Autism and girls- Why the rate of diagnosis is lower than boys, and later despite early signs……

A couple of years ago, a Mum brought her five year old daughter in to see me for an Occupational Therapy assessment due to concerns regarding her ability to learn at school. Her teachers reported that she was having general difficulties “catching on” and “keeping up” and tasks such as handwriting were really difficult and stressful for her.

So they came in for an assessment. The young girl was very sweet and polite. She was well dressed and well mannered. She said hello and asked me my name. She told me her name and complimented me on my “fun” room. I began to interview Mum to get some more information. Mum agreed with the teacher’s report- her daughter was having a great deal of trouble with school work. She spoke of homework always being a struggle and ending in tears, and attempts were only made with an ongoing rewards system that was changing every day. She spoke of seeing an Occupational Therapist in the past for fine motor skills and scissor skills and how those things had improved with lots of practice, only to get to school to discover handwriting was so difficult. She spoke of her daughter’s “poor attention ” and constant need for redirecting.

I then asked about how her daughter was going at home with everyday activities such as eating, dressing, brushing her teeth and sleeping. She told me that her daughter was not motivated to participate in everyday activities required of her and that everything was a struggle, requiring constant nagging. She spoke of her daughter’s avoidance and fear of tasks that she perceived she could not do. She spoke of rigid bedtime routines consisting of lining toys up in a particular order and reading the same three books in the same order every night.

She reported that her daughter had difficulty with social skills, preferring to play on her own and in her ‘own world’ and showing general disinterest in other children. She spoke of her daughter playing the same games in the same way each time. She discussed her daughter’s difficulty initiating and maintaining social interaction. She mentioned her daughter’s “unusual obsession” with animals and said that she would sometimes pretend to be a cat or dog.

Mum spoke of fussy eating and avoidance of foods, her daughter’s aversion to the sensory feeling of grooming activities, particularly hair brushing, hair washing and hair cutting, her dislike of social touch, and her avoidance of textures such as grass, sand and dirt. She told me about her daughter’s distress in response to noisy environments, thunder, the school toilets and specific noises relating to the operations of her mother’s computer. She spoke of her daughter’s reluctance to go to new places and her daughter’s anxiety in unpredictable environments. She spoke of her daughter’s aggressive outbursts and inconsolable meltdowns.

At this point it became very clear- on the surface this was a sweet, little girl, well -mannered and polite, who had learnt the right social etiquette for the occasion. A little girl that was having “some difficulty at school”. But underneath was a girl struggling with Asperger’s syndrome (now known as High Functioning Autism). I (very warily) asked Mum if anyone had brought up the idea of Autism and she replied that she has brought it up. Many times. With many people. With her daughter’s teacher. With her daughter’s GP. With her daughter’s previous Occupational Therapist. Only to be told that her daughter was “just immature”, “was spoilt”, and “will grow out of it”. This was sad but not overly surprising given how differently this little girl presented compared with her Mum’s report. I sent her off to a Paediatrician with my report and she was diagnosed with High Functioning Autism.

I have reflected on this little girl’s story quite a lot over the last few years as it is anchored in my mind as a true example of how girls on the Autism Spectrum present differently to boys and often go undiagnosed for a long time. I don’t mean that they present differently in the core characteristics of Autism, the criteria used for diagnosis, but in terms of how they cope or adjust with being different to their peers.

Professor Tony Attwood wrote a thorough article outlining these fundamental differences, differences which may explain why diagnosis is at a lower rate in girls than in boys. Following is an outline of some of the content in the article, giving my story above some perspective.

  • Girls will typically use coping and adjustment strategies to “mask” their social difficulties.
  • Girls can often observe, learn and copy other children to determine what to do in specific social situations.
  • Alternatively, some girls escape into imagination and create an alternative world. They may prefer to play alone or spend time with pets and animals.
  • Girls with an ASD may have the same interests as other girls however may differ in the quality of their interests. For example, the may prefer to “organise toys rather than share them, and not play with toys in conventional ways.
  • Many girls have an intense interest in reading, with some being hyper-lexic, developing an amazing vocabulary and escaping into fiction, enjoying a fantasy world, creating a new persona for herself, talking to imaginary friends and writing fiction at an early age.
  • Girls with an ASD may escape to nature, preferring to play with animals.
  • Many girls with an ASD prefer to play with boys as their play is typically more “constructive and adventurous”, avoiding the emotional interactions that socialising with girls can often attract.
  • Girls with an ASD will increasingly “recognise their own social confusion and mistakes and may react by trying to stay on the periphery of social situations”.
  • Another strategy is to be extremely well behaved and compliant in class so as not to be noticed or recognised as different by the teacher. At home, the “mask” is removed and a complete opposite “character” will present, often using passive-aggressive ways of controlling her family.

