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Focusing on Autism Symptoms Masks Sex-Specific Needs of Autistic Children: An Example from the Sydney Child Neurodevelopment Research Registry

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Title: Focusing on Autism Symptoms Masks Sex-Specific Needs of Autistic Children: An Example from the Sydney Child Neurodevelopment Research Registry
Language: English
Authors: Marie Antoinette Hodge (ORCID 0000-0003-4101-9616), Rebecca Sutherland (ORCID 0000-0002-4522-058X), Kelsie A. Boulton (ORCID 0000-0002-9408-7367), Sarah Jane Baracz, Natalie Ong (ORCID 0000-0002-0962-443X), Beverley Bennett, Adam J. Guastella (ORCID 0000-0001-8178-4625), Natalie Silove
Source: Autism: The International Journal of Research and Practice. 2025 29(5):1318-1332.
Availability: SAGE Publications. 2455 Teller Road, Thousand Oaks, CA 91320. Tel: 800-818-7243; Tel: 805-499-9774; Fax: 800-583-2665; e-mail: journals@sagepub.com; Web site: https://sagepub.com
Peer Reviewed: Y
Page Count: 15
Publication Date: 2025
Document Type: Journal Articles
Reports - Research
Descriptors: Autism Spectrum Disorders, Symptoms (Individual Disorders), Children, Gender Differences, Individual Characteristics, Severity (of Disability), Behavior Problems, Age Differences, Clinical Diagnosis, Foreign Countries, Parent Background, Educational Attainment
Geographic Terms: Australia
Assessment and Survey Identifiers: Autism Diagnostic Observation Schedule, Vineland Adaptive Behavior Scales, Stanford Binet Intelligence Scale, Wechsler Preschool and Primary Scale of Intelligence, Wechsler Intelligence Scale for Children, Mullen Scales of Early Learning, Bayley Scales of Infant and Toddler Development
DOI: 10.1177/13623613241303550
ISSN: 1362-3613
1461-7005
Abstract: Studies have shown that there are differences between the presentations of males and females diagnosed with autism. There remains a developing understanding about how the presentation of autism differs between boys (hereafter referred to as 'assigned males at birth') and girls (assigned females at birth). This study sought to investigate the presence of sex differences in autistic children. Participants (1.11-17.97 years) attended an assessment clinic and participated in measures of intelligence/development, social/communication skills and behaviour. Adaptive skills were evaluated using a range of standardised measures, and other clinical and demographic variables were collected (e.g. age, intelligence quotient, ratio of male to female). Assigned males at birth displayed more autism characteristics and greater symptom autism severity than assigned females at birth. No significant differences were found between assigned males at birth and assigned females at birth on any measure of intelligence. Children assigned males at birth received assessments 6 months earlier than children assigned females at birth on average. Externalising behaviour problems were more evident in assigned males at birth, but statistically significant differences in adaptive skills were not apparent between assigned males at birth and assigned females at birth. This study showed assigned females at birth and assigned males at birth differ in autism symptoms and severity and age at diagnosis based on a real-world sample. It highlights the importance of balancing assessments of symptoms with assessment of adaptive function.
Abstractor: As Provided
Entry Date: 2025
Accession Number: EJ1469264
Database: ERIC
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  Value: <anid>AN0184797755;f9d01may.25;2025Apr30.05:47;v2.2.500</anid> <title id="AN0184797755-1">Focusing on autism symptoms masks sex-specific needs of autistic children: An example from the Sydney Child Neurodevelopment Research Registry </title> <p>Studies have shown that there are differences between the presentations of males and females diagnosed with autism. There remains a developing understanding about how the presentation of autism differs between boys (hereafter referred to as 'assigned males at birth') and girls (assigned females at birth). This study sought to investigate the presence of sex differences in autistic children. Participants (1.11–17.97 years) attended an assessment clinic and participated in measures of intelligence/development, social/communication skills and behaviour. Adaptive skills were evaluated using a range of standardised measures, and other clinical and demographic variables were collected (e.g. age, intelligence quotient, ratio of male to female). Assigned males at birth displayed more autism characteristics and greater symptom autism severity than assigned females at birth. No significant differences were found between assigned males at birth and assigned females at birth on any measure of intelligence. Children assigned males at birth received assessments 6 months earlier than children assigned females at birth on average. Externalising behaviour problems were more evident in assigned males at birth, but statistically significant differences in adaptive skills were not apparent between assigned males at birth and assigned females at birth. This study showed assigned females at birth and assigned males at birth differ in autism symptoms and severity and age at diagnosis based on a real-world sample. It highlights the importance of balancing assessments of symptoms with assessment of adaptive function. Studies have shown that there is a difference between biological sex at birth in autism spectrum disorder. There remains a lack of understanding about how the symptoms of autism differ between assigned males at birth and assigned females at birth. We looked at the presence of sex differences in a large group of autistic toddlers, children and adolescents, who were seen in a large diagnosis and assessment clinic. They participated in measures of intelligence/development, social/communication skills and behaviour. Their adaptive skills were evaluated and other clinical and information were collected. Assigned males at birth displayed more autism characteristics and greater symptom autism severity than assigned females at birth. There were no statistically significant differences between assigned males at birth and assigned females at birth on any measure of intellectual assessment. Assigned females at birth showed better nonverbal performance than assigned males at birth on formal developmental assessments. Children assigned males at birth received assessments 6 months earlier than children assigned females at birth. Externalising behaviour problems were more evident in assigned males at birth. This study provides evidence to show that autistic children assigned females at birth and assigned males at birth differ in terms of autism symptoms and severity and age at diagnosis based on a sample recruited in a real-world clinic. It highlights the importance of the growing debate between balancing assessments of symptoms with assessment of adaptive function.</p> <p>Keywords: adaptive skills; age at diagnosis; assigned sex at birth; autism symptoms; developmental skills; intellectual ability</p> <hd id="AN0184797755-2">Background</hd> <p>Since the earliest descriptions of autism, assigned males at birth (AMAB)[<reflink idref="bib8" id="ref1">8</reflink>] have outnumbered assigned females at birth (AFAB) in terms of the prevalence of diagnosed autism cases ([<reflink idref="bib29" id="ref2">29</reflink>]; [<reflink idref="bib59" id="ref3">59</reflink>]). This difference in biological sex at birth has persisted with an estimated ratio of 4.56:1 AMAB to AFAB ([<reflink idref="bib38" id="ref4">38</reflink>]) despite changes to the diagnostic criteria. Even so, there remains a developing understanding about why this sex difference exists and how the presentation of autism differs between AMAB and AFAB. There have been a number of reasons proposed for this difference, including sex biases inherent to the diagnostic criteria of autism ([<reflink idref="bib20" id="ref5">20</reflink>]) and the way that sex roles can impact detection of autism in populations ([<reflink idref="bib18" id="ref6">18</reflink>]). Even accounting for these social factors, however, there might be other factors at play to account for these differences between sex. This article sought to describe current understandings of the differences between sexes and to present new data regarding the differences between AMAB and AFAB autistic children using both broader assessment results and item-level analysis on relevant tools.</p> <hd id="AN0184797755-3">Autism characteristics</hd> <p>Sex differences have emerged in the profile of autism characteristics, including communication, social interaction and special interests. When sex differences in social communication are observed, older AMAB typically had greater difficulty using nonverbal communication, sharing enjoyment and engaging in social imitative play as well as more often using stereotyped, repetitive or idiosyncratic speech relative to AFAB ([<reflink idref="bib11" id="ref7">11</reflink>]). In contrast, some studies have found that young AFAB have poorer language levels than AMAB ([<reflink idref="bib16" id="ref8">16</reflink>]; [<reflink idref="bib32" id="ref9">32</reflink>]), but it is important to note that the AFAB with low language levels may have been brought to the attention of diagnosticians earlier due to more obvious developmental delays and co-occurring conditions. Previous studies have also described evidence against the existence of sex differences in communication, reporting equivalent algorithm scores on diagnostic measures such as the Autism Diagnostic Interview–Revised (ADI-R; [<reflink idref="bib40" id="ref10">40</reflink>]) and Autism Diagnostic Observation Schedule–Second Edition (ADOS-2; [<reflink idref="bib31" id="ref11">31</reflink>]; [<reflink idref="bib60" id="ref12">60</reflink>]). However, item-level analysis of such measures in older children revealed that AMAB had more difficulty than do AFAB with communication elements, including reciprocal conversations, offering information and recalling events ([<reflink idref="bib56" id="ref13">56</reflink>]), although this is not a consistent finding with [<reflink idref="bib68" id="ref14">68</reflink>] finding few differences in terms of quality of social overtures, conversations and gestures between sexes.