight a lack of initial and ongoing
teacher training on the topic of ASD and, more specifically, ASD and girls. Critchley
(2019) identified the “unrealistic” expectations of teachers to support girls with ASD,
given the lack of access to appropriate training. There is a clear need for the develop­
ment of ASD-specific training at both a teacher-training level and more widely through
the continuous professional development of all educational and health professionals.
This brings into consideration the role of an Educational Psychologist (EP), which,
alongside other responsibilities, encompasses working at a systemic level and upskilling
school staff. As such, local authority Educational Psychology Services could be better
utilised to increase the capacity of schools and improve the support provided to girls
with ASD.
EPs may also be well placed to bridge the gap between home and school and to
offer pre and post-diagnosis support to parents/carers. Both past and present find­
ings revealed feelings of isolation experienced by parents of girls with ASD and
difficulties in navigating the education system. Critchley (2019) discussed the impor­
tance of a holistic approach to the support of girls with ASD, arguing that partner­
ship-working between schools and families is vitally important to providing
effectively tailored support. Considering the dearth of research eliciting parental
views, future research should aim to further explore collaborative working between
parents and school staff in the support of girls with ASD. At a wider level, it is
suggested that EPs support local authorities in the development of this type of
support, using their understanding of psychological theory to underpin the genera­
tion of new systems, procedures and relationships.

Future directions
Current findings contribute towards a limited body of research that elicits parental
and school voices to better understand the identification and subsequent support
of females with ASD in educational settings. It is recommended that future research
90 L. GRAY ET AL.

focuses on how to reliably identify girls presenting with ASD, considering the male
bias that exists within current diagnostic tools and wider practice. Clinically based
research could, perhaps, gather diagnosing clinicians’ views on the female presen­
tation of autism and how sensitively commonly used diagnostic tools recognise
potential differences in such presentation. At an educational level, further studies
may include the exploration of how systems, such as early years foundation stage
(EYFS) tracking goals, could be implemented to support the early identification of
young girls with autistic traits. Additionally, future research may focus on apprais­
ing the type of intervention that works best for girls at school and at home.
Building on this, research investigating how Educational Psychology Services can
contribute towards the upskilling of school staff could provide insights into how
best to support the development of educational practitioners. Throughout all future
research, the authors consider that it is vitally important that the voices of girls
with ASD and their parents continue to be elicited; it is hoped that this may help
facilitate stronger partnership working and contribute towards the improved iden­
tification and support of females presenting with autistic traits.

Disclosure statement
No potential conflict of interest was reported by the authors.

ORCID
Laura Gray http://orcid.org/0000-0002-0228-0136

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