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Brief Report: Predicting Sex Differences and Diagnosis from Early Parent Concerns

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Title: Brief Report: Predicting Sex Differences and Diagnosis from Early Parent Concerns
Language: English
Authors: Wallisch, Anna (ORCID 0000-0003-0951-8810), Behrens, Sarah, Salley, Brenda, Jamison, Rene, Boyd, Brian
Source: Journal of Autism and Developmental Disorders. Nov 2021 51(11):4160-4165.
Availability: Springer. Available from: Springer Nature. One New York Plaza, Suite 4600, New York, NY 10004. Tel: 800-777-4643; Tel: 212-460-1500; Fax: 212-460-1700; e-mail: customerservice@springernature.com; Web site: https://link.springer.com/
Peer Reviewed: Y
Page Count: 6
Publication Date: 2021
Document Type: Journal Articles
Reports - Research
Descriptors: Autism, Pervasive Developmental Disorders, Gender Differences, Disability Identification, Clinical Diagnosis, Symptoms (Individual Disorders), Behavior Problems, Language Impairments, Problem Solving, Interpersonal Communication, Parent Attitudes
DOI: 10.1007/s10803-020-04866-w
ISSN: 0162-3257
Abstract: Autism spectrum disorder (ASD) research is largely based on males, and females with ASD are at risk for under-identification. Research recommends listening to parent concerns since these are often predictive of a child's eventual diagnosis. This study examined how patterns of parent concerns predicted sex differences and eventual child diagnosis (ASD or developmental delay [DD]). We performed a secondary analysis with n = 273 children ages 36-72 months. Results suggested males with ASD had a higher likelihood of repetitive behavior and speech and language concerns compared to females with ASD. Females with DD were significantly more likely to have problem-solving concerns; whereas, males with DD were significantly less likely to have social communication concerns compared to females with ASD.
Abstractor: As Provided
Entry Date: 2021
Accession Number: EJ1312790
Database: ERIC
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  Value: <anid>AN0152974382;aut01nov.21;2021Oct14.06:59;v2.2.500</anid> <title id="AN0152974382-1">Brief Report: Predicting Sex Differences and Diagnosis from Early Parent Concerns </title> <p>Autism spectrum disorder (ASD) research is largely based on males, and females with ASD are at risk for under-identification. Research recommends listening to parent concerns since these are often predictive of a child's eventual diagnosis. This study examined how patterns of parent concerns predicted sex differences and eventual child diagnosis (ASD or developmental delay [DD]). We performed a secondary analysis with n = 273 children ages 36–72 months. Results suggested males with ASD had a higher likelihood of repetitive behavior and speech and language concerns compared to females with ASD. Females with DD were significantly more likely to have problem-solving concerns; whereas, males with DD were significantly less likely to have social communication concerns compared to females with ASD.</p> <p>Keywords: Autism spectrum disorder; Developmental delays; Parent concerns; Females</p> <hd id="AN0152974382-2">Introduction</hd> <p>Females with autism spectrum disorder (ASD) often exhibit less salient symptoms and characteristics resulting in misdiagnoses, under-identification, and late identification (Begeer et al. [<reflink idref="bib3" id="ref1">3</reflink>]; Lai and Szatmari [<reflink idref="bib13" id="ref2">13</reflink>]). With ASD diagnosed more frequently in males than females, data related to males are largely driving our existing research on early identification methods, autism assessments, and interventions (Lai et al. [<reflink idref="bib14" id="ref3">14</reflink>]; Rynkiewicz et al. [<reflink idref="bib20" id="ref4">20</reflink>]). This results in a male bias in the diagnostic process and ASD profile; it also creates a critical barrier for the early identification of females with ASD (Dean et al. [<reflink idref="bib5" id="ref5">5</reflink>]). Thus, gaps remain in understanding how the early presentation of symptoms may differ in females.</p> <p>Emerging research is examining differences across core ASD diagnostic symptoms between males and females; however, findings vary. For example, some studies suggest preschool females were more likely to show lower autism symptom severity, better cognitive abilities, advanced imitation, better linguistic abilities, fewer restricted interests and repetitive behaviors, and increased anxiety compared to males (e.g., Hiller et al. [<reflink idref="bib9" id="ref6">9</reflink>]; Szatmari et al. [<reflink idref="bib21" id="ref7">21</reflink>]; Hartley and Sikora [<reflink idref="bib8" id="ref8">8</reflink>]). Whereas, other studies indicate few differences among the developmental profiles of preschool females and males with ASD (e.g., Postorino et al. [<reflink idref="bib18" id="ref9">18</reflink>]; Andersson et al. [<reflink idref="bib1" id="ref10">1</reflink>]). Further, the developmental trajectories of females appear nonlinear with lower autism severity during preschool and school-age, and a subsequent increase in social challenges in adolescence compared to males (Szatmari et al. [<reflink idref="bib21" id="ref11">21</reflink>]; Mahendiran et al. [<reflink idref="bib16" id="ref12">16</reflink>]). Given the mixed findings, as well as the possibility our typical assessments may not capture the symptoms of females at an early age, more research is warranted to better understand the early profiles of females with ASD to reduce disparities associated with later identification.