</p> <p>Differences in social interaction have been noted between autistic AMAB and AFAB in that AFAB tend to exhibit higher social motivation than AMAB ([<reflink idref="bib23" id="ref15">23</reflink>]; [<reflink idref="bib63" id="ref16">63</reflink>]). It has been suggested that AFAB are more likely to camouflage than AMAB, masking their autism characteristics and compensating for areas of weakness such as social difficulties ([<reflink idref="bib72" id="ref17">72</reflink>]) This may give the impression of superficially stronger social interaction abilities. The pattern of special interests and repetitive behaviours may also differ between sexes. For example, the types of special interests appear more aligned with sex stereotypes ([<reflink idref="bib69" id="ref18">69</reflink>]). Sensory features were less likely to be seen in AFAB in some studies ([<reflink idref="bib33" id="ref19">33</reflink>]), but no major sex differences were found in others ([<reflink idref="bib3" id="ref20">3</reflink>]; [<reflink idref="bib6" id="ref21">6</reflink>]; [<reflink idref="bib8" id="ref22">8</reflink>]). Not only were there different types but some studies have found reduced number of such restricted repetitive behaviours in AFAB relative to AMAB ([<reflink idref="bib4" id="ref23">4</reflink>]; [<reflink idref="bib10" id="ref24">10</reflink>]; [<reflink idref="bib31" id="ref25">31</reflink>]; [<reflink idref="bib71" id="ref26">71</reflink>]).</p> <hd id="AN0184797755-4">Co-occurring conditions</hd> <p>Sex differences have also emerged in the presence of and type of co-occurring conditions. Externalising behaviour problems are more evident in AMAB ([<reflink idref="bib24" id="ref27">24</reflink>]; [<reflink idref="bib42" id="ref28">42</reflink>]) while the presence of internalising behaviour difficulties such as emotion regulation concerns and suicidal ideation are often prevalent in autistic AFAB ([<reflink idref="bib26" id="ref29">26</reflink>], [<reflink idref="bib25" id="ref30">25</reflink>]; [<reflink idref="bib44" id="ref31">44</reflink>]; [<reflink idref="bib80" id="ref32">80</reflink>]). Anxiety, however, appears to occur in both AMAB and AFAB equally in some studies ([<reflink idref="bib1" id="ref33">1</reflink>]; [<reflink idref="bib52" id="ref34">52</reflink>]).</p> <p>Most studies that find sex differences report advantages for AMAB on language and motor developmental tasks particularly in those with intellectual disability ([<reflink idref="bib62" id="ref35">62</reflink>]), and delayed attainment of walking milestones appears to be a more common early indicator of autism for AFAB than AMAB ([<reflink idref="bib17" id="ref36">17</reflink>]). On the other hand, studies of broader developmental measures such as the Mullen Scales of Early Learning ([<reflink idref="bib79" id="ref37">79</reflink>]) or The Griffith Mental Development Scales ([<reflink idref="bib61" id="ref38">61</reflink>]) have found no sex differences. Examination of intelligence test (Wechsler Intelligence Scale for Children Third Edition) profiles in autism showed that AMAB outperformed AFAB on visual spatial tasks while AFAB showed faster processing speed scores than AMAB ([<reflink idref="bib70" id="ref39">70</reflink>]). Looking specifically at those with at least average abilities, [<reflink idref="bib32" id="ref40">32</reflink>] found that AMAB had higher scores than AFAB and in Koyama et al.'s ([<reflink idref="bib34" id="ref41">34</reflink>]) group boys showed strengths in visual spatial reasoning.</p> <hd id="AN0184797755-5">Adaptive functioning</hd> <p>Very few studies have examined adaptive functioning comparisons between sexes. Adaptive functions are the practical skills needed to function efficiently in the community, at home and in educational settings. In primary school age children, despite having similar autism symptoms on formal measures, AFAB showed poorer adaptive skills as rated by their parents particularly in the domain of daily living skills ([<reflink idref="bib55" id="ref42">55</reflink>]). [<reflink idref="bib36" id="ref43">36</reflink>] also found that autistic AFAB displayed greater adaptive deficits during the adolescent period. [<reflink idref="bib46" id="ref44">46</reflink>] found a statistically significant difference between autistic AFAB and AMAB in relation to the adaptive-intellectual functioning gap, with the size of the gap being larger for AMAB.</p> <hd id="AN0184797755-6">Barriers to identification and age of diagnosis</hd> <p>It has been suggested that autistic AFAB are not as easily identified and therefore underdiagnosed compared with AMAB. This difficulty in diagnosing autism, whether through tools that are not sufficiently sensitive or are biased, or different interpretations of behaviours based on gender, also impacts on the involvement of AFAB in research that would help better understand the profiles and needs of these children. [<reflink idref="bib36" id="ref45">36</reflink>] suggested that standard measures (originally developed with autistic AMAB in mind) may not capture autism characteristics in AFAB due to their female sex-typical interests, higher social attention, expressive language skills and better camouflaging skills. Tubio-Funguerino et al. (2021) reported that AFAB engaged in camouflaging behaviours such as making themselves make eye contact, reducing talk about preferred topics of interest and systematising the social world. While not exclusive to AFAB (see [<reflink idref="bib13" id="ref46">13</reflink>], for a useful discussion), this may particularly affect the recognition of autistic characteristics by parents, teachers and diagnosticians.</p> <p>Furthermore, the general bias in research recruitment favouring AMAB has been suggested as another complicating factor in understanding barriers to the identification and diagnosis of AFAB ([<reflink idref="bib15" id="ref47">15</reflink>]). Finally, participant characteristics may have resulted in variable findings regarding sex differences and age of diagnosis of autism. On the one hand, some have identified no difference in age at diagnosis ([<reflink idref="bib49" id="ref48">49</reflink>]). [<reflink idref="bib73" id="ref49">73</reflink>] meta-analysis found that most of the studies reviewed found no difference while five reported a higher age at diagnosis for AFAB. [<reflink idref="bib7" id="ref50">7</reflink>] and [<reflink idref="bib45" id="ref51">45</reflink>] also found that AFAB were older at first diagnosis. This was recently supported in a study by [<reflink idref="bib47" id="ref52">47</reflink>] in a large clinic and the community sample. AFAB children with more severe symptomatology and/or co-occurring intellectual disability seem more likely to be recognised as autistic at an earlier age ([<reflink idref="bib27" id="ref53">27</reflink>]).</p> <hd id="AN0184797755-7">Study aims</hd> <p>This study sought to investigate the presence of sex differences in children presenting to public tertiary developmental assessment services with an autism spectrum diagnosis. These services are some of the most widely used developmental assessment services in the state of New South Wales, Australia. The study sought to understand whether sex differences in presenting children were observed on demographic variables (including child age), autism symptom specific, cognitive, development, adaptive and assessments of co-occurring conditions conducted. In addition, where differences were identified, we sought to undertake fine grained analysis at the item level of commonly used measures in autism diagnosis such as the ADOS-2 and Childhood Autism Rating Scale-2 (CARS-2), and measures of intellectual/developmental as well as adaptive functioning. We predicted, based on past literature, that there would be differences between AFAB and AMAB on clinical variables.</p> <p>The findings of this study may have implications for clinical diagnosis and assessment practices.</p> <hd id="AN0184797755-8">Methods</hd> <p></p> <hd id="AN0184797755-9">Participants</hd> <p>Participants were children aged between 1.11 and 17.97 years (M = 5.35, SD = 2.89) who attended a diagnosis and assessment clinic in Western Sydney known as the Child Development Unit (CDU), which has two locations (The Children's Hospital at Westmead and the Parramatta Early Childhood Assessment Team (PECAT) at Auburn Community Health Centre) for a diagnostic assessment from 2019 to 2023. Participants consented to clinically integrated research in partnership with the Clinic for Autism and Neurodevelopmental (CAN) Research at The University of Sydney. All children assessed by the service in the time period were included in the research unless their families opted out. A detailed description of the clinic cohort and integrated research registry is available elsewhere ([<reflink idref="bib9" id="ref54">9</reflink>]). All children were assessed by a multidisciplinary team and received gold standard, comprehensive assessments to evaluate their developmental or intellectual ability, adaptive functioning and autism symptoms and parents were interviewed about their early developmental history. To be included in the study, children were required to have received a consensus diagnosis of autism spectrum disorder (ASD) according to the <emph>Diagnostic and Statistical Manual of Mental Disorders</emph> (5th ed., text rev.; DSM-5-TR; [<reflink idref="bib2" id="ref55">2</reflink>]) by the assessment team. They were excluded from the study if their caregivers opted out. In total, 1079 children (269 AFAB) were included in this study. Overall, 76% of the sample (<emph>n</emph> = 822) were recruited from the CDU, and 24% (<emph>n</emph> = 257) were recruited from PECAT.</p> <hd id="AN0184797755-10">Measures</hd> <p>All measures included in this study were administered by trained and qualified professionals employed by the service; all met the professional requirements of their respective disciplines to practice in this area.</p> <hd id="AN0184797755-11">Autism symptoms and diagnosis</hd> <p>The ADOS-2 is a standardised assessment to measure one's communication, social interaction, play, and restricted and repetitive behaviours. The ADOS-2 provides diagnostic algorithms with cut-off scores to determine diagnostic classification of autism, autism spectrum or non-spectrum. The ADOS-2 has been widely used in clinical and research settings and is recognised as the gold-standard assessment tool to diagnose autism. It demonstrates excellent internal consistency, inter-rater reliability as well as validity ([<reflink idref="bib39" id="ref56">39</reflink>]). The Childhood Autism Rating Scale–Second Edition Standard Version (CARS-2 ST) is a clinician completed scale for children under 6 years of age that consists of 15 items. Research has shown strong reliability and validity, and strong correlation with ADOS-2 results ([<reflink idref="bib30" id="ref57">30</reflink>]).