To read the full article, go to:

Check out what these amazing Limpsfield Grange Girls with an ASD have to say on their youtube video……

The more we can understand about girls on the Autism Spectrum, the earlier we can diagnose and get on with supporting these kids in home, at school and in the community.

Ten ways to use kinetic sand that are fun and great for child development…..

kinetic sandPhoto from

Right before Christmas I was asking the Mums and Dads what they were getting their kids for Christmas and one of the common answers was kinetic sand. I love this stuff- for the sensory benefits, the creative benefits, the play benefits, the calming benefits and the engagement benefits (and the quiet time benefits). You can build castles and other 3D shapes just like ordinary sand (but with very little mess and you can do it indoors). You can also do heaps of other cool things that will help your child’s development. Check out the following list to keep your little one busy……

  • Make a mini treasure hunt by hiding all sorts of little objects in the sand- marbles, figurines, beads, sequins, feathers, “jewels”, plastic coins, nuts and bolts and screws, and see what they can find. If your child dislikes the feeling of the sand, encourage him to use tweezers or tongs to retrieve the items. This will allow your child to continue to explore and be exposed to the sand without having to touch it, and will continue to develop fine motor skills and pre-scissor skills.
  • Build an indoor castle- decorate it with sticks and leaves and feathers and stones from around the yard or other crafty items that your child might like. This will encourage your child to explore a variety of textures.
  • Hide little plastic letters of the alphabet in the sand. Start with the letters in your child’s name and encourage her to retrieve and arrange them. This one is great to help kids recognise their name and for individual letter recognition.
  • Try squeezing the sand for “heavy work” for kids who are either over-stimulated or children that are hard to get going. Heavy work includes activities that provides sensory input to our joints and muscles through resistance or compression. Remember heavy work brings you down when you are up and up when you are down.
  • Make mini pizzas out of the sand- “knead” and push the sand down to make a pizza base. Add the toppings (beads, match sticks, stones) and then sprinkle some cheese on top (extra sand). The kneading and pushing of the sand is a great way to get heavy work involved and the decorating is great for fine motor skills and ideation/planning.
  • Get the cookie cutters and pretend to make cookies. This is another great little fine motor game but also offers the opportunity to engage in some pretend play.
  • Make faces with different faces and emotions and discuss these with your child. This is a great one for our kids that have trouble understanding, and picking up on, different emotions, or for kids who have difficulty identifying and regulating their own emotions.
  • Use rubber stamps to stamp patterns/letters/pictures into the sand
  • Help children with letter/number formation by molding letters/numbers in the sand and then tracing over them with their fingers in the correct formation. For kids having difficulty picking up on letter formation visually, it is important to use other sensory channels such as the tactile (touch) system to help learn these skills.
  • Make a construction site with mini trucks, diggers, rollers etc.

Following is a link to a tutorial on how to make your own kinetic sand. I haven’t made and yet but I plan to in the coming weeks- let me know if you do have a go at making it and how it turns out. Have fun!



The ideas presented on this blog are for informational purposes only and do not replace medical advice or an individualised treatment plan developed between therapist, caregiver, and child. If you are concerned about the development or functional abilities of a particular child in your life, then that child’s parent should talk with his/her paediatrician or seek out the services of a developmental Paediatrician or a local Occupational Therapist. Where, activities have been suggested, I take no responsibility or liability for any injury or accident occurring as a result of participation in these activities. Children should only engage in these activities with suitable caregiver supervision and child safety should be of highest priority. It is at the caregiver’s discretion to ascertain whether an activity is suitable and appropriate for children in their care.

3 Quick ways to calm the morning (and any other time of day) crankies…….

3 quick ways

This year we made the ten hour trip to my Mother in-law’s home for Christmas. With arts and crafts and DVDs, and a few breaks along the way, we actually made it pretty well unscathed. Being in an unfamiliar house with unfamiliar people and completely out of the routine and safety of home is particularly challenging for our little guy so the next morning, Christmas Eve, I held my breath, waiting for the meltdown to come. But it didn’t. That night, we gathered at my husband’s uncle and aunt’s home to start our Christmas celebrations. It was busy and cheery, loving and festive with lots of hugs and kisses. The house smelled of a mixture of beautiful foods. The kids played loudly and cheerfully. It was everything Christmas means to me yet it was everything that our little guy struggles to cope with. I held my breath again and watched him eat his periogi (the only thing that didn’t have sauce or spice on it). Still the meltdown did not come.

The next morning, Christmas Day, the struggles of the previous two days were unleashed. Only Daddy can get my cereal. I want Mummy to get my cereal. Not that cereal, the other cereal. But I want the big bowl. I want the blue bowl. Don’t look at me. I want a cuddle. Don’t sit near me with your smoothie. Why aren’t you sitting with me? Don’t sing. Only Daddy can put my Lego together……… You get the gist and I’m sure many of you can relate. This is what I call the morning crankies, an all too common experience in our home.