</p> <p>The American Academy of Pediatrics guidelines indicate the importance of listening to parent concerns as an effective strategy to identify children with ASD earlier because parent concerns are often considered predictive of a child's eventual ASD diagnosis (Hyman et al. [<reflink idref="bib11" id="ref13">11</reflink>]). Research indicates parents' first concerns often go unnoticed longer for females, compared to males (Horovitz et al. [<reflink idref="bib10" id="ref14">10</reflink>]) and parent concerns differ between females and males. Specifically, Little et al. ([<reflink idref="bib15" id="ref15">15</reflink>]) suggested males with ASD had a significantly higher likelihood of social interaction concerns (via coded open-ended parent concern statements) when compared to females with ASD, as well as males and females with developmental delays. To date, research has primarily reported on open-ended parent concern statements (e.g., Little et al. [<reflink idref="bib15" id="ref16">15</reflink>]), or parent recall (e.g., Guinchat et al. [<reflink idref="bib7" id="ref17">7</reflink>]) which may result in a bias in the types of concerns parents report. Few studies have examined the broad range of parent concerns when they first seek out a diagnostic evaluation for their child, as well as examined parent concerns prior to both an ASD and developmental delay (DD) diagnosis. We need to better understand parent concerns that precede assessment and diagnosis for girls with ASD and note additional or different "red flags" to inform early identification. Therefore, the objective of this study was to examine how patterns of multiple parent concerns preceding a diagnosis predict sex differences and eventual child diagnosis (ASD or DD). We answered the following research questions:</p> <p></p> <ulist> <item> To what extent do females with ASD differ from males with ASD on parent concerns prior to a diagnostic evaluation?</item> <p></p> <item> To what extent do parent concerns for females with ASD differ from males and females with DD?</item> </ulist> <p>We hypothesized that females with ASD would be significantly differentiated from all other groups by parent concerns.</p> <hd id="AN0152974382-3">Methods</hd> <p></p> <hd id="AN0152974382-4">Participants</hd> <p>We included 273 children ages 36 months to 72 months (<emph>M</emph> = 50.69 months; <emph>SD</emph> 10.02), who were seeking a diagnostic evaluation at a university-based medical center, and eventually received either a diagnosis of ASD (<emph>n</emph> = 168) or DD (<emph>n</emph> = 105). We included this age range because children with ASD are often diagnosed between 36 to 72 months of age (Baio et al. [<reflink idref="bib2" id="ref18">2</reflink>]). The sample included both males (<emph>n</emph> = 203 total; <emph>n</emph> = 123 ASD; <emph>n</emph> = 80 DD) and females (<emph>n</emph> = 70 total; <emph>n</emph> = 45 ASD; <emph>n</emph> = 25 DD), and mean ages were similar across groups (ASD males <emph>M</emph> = 51.17 months, <emph>SD</emph> 10.25; ASD females <emph>M</emph> = 49.98 months <emph>SD</emph> 10.95; DD males <emph>M</emph> = 50.61 months, <emph>SD</emph> 9.45; DD females <emph>M</emph> = 49.80 months, <emph>SD</emph> 9.36). While only a subset of our data (n = 81) included cognitive assessment scores [i.e., Bayley Scales of Infant and Toddler Development III (BSID-III) cognitive composite score or the Kauffman Brief Intelligence Test- 2 (KBIT-2) IQ composite standard score], the IQ scores across groups were similar (ASD male <emph>M</emph> = 84.62, <emph>SD</emph> 15.97; ASD female <emph>M</emph> = 89.58, <emph>SD</emph> 14.09; DD male <emph>M</emph> = 86.92, <emph>SD</emph> 10.42; DD female <emph>M</emph> = 73.33, <emph>SD</emph> 12.91). In our sample, 21.6% (<emph>n</emph> = 59) were Caucasian, 4.4% (<emph>n</emph> = 12) selected two or more races, 3.7% <emph>(n</emph> = 10) were Black or African American, 0.7% (<emph>n</emph> = 2) were American Indian or Alaskan Native, 0.4% (n = 1) were Asian. Further, 6.2% (<emph>n</emph> = 17) reported Hispanic or Latino as their ethnicity (10 individuals reported on both race and ethnicity and 7 individuals only reported ethnicity); however, 66.7% (<emph>n</emph> = 182) of race and ethnicity data were not reported by parents. Overall, participants were included in our analyses if they had no missing data on our Parent Concern Domain measure described below. This study was approved by the University of Kansas Medical Center Institutional Review Board. Some participants were prospectively consented for their deidentified data to be used. Other families who were evaluated in the clinic before the prospective consent process was initiated were included retrospectively through an IRB approved HIPAA waiver to retrieve deidentified retrospective data. The process varied based on the timing of consent; however, the same information was obtained from all families for both the prospective and retrospective consent process. For the purposes of this paper, we refer to parents as any primary caregiver(s) of the child, who may or may not be biologically related to the child.