</p> <hd id="AN0184797755-12">Intellectual ability</hd> <p>Children's intellectual ability was assessed by the Stanford Binet Intelligence Scales–Fifth Edition (SB-5), Wechsler Preschool and Primary Scale of Intelligence–Fourth Edition (WPPSI-IV) or the Wechsler Intelligence Scale for Children–Fifth Edition (WISC-V) depending on children's chronological age and level of language. The SB-5 is a standardised assessment to measure individual's intellect from age 2 to 85 ([<reflink idref="bib57" id="ref58">57</reflink>]). The WPPSI-IV measures cognitive development of preschoolers and children aged 2 years and 6 months to 7 years and 7 months ([<reflink idref="bib76" id="ref59">76</reflink>]). Finally, the WISC-V is a standardised assessment to measure children's cognitive ability from the age of 6 to 16 years and 11 months ([<reflink idref="bib77" id="ref60">77</reflink>]).</p> <hd id="AN0184797755-13">Early childhood development</hd> <p>Children's development was assessed by the Mullen Scales of Early Learning (MSEL), the Griffiths Scales of Child Development–3rd Edition (Griffiths-III) or the Bayley Scales of Infant and Toddler Development–3rd (Bayley–III) or 4th Edition (Bayley-4), with decisions made based on child age and team composition. The MSEL ([<reflink idref="bib50" id="ref61">50</reflink>]) is a standardised developmental assessment to measure cognitive skill, language and motor development in infants and toddlers from birth to 68 months of age. The Griffiths-III is a standardised developmental assessment that measures cognition, language, motor, self-care and social-emotional skills ([<reflink idref="bib19" id="ref62">19</reflink>]). It can be administered to infants and toddlers from birth to 72 months of age. The Bayley-III and Bayley-4 are standardised developmental assessments that measure five domains in infants and toddlers aged between 1 and 42 months: cognitive, language, motor, social-emotional and adaptive behaviour ([<reflink idref="bib78" id="ref63">78</reflink>]).</p> <hd id="AN0184797755-14">Adaptive functioning</hd> <p>The Vineland Adaptive Behaviour Scales–Third Edition (VABS-3) is a standardised measure of adaptive functioning of individuals from birth to 90 years old in three domains: communication, daily living skills and socialisation ([<reflink idref="bib66" id="ref64">66</reflink>]). The VABS-3 can be administered by clinicians as interviews with parents/caregivers or completed by parents.</p> <hd id="AN0184797755-15">Demographic data</hd> <p>Children's demographic information, such as age at assessment, age when concerns were first identified and sex, was collected in the parent/caregiver questionnaire prior to the diagnostic developmental assessment. Parents/caregivers demographic data was also collected in the pre-assessment questionnaire, including parents' educational level, country of birth and language primarily spoken at home. Data pertaining to cultural and linguistic diversity (CALD status) was calculated based on recommendations of [<reflink idref="bib54" id="ref65">54</reflink>], with caregivers defined as being from a CALD background when their country of birth was non-English speaking and/or they did not speak English at home.</p> <hd id="AN0184797755-16">Procedure</hd> <p>The study was approved by the Sydney Children's Hospital Human Research Ethics Committee (HREC/14/SCHN/269 and LNR/17/SCHN/293). The CDU is a state-wide, tertiary assessment clinic specialising in providing comprehensive multidisciplinary care to children with complex neurodevelopmental problems. The team includes paediatricians, clinical neuropsychologists, speech pathologists, occupational therapists, social workers and a clinical nurse consultant. PECAT is a tertiary early childhood assessment clinic that provides multidisciplinary assessments to infants and children with complex neurodevelopmental problems living in the Western Sydney Local Health district. The team includes paediatricians, clinical neuropsychologists, developmental and educational psychologist, social worker and clinical nurse specialist.</p> <p>Children included in this study were offered an appointment to complete clinical assessments. Prior to their assessment, families were sent a link to an online questionnaire to provide information about demographic characteristics of their children and themselves as part of standard practice. This questionnaire was sent electronically via the Research Enterprise Data Capture (REDCap) platform, an electronic data collection system endorsed by the University of Sydney ([<reflink idref="bib22" id="ref66">22</reflink>], [<reflink idref="bib21" id="ref67">21</reflink>]). All families participated in this study using opt-out consent procedures. A total of 35 families (3.2%) opted out of this study. Children were included in this study if they received a diagnosis of ASD and had completed an Autism (ADOS-2, CARS-2), adaptive functioning (VABS-3), intellectual ability (SB-5, WISC-V, WPPSI-IV) or developmental ability (Griffiths-III, MSEL, Bayley-4) assessment. See Supplementary Table 1 for a summary of available data across assessment measures. At the end of the appointment, families received feedback from the multidisciplinary team about the assessment results and recommendations about their children's diagnoses ([<reflink idref="bib51" id="ref68">51</reflink>]). A written report was also provided to the families after the appointment.</p> <hd id="AN0184797755-17">Statistical analyses</hd> <p>IBM SPSS Statistics for Windows, version 29 ([<reflink idref="bib28" id="ref69">28</reflink>]) was used to complete data analysis. Descriptive statistics were used to demonstrate the demographics, clinical and genetic profiles of the sample. Standardised <emph>z</emph>-scores were calculated to compare performance across males and females on the selected IQ measures (Stanford Binet-5, WIPPSI-IV, WISC-V) and the measures of developmental ability (the Griffiths-III, the MSEL and the Bayleys). A series of <emph>t</emph>-tests were then performed to compare the differences in autism symptoms, cognitive ability, developmental profile and adaptive functioning between males and females. Following the procedure outlined by [<reflink idref="bib56" id="ref70">56</reflink>], we then used a series of multinomial logistic regressions to assess gender differences in specific items of the ADOS-2 and the CARS-2. Only scoring items that overlapped between ADOS-2 modules were included in these analyses, in line with the process described in [<reflink idref="bib56" id="ref71">56</reflink>]. Given that this data was collected as part of standard clinical practice, there needed to be a decision between presenting outcomes for the whole sample but with varying amounts of missing data on each measure or presenting data on those smaller number of participants with no missing data across key measures. The latter may be more complete across measures but also does not provide the most inclusive approach to reporting outcomes. To check if the pattern of results differed, the overall pattern of findings across the whole sample was compared to a subset of participants who had available data on all three assessment types (an ASD assessment, the VABS, and an IQ or DQ assessment; <emph>n</emph> = 180). Shapiro–Wilk tests indicated that some variables deviated significantly from normality. Consequently, all analyses were conducted using bootstrapping (2000 resamples).</p> <p>Due to the small sample sizes in some measures, and to minimise the likelihood of a Type II error, the <emph>p</emph> value was set to 0.05 for all analyses (see [<reflink idref="bib58" id="ref72">58</reflink>]). For any results at or near the 0.05 level of significance, moderate to large effect sizes would rule out the likelihood of a Type I error ([<reflink idref="bib58" id="ref73">58</reflink>]), and, as such, effect sizes were reported for all analyses using Cohen's <emph>d</emph>, where 0.2 indicates a small effect size, 0.5 indicates a medium effect size and 0.8 indicates a large effect size ([<reflink idref="bib12" id="ref74">12</reflink>]).</p> <hd id="AN0184797755-18">Results</hd> <p></p> <hd id="AN0184797755-19">Demographics and comorbidities</hd> <p>Demographic characteristics of participants are summarised in Table 1. Other than their autism diagnosis, the sample also had co-existing diagnoses, the most frequent of which were Global Developmental Delay (<emph>n</emph> = 372/1079; 34.5%), attention-deficit/hyperactivity disorder (ADHD, <emph>n</emph> = 183/1079; 17.0%) and Intellectual Development Disorder (<emph>n</emph> = 123/1079; 11.4%), Refer to Supplementary Table 2 for a breakdown of participants within each diagnostic category. In total, 658 (61.0%) children received an autism assessment, 781 (72.4%) children received an adaptive functioning assessment, 425 (39.4%) children received an assessment of developmental skills and 363 (33.6%) children received an assessment of intellectual ability.</p> <p>Table 1. Demographic characteristics of children and caregivers.