Sometimes the morning crankies are a result of “just having a bad morning” or lack of sleep. But mostly, the morning crankies are a result of a child’s nervous system becoming “out of sync”. That is, the nervous system is not able to process sensory information effectively, resulting in a range of behaviours, including becoming hard to please, hostile and aggressive, and controlling, and the morning crankies have been known to go on for an hour (or more)!

Over the years, I have trialled and tested many different ways believed to help calm and “regulate” cranky kids- my own and the many that I have worked with. These are my top 3 that work almost without fail.

1. Heavy Work/Proprioception

Heavy work/proprioception is my go-to mood changer- it brings you up when you are down and down when you are up. Proprioception is our sensation of joints and muscles which gives us an understanding of where we are in space. Heavy work includes activities that provides sensory input to our joints and muscles trough resistance or compression. Proprioception typically has a calm-alerting impact on the body and can include whole body movements involving pushing, pulling, lifting, playing, and moving; oral actions such as chewing, sucking, and blowing and; use of hands for squeezing, pinching, or “fidgeting”.

There are many ways to provide proprioceptive input but following are my favourites- they are quick and easy in the mornings and require minimal equipment………

My favourite movement activities include animal walks/wheelbarrow walks, jumping and crashing into crash mats or pillows, crawling over a pillow mountain, squishy sandwiches where pillows are the bread and your child is the filling- see if they can get out of the sandwich before you take a bite (“I’m going to eat you up in10,9,8,7,……”- apply enough “squish” that they can get out within the 10 seconds but need to work a little bit), and a recent favourite is playing elastics with my older child- this is a really nice activity for starting the day with rhythm too.

Great oral-motor activities include bubble monsters (fill up a container with water and some bubble mixture and blow into the water using crazy straws or everyday straws. When the monster gets big either blow or squish it back down again), drinking yoghurt or a thick smoothie/milkshake through a thick straw like McDonalds straws, chewing gum (I use xylitol gum with my kids purely to avoid nasty artificial sweeteners), or a drink of juice with ice cubes for crunching.

My favourite way to provide proprioception through the hands is with theraputty or playdough- hide beads in it, roll it, squish it, poke it, make a spikey dinosaur by pinching it, cut it, use shapes with it. I also like spray bottles (the kids water the plants with them) and we have been using Sands Alive kinetic sand that Santa gave us so watch this space for a review on that but so far so good.

2. Respiration

Many of our children that are “out of sync” are often over-sensitive, or defensive, to everyday, non-noxious sensory input such as social touch, everyday sounds such as the vacuum and air conditioner, and movement experiences. When a child is over-sensitive or overwhelmed, they will often display rapid and/or shallow breathing. These kids need to “calm down and take some deep breaths” just as we would tell an adult friend to do if they were overwhelmed. Most of the children I have worked with find it difficult to take deep breaths on cue, particularly if they are already overwhelmed, so I encourage deep breathing in the following ways……

* Bubble Monsters (as mentioned above)

* Respiration tools/whistles- my favourites are blow pipes (pipes with a little net/basket on the end with a ball inside. When you blow the pipe, the ball floats up and you need to try and catch it in the net), balloons, lip whistles.

* Blowing bubbles through a bubble wand

* Singing songs, particularly rhythmic songs

For all of these, remember, the longer the exhale the longer the inhale, so focus on long breaths out to encourage long, deep breaths in.


3. Listening to music/sound

The auditory system has many connections to the brain and can therefore impact the nervous system and, consequently, arousal, mood, attention and many other everyday functions. Music choice will depend on you child’s level of arousal and preferences. Children that are hard to get moving in the morning may benefit from more upbeat music whereas children that are bouncing off the walls may benefit from more calming music. Top 40/chart music seems to be the music of choice in our house however I have used more mellow music in the past such as Jack Johnson and even the Rockabye Baby Lullaby Renditions (this company produces lullaby renditions of all your favourite albums from the Rolling Stones to Bon Jovi to Foo Fighters).

Each child will respond individually to the above suggestions. Sometimes I use one of these suggestions, sometimes I use all three at the same time (as pictured). It often takes trial and error to find the best fit for your child. Please listen to your child and be guided by your child’s abilities and tolerances. The key is to make sure your child is safe and feels supported- and have FUN!


The ideas presented on this blog are for informational purposes only and do not replace medical advice or an individualised treatment plan developed between therapist, caregiver, and child. If you are concerned about the development or functional abilities of a particular child in your life, then that child’s parent should talk with his/her paediatrician or seek out the services of a developmental Paediatrician or a local Occupational Therapist. Where, activities have been suggested, I take no responsibility or liability for any injury or accident occurring as a result of participation in these activities. Children should only engage in these activities with suitable caregiver supervision and child safety should be of highest priority. It is at the caregiver’s discretion to ascertain whether an activity is suitable and appropriate for children in their care.