</p> <hd id="AN0152974382-5">Measures</hd> <p></p> <hd id="AN0152974382-6">Parent Concern Domain</hd> <p>Data was drawn from an intake questionnaire completed by parents preceding the child's diagnostic evaluation. Parents responded to a list of potential concerns related to child development, behaviors, and skills (for specific wording of the concerns see Table 1). Two types of intake questions were included, which asked parents to either, (<reflink idref="bib1" id="ref19">1</reflink>) 'check all that apply' from a list of behavior or development concerns, or (<reflink idref="bib2" id="ref20">2</reflink>) select if a specific concern occurred in the past, present, or was not a concern. Our team reviewed each question and 'check all that apply' options, and categorized each option into developmental domains until team members came to agreement. The concerns were categorized into the following eight concern domains: (<reflink idref="bib1" id="ref21">1</reflink>) externalizing behavior, (<reflink idref="bib2" id="ref22">2</reflink>) internalizing behavior, (<reflink idref="bib3" id="ref23">3</reflink>) repetitive behaviors, (<reflink idref="bib4" id="ref24">4</reflink>) social communication, (<reflink idref="bib5" id="ref25">5</reflink>) problem solving, (<reflink idref="bib6" id="ref26">6</reflink>) speech and language, (<reflink idref="bib7" id="ref27">7</reflink>) sensory, and (<reflink idref="bib8" id="ref28">8</reflink>) play.</p> <p>Table 1 Parent concern categories and intake questions</p> <p> <ephtml> <table frame="hsides" rules="groups"><thead><tr><th align="left"><p>Category</p></th><th align="left"><p>Concern intake questions</p></th><th align="left"><p>ASD F</p></th><th align="left"><p>ASD M</p></th><th align="left"><p>DD F</p></th><th align="left"><p>DD M</p></th><th align="left"><p>Overall</p></th></tr></thead><tbody><tr><td align="left"><p>Externalizing Behaviors <italic>M</italic> (<italic>SD</italic>)<sup>a</sup></p></td><td align="left"><p>Short attention span</p><p>Hyperactivity</p><p>Impulsive</p><p>Non-compliant</p><p>Aggressive</p></td><td char="(" align="char"><p>0.37 (0.32)</p></td><td char="(" align="char"><p>0.34 (0.32)</p></td><td char="(" align="char"><p>0.30 (0.33)</p></td><td char="(" align="char"><p>0.51 (0.39)</p></td><td char="(" align="char"><p>0.39 (0.35)</p></td></tr><tr><td align="left"><p>Internalizing Behaviors <italic>M</italic> (<italic>SD</italic>)<sup>a</sup></p></td><td align="left"><p>Anxious or worries</p><p>Unusual or excessive fears</p><p>Depression</p></td><td char="(" align="char"><p>0.21 (0.30)</p></td><td char="(" align="char"><p>0.21 (0.27)</p></td><td char="(" align="char"><p>0.21 (0.27)</p></td><td char="(" align="char"><p>0.21 (0.28)</p></td><td char="(" align="char"><p>0.21 (0.28)</p></td></tr><tr><td align="left"><p>Repetitive Behaviors <italic>M</italic> (<italic>SD</italic>)<sup>a</sup></p></td><td align="left"><p>Obsessive behaviors</p><p>Moves body/hands in the same way repeatedly</p><p>Self-injury</p></td><td char="(" align="char"><p>0.30 (0.29)</p></td><td char="(" align="char"><p>0.39 (0.32)</p></td><td char="(" align="char"><p>0.25 (0.31)</p></td><td char="(" align="char"><p>0.35 (0.35)</p></td><td char="(" align="char"><p>0.35 (0.32)</p></td></tr><tr><td align="left"><p>Social Communication <italic>M</italic> (<italic>SD</italic>)<sup>a</sup></p></td><td align="left"><p>Social development (play skills, interest in other children)—checked current or past concern</p><p>Little or no eye contact</p><p>Little or no gestures</p><p>Difficulty understanding emotions and feelings of others</p><p>Repeats words or phrases</p><p>Difficulty making conversation</p><p>Often talks about the same topics</p></td><td char="(" align="char"><p>0.53 (0.27)</p></td><td char="(" align="char"><p>0.50 (0.27)</p></td><td char="(" align="char"><p>0.46 (0.28)</p></td><td char="(" align="char"><p>0.48 (0.26)</p></td><td char="(" align="char"><p>0.49 (0.27)</p></td></tr><tr><td align="left"><p>Problem solving % (n)<sup>b</sup></p></td><td align="left"><p>Problem solving (learning)—checked current or past concern</p></td><td char="(" align="char"><p>35.56 (16)</p></td><td char="(" align="char"><p>40.65 (50)</p></td><td char="(" align="char"><p>64 (16)</p></td><td char="(" align="char"><p>51.25 (41)</p></td><td