</p> <p>Graph</p> <p> <ephtml> <table><colgroup><col align="left" /><col align="char" char="." /></colgroup><thead><tr><th align="left">Caregiver characteristics</th><th align="left"><italic>n</italic> (%)</th></tr></thead><tbody><tr><td colspan="2">Mother's highest level of education (<italic>n</italic> = 678)</td></tr><tr><td> Primary or secondary schooling</td><td>129 (19.0%)</td></tr><tr><td> Vocational training</td><td>207 (30.5%)</td></tr><tr><td> Bachelor's degree</td><td>203 (29.9%)</td></tr><tr><td> Postgraduate degree</td><td>139 (20.5%)</td></tr><tr><td colspan="2">Father's highest level of education (<italic>N</italic> = 646)</td></tr><tr><td> Primary or secondary schooling</td><td>165 (25.5%)</td></tr><tr><td> Vocational training</td><td>182 (28.2%)</td></tr><tr><td> Bachelor's degree</td><td>178 (27.6%)</td></tr><tr><td> Postgraduate degree</td><td>121 (18.7%)</td></tr><tr><td colspan="2">Mother's CALD status (<italic>N</italic> = 682)</td></tr><tr><td> CALD</td><td>401 (58.8%)</td></tr><tr><td> Non-CALD</td><td>281 (41.2%)</td></tr><tr><td colspan="2">Father's CALD status (<italic>N</italic> = 652)</td></tr><tr><td> CALD</td><td>402 (61.7%)</td></tr><tr><td> Non-CALD</td><td>250 (38.3%)</td></tr><tr><td>Child characteristics</td><td><italic>n</italic> (%)</td></tr><tr><td colspan="2">Sex (<italic>n</italic> = 1079)</td></tr><tr><td> Assigned male at birth</td><td>810 (75.1%)</td></tr><tr><td> Assigned female at birth</td><td>269 (24.9%)</td></tr><tr><td /><td>Mean (SD)</td></tr><tr><td>Age at developmental assessment in years (<italic>n</italic> = 1079)</td><td>5.35 (2.89)</td></tr><tr><td>Age at identification of first concern in months (<italic>n</italic> = 631)</td><td>26.98 (17.39)</td></tr></tbody></table> </ephtml> </p> <p>1 CALD, culturally and linguistically diverse. <emph>n</emph> is varied across variables due to missing data across responses. See Supplementary Table 1 for missing data summary.</p> <hd id="AN0184797755-20">Clinical and demographic variables</hd> <p>Descriptive statistics for measures of autism symptoms, intellectual ability, early childhood development, adaptive functioning and demographic characteristics, split by sex, are shown in Table 2.</p> <p>Table 2. Descriptive statistics and comparisons for clinical measures, split by sex.</p> <p>Graph</p> <p> <ephtml> <table><colgroup><col align="left" /><col align="char" char="." /><col align="char" char="." /><col align="char" char="." /><col align="char" char="." /><col align="char" char="." /><col align="char" char="." /></colgroup><thead><tr><th align="left">Autism symptoms</th><th align="left" colspan="2">Assigned males at birth (<italic>n</italic> = 810)</th><th align="left" colspan="2">Assigned females at birth (<italic>n</italic> = 269)</th><th align="left"><italic>p</italic>-value</th><th align="left">Effect size <italic>(d)</italic></th></tr><tr><th /><th align="left"><italic>n</italic></th><th align="left">M (SD) <italic>range</italic></th><th align="left"><italic>n</italic></th><th align="left">M (SD) <italic>range</italic></th><th /><th /></tr></thead><tbody><tr><td>ADOS-2 – Module 1 CSS</td><td>119</td><td>8.13 (1.79) <italic>1–10</italic></td><td>47</td><td>7.60 (2.23) <italic>1–10</italic></td><td>0.106</td><td>0.28</td></tr><tr><td>ADOS-2 – Module 1 CSS – Social Affect Domain</td><td>119</td><td>8.16 (1.71) <italic>2–10</italic></td><td>47</td><td>7.91 (2.36) <italic>1–10</italic></td><td>0.531</td><td>0.13</td></tr><tr><td>ADOS-2 – Module 1 CSS – Restricted and Repetitive Behaviours Domain</td><td>119</td><td>8.10 (1.73) <italic>1–10</italic></td><td>47</td><td>7.53 (2.15) <italic>1–10</italic></td><td>0.096</td><td>0.31</td></tr><tr><td>ADOS-2 – Module 2 CSS</td><td>80</td><td>7.99 (1.70) <italic>3–10</italic></td><td>32</td><td>7.72 (1.71) <italic>3–10</italic></td><td>0.452</td><td>0.16</td></tr><tr><td>ADOS-2 – Module 2 CSS – Social Affect Domain</td><td>80</td><td>8.20 (1.59) <italic>3–10</italic></td><td>32</td><td>7.59 (1.68) <italic>3–10</italic></td><td>0.075</td><td>0.38</td></tr><tr><td>ADOS-2 – Module 2 CSS – Restricted and Repetitive Behaviours Domain</td><td>80</td><td>7.34 (1.92) <italic>1-10</italic></td><td>32</td><td>8.06 (1.27) <italic>6–10</italic></td><td>0.051</td><td>−0.41</td></tr><tr><td>ADOS-2 – Module 3 CSS</td><td>147</td><td>8.41 (1.60) <italic>3–10</italic></td><td>62</td><td>7.53 (1.92) <italic>3–10</italic></td><td>0.001<xref ref-type="table-fn" rid="tfn2">*</xref></td><td>0.52</td></tr><tr><td>ADOS-2 – Module 3 CSS – Social Affect Domain</td><td>147</td><td>8.33 (1.65) <italic>3–10</italic></td><td>62</td><td>7.58 (1.90) <italic>3–10</italic></td><td>0.007<xref ref-type="table-fn" rid="tfn2">*</xref></td><td>0.44</td></tr><tr><td>ADOS-2 – Module 3 CSS – Restricted and Repetitive Behaviours Domain</td><td>147</td><td>7.61 (2.16) <italic>1–10</italic></td><td>62</td><td>6.76 (2.42) <italic>1–10</italic></td><td>0.015<xref ref-type="table-fn" rid="tfn2">*</xref></td><td>0.38</td></tr><tr><td>ADOS-2 – Module 4 CSS</td><td>9</td><td>7.33 (1.73) <italic>5–10</italic></td><td>5</td><td>5.80 (1.30) <italic>4–7</italic></td><td>0.112</td><td>0.96</td></tr><tr><td>ADOS-2 – Module 4 CSS – Social Affect Domain</td><td>9</td><td>8.44 (1.24) <italic>7–10</italic></td><td>5</td><td>7.40 (0.89) <italic>6–8</italic></td><td>0.124</td><td>0.92</td></tr><tr><td>ADOS-2 – Module 4 CSS – Restricted and Repetitive Behaviours Domain</td><td>9</td><td>3.33 (2.24) <italic>1–6</italic></td><td>5</td><td>5.40 (2.70) <italic>1–8</italic></td><td>0.149</td><td>−0.86</td></tr><tr><td>ADOS-2 – CSS across modules</td><td>355</td><td>8.19 (1.70) <italic>1–10</italic></td><td>146</td><td>7.53 (1.98) <italic>1–10</italic></td><td>0.001<xref ref-type="table-fn" rid="tfn2">*</xref></td><td>0.37</td></tr><tr><td>ADOS-2 – CSS across modules – Social Affect Domain</td><td>355</td><td>8.25 (1.64) <italic>2–10</italic></td><td>146</td><td>7.68 (1.98) <italic>1–10</italic></td><td>0.003<xref ref-type="table-fn" rid="tfn2">*</xref></td><td>0.32</td></tr><tr><td>ADOS-2 – CSS across modules – Restricted and Repetitive Behaviours Domain</td><td>355</td><td>7.60 (2.10) <italic>1–10</italic></td><td>146</td><td>7.25 (2.21) <italic>1–10</italic></td><td>0.101</td><td>0.17</td></tr><tr><td>CARS-2 Summary Total Score</td><td>125</td><td>38.58 (5.84) <italic>24–57.5</italic></td><td>32</td><td>34.94 (7.15) <italic>20.5–51.5</italic></td><td>0.010<xref ref-type="table-fn" rid="tfn2">*</xref></td><td>0.59</td></tr><tr><td>CARS-2T-score</td><td>125</td><td>50.94 (7.04) <italic>34–69</italic></td><td>32</td><td>46.63 (8.71) <italic>29–67</italic></td><td>0.012<xref ref-type="table-fn" rid="tfn2">*</xref></td><td>0.58</td></tr><tr><td colspan="7"><bold>Intellectual Ability</bold></td></tr><tr><td colspan="7">SB-5</td></tr><tr><td> FSIQ Standard Score</td><td>43</td><td>60.95 (17.02) <italic>40–108</italic></td><td>11</td><td>67.45 (16.07) <italic>49–91</italic></td><td>0.258</td><td>−0.39</td></tr><tr><td> VIQ Standard Score</td><td>43</td><td>58.81 (15.04) <italic>43–101</italic></td><td>11</td><td>60.91 (14.47) <italic>44–91</italic></td><td>0.636</td><td>−0.14</td></tr><tr><td> NVIQ Standard Score</td><td>46</td><td>66.72 (19.87) <italic>42–115</italic></td><td>11</td><td>76.82 (19.35) <italic>48–109</italic></td><td>0.128</td><td>−0.51</td></tr><tr><td colspan="7">WPPSI-IV</td></tr><tr><td> Full Scale Composite Score</td><td>128</td><td>81.93 (14.93) <italic>47–140</italic></td><td>46</td><td>81.16 (13.77) <italic>59–127</italic></td><td>0.392</td><td>0.05</td></tr><tr><td> Verbal Comprehension Composite Score</td><td>133</td><td>78.71 (16.34) <italic>45–127</italic></td><td>49</td><td>78.79 (15.23) <italic>56–118</italic></td><td>0.980</td><td>−0.01</td></tr><tr><td> Visual Spatial Composite Score</td><td>129</td><td>88.66 (19.47) <italic>45–144</italic></td><td>47</td><td>88.72 (15.41) <italic>65–137</italic></td><td>0.329</td><td>−0.01</td></tr><tr><td colspan="7">WISC-V</td></tr><tr><td> Full Scale Composite Score</td><td>81</td><td>87.58 (18.44) <italic>42–139</italic></td><td>36</td><td>91.36 (16.18) <italic>63–124</italic></td><td>0.291</td><td>−0.21</td></tr><tr><td> Verbal Comprehension Composite Score</td><td>82</td><td>92.02 (17.14) <italic>45–142</italic></td><td>37</td><td>90.92 (16.37) <italic>55–118</italic></td><td>0.674</td><td>0.07</td></tr><tr><td> Visual Spatial Composite Score</td><td>78</td><td>90.55 (18.04) <italic>49–114</italic></td><td>36</td><td>92.36 (16.67) <italic>57–122</italic></td><td>0.611</td><td>−0.10</td></tr><tr><td colspan="7"><bold>Early Childhood Development</bold></td></tr><tr><td colspan="7">Bayleys 4</td></tr><tr><td> Verbal DQ</td><td>26</td><td>42.84 (21.97) <italic>8.71–95.79</italic></td><td>8</td><td>45.92 (19.16) <italic>31.86–80.73</italic></td><td>0.697</td><td>−0.14</td></tr><tr><td> Nonverbal DQ</td><td>27</td><td>58.48 (19.42) <italic>13.60–102.53</italic></td><td>9</td><td>58.78 (24.96) <italic>19.75–102.81</italic></td><td>0.680</td><td>−0.01</td></tr><tr><td colspan="7">MSEL</td></tr><tr><td> Verbal DQ</td><td>148</td><td>43.84 (24.06) <italic>9.45–117.95</italic></td><td>49</td><td>51.28 (27.29) <italic>8.44–103.67</italic></td><td>0.061</td><td>−0.30</td></tr><tr><td> Nonverbal DQ</td><td>160</td><td>59.73 (22.06) <italic>8.11–135.99</italic></td><td>54</td><td>69.44 (25.55) <italic>23.35–121.09</italic></td><td>0.010<xref ref-type="table-fn" rid="tfn2">*</xref></td><td>−0.42</td></tr><tr><td colspan="7">Griffiths-III</td></tr><tr><td> Language and Communication DQ</td><td>98</td><td>56.11 (15.32) <italic>9.16–100.82</italic></td><td>28</td><td>57.52 (13.82) <italic>20.67–85.45</italic></td><td>0.745</td><td>−0.09</td></tr><tr><td> Foundations of Learning DQ</td><td>108</td><td>63.35 (13.27) <italic>28.31–97.50</italic></td><td>29</td><td>63.33 (14.25) <italic>39.62–103.13</italic></td><td>0.967</td><td>0.01</td></tr><tr><td colspan="7"><bold>Adaptive Functioning (Vineland Adaptive Behaviour Scales – Third Edition)</bold></td></tr><tr><td>Communication – Standard Score</td><td>589</td><td>59.16 (20.91) <italic>20–122</italic></td><td>192</td><td>61.84 (20.10) <italic>20–115</italic></td><td>0.124</td><td>−0.13</td></tr><tr><td>Daily Living Skills – Standard Score</td><td>589</td><td>67.96 (12.91) <italic>24–116</italic></td><td>192</td><td>69.37 (12.86) <italic>33–129</italic></td><td>0.064</td><td>−0.11</td></tr><tr><td>Socialisation – Standard Score</td><td>589</td><td>60.90 (15.37) <italic>27–120</italic></td><td>192</td><td>62.04 (15.57) <italic>29–135</italic></td><td>0.326</td><td>−0.07</td></tr><tr><td>Motor Skills – Standard Score</td><td>526</td><td>75.95 (13.74) <italic>20–121</italic></td><td>168</td><td>76.97 (12.91) <italic>45–126</italic></td><td>0.360</td><td>−0.08</td></tr><tr><td>Adaptive Behaviour Composite – Standard Score</td><td>589</td><td>62.88 (13.60) <italic>27–120</italic></td><td>192</td><td>64.60 (13.33) <italic>34–126</italic></td><td>0.094</td><td>−0.13</td></tr><tr><td colspan="7"><bold>Demographics</bold></td></tr><tr><td>Age at identification of first concern (months)</td><td>465</td><td>27.21 (16.25) <italic>3–156</italic></td><td>166</td><td>27.96 (19.64) <italic>3–120</italic></td><td>0.669</td><td>−0.04</td></tr><tr><td>Age at assessment (years)</td><td>810</td><td>5.23 (2.79) <italic>1.11–17.97</italic></td><td>269</td><td>5.72 (3.16) <italic>1.53–16.64</italic></td><td>0.024<xref ref-type="table-fn" rid="tfn2">*</xref></td><td>−0.17</td></tr></tbody></table> </ephtml> </p> <ulist> <item>2 <emph>p</emph><emph><</emph> 0.05.