char="(" align="char"><p>45.05 (123)</p></td></tr><tr><td align="left"><p>Speech and Language % (n)<sup>b</sup></p></td><td align="left"><p>Speech and language (using words and understanding words)—checked current or past concern</p></td><td char="(" align="char"><p>55.56 (25)</p></td><td char="(" align="char"><p>72.36 (89)</p></td><td char="(" align="char"><p>76 (19)</p></td><td char="(" align="char"><p>75 (60)</p></td><td char="(" align="char"><p>70.7 (193)</p></td></tr><tr><td align="left"><p>Sensory % (n)<sup>b</sup></p></td><td align="left"><p>Sensory differences</p></td><td char="(" align="char"><p>37.78 (17)</p></td><td char="(" align="char"><p>49.59 (61)</p></td><td char="(" align="char"><p>36 (9)</p></td><td char="(" align="char"><p>46.25 (37)</p></td><td char="(" align="char"><p>45.42 (124)</p></td></tr><tr><td align="left"><p>Play <italic>M</italic> (<italic>SD</italic>)<sup>a</sup></p></td><td align="left"><p>Difficulty playing with same age children</p><p>Doesn't imitate or has little or no pretend play</p><p>Plays in unusual ways with toys</p></td><td char="(" align="char"><p>0.44 (0.33)</p></td><td char="(" align="char"><p>0.40 (0.34)</p></td><td char="(" align="char"><p>0.32 (0.38)</p></td><td char="(" align="char"><p>0.39 (0.31)</p></td><td char="(" align="char"><p>0.40 (0.33)</p></td></tr></tbody></table> </ephtml> </p> <p> <emph>ASD F</emph> females with autism spectrum disorder, <emph>ASD M</emph> males with autism spectrum disorder, <emph>DD F</emph> females with developmental delay, <emph>DD M</emph> males with developmental delay <sups>a</sups>Check all that apply questions and numbers based on parent concern domain score <sups>b</sups>Numbers based on binary 'concern in the past or present'/'not a concern' responses</p> <hd id="AN0152974382-7">Diagnostic Category</hd> <p>Our sample includes children with a diagnosis of ASD or Developmental Delay (DD) without ASD. We obtained data for diagnosis from medical records following an interdisciplinary (e.g., developmental medicine, psychology, speech and language) evaluation at a university based clinic. Assessments included medical/family history, developmental or cognitive assessments, review of developmental and/or school records, and autism specific measures (e.g., Autism Diagnostic Observation Schedule, Second Edition). Clinicians utilized information from parent interview, review of records, child assessments, and observation to inform determination of autism based on the Diagnostic and Statistical Manual of Mental Disorders, 5th Edition (DSM-5). Individuals that did not meet criteria for ASD but that had a diagnosis of a developmental or speech delay (i.e., Global Developmental Delay, Expressive Language Disorder, Intellectual Disability, Mixed Receptive Expressive Language Disorder, Social Pragmatic Communication Disorder, Unspecified Communication Disorder) were categorized as DD. Approximately 6 children in our sample had a co-occurring genetic disorder (2 in ASD males group; 1 in ASD females group; 3 in DD males group).</p> <hd id="AN0152974382-8">Data Analysis</hd> <p>We performed a secondary analysis and first used ANOVAs to examine group differences on age and IQ. Next, we performed a multinomial regression to examine how parent concerns prior to evaluation predicted sex differences and diagnosis categories. The analysis included four diagnostic/sex categories (i.e., ASD females, ASD males, DD females, and DD males) as the dependent variables and parent concern domains as the independent variables (i.e., externalizing behavior, internalizing behavior, repetitive behaviors, social communication, problem solving, speech and language, sensory, and play). Since the total number of items within concern domains varied among 'check all that apply' options, we computed a Domain Score for these questions. To compute the Domain Score, we first converted all 'check that apply' options to binary variables as 'checked/not checked.' Next, we used our Domain Score formula (number of checked concerns within a domain/total possible 'check all that apply' options within domain) to represent level of concern within each domain for each child. For concern questions that asked if the concern was a past or current concern, we left these variables as binary 'concern in the past or present'/'not a concern' responses (see Table 1). All analyses were performed in SPSS 25 (IBM, [<reflink idref="bib12" id="ref29">12</reflink>]).</p> <hd id="AN0152974382-9">Results</hd> <p>Overall, ANOVA results suggested no significant groups differences on age (<emph>F</emph>(<reflink idref="bib3" id="ref30">3</reflink>, 269) = 0.24, <emph>p</emph> = 0.87) or IQ (<emph>F</emph>(<reflink idref="bib3" id="ref31">3</reflink>, 77) = 2.01, <emph>p</emph> = 0.12). Further, results of the multinomial logistic regression suggested a significant model (<emph>x</emph><sups>2</sups> = 51.55, <emph>df</emph> = 24, <emph>p</emph> < 0.01); however, play, sensory, and internalizing behavior concern domains were not significant in the overall model fit and did not significantly differentiate diagnostic/sex groups (see Table 2). Therefore, we eliminated these three concern domains from the multinomial logistic regression to produce a more parsimonious model; results, again, demonstrated a significant model fit (<emph>x</emph><sups>2</sups> = 44.14, <emph>df</emph> = 15, <emph>p</emph> < 0.01).</p> <p>Table 2 Parent concerns predicting groups</p> <p> <ephtml> <table frame="hsides" rules="groups"><thead><tr><th align="left" rowspan="2" /><th align="left" colspan="3"><p>Externalizing behaviors</p></th><th align="left" colspan="3"><p>Repetitive behaviors</p></th><th align="left" colspan="3"><p>Social communication</p></th><th align="left" colspan="3"><p>Problem solving</p></th><th align="left" colspan="3"><p>Speech & language</p></th></tr><tr><th align="left"><p>χ<sup>2</sup></p></th><th align="left"><p>β</p></th><th align="left"><p>SE</p></th><th align="left"><p>χ<sup>2</sup></p></th><th align="left"><p>β</p></th><th align="left"><p>SE</p></th><th align="left"><p>χ<sup>2</sup></p></th><th align="left"><p>β</p></th><th align="left"><p>SE</p></th><th align="left"><p>χ<sup>2</sup></p></th><th align="left"><p>β</p></th><th align="left"><p>SE</p></th><th align="left"><p>χ<sup>2</sup></p></th><th align="left"><p>β</p></th><th align="left"><p>SE</p></th></tr></thead><tbody><tr><td align="left"><p>ASD M<sup>a</sup></p></td><td char="." align="char"><p>2.25</p></td><td char="." align="char"><p>− 1.00</p></td><td char="." align="char"><p>.66</p></td><td char="." align="char"><p>4.72</p></td><td char="." align="char"><p>1.47</p></td><td char="." align="char"><p>.68*</p></td><td char="." align="char"><p>2.91</p></td><td char="." align="char"><p>− 1.38</p></td><td char="." align="char"><p>.81</p></td><td char="." align="char"><p>.04</p></td><td char="." align="char"><p>−.09</p></td><td char="." align="char"><p>.47</p></td><td char="." align="char"><p>5.95</p></td><td char="." align="char"><p>1.14</p></td><td char="." align="char"><p>.47*</p></td></tr><tr><td align="left"><p>DD F<sup>a</sup></p></td><td char="." align="char"><p>2.50</p></td><td char="." align="char"><p>− 1.53</p></td><td char="." align="char"><p>.97</p></td><td char="." align="char"><p>.12</p></td><td char="." align="char"><p>−.35</p></td><td char="." align="char"><p>1.03</p></td><td char="." align="char"><p>1.49</p></td><td char="." align="char"><p>− 1.45</p></td><td char="." align="char"><p>1.19</p></td><td char="." align="char"><p>4.79</p></td><td char="." align="char"><p>1.56</p></td><td char="." align="char"><p>.71*</p></td><td char="." align="char"><p>1.11</p></td><td char="." align="char"><p>.80</p></td><td char="." align="char"><p>.76</p></td></tr><tr><td align="left"><p>DD M<sup>a</sup></p></td><td char="." align="char"><p>2.24</p></td><td char="." align="char"><p>1.06</p></td><td char="." align="char"><p>.71</p></td><td char="." align="char"><p>.53</p></td><td char="." align="char"><p>.53</p></td><td char="." align="char"><p>.72</p></td><td char="." align="char"><p>6.66</p></td><td char="." align="char"><p>− 2.29</p></td><td char="." align="char"><p>.89**</p></td><td char="." align="char"><p>.20</p></td><td char="." align="char"><p>.23</p></td><td char="." align="char"><p>.50</p></td><td char="." align="char"><p>2.42</p></td><td char="." align="char"><p>.81</p></td><td char="." align="char"><p>.52</p></td></tr><tr><td align="left"><p>DD F<sup>b</sup></p></td><td char="." align="char"><p>.40</p></td><td char="." align="char"><p>−.54</p></td><td char="." align="char"><p>.85</p></td><td char="." align="char"><p>4.05</p></td><td char="." align="char"><p>− 1.83</p></td><td char="." align="char"><p>.91*</p></td><td char="." align="char"><p> <.01</p></td><td char="." align="char"><p>−.07</p></td><td char="." align="char"><p>1.05</p></td><td char="." align="char"><p>7.02</p></td><td char="." align="char"><p>1.66</p></td><td char="." align="char"><p>.63**</p></td><td char="." align="char"><p>.25</p></td><td char="." align="char"><p>−.34</p></td><td char="." align="char"><p>.69</p></td></tr><tr><td align="left"><p>DD M<sup>b</sup></p></td><td char="." align="char"><p>14.09</p></td><td char="." align="char"><p>2.06</p></td><td char="." align="char"><p>.55**</p></td><td char="." align="char"><p>3.06</p></td><td char="." align="char"><p>− 0.95</p></td><td char="." align="char"><p>0.54</p></td><td char="." align="char"><p>1.70</p></td><td char="." align="char"><p>−.90</p></td><td char="." align="char"><p>.69</p></td><td char="." align="char"><p>.76</p></td><td char="." align="char"><p>.32</p></td><td char="." align="char"><p>.37</p></td><td char="." align="char"><p>.67</p></td><td char="." align="char"><p>−.34</p></td><td char="." align="char"><p>.41</p></td></tr><tr><td align="left"><p>DD M<sup>c</sup></p></td><td char="." align="char"><p>8.50</p></td><td char="." align="char"><p>2.59</p></td><td char="." align="char"><p>.89**</p></td><td char="." align="char"><p>.87</p></td><td char="." align="char"><p>.88</p></td><td