</item> <item>3 Abbreviations: ADOS-2, Autism Diagnostic Observation Schedule-2; CSS, Calibrated Severity Score; CARS-2, Childhood Autism Rating Scale – Second Edition; SB-5, Stanford Binet Intelligence Scales – Fifth Edition; FSIQ, Full-Scale Intelligence Quotient; VIQ, Verbal Intelligence Quotient; NVIQ, Non-verbal Intelligence Quotient; WPPSI-IV, Wechsler Preschool and Primary Scale of Intelligence – Fourth Edition; WISC-V, Wechsler Intelligence Scale for Children – Fifth Edition; Bayleys 4, Bayley Scales of Infant and Toddler Development – 4th Edition; MSEL, Mullens Scales of Early Learning; Griffiths-III, Griffiths Scales of Child Development – 3rd Edition; DQ, Development Quotient.</item> </ulist> <hd id="AN0184797755-21">Autism symptoms and sex at birth</hd> <p>Autism symptom data was available for 658 participants (AMAB <emph>n</emph> = 480; AFAB <emph>n</emph> = 178). Overall, 501 participants had ADOS-2 data available (AMAB <emph>n</emph> = 355, AFAB <emph>n</emph> = 146) and 157 participants had CARS-2 data available (AMAB <emph>n</emph> = 125; AFAB <emph>n</emph> = 32). With respect to autism characteristics, AMAB displayed more autism characteristics than AFAB when assessed using the ADOS-2 Module 3 (<emph>p</emph> = 0.001, <emph>d</emph><emph>=</emph> 0.52). Similarly, when comparing calibrated severity scores (CSS) across all ADOS-2 modules, AMAB had higher severity scores overall <emph>(p</emph> < 0.001, <emph>d</emph> = 0.37), as well as on the Social Affect domain <emph>(p</emph> = 0.003, <emph>d</emph> = 0.32), compared to AFAB. Considering those children assessed with the CARS-2, AMAB displayed more autism characteristics relative to AFAB on both summary scores (<emph>p</emph> = 0.010, <emph>d</emph> = 0.59) and <emph>T</emph>-scores (<emph>p</emph> = 0.012, <emph>d</emph><emph>=</emph> 0.58).</p> <p>Chi-square tests indicated differences between AMAB and AFAB in terms of scores within different concern ranges on the ADOS-2, χ<sups>2</sups>(<reflink idref="bib3" id="ref75">3</reflink>) = 13.29, <emph>p</emph> = 0.004. On average, AMAB were more likely to receive scores in the 'high' concern range (<emph>n</emph> = 244/355; 68.7%), compared to AFAB (<emph>n</emph> = 81/146; 55.5%). Similarly, there were statistically significant differences between AMAB and AFAB when looking at cut-off scores for the CARS-2, χ<sups>2</sups>(<reflink idref="bib2" id="ref76">2</reflink>) = 6.58, <emph>p</emph> = 0.037. On average, AMAB were more likely to receive scores in the 'severe' symptom range (<emph>n</emph> = 75/125; 60.0%) compared to AFAB (<emph>n</emph> = 14/32; 43.8%). Multinomial logistic regressions were used to analyse sex differences in items on the ADOS-2 and the CARS-2. As shown in Table 3, analyses revealed that on items pertaining to nonverbal communication, AMAB were more likely to show challenges in their use of gestures (<emph>p</emph> = 0.013, odds ratio = 2.04), unusual eye contact (<emph>p</emph> = 0.014, odds ratio = 2.36), and showed more challenges in directing a range of facial expressions to the examiner (<emph>p</emph> = 0.034, odds ratio = 2.48). AMAB were also more likely to show challenges in their ability to indicate shared enjoyment in interactions and were more likely to be rated as showing excessive interests or unusually repetitive interests or behaviours compared to AFAB (<emph>p</emph> values = 0.003 and 0.001, odds ratios = 2.55 and 3.36, respectively). For the CARS-2, sex differences were observed on items pertaining to relating to other people (<emph>p</emph><emph>=</emph> 0.020, odds ratio = 1.65), object use (<emph>p</emph> = 0.003, odds ratio = 11.60), visual response (<emph>p</emph> = 0.033, odds ratio = 3.96), and general impressions (<emph>p</emph> = 0.023, odds ratio = 1.98). Across all items, AMAB were more likely to score in the 'abnormal' range than AFAB. The regression results for each analysis are presented in Supplementary Table 3.</p> <p>Table 3. ADOS-2 and CARS-2 items, split by sex.</p> <p>Graph</p> <p> <ephtml> <table><colgroup><col align="left" /><col align="char" char="." /><col align="char" char="." /><col align="char" char="." /><col align="char" char="." /></colgroup><thead><tr><th /><th align="left">Overall mean (SD) <italic>n</italic> = 658</th><th align="left">Assigned males at birth mean (SD) <italic>n</italic> = 480</th><th align="left">Assigned females at birth mean (SD) <italic>n</italic> = 178</th><th align="left"><italic>p</italic>-value</th></tr></thead><tbody><tr><td colspan="5"><bold>ADOS-2 Items</bold></td></tr><tr><td>Non-echoed spoken language</td><td>0.81 (0.75)</td><td>0.85 (0.75)</td><td>0.70 (0.75)</td><td>0.064</td></tr><tr><td>Speech abnormalities</td><td>1.25 (0.72)</td><td>1.26 (0.72)</td><td>1.22 (0.70)</td><td>0.518</td></tr><tr><td>Echolalia</td><td>0.66 (0.78)</td><td>0.68 (0.80)</td><td>0.60 (0.74)</td><td>0.295</td></tr><tr><td>Stereotyped language</td><td>0.71 (0.76)</td><td>0.74 (0.78)</td><td>0.64 (0.71)</td><td>0.204</td></tr><tr><td>Gestures</td><td>0.96 (0.82)</td><td>1.03 (0.82)</td><td>0.79 (0.80)</td><td>0.013<xref ref-type="table-fn" rid="tfn4">*</xref></td></tr><tr><td>Unusual eye contact</td><td>1.85 (0.53)</td><td>1.89 (0.46)</td><td>1.75 (0.80)</td><td>0.014<xref ref-type="table-fn" rid="tfn4">*</xref></td></tr><tr><td>Directed facial expressions</td><td>1.22 (0.60)</td><td>1.26 (0.58)</td><td>1.13 (0.64)</td><td>0.034<xref ref-type="table-fn" rid="tfn4">*</xref></td></tr><tr><td>Shared enjoyment</td><td>1.22 (0.72)</td><td>1.28 (0.69)</td><td>1.05 (0.76)</td><td>0.003<xref ref-type="table-fn" rid="tfn4">**</xref></td></tr><tr><td>Quality of social overtures</td><td>1.32 (0.57)</td><td>1.36 (0.57)</td><td>1.22 (0.58)</td><td>0.051</td></tr><tr><td>Amount of social overtures</td><td>1.32 (0.76)</td><td>1.35 (0.74)</td><td>1.24 (0.81)</td><td>0.187</td></tr><tr><td>Quality of social response</td><td>1.34 (0.53)</td><td>1.34 (0.53)</td><td>1.32 (0.51)</td><td>0.663</td></tr><tr><td>Quality of rapport</td><td>1.43 (0.58)</td><td>1.46 (0.57)</td><td>1.34 (0.60)</td><td>0.082</td></tr><tr><td>Imagination/creativity</td><td>1.25 (0.72)</td><td>1.30 (0.71)</td><td>1.13 (0.75)</td><td>0.073</td></tr><tr><td>Unusual sensory interests</td><td>1.09 (0.84)</td><td>1.09 (0.86)</td><td>1.11 (0.81)</td><td>0.311</td></tr><tr><td>Hand and finger mannerisms</td><td>0.83 (0.88)</td><td>0.80 (0.88)</td><td>0.91 (0.89)</td><td>0.429</td></tr><tr><td>Self-injurious behaviour</td><td>0.06 (0.31)</td><td>0.07 (0.32)</td><td>0.04 (0.26)</td><td>0.530</td></tr><tr><td>Excessive interests</td><td>1.13 (0.81)</td><td>1.24 (0.80)</td><td>0.86 (0.76)</td><td>0.001<xref ref-type="table-fn" rid="tfn4">**</xref></td></tr><tr><td colspan="5"><bold>CARS-2 items</bold></td></tr><tr><td>Relating to people</td><td>2.67 (0.50)</td><td>2.71 (0.45)</td><td>2.50 (0.62)</td><td>0.020<xref ref-type="table-fn" rid="tfn4">*</xref></td></tr><tr><td>Imitation</td><td>2.45 (0.73)</td><td>2.52 (0.68)</td><td>2.19 (0.86)</td><td>0.051</td></tr><tr><td>Emotional response</td><td>2.69 (0.52)</td><td>2.70 (0.49)</td><td>2.63 (0.61)</td><td>0.409</td></tr><tr><td>Body use</td><td>2.60 (0.64)</td><td>2.66 (0.59)</td><td>2.38 (0.75)</td><td>0.087</td></tr><tr><td>Object use</td><td>2.59 (0.60)</td><td>2.67 (0.52)</td><td>2.28 (0.77)</td><td>0.003<xref ref-type="table-fn" rid="tfn4">**</xref></td></tr><tr><td>Adaptation to change</td><td>2.60 (0.62)</td><td>2.64 (0.57)</td><td>2.44 (0.76)</td><td>0.146</td></tr><tr><td>Visual response</td><td>2.60 (0.61)</td><td>2.66 (0.57)</td><td>2.34 (0.70)</td><td>0.033<xref ref-type="table-fn" rid="tfn4">*</xref></td></tr><tr><td>Listening response</td><td>2.34 (0.62)</td><td>2.40 (0.60)</td><td>2.13 (0.66)</td><td>0.078</td></tr><tr><td>Taste, smell, and touch response</td><td>2.44 (0.64)</td><td>2.48 (0.60)</td><td>2.28 (0.77)</td><td>0.089</td></tr><tr><td>Fear of nervousness</td><td>2.49 (0.69)</td><td>2.50 (0.68)</td><td>2.44 (0.72)</td><td>0.887</td></tr><tr><td>Verbal communication</td><td>2.70 (0.47)</td><td>2.72 (0.47)</td><td>2.63 (0.49)</td><td>0.392</td></tr><tr><td>Nonverbal communication</td><td>2.32 (0.63)</td><td>2.35 (0.60)</td><td>2.19 (0.74)</td><td>0.130</td></tr><tr><td>Activity level</td><td>2.45 (0.68)</td><td>2.50 (0.66)</td><td>2.22 (0.75)</td><td>0.118</td></tr><tr><td>Intellectual response</td><td>2.54 (0.58)</td><td>2.53 (0.58)</td><td>2.56 (0.62)</td><td>0.652</td></tr><tr><td>General impressions</td><td>2.89 (0.35)</td><td>2.93 (0.26)</td><td>2.75 (0.57)</td><td>0.023<xref ref-type="table-fn" rid="tfn4">*</xref></td></tr></tbody></table> </ephtml> </p> <ulist> <item>4 <emph>p</emph> <.05; **<emph>p</emph> <.01.</item> <item>5 Abbreviations: ADOS-2, Autism Diagnostic Observation Schedule-2; CARS-2, Childhood Autism Rating Scale – Second Edition.</item> </ulist> <hd id="AN0184797755-22">Cognitive ability and sex at birth</hd> <p>Considering cognitive ability, Full-Scale IQ data was available for 345 participants (AMAB <emph>n</emph> = 252; AFAB <emph>n</emph> = 93), Verbal IQ data was available for 355 participants (AMAB <emph>n</emph> = 258; AFAB <emph>n</emph> = 97) and Nonverbal IQ data was available for 347 participants (AMAB <emph>n</emph> = 253; AFAB <emph>n</emph> = 94). There were no statistically significant differences between AMAB and AFAB on any measure of intellectual assessment. Considering developmental ability, verbal DQ data was available for 357 participants (AMAB = 272; AFAB = 85) and nonverbal DQ data was available for 387 participants (AMAB = 295; AFAB = 92). There was a statistically significant effect of sex for nonverbal DQ on the MSEL, in that AFAB demonstrated higher DQs relative to AMAB (<emph>p</emph> = 0.010, <emph>d</emph> = −0.42). No statistically significant differences were seen for other DQ measures. We then calculated standardised <emph>z</emph>-scores for Full-Scale IQ, Verbal IQ and Nonverbal IQ, to compare performance between sex on our three IQ measures, the SB-5, the WPPSI-IV and the WISC V. Similarly, standardised <emph>z</emph>-scores were created for verbal and nonverbal developmental quotients, to compare performance between sex on our measures of developmental ability, the Griffiths-III, the MSEL and the Bayley. Independent samples <emph>t</emph>-tests showed no statistically significant differences on Full Scale IQ, Verbal IQ or nonverbal IQ (<emph>p-</emph>values > 0.388, <emph>d</emph> ranging from −0.11 to −0.03). There was no statistically significant difference on nonverbal DQ (<emph>p</emph> = 0.057, <emph>d</emph> = −0.21) or verbal DQ (<emph>p</emph> = 0.085, <emph>d</emph> = −0.21).