char="." align="char"><p>.94</p></td><td char="." align="char"><p>.57</p></td><td char="." align="char"><p>−.84</p></td><td char="." align="char"><p>1.11</p></td><td char="." align="char"><p>4.19</p></td><td char="." align="char"><p>− 1.34</p></td><td char="." align="char"><p>.65*</p></td><td char="." align="char"><p> <.01</p></td><td char="." align="char"><p>.01</p></td><td char="." align="char"><p>.73</p></td></tr></tbody></table> </ephtml> </p> <p>χ2 Wald χ<sups>2</sups> statistic, <emph>ASD</emph> autism spectrum disorder, <emph>DD</emph> developmental delay, <emph>F</emph> female, <emph>M</emph> male <sups>a</sups>Reference group is female children with ASD <sups>b</sups>Reference group is male children with ASD <sups>c</sups>Reference group is female children with DD *<emph>p</emph> ≤.05; **<emph>p</emph> ≤.01</p> <p>Results from the multinomial logistic regression are presented in Table 2 and will be described as the likelihood of concerns differentiating two groups. Specifically, ASD males were significantly differentiated from ASD females by a higher likelihood of repetitive behavior (OR = 4.37 (<reflink idref="bib1" id="ref32">1</reflink>), <emph>p</emph> = 0.03) and a higher likelihood of speech and language concerns (OR 3.14 (<reflink idref="bib1" id="ref33">1</reflink>), <emph>p</emph> = 0.02). ASD males were also significantly differentiated from DD females by a higher likelihood of repetitive behavior concerns (OR 6.21 (<reflink idref="bib1" id="ref34">1</reflink>), <emph>p</emph> = 0.04). Both ASD males (OR 0.19, <emph>p</emph> = 0.01) and ASD females (OR 0.21 (<reflink idref="bib1" id="ref35">1</reflink>), <emph>p</emph> = 0.03) were significantly differentiated from DD females by a lower likelihood of problem solving concerns. Females with ASD were significantly more likely to have social communication concerns (OR 9.83 (<reflink idref="bib1" id="ref36">1</reflink>), <emph>p</emph> = 0.01) when compared to DD males. Whereas, males with ASD were significantly differentiated by males with DD by having a lower likelihood of externalizing concerns (OR 0.13, <emph>p</emph> < 0.001). Males with DD were significantly differentiated from DD females by a higher likelihood of externalizing concerns (OR 13.36 (<reflink idref="bib1" id="ref37">1</reflink>), <emph>p</emph> = 0.004) and a lower likelihood of problem solving concerns (OR.26, <emph>p</emph> = 0.04).</p> <hd id="AN0152974382-10">Discussion</hd> <p>Our results suggest that parent concerns preceding an evaluation for ASD significantly differentiated females with ASD from males with ASD, as well as from children with DD. This aligns with previous research suggesting females with ASD demonstrate a different behavioral profile when compared to males (Dean et al. [<reflink idref="bib5" id="ref38">5</reflink>]). Similar to other studies, females with ASD had fewer repetitive behavior concerns—a core symptom associated with an autism diagnosis – when compared to males with ASD. Previous research suggests that females with ASD demonstrate fewer repetitive behaviors (Frazier et al. [<reflink idref="bib6" id="ref39">6</reflink>]), and these repetitive behaviors may be less salient and go unnoticed in females. That is, the restricted interests of females have been found to be more socially acceptable (e.g., movie stars, animals) than some of the more idiosyncratic restricted interests reported for males with ASD (Lai and Szatmari [<reflink idref="bib13" id="ref40">13</reflink>]).</p> <p>Our results also indicated that parents reported fewer speech and language concerns for females with ASD when compared to males with ASD. Previous research suggests that females often present with better linguistic abilities (e.g., Conlon et al. [<reflink idref="bib4" id="ref41">4</reflink>]; Parish-Morris et al. [<reflink idref="bib17" id="ref42">17</reflink>]); yet this may place females at a disadvantage for early diagnosis, since parent concerns about speech and language concerns tends to result in earlier diagnoses (Zablotsky et al. [<reflink idref="bib22" id="ref43">22</reflink>]; Lai and Szatmari [<reflink idref="bib13" id="ref44">13</reflink>]). Given that females with ASD are often identified later when compared to boys, this may be due to a lack of initial speech and language concerns. While other theories suggest camouflaging, or masking social challenges, may be common in females and a potential reason for the under-identification of females (Lai and Szatmari [<reflink idref="bib13" id="ref45">13</reflink>]), our study suggests females and males with ASD were not significantly different on social communication parent concerns. However, with fewer repetitive behavior and speech and language concerns females may show a different symptom profile early in development that is less noticeable when compared to males with ASD.</p> <p>We cross-examined the ASD and DD groups specifically highlighting the similarities and differences in females compared to males. Females with ASD significantly differed from both females and males with DD. Females with DD presented with increased problem-solving parent concerns compared to females and males with ASD, which makes sense given that developmental disabilities are often diagnosed due to differences in cognitive development and challenges in learning. Lastly, females with ASD had increased social communication concerns when compared to boys with DD. This is expected as social communication challenges are a core diagnostic criterion of ASD. Taken together, these results suggest that females with ASD demonstrate social communication concerns in a similar manner to boys with ASD, and are distinguished from children with DD based on social communication and problem-solving concerns.</p> <p>While all groups were differentiated by at least one parent concern domain, there were some overlapping patterns across groups. For example, both females with ASD and DD were differentiated from males with ASD by fewer repetitive behavior concerns. Since males with DD were not differentiated by repetitive behaviors, this may reflect a potential sex difference with repetitive behaviors more commonly occurring in males. Further, both males with ASD and females with DD were differentiated from males with DD by fewer externalizing behavior concerns; however, females with ASD were not differentiated from males with DD by externalizing concerns. Interestingly, this finding is contrary to some literature that suggests males have increased externalizing behaviors (Lai and Szatmari [<reflink idref="bib13" id="ref46">13</reflink>]); however, much of this literature is mixed. Last, females with DD were the only group differentiated from all three groups by a higher likelihood of problem solving concerns. This means that females with DD presented with a more consistent parent concern pattern across three groups. Clearly, the patterns of parent concerns are highly complex and more research is needed to understand the early parent concerns of females with ASD.</p> <p>Overall, our results align with previous studies and support the importance of early parent concerns as a critical tool in the screening and diagnostic process (Richards et al. [<reflink idref="bib19" id="ref47">19</reflink>]) and add to the literature on parent concerns for females with ASD. Further, practitioners may need to listen closely to parent concerns and recognize there may be differences in the types and ways that parents of females with ASD report their concerns. Specifically, our study suggests that parents of females with ASD may report fewer concerns related to repetitive behaviors, speech and language, and problem solving concerns. This also means the concern domains in our study still may not capture the concerns that are highly prevalent among females with ASD. Taken together, this means we need to be vigilant listeners when discussing parent concerns and recognize these may appear less salient for females with ASD.</p> <hd id="AN0152974382-11">Study Limitations and Future Directions</hd> <p>While a strength of this study is the large sample size there remain limitations. Specifically, even though our sample distribution across males and females matches that of diagnostic rates across sex, we still had fewer females with ASD. Further, the generalizability of our data is somewhat limited due to the lack of diversity among parents; however, the race and ethnicity of parents was reported by only 33.33% of respondents. Last, the DD group in our sample was heterogenous and included multiple diagnoses which may also reduce the generalizability of our results. Examining datasets with less heterogeneity in the DD group, as well as a larger representation of females, and racially and ethnically diverse children is critical to future studies. An additional strength of this paper is capturing parent concerns preceding a diagnostic evaluation and using multiple intake questions to examine specific concerns related to diagnoses. However, while the intake questions provided a range of concern types, we still may have missed certain parent concerns. Future research needs to examine additional concern categories, or examine interactions among concern categories, that may be more representative of females with ASD.</p> <hd id="AN0152974382-12">Acknowledgments</hd> <p>There is no funding or financial support affiliated with this study.</p> <hd id="AN0152974382-13">Author Contributions</hd> <p>All authors contributed to the study conceptualization and methodology. Data analysis was performed by Anna Wallisch and Sarah Behrens and reviewed and discussed with Brenda Salley, Rene Jamison, and Brian Boyd for further interpretation. The first draft of the manuscript was written by Anna Wallisch and all authors reviewed and edited the manuscript. All authors read and approved the final manuscript.</p> <hd id="AN0152974382-14">Publisher's Note</hd> <p>Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.