</p> <hd id="AN0184797755-23">Adaptive function, comorbidity and sex at birth</hd> <p>Adaptive functioning data was available for 781 participants in total (AMAB <emph>n</emph> = 589; AFAB <emph>n</emph> = 192). In terms of adaptive functioning, there were no statistically significant differences as a function of sex on any adaptive domain or on overall adaptive behavioural scores. With regard to the number of DSM-5-TR diagnoses other than autism between sex, there were no statistically significant differences (<emph>p</emph> = 0.297). However, AMAB were more likely to receive diagnoses of ADHD compared to AFAB (odds ratio = 1.47), <emph>p</emph> = 0.046.</p> <hd id="AN0184797755-24">Age at diagnosis and sex at birth</hd> <p>There was a difference in age at assessment as a function of sex, with AMAB receiving assessments when they were 6 months younger, on average, compared to AFAB (<emph>p</emph> = 0.024, <emph>d</emph> = −0.17).</p> <hd id="AN0184797755-25">Comparisons with subset of participants with data available across all assessment measures</hd> <p>There were no differences in age at assessment or gender when comparing results between the larger sample of 1079 participants and the subset of 180 participants who had data available on all measures (<emph>p</emph>-values = 0.315 and 0.747, respectively). However, some small differences were apparent for the clinical measures. Considering autism characteristics, the subset of participants did not demonstrate any statistically significant sex differences on the ADOS, although similar differences were seen on the CARS, with AMAB displaying more autism characteristics compared to AFAB (<emph>p</emph> = 0.033, <emph>d</emph> = 0.65).</p> <p>Considering cognitive or developmental ability, there were some differences as a function of sex in the subset of 180 participants, with AFAB showing higher scores on the WPPSI, as well as higher performance on overall Full-Scale IQ and Verbal IQ, compared to AMAB (<emph>p</emph>-values < 0.041, <emph>d</emph> ranging from −0.49 to −0.81).</p> <p>Considering adaptive functioning, while the overall direction of the results remained the same when looking at the subset of 180 participants, AFAB in this subset of participants displayed higher standard scores on domains of communication and daily living skills, as well as overall adaptive functioning, compared to AMAB (<emph>p-</emph>values < 0.026, <emph>d</emph> ranging from −0.38).</p> <p>When multinomial logistic regressions were used to analyse sex differences in items on the ADOS-2 and the CARS-2, the overall pattern of results remained the same; however, statistically significant differences were only observed for the excessive interests item of the ADOS-2 and the visual response items of the CARS-2 (<emph>p</emph> values < 0.043). Results across all measures for the subset of 180 participants who had complete data available across all measures are displayed in Supplementary Tables 4 and 5.</p> <hd id="AN0184797755-26">Discussion</hd> <p>There is growing awareness of potentially important differences between autistic children of different sexes that contributes to how autism presents and how this may influence assessment pathways. This study sought to build further on this literature by delineating the relationship between the sex of autistic children and autism symptoms, cognitive and adaptive function profiles, comorbidities and age at assessment in a publicly funded tertiary developmental assessment service. Results showed that both the number and severity of autism symptoms was greater for AMAB in comparison to AFAB according to a range of measures including ADOS-2, CARS-2 and VABS-3 assessments, and while these differences were statistically significant, it is not clear that these were clinically meaningful differences. Item-level analysis showed that a cluster of both social (eye-gaze, gestures, facial expression and shared enjoyment) and repetitive behaviour symptoms were more severe in AMAB. Results also showed autistic AMAB children showed a greater number of co-occurring diagnoses than did AFAB children. Despite these differences in symptom profiles, however, there was no evidence to suggest any differences in adaptive function between the sexes. This suggests that despite the greater number and severity of developmental symptoms that were identified in AMAB children, the functioning needs remained similar. It is possible that diagnostic assessment tools and informants may be less sensitive to the differences and difficulties experienced by AFAB children ([<reflink idref="bib31" id="ref77">31</reflink>]) while their actual needs, in terms of adaptive functioning, are still significant. It suggests that those services which may focus on diagnostic symptoms alone may underestimate the support needs of autistic AFAB children.</p> <p>There was a slightly greater severity of autism symptoms in AMAB compared with AFAB. Of the ADOS-2 modules, the difference between groups was more apparent on Module 3, typically administered with primary school-aged children. The findings are in line with the results of [<reflink idref="bib56" id="ref78">56</reflink>], who found greater symptom severity in their sample of older male children. In addition, it is possible that this difference is reflective of some level of camouflaging among AFAB children in this age group, which is more likely in older, verbal children than the younger, less verbal groups, as previously noted. The earlier age at diagnosis of AMAB than AFAB despite having similar age at identification of concern is noteworthy and appears to be a consistent finding in the literature. For example, [<reflink idref="bib64" id="ref79">64</reflink>] reported that girls were diagnosed on average 7 months later than boys in their multisite study. Similarly, female children had a longer time than boys between first concerns being raised with a professional to diagnosis, and a trend towards later diagnoses than boys in an earlier, small-scale study ([<reflink idref="bib65" id="ref80">65</reflink>]).</p> <p>The 6-month lag in diagnosis for AFAB children can be impactful particularly in the preschool period when access to early intervention programmes is vital. Indeed, studies have shown that children who attend early intervention programmes show positive outcomes particularly in those with higher cognitive abilities and adaptive skills ([<reflink idref="bib53" id="ref81">53</reflink>]). Further research is required to investigate the potential child/family factors that are associated with later diagnosis in AFAB. Responses to parent concerns by 'first responders' may be a factor. Indeed, in a qualitative study evaluating the concerns of parents of AFAB individuals, they reported barriers to receiving an early diagnosis which seemed to be related to how their AFAB child was perceived by clinicians. They also reported feeling the need to make their AFAB child seem more impaired in order to receive a diagnosis ([<reflink idref="bib41" id="ref82">41</reflink>]). This is supported by reports that AMAB children are referred to specialist diagnostic services 10 times more frequently than AFAB and when AFAB children are referred, they are less likely to receive a diagnosis, even if their symptom presentation is similar in severity to AMAB children ([<reflink idref="bib37" id="ref83">37</reflink>]). Similar levels of adaptive functioning in AMAB compared to AFAB in this sample are consistent with previous research. Even though those with AMAB had somewhat more severe symptoms than AFAB, the mean level of adaptive functioning was at the level of a mild disability for both groups. When reflecting on this finding, one consideration may be that there are other variables in addition to autism symptomatology that may have a relevance to adaptive skills. For example, [<reflink idref="bib48" id="ref84">48</reflink>] have found that the presence of psychiatric comorbidities and challenging behaviours were associated with day-to-day functioning in their group of autistic children and adolescents. It is also unclear what role bias and gender expectations may play in parent reporting of adaptive functioning. Further research is needed to explore the multivariate reasons for why AMAB function similarly to AFAB even though their autism symptom severity is higher.</p> <p>In practical terms, the results indicate a need to evaluate not only autism symptoms but also adaptive functioning. Services that primarily focus on symptoms associated with autism may not address the additional support needs of AFAB children observed when focusing on adaptive function. In addition to measuring observable behaviours, it is important to capture the broader aspects of an individual including their own personal experiences. The findings also highlight the need to examine co-occurring conditions such as ADHD in autistic individuals to initiate appropriate comprehensive strategies that extend beyond social and communication impairments associated with autism. For example, it is important to address co-occurring attention and behavioural concerns. This is particularly important given that attention difficulties can interfere with the child's ability to obtain maximal effects from intervention ([<reflink idref="bib5" id="ref85">5</reflink>]).</p> <hd id="AN0184797755-27">Limitations and future directions</hd> <p>This study has some limitations. It only includes children who were referred to tertiary diagnostic teams. This study is cross-sectional and therefore was unable to explore the longitudinal trajectories of symptoms. It has been suggested that with increasing environmental demands, difficulties may become apparent over time ([<reflink idref="bib43" id="ref86">43</reflink>]). Furthermore, the sample size for Module 4 of the ADOS-2 was <emph>N</emph> = 5, but the effect size of gender was both large and non-significant. This small sample size is to be expected in clinical services that focus assessment on younger children. For this Module 4 group, we do not know whether this large effect size of gender is due to the variability caused by having a small number of participants, or, alternatively, reflects a real effect size that would be statistically significant in larger samples. Care should be taken when interpreting data from our Module 4 assessments specifically. Results should be interpreted with acknowledgement of the population we have tested, including the context and the demographic factors associated with this population. Another limitation is that not all measures were available for all children, which reflects the reality of clinical practice. Some measures may be more likely to be completed on certain children, and this can lead to a degree of recruitment bias for specific measures within the population. As noted above, there were no differences between the subset of children with all measure completed and the larger sample in terms of age or gender distribution. Those with more complete data were spread across the centres and year of recruitment. The choice of assessment measures is made by the individual assessment teams, based on the available information at hand and the child's presentation on the day of assessment. For example, it may be deemed unnecessary to conduct an ADOS-2 if there is sufficient information from multiple sources to arrive at a diagnosis using the diagnostic criteria. On the other hand, developmental/intelligence assessments may not be completed due to the child's limited receptive language and engagement. One might speculate that the group with the incomplete data represents a phenotype of individuals with more significant symptoms and lower levels of functioning, worthy of further investigation. Furthermore, although this study characterised assigned sex at birth, it did not characterise gender identity ([<reflink idref="bib47" id="ref87">47</reflink>]). Studies have shown that there is an over-representation of diverse gender identities in autistic people, and this may be associated with delays in diagnosis ([<reflink idref="bib47" id="ref88">47</reflink>]; [<reflink idref="bib67" id="ref89">67</reflink>]; [<reflink idref="bib74" id="ref90">74</reflink>].; [<reflink idref="bib75" id="ref91">75</reflink>]). The opportunity exists to obtain information about gender identity in the future. Furthermore, future studies should investigate the heterogeneity among age groups. In addition, there could be further exploration regarding the role and utility of diagnostic tools (including measures of psychiatric co-occurring conditions) for AFAB and AMAB children.</p> <p>The current study provides the basis for future work, including a more comprehensive battery such as more specific cognitive measures. It is important to follow the trajectory of these individuals with repeat assessments over time and to offer intervention and support targeting difficulties that affect functioning (as suggested by [<reflink idref="bib35" id="ref92">35</reflink>]). Furthermore, our findings highlight the need for triangulation of clinical information from a range of sources, including caregiver/teacher report, self-report, naturalistic observations and checklists, as well as formal assessments.</p> <hd id="AN0184797755-28">Conclusion</hd> <p>In conclusion, this study provides evidence to show that autistic AFAB and AMAB differ in terms of autism symptoms and severity and age at diagnosis based on a sample recruited in a real-world clinic. It highlights the importance of the growing debate between balancing assessments of symptoms with assessment of adaptive function. These study results suggest that the former will result in the identification of greater needs in autistic AMAB children, whereas the latter may show similar support needs between children of both sexes.</p> <hd id="AN0184797755-29">Supplemental Material</hd> <p>Graph: Supplemental material, sj-docx-1-aut-10.1177_13623613241303550 for Focusing on autism symptoms masks sex-specific needs of autistic children: An example from the Sydney Child Neurodevelopment Research Registry by Marie Antoinette Hodge, Rebecca Sutherland, Kelsie A Boulton, Sarah Jane Baracz, Natalie Ong, Beverley Bennett, Adam J Guastella and Natalie Silove in Autism</p> <p>We thank children and families who participated in this study. We also thank the staff at the Child Development Unit and Parramatta Early Childhood Assessment Team.</p> <ref id="AN0184797755-30"> <title> References </title> <blist> <bibl id="bib1" idref="ref33" type="bt">1</bibl> <bibtext> Ambrose K., Adams D., Simpson K., Keen D. (2020). 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Frontiers in Psychiatry, 9, Article 50. https://doi.org/10.3389/fpsyt.2018.00050</bibtext> </blist> </ref> <ref id="AN0184797755-31"> <title> Footnotes </title> <blist> <bibtext> Marie Antoinette Hodge: Conceptualization; Data curation; Investigation; Methodology; Project administration; Supervision; Writing – original draft; Writing – review & editing. Rebecca Sutherland: Conceptualization; Data curation; Investigation; Methodology; Writing - original draft; Writing - review & editing. Kelsie A Boulton: Conceptualization; Data curation; Formal analysis; Investigation; Methodology; Writing – original draft; Writing – review & editing. Sarah Jane Baracz: Methodology; Writing – original draft; Writing – review & editing. Natalie Ong: Writing – original draft; Writing – review & editing. Beverley Bennett: Writing – original draft; Writing – review & editing. Adam J Guastella: Conceptualization; Data curation; Project administration; Resources; Writing – original draft; Writing – review & editing. Natalie Silove: Project administration; Resources; Writing – original draft; Writing – review & editing.</bibtext> </blist> <blist> <bibtext> Data will be made available upon reasonable request to the authors.</bibtext> </blist> <blist> <bibtext> The author(s) declared no potential conflicts of interest with respect to the research, authorship and/or publication of this article.</bibtext> </blist> <blist> <bibtext> The author(s) received no financial support for the research, authorship and/or publication of this article.</bibtext> </blist> <blist> <bibtext> The study was approved by the Sydney Children's Hospital Human Research Ethics Committee (HREC/14/SCHN/269 and LNR/17/SCHN/293).</bibtext> </blist> <blist> <bibtext> Marie Antoinette Hodge</bibtext> </blist> <blist> <bibtext>Graph</bibtext> </blist> <blist> <bibtext>https://orcid.org/0000-0003-4101-9616 Rebecca Sutherland</bibtext> </blist> <blist> <bibtext>Graph</bibtext> </blist> <blist> <bibtext>https://orcid.org/0000-0002-4522-058X Kelsie A Boulton</bibtext> </blist> <blist> <bibtext>Graph</bibtext> </blist> <blist> <bibtext>https://orcid.org/0000-0002-9408-7367 Natalie Ong</bibtext> </blist> <blist> <bibtext>Graph</bibtext> </blist> <blist> <bibtext>https://orcid.org/0000-0002-0962-443X Adam J Guastella</bibtext> </blist> <blist> <bibtext>Graph https://orcid.org/0000-0001-8178-4625</bibtext> </blist> <blist> <bibtext> Supplemental material for this article is available online.</bibtext> </blist> <blist> <bibtext> We have chosen to describe biological sex as either 'assigned male at birth (AMAB)' or 'assigned female at birth (AFAB)', recognising that biological sex may not reflect gender, particularly among autistic people who are more likely to experience gender beyond the male/female binary and/or gender that differs to their biological sex ([14]).</bibtext> </blist> </ref> <aug> <p>By Marie Antoinette Hodge; Rebecca Sutherland; Kelsie A Boulton; Sarah Jane Baracz; Natalie Ong; Beverley Bennett; Adam J Guastella and Natalie Silove</p> <p>Reported by Author; Author; Author; Author; Author; Author; Author; Author</p> </aug> <nolink nlid="nl1" bibid="bib29" firstref="ref2"></nolink> <nolink nlid="nl2" bibid="bib59" firstref="ref3"></nolink> <nolink nlid="nl3" bibid="bib38" firstref="ref4"></nolink> <nolink nlid="nl4" bibid="bib20" firstref="ref5"></nolink> <nolink nlid="nl5" bibid="bib18" firstref="ref6"></nolink> <nolink nlid="nl6" bibid="bib11" firstref="ref7"></nolink> <nolink nlid="nl7" bibid="bib16" firstref="ref8"></nolink> <nolink nlid="nl8" bibid="bib32" firstref="ref9"></nolink> <nolink nlid="nl9" bibid="bib40" firstref="ref10"></nolink> <nolink nlid="nl10" bibid="bib31" firstref="ref11"></nolink> <nolink nlid="nl11" bibid="bib60" firstref="ref12"></nolink> <nolink nlid="nl12" bibid="bib56" firstref="ref13"></nolink> <nolink nlid="nl13" bibid="bib68" firstref="ref14"></nolink> <nolink nlid="nl14" bibid="bib23" firstref="ref15"></nolink> <nolink nlid="nl15" bibid="bib63" firstref="ref16"></nolink> <nolink nlid="nl16" bibid="bib72" firstref="ref17"></nolink> <nolink nlid="nl17" bibid="bib69" firstref="ref18"></nolink> <nolink nlid="nl18" bibid="bib33" firstref="ref19"></nolink> <nolink nlid="nl19" bibid="bib10" firstref="ref24"></nolink> <nolink nlid="nl20" bibid="bib71" firstref="ref26"></nolink> <nolink nlid="nl21" bibid="bib24" firstref="ref27"></nolink> <nolink nlid="nl22" bibid="bib42" firstref="ref28"></nolink> <nolink nlid="nl23" bibid="bib26" firstref="ref29"></nolink> <nolink nlid="nl24" bibid="bib25" firstref="ref30"></nolink> <nolink nlid="nl25" bibid="bib44" firstref="ref31"></nolink> <nolink nlid="nl26" bibid="bib80" firstref="ref32"></nolink> <nolink nlid="nl27" bibid="bib52" firstref="ref34"></nolink> <nolink nlid="nl28" bibid="bib62" firstref="ref35"></nolink> <nolink nlid="nl29" bibid="bib17" firstref="ref36"></nolink> <nolink nlid="nl30" bibid="bib79" firstref="ref37"></nolink> <nolink nlid="nl31" bibid="bib61" firstref="ref38"></nolink> <nolink nlid="nl32" bibid="bib70" firstref="ref39"></nolink> <nolink nlid="nl33" bibid="bib34" firstref="ref41"></nolink> <nolink nlid="nl34" bibid="bib55" firstref="ref42"></nolink> <nolink nlid="nl35" bibid="bib36" firstref="ref43"></nolink> <nolink nlid="nl36" bibid="bib46" firstref="ref44"></nolink> <nolink nlid="nl37" bibid="bib13" firstref="ref46"></nolink> <nolink nlid="nl38" bibid="bib15" firstref="ref47"></nolink> <nolink nlid="nl39" bibid="bib49" firstref="ref48"></nolink> <nolink nlid="nl40" bibid="bib73" firstref="ref49"></nolink> <nolink nlid="nl41" bibid="bib45" firstref="ref51"></nolink> <nolink nlid="nl42" bibid="bib47" firstref="ref52"></nolink> <nolink nlid="nl43" bibid="bib27" firstref="ref53"></nolink> <nolink nlid="nl44" bibid="bib39" firstref="ref56"></nolink> <nolink nlid="nl45" bibid="bib30" firstref="ref57"></nolink> <nolink nlid="nl46" bibid="bib57" firstref="ref58"></nolink> <nolink nlid="nl47" bibid="bib76" firstref="ref59"></nolink> <nolink nlid="nl48" bibid="bib77" firstref="ref60"></nolink> <nolink nlid="nl49" bibid="bib50" firstref="ref61"></nolink> <nolink nlid="nl50" bibid="bib19" firstref="ref62"></nolink> <nolink nlid="nl51" bibid="bib78" firstref="ref63"></nolink> <nolink nlid="nl52" bibid="bib66" firstref="ref64"></nolink> <nolink nlid="nl53" bibid="bib54" firstref="ref65"></nolink> <nolink nlid="nl54" bibid="bib22" firstref="ref66"></nolink> <nolink nlid="nl55" bibid="bib21" firstref="ref67"></nolink> <nolink nlid="nl56" bibid="bib51" firstref="ref68"></nolink> <nolink nlid="nl57" bibid="bib28" firstref="ref69"></nolink> <nolink nlid="nl58" bibid="bib58" firstref="ref72"></nolink> <nolink nlid="nl59" bibid="bib12" firstref="ref74"></nolink> <nolink nlid="nl60" bibid="bib64" firstref="ref79"></nolink> <nolink nlid="nl61" bibid="bib65" firstref="ref80"></nolink> <nolink nlid="nl62" bibid="bib53" firstref="ref81"></nolink> <nolink nlid="nl63" bibid="bib41" firstref="ref82"></nolink> <nolink nlid="nl64" bibid="bib37" firstref="ref83"></nolink> <nolink nlid="nl65" bibid="bib48" firstref="ref84"></nolink> <nolink nlid="nl66" bibid="bib43" firstref="ref86"></nolink> <nolink nlid="nl67" bibid="bib67" firstref="ref89"></nolink> <nolink nlid="nl68" bibid="bib74" firstref="ref90"></nolink> <nolink nlid="nl69" bibid="bib75" firstref="ref91"></nolink> <nolink nlid="nl70" bibid="bib35" firstref="ref92"></nolink>
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  Label: Title
  Group: Ti
  Data: Focusing on Autism Symptoms Masks Sex-Specific Needs of Autistic Children: An Example from the Sydney Child Neurodevelopment Research Registry
– Name: Language
  Label: Language
  Group: Lang
  Data: English
– Name: Author
  Label: Authors
  Group: Au
  Data: <searchLink fieldCode="AR" term="%22Marie+Antoinette+Hodge%22">Marie Antoinette Hodge</searchLink> (ORCID <externalLink term="https://orcid.org/0000-0003-4101-9616">0000-0003-4101-9616</externalLink>)<br /><searchLink fieldCode="AR" term="%22Rebecca+Sutherland%22">Rebecca Sutherland</searchLink> (ORCID <externalLink term="https://orcid.org/0000-0002-4522-058X">0000-0002-4522-058X</externalLink>)<br /><searchLink fieldCode="AR" term="%22Kelsie+A%2E+Boulton%22">Kelsie A. Boulton</searchLink> (ORCID <externalLink term="https://orcid.org/0000-0002-9408-7367">0000-0002-9408-7367</externalLink>)<br /><searchLink fieldCode="AR" term="%22Sarah+Jane+Baracz%22">Sarah Jane Baracz</searchLink><br /><searchLink fieldCode="AR" term="%22Natalie+Ong%22">Natalie Ong</searchLink> (ORCID <externalLink term="https://orcid.org/0000-0002-0962-443X">0000-0002-0962-443X</externalLink>)<br /><searchLink fieldCode="AR" term="%22Beverley+Bennett%22">Beverley Bennett</searchLink><br /><searchLink fieldCode="AR" term="%22Adam+J%2E+Guastella%22">Adam J. Guastella</searchLink> (ORCID <externalLink term="https://orcid.org/0000-0001-8178-4625">0000-0001-8178-4625</externalLink>)<br /><searchLink fieldCode="AR" term="%22Natalie+Silove%22">Natalie Silove</searchLink>
– Name: TitleSource
  Label: Source
  Group: Src
  Data: <searchLink fieldCode="SO" term="%22Autism%3A+The+International+Journal+of+Research+and+Practice%22"><i>Autism: The International Journal of Research and Practice</i></searchLink>. 2025 29(5):1318-1332.
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  Label: Availability
  Group: Avail
  Data: SAGE Publications. 2455 Teller Road, Thousand Oaks, CA 91320. Tel: 800-818-7243; Tel: 805-499-9774; Fax: 800-583-2665; e-mail: journals@sagepub.com; Web site: https://sagepub.com
– Name: PeerReviewed
  Label: Peer Reviewed
  Group: SrcInfo
  Data: Y
– Name: Pages
  Label: Page Count
  Group: Src
  Data: 15
– Name: DatePubCY
  Label: Publication Date
  Group: Date
  Data: 2025
– Name: TypeDocument
  Label: Document Type
  Group: TypDoc
  Data: Journal Articles<br />Reports - Research
– Name: Subject
  Label: Descriptors
  Group: Su
  Data: <searchLink fieldCode="DE" term="%22Autism+Spectrum+Disorders%22">Autism Spectrum Disorders</searchLink><br /><searchLink fieldCode="DE" term="%22Symptoms+%28Individual+Disorders%29%22">Symptoms (Individual Disorders)</searchLink><br /><searchLink fieldCode="DE" term="%22Children%22">Children</searchLink><br /><searchLink fieldCode="DE" term="%22Gender+Differences%22">Gender Differences</searchLink><br /><searchLink fieldCode="DE" term="%22Individual+Characteristics%22">Individual Characteristics</searchLink><br /><searchLink fieldCode="DE" term="%22Severity+%28of+Disability%29%22">Severity (of Disability)</searchLink><br /><searchLink fieldCode="DE" term="%22Behavior+Problems%22">Behavior Problems</searchLink><br /><searchLink fieldCode="DE" term="%22Age+Differences%22">Age Differences</searchLink><br /><searchLink fieldCode="DE" term="%22Clinical+Diagnosis%22">Clinical Diagnosis</searchLink><br /><searchLink fieldCode="DE" term="%22Foreign+Countries%22">Foreign Countries</searchLink><br /><searchLink fieldCode="DE" term="%22Parent+Background%22">Parent Background</searchLink><br /><searchLink fieldCode="DE" term="%22Educational+Attainment%22">Educational Attainment</searchLink>
– Name: Subject
  Label: Geographic Terms
  Group: Su
  Data: <searchLink fieldCode="DE" term="%22Australia%22">Australia</searchLink>
– Name: SubjectThesaurus
  Label: Assessment and Survey Identifiers
  Group: Su
  Data: <searchLink fieldCode="SU" term="%22Autism+Diagnostic+Observation+Schedule%22">Autism Diagnostic Observation Schedule</searchLink><br /><searchLink fieldCode="SU" term="%22Vineland+Adaptive+Behavior+Scales%22">Vineland Adaptive Behavior Scales</searchLink><br /><searchLink fieldCode="SU" term="%22Stanford+Binet+Intelligence+Scale%22">Stanford Binet Intelligence Scale</searchLink><br /><searchLink fieldCode="SU" term="%22Wechsler+Preschool+and+Primary+Scale+of+Intelligence%22">Wechsler Preschool and Primary Scale of Intelligence</searchLink><br /><searchLink fieldCode="SU" term="%22Wechsler+Intelligence+Scale+for+Children%22">Wechsler Intelligence Scale for Children</searchLink><br /><searchLink fieldCode="SU" term="%22Mullen+Scales+of+Early+Learning%22">Mullen Scales of Early Learning</searchLink><br /><searchLink fieldCode="SU" term="%22Bayley+Scales+of+Infant+and+Toddler+Development%22">Bayley Scales of Infant and Toddler Development</searchLink>
– Name: DOI
  Label: DOI
  Group: ID
  Data: 10.1177/13623613241303550
– Name: ISSN
  Label: ISSN
  Group: ISSN
  Data: 1362-3613<br />1461-7005
– Name: Abstract
  Label: Abstract
  Group: Ab
  Data: Studies have shown that there are differences between the presentations of males and females diagnosed with autism. There remains a developing understanding about how the presentation of autism differs between boys (hereafter referred to as 'assigned males at birth') and girls (assigned females at birth). This study sought to investigate the presence of sex differences in autistic children. Participants (1.11-17.97 years) attended an assessment clinic and participated in measures of intelligence/development, social/communication skills and behaviour. Adaptive skills were evaluated using a range of standardised measures, and other clinical and demographic variables were collected (e.g. age, intelligence quotient, ratio of male to female). Assigned males at birth displayed more autism characteristics and greater symptom autism severity than assigned females at birth. No significant differences were found between assigned males at birth and assigned females at birth on any measure of intelligence. Children assigned males at birth received assessments 6 months earlier than children assigned females at birth on average. Externalising behaviour problems were more evident in assigned males at birth, but statistically significant differences in adaptive skills were not apparent between assigned males at birth and assigned females at birth. This study showed assigned females at birth and assigned males at birth differ in autism symptoms and severity and age at diagnosis based on a real-world sample. It highlights the importance of balancing assessments of symptoms with assessment of adaptive function.
– Name: AbstractInfo
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  Data: As Provided
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  Label: Entry Date
  Group: Date
  Data: 2025
– Name: AN
  Label: Accession Number
  Group: ID
  Data: EJ1469264
PLink https://search.ebscohost.com/login.aspx?direct=true&site=eds-live&db=eric&AN=EJ1469264
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        Value: 10.1177/13623613241303550
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      – Text: English
    PhysicalDescription:
      Pagination:
        PageCount: 15
        StartPage: 1318
    Subjects:
      – SubjectFull: Autism Spectrum Disorders
        Type: general
      – SubjectFull: Symptoms (Individual Disorders)
        Type: general
      – SubjectFull: Children
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      – SubjectFull: Gender Differences
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      – SubjectFull: Australia
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      – SubjectFull: Autism Diagnostic Observation Schedule
        Type: general
      – SubjectFull: Vineland Adaptive Behavior Scales
        Type: general
      – SubjectFull: Stanford Binet Intelligence Scale
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      – SubjectFull: Wechsler Preschool and Primary Scale of Intelligence
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      – SubjectFull: Wechsler Intelligence Scale for Children
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      – SubjectFull: Mullen Scales of Early Learning
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      – SubjectFull: Bayley Scales of Infant and Toddler Development
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      – TitleFull: Focusing on Autism Symptoms Masks Sex-Specific Needs of Autistic Children: An Example from the Sydney Child Neurodevelopment Research Registry
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            – D: 01
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            – TitleFull: Autism: The International Journal of Research and Practice
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