</p> <ref id="AN0152974382-15"> <title> References </title> <blist> <bibl id="bib1" idref="ref10" type="bt">1</bibl> <bibtext> Andersson GW, Gillberg C, Miniscalco C. Pre-school children with suspected autism spectrum disorders: Do girls and boys have the same profiles?. Research in Developmental Disabilities. 2013; 34; 1: 413-422. 10.1016/j.ridd.2012.08.025</bibtext> </blist> <blist> <bibl id="bib2" idref="ref18" type="bt">2</bibl> <bibtext> Baio, J, Wiggins, L, Christensen, D. L, Maenner, M. J, Daniels, J, Warren, Z,. & Dowling, N. F. (2018). Prevalence of autism spectrum disorder among children aged 8 years—autism and developmental disabilities monitoring network, 11 sites, United States, 2014. 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American Journal of Intellectual and Developmental Disabilities. 2017; 122; 1: 49-61. 10.1352/1944-7558-122.1.49</bibtext> </blist> </ref> <aug> <p>By Anna Wallisch; Sarah Behrens; Brenda Salley; Rene Jamison and Brian Boyd</p> <p>Reported by Author; Author; Author; Author; Author</p> </aug> <nolink nlid="nl1" bibid="bib13" firstref="ref2"></nolink> <nolink nlid="nl2" bibid="bib14" firstref="ref3"></nolink> <nolink nlid="nl3" bibid="bib20" firstref="ref4"></nolink> <nolink nlid="nl4" bibid="bib21" firstref="ref7"></nolink> <nolink nlid="nl5" bibid="bib18" firstref="ref9"></nolink> <nolink nlid="nl6" bibid="bib16" firstref="ref12"></nolink> <nolink nlid="nl7" bibid="bib11" firstref="ref13"></nolink> <nolink nlid="nl8" bibid="bib10" firstref="ref14"></nolink> <nolink nlid="nl9" bibid="bib15" firstref="ref15"></nolink> <nolink nlid="nl10" bibid="bib12" firstref="ref29"></nolink> <nolink nlid="nl11" bibid="bib17" firstref="ref42"></nolink> <nolink nlid="nl12" bibid="bib22" firstref="ref43"></nolink> <nolink nlid="nl13" bibid="bib19" firstref="ref47"></nolink>
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  Data: Brief Report: Predicting Sex Differences and Diagnosis from Early Parent Concerns
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  Data: <searchLink fieldCode="AR" term="%22Wallisch%2C+Anna%22">Wallisch, Anna</searchLink> (ORCID <externalLink term="http://orcid.org/0000-0003-0951-8810">0000-0003-0951-8810</externalLink>)<br /><searchLink fieldCode="AR" term="%22Behrens%2C+Sarah%22">Behrens, Sarah</searchLink><br /><searchLink fieldCode="AR" term="%22Salley%2C+Brenda%22">Salley, Brenda</searchLink><br /><searchLink fieldCode="AR" term="%22Jamison%2C+Rene%22">Jamison, Rene</searchLink><br /><searchLink fieldCode="AR" term="%22Boyd%2C+Brian%22">Boyd, Brian</searchLink>
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  Data: <searchLink fieldCode="SO" term="%22Journal+of+Autism+and+Developmental+Disorders%22"><i>Journal of Autism and Developmental Disorders</i></searchLink>. Nov 2021 51(11):4160-4165.
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  Data: <searchLink fieldCode="DE" term="%22Autism%22">Autism</searchLink><br /><searchLink fieldCode="DE" term="%22Pervasive+Developmental+Disorders%22">Pervasive Developmental Disorders</searchLink><br /><searchLink fieldCode="DE" term="%22Gender+Differences%22">Gender Differences</searchLink><br /><searchLink fieldCode="DE" term="%22Disability+Identification%22">Disability Identification</searchLink><br /><searchLink fieldCode="DE" term="%22Clinical+Diagnosis%22">Clinical Diagnosis</searchLink><br /><searchLink fieldCode="DE" term="%22Symptoms+%28Individual+Disorders%29%22">Symptoms (Individual Disorders)</searchLink><br /><searchLink fieldCode="DE" term="%22Behavior+Problems%22">Behavior Problems</searchLink><br /><searchLink fieldCode="DE" term="%22Language+Impairments%22">Language Impairments</searchLink><br /><searchLink fieldCode="DE" term="%22Problem+Solving%22">Problem Solving</searchLink><br /><searchLink fieldCode="DE" term="%22Interpersonal+Communication%22">Interpersonal Communication</searchLink><br /><searchLink fieldCode="DE" term="%22Parent+Attitudes%22">Parent Attitudes</searchLink>
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  Data: 10.1007/s10803-020-04866-w
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  Data: Autism spectrum disorder (ASD) research is largely based on males, and females with ASD are at risk for under-identification. Research recommends listening to parent concerns since these are often predictive of a child's eventual diagnosis. This study examined how patterns of parent concerns predicted sex differences and eventual child diagnosis (ASD or developmental delay [DD]). We performed a secondary analysis with n = 273 children ages 36-72 months. Results suggested males with ASD had a higher likelihood of repetitive behavior and speech and language concerns compared to females with ASD. Females with DD were significantly more likely to have problem-solving concerns; whereas, males with DD were significantly less likely to have social communication concerns compared to females with ASD.
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            – Type: issue
              Value: 11
          Titles:
            – TitleFull: Journal of Autism and Developmental Disorders
              